February 2019

REFRACTIVE

YES connect
Patient considerations for advanced technology IOLs


by Liz Hillman EyeWorld Senior Staff Writer

“Ninety-nine percent of my patients are rigid engineers and they all do fine with these lenses. In the end, what matters is their motivation.”
—Huck Holz, MD





Intraoperative appearance of ZLB00 (multifocal) vs. ZXR00 (Symfony)
Source: Sam Garg, MD

 

In order to be a successful cataract surgeon in modern times, one has to be comfortable embracing and offering new technology. Advanced technology IOLs (ATIOLs) have been available to us in the United States since the mid-90s with varying degrees of success and adoption. We now have access to newer technologies such as extended depth of focus (EDOF) IOLs and low-add multifocals, with high degrees of patient satisfaction.
I think that it is just as important to hone your skills conversing with patients, setting expectations, and picking excellent candidates as it is to master a perfect capsulorhexis. In this month’s column we discuss patient considerations when deciding on ATIOLs and how to decipher who will ultimately end up happy with their IOL choice. We start by hearing my thoughts presented at the 2018 ASCRS YES Advanced Cataract Training meeting, and we will hear from Huck Holz, MD, about his experience. We then shift gears and hear from Manjool Shah, MD, about utilizing these technologies in the context of glaucoma.

Samuel Lee, MD,
YES connect co-editor



There are several factors to think about when selecting candidates for presbyopia- correcting IOLs

Is there a way to predict who is going to be happy with advanced technology—namely, multifocal and extended depth of focus—IOLs? That’s what Samuel Lee, MD, Sacramento Eye Consultants, Sacramento, California, asked at the 2018 ASCRS YES Advanced Cataract Training meeting.
“As we all know, happy patients equal happy surgeons,” Dr. Lee said. “Today, an excellent outcome is an expectation every patient has. The expectation is no broken posterior capsule, a perfectly centered IOL—those types of things. I know that in residency, just getting a one-piece IOL in the bag is enough to celebrate, but in the real world, you need to exceed those goals. Patients will judge you as a surgeon, as a doctor, based on what they see on a daily basis. What they will really judge you on is what they can read at distance and near.”
Picking a patient carefully could be one of the most important steps for success when offering an advanced technology IOL (ATIOL), such as a multifocal or extended depth of focus lens.
Reaching a successful outcome for patients involves their presurgical refraction, the health of the ocular surface, preexisting astigmatism, personality, their occupation and hobbies, and their physical characteristics.
When a patient comes to your office, you have to “dissect” them as you consider candidacy for a multifocal or EDOF lens, Dr. Lee said, providing two case examples.
The first was a 58-year-old software engineer complaining of intermittent blurred vision and glare. These latter conditions suggest to Dr. Lee that he might have some ocular surface disease and could be experiencing cortical changes or intolerance to any sort of dysphotopsia. “Right off the bat, I’ve got a few red flags,” Dr. Lee said, noting the personality stereotypical of software engineers and the fact that this patient builds model boats as a hobby. What’s more, this patient is a myope with a little bit of astigmatism, signaling he’s used to good near vision and might not accept the near vision provided by ATIOLs. This patient, expressing his desire for spectacle independence, asked what Dr. Lee’s policy was for LASIK touch-ups—another red flag perhaps signaling unrealistic patient expectations. He is also 5’5”, which Dr. Lee said could indicate shorter arm length and thus a shorter distance at which he holds reading materials, which might not be ideal for the reading vision provided by EDOF and low-add multifocal lenses.
The other case was a 75-year-old woman who came to the office not wearing glasses but refracted at 20/70, 20/60. To Dr. Lee, this indicated that she was tolerant of not having perfect vision already. She was also a hyperope with some astigmatism. This patient said she would like to be out of glasses, but if she needed them for some tasks, she was OK with that. She is also 5’10”, indicating she would have a longer length at which to hold reading materials.
Dr. Lee said choosing a patient who has a healthy ocular surface, no astigmatism or regular correctable astigmatism, is taller with long arms, and who seems tolerant of some glasses use is ideal for at least your first few patients. Dr. Lee said he tells all patients they’ll experience some glare and halo with these lenses, gauging their response.
In his practice, Dr. Lee has patients fill out a Dell questionnaire when they come in for consult. He obtains their biometry, topography, and performs an exam to make sure the eye is healthy enough for an advanced technology IOL. Then he’ll speak with them about their expectations and post-surgery goals, regular hobbies, and what they do with and without glasses in their life.
“Hopefully, if you do all these things you will increase your chances that you will have happy patients with these lenses,” Dr. Lee said.

