Until recently the goal for most cataract surgeons was restoration of vision. Today’s technology has empowered us to shift our focus from merely restoring visual function, to optimizing vision in profound ways. The key to successfully integrating the variety of IOL choices into our practices is knowing how and why certain IOL combinations can provide the best outcomes. Beyond understanding the technology, surgeons must be dedicated and careful listeners in order to determine which patients are appropriate surgical candidates and to ensure that a patient’s goals are attainable. In the first of a two-part series, Dr. Rick Milne shares strategies in the art and science of “mixing and matching” IOLs, as well as his approach to the surgical planning process. Next month, several surgeons, along with marketing consultant, Shareef Mahdavi, will weigh-in on the “refractive shopping experience” and discuss which factors most influence a prospective patient’s choice. You may be very surprised by some of the research and anecdotal evidence we have to share. As always, your questions and comments are most welcome -- Marguerite McDonald, MD, FACS
- Successfully Integrating Multifocal IOLs Into Your Practice
- Choice of microkeratome, pachymeter and laser has a marked impact on the safety of LASIK
- Intrastromal corneal rings demonstrate good safety profile at 10 years
- Epi-LASIK appears to offer lower postoperative pain and stable refractive and visual results
- Promising early results with Medennium phakic refractive lens for high myopia
- PRK for low to moderate myopia showed good refractive stability, patient satisfaction at 12 years
- New publication schedule
- Record-breaking attendance at this year’s ISRS/AAO Refractive Surgery Subspecialty Day meeting
- E-Posters from the 2006 Refractive Surgery Subspecialty Day meeting in Las Vegas are now online
- Read the best refractive surgery articles appearing in EyeNet Magazine in 2006
- LASIK remained the most popular type of refractive surgery in the U.S. in 2005
- FDA requests more information before considering approval of STAAR’s new collamer lens
- Upcoming meetings
Choice of microkeratome, pachymeter and laser has a marked impact on the safety of LASIK
Researchers found each parameter had a significant impact on the variation of the depth of keratectomy and thus on the risk of ectasia. The authors recommend that residual stromal bed thickness be directly measured postoperatively in three dimensions using modern high resolution imaging techniques such as VHF digital ultrasound or optical coherence tomography. Journal of Refractive Surgery, November 2006
Intrastromal corneal rings demonstrate good safety profile at 10 years
No significant structural abnormalities of the cornea were observed in 10 patients (10 eyes) whose myopia was treated with 360° complete intrastromal corneal rings with the ends sutured together. Corneal thickness remained stable between one and 10 years, slit-lamp findings were normal and BSCVA was maintained in most patients. Journal of Refractive Surgery, November 2006
Epi-LASIK appears to offer lower postoperative pain and stable refractive and visual results
Based on responses to a subjective questionnaire, Epi-LASIK patients had significantly less pain in the first few postoperative hours compared to LASEK and PRK patients. At four hours, all patients reported the same level of pain. There was no significant difference among groups in terms of vision, refractive error or haze. But epi-LASIK patients had the best visual acuity at day one. Journal of Cataract & Refractive Surgery, November 2006
Promising early results with Medennium phakic refractive lens for high myopia
This series of 31 patients (50 eyes) finds that after two years UCVA was 20/40 or better in 82 percent of eyes and 20/20 or better in 44 percent. BSCVA was 20/40 or better in 84 percent of eyes and 20/20 or better in 54 percent of eyes. A gain of one or more lines of BSCVA was seen in 24 percent of eyes and a gain of two or more lines was noted in 14 percent of eyes. Also, 96 percent of eyes were within 1 D of the targeted refraction. Serious complications, such as cataract and acute angle closure glaucoma, may occur, and long-term safety needs to be evaluated. Journal of Refractive Surgery, November 2006
PRK for low to moderate myopia showed good refractive stability, patient satisfaction at 12 years
This small retrospective study finds preoperative BSCVA was maintained or improved in 87.9 percent of eyes, while 34.5 percent of eyes gained one line and 12.1 percent lost one line of BSCVA. A majority of patients could see at least 20/20 without glasses (67 percent), while 62.1 percent were within .50 D of emmetropia. Trace haze was noted in 17.2 percent of eyes. All patients said they would have the procedure again. Journal of Refractive Surgery, November 2006
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New publication schedule
Beginning January 2007, Refractive Surgery Outlook will be published by the 15th of the month.
Record-breaking attendance at this year’s ISRS/AAO Refractive Surgery Subspecialty Day meeting
Attendance was up 34 percent for another highly successful meeting that featured leaders in the field. Read the highlights featured in EyeNet’s Academy Live publications.
E-Posters from the 2006 Refractive Surgery Subspecialty Day meeting in Las Vegas are now online
You can access a complete listing of Refractive Surgery E-Posters and ISRS/AAO E-Papers.
Read the best refractive surgery articles appearing in EyeNet Magazine in 2006
ISRS/AAO sponsored this year’s publication of EyeNet Selections: The Best of Refractive Surgery, which includes articles on conductive keratoplasty, the femtosecond laser, Epi-LASIK and refractive lens exchange.
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LASIK remained the most popular type of refractive surgery in the U.S. in 2005
The annual ISRS/AAO survey, Trends in Refractive Surgery in the United States, was released during the Joint Meeting in Las Vegas. Among the findings: For refractive errors between -10 D and + 3 D, LASIK remained the preferred choice. Refractive lens exchange was preferred for high hyperopes and LASIK was preferred over phakic IOLs for high myopes. LASEK, epiLASIK, RLE, P-IOLs and conductive keratoplasty appear to have promising futures, while Intacs, laser thermal keratoplasty and SE have fallen out of favor.
FDA requests more information before considering approval of STAAR’s new collamer lens
The company submitted an application to the U.S. Food and Drug Administration last April for the Visian TICL, a collamer lens designed to treat both astigmatism and nearsightedness. The request for additional analysis of clinical data could extend the review period by up to 180 days.
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|UPCOMING MEETINGS || |
|Jan. 18-19, 2007 |
1st Cairo Middle East Refractive and Cataract Surgery Symposium
May 26-27, 2007
2007 ISRS/AAO Meeting:
Expanding Horizons in Refractive and Cataract Surgery
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Current and Future Roles of Phakic IOLs
Rick Milne, MD: The Eye Center, Columbia, SC
Why is custom matching IOLs important?
The recent introduction of multifocal and accommodating IOLs demonstrates how well the human visual system can accommodate dissimilar optics due to neural adaptation. This use of disparate optics has also been widely used in bifocal lens fittings.
Richard Lindstrom, MD, reports that his practice successfully combines a multifocal or accommodating IOL in one eye with a monofocal IOL in the fellow eye. Multifocal or accommodating IOLs paired with a natural crystalline lens or complementary, multifocal/accommodating IOLs have provided superior outcomes for more patients than symmetrical implants of the same IOL in both eyes, especially for intermediate vision.
As we transition from a “one lens fits all” world, cataract surgeons can no longer fit the procedure to the patient. Research from multiple studies indicates that new multifocal and accommodating IOLs allow surgeons to “mix and match”, providing patients a customized approach for achieving visual goals.
Recent study results
There have been several multifocal IOL “mix and matching” studies to date: three from Frank Bucci, MD (Wilkes-Barre, Pa., USA), Leonardo Akaishi, MD, and Pedro Paolo Fabri, MD (Sao Paolo, Brazil), as well as my own practice in Columbia, S.C.
Is intermediate vision important for older patients?
Increasingly, the answer is yes. Intermediate vision has traditionally been associated with activities like computer use, which has been a lower priority for cataract patients in the past. However, the Internet has changed all of that. A 2006 study by the American Association of Retired Persons (AARP)¹ shows the demand for improved intermediate vision has been on the rise in the last seven years.
- 31 percent of 50 to 64 year olds used the Internet. In 2005 that number more than doubled to 65 percent.
- 12 percent of 65 to 74 year olds used the Internet. In 2005, that number rose to 45 percent.
- Only 4 percent of 75 year olds used the Internet. In 2005, that number jumped to 25 percent.
Bucci Study Results
Dr. Bucci’s study consisted of two cohorts: 55 patients bilaterally implanted with the ReSTOR (RS/RS) lens and 39 patients implanted with a ReSTOR/ReZoom (RS/RZ) IOL combination. There was no statistically significant difference in near vision outcomes for both study groups.
Bilateral Intermediate Vision Outcomes
There was a statistically significant difference in intermediate vision for the same two cohorts: 25 percent of RS/RS patients volunteered an intermediate complaint, while more than 30 percent of RS/RS lensectomy patients volunteered an intermediate complaint.
Dr. Bucci’s study also found that a RS/RZ combination appears to alleviate intermediate complaints and that RS/RZ bilateral intermediate vision was statistically significantly better than in the RS/RS group.