Taking a different approach

Huck Holz, MD, Kaiser Permanente, Santa Clara, California, practices in the heart of the Silicon Valley where the type A, engineering personality abounds. But he doesn’t see that personality as a contraindication to these IOLs.
“Ninety-nine percent of my patients are rigid engineers and they all do fine with these lenses. In the end, what matters is their motivation,” Dr. Holz said.
Dr. Holz finds that his patients often come in knowing about multifocal and EDOF IOLs, but he thinks it’s his duty to bring up these lenses upon consultation, even if the patient doesn’t.
“I like them to at least have heard it out of my mouth. They’ll find out about it online later and they’ll come back and say, ‘Why didn’t you talk to me about this?” Dr. Holz said.
To determine candidacy, Dr. Holz and his staff rule out standard items: corneal disease, macular pathology, ectasia, a certain level of higher order aberrations, and more. As for physical stature and arm length, Dr. Holz said he does observe this but finds it’s less of a consideration as he is not implanting the Crystalens (Bausch + Lomb, Bridgewater, New Jersey) any longer. They also talk to patients about their priorities and motivations in cataract surgery.
“I want to make sure they prioritize convenience of spectacle independence over nighttime driving clarity, that they don’t mind the idea of having a little bit of halo at night. We also look at personality traits. The flexible optimists are the best, but that doesn’t mean you can’t implant the rigid engineer,” he said.
Determining patient priorities and personality traits starts with cataract surgery counselors at Dr. Holz’s practice. These counselors, he explained, will often alert him to potential problems or personality pitfalls they might sense with a patient.
“So much of what we do as ophthalmologists is also psychology work. We get a sense of how patients should react within the 15- to 30-minute exam and counseling session; we get a sense of how people would normally react to all of those questions and how our discussion goes,” Dr. Holz said.
In the end, Dr. Holz said patients need to be honest with themselves when considering the pros and cons of multifocal or EDOF lenses vs. monofocal varieties. In addition to verbal discussion, he provides a pre-counseling video before their appointment and during the appointment using a laminated placard that features examples of visuals of what the lenses can achieve and what glare and halo look like.
“I do ask them to be honest with themselves. How picky are you about your vision? How important is fine detail? Are you a person of convenience or are you a person of exacting precision?”
What he’s paying attention to more recently is the distance at which patients say they do most of their reading. Dr. Holz said most of his patients are using computers, tablets, and phones—not so much books and newspapers—which rely on a more intermediate distance. Typically, patients are showing him a distance of about 20 inches, but he emphasized taking a detailed social history from the patient to identify near-vision hobbies.
In the end, provided the patient is a good candidate from an ocular standpoint, Dr. Holz said he allows his patients to make an informed decision about the lens they think they could be happy with.
“I’m not in the business of telling people they aren’t candidates because I think they have a picky personality,” he said.

Approaching ATIOLs in the face of glaucoma

Though there are many ocular contraindications that could limit a patient’s candidacy with an ATIOL, glaucoma is not an absolute contraindication, said Manjool Shah, MD, assistant professor, University of Michigan, Kellogg Eye Center, Ann Arbor, Michigan. With 2.7 million Americans older than 40 diagnosed with glaucoma, this pool of possible candidates is significant.
“Based on the severity of the disease, as well as the patient’s prognosis, it may be reasonable to consider multifocal or EDOF technology,” Dr. Shah said. “Of course, we have to be mindful of the fact that even milder glaucomas can have some decline in contrast sensitivity, which can be exacerbated by ATIOL optics.”
In addition to the health and visual potential a patient has, Dr. Shah said he needs to hear that the patient desires spectacle independence.
“If they are motivated to be free of glasses, then I focus my exam with ATIOLs in mind,” he said.
If a patient with glaucoma is interested in spectacle independence but due to ocular conditions is not a candidate, Dr. Shah will employ monovision. Even in asymmetric glaucomas where one eye has more visual field loss than the other, he said, monovision can work well. Dr. Shah will do a contact lens trial in these patients first and will assess ocular dominance.
“I will sometimes set the more injured eye at near, regardless of the ocular dominance in some situations,” he said.

Editors’ note: The physicians have no financial interests related to their comments.

Contact information

Holz
: drhuckholz@gmail.com
Lee: samuel.lee.md@gmail.com
Shah: manjool@med.umich.edu

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