The study also found that the relative risk of an intermediate vision complaint from the RS/RS group increases with decreased age (patients under 60 years of age), and that the relative risk increases by procedure type – for example, lensectomy patients demonstrated more risk than cataract patients.
In my multifocal IOL study, we looked at patient satisfaction with bilateral distance vision and found that 74 percent of RS/RS patients were either satisfied or very satisfied, while 98 percent of patients implanted with RS/RZ were satisfied or very satisfied.
Our study included a patient survey which indicated that 30 percent of patients implanted with RS/RS would not repeat the procedure, while only 2 percent of those implanted with the RS/RZ combination expressed displeasure.
Another remarkable finding: 65 percent of the RS/RS group had total independence from glasses, while 91 percent of the RS/RZ group experienced total independence from glasses.
We also found that daytime halo effects were significantly higher in the RS/RS group (43 percent) compared to the RS/RZ patient (18 percent), while 86 percent in the RS/RS group experienced nighttime halos compared to 72 percent in the RS/RZ group.
In our study the average patient could see from 7 inches to beyond arms length (BAL). The worst patient could see from 10 inches to arms length (AL), while the best patient could see from five inches to BAL.
Among the 50 patients in the RS/RS group, three demanded explants, while none of the 350 patients in the RS/RZ group requested explants.
Other studies, such as Trevor Woodham, MD (Atlanta, Ga.), have also reported encouraging results with alternative IOL combinations such as Crystalens/RS, especially in regard to uncorrected intermediate vision.
Clearly, technology has provided surgeons with a myriad of choices. With multifocal and accommodating IOLs, knowledge is power. With greater understanding and appropriate staff education, we can offer more options to our patients and expand our practices in new directions.
Once surgeons become comfortable with mixing and matching IOLs, it is imperative that staff understands the variety of lenses available to patients. Ideally, everyone from the receptionist to clinical staff should have some degree of familiarity with IOLs.
Patient education tools such as brochures and/or a website can be offered to patients in advance. An important part of our protocol is to mail information to patients as soon as a consult appointment is made. Patients can view an educational video before the appointment, providing another opportunity to accurately describe services and surgical options, which can contribute to a more productive patient-surgeon conversation during the consult.
The Consult: Communication leads to happy patients
Lens surgeons are selling intangible products and services, which makes it even more important to listen carefully to each patient’s desires to avoid potential misunderstandings later on. Patients who pay premium dollars for premium lenses expect to be completely free of glasses -- forever.
A number of tools are available to help determine your patient’s visual goals. For example, Steve Dell, MD (Austin, Texas) created the Dell Scale, which asks patients to choose among three of five contiguous regions of vision that are most important to their lifestyle and visual goals.
Anything that clarifies patient goals will ultimately effect their feelings about their surgical outcome. For example, simple questions such as “Do you do beadwork?” or “Does your job require night driving?” can help a surgeon explain which IOLs are most appropriate for specific activities or needs. The goal is to manage realistic expectations with proper lens selection to maximize patient satisfaction.
These days I custom match ReZoom/ReStor (RZ/RS) IOLs for the majority of multifocal IOL procedures.
During a surgical consult, I recommend the following:
1. Listen. Allow the patient to speak first and fully. Determine their desires, expectations and fears.
2. Accurately explain what you can offer.
3. Discuss the strengths and limitations of each lens, along with the pros and cons of custom-matching IOLs
4. Stress that this is a bilateral procedure and that there is potential need for post-operative fine tuning.
Typically my approach is to implant the ReZoom lens in the first eye with a post operative goal of -.25 sphere.
Procedures are then scheduled at least three weeks apart. During that time I ask patients to observe the visual performance of their new eye at distance, near and intermediate.
Patients are asked to note any visual limitations, checking under different lighting conditions.
The patient’s feedback from the first implantation – regardless of the IOL type - can help surgeons with their selection for the second implantation – whether to use the same IOL or a combination approach. It also helps the patient understand the rationale for your choice. For example, if a patient is not experiencing limitations in their vision after the first IOL implantation, I will probably implant the same IOL in the second eye. If there is a limitation, I will probably choose an IOL with a particular zone of vision to compensate.
This is typically scheduled one to two weeks post-operatively. A post-operative refraction is important. After carefully checking near and intermediate vision under different lighting conditions, I inquire about limitations the patient has noticed.
If a visual limitation is indicated, the refraction is carefully checked. If a great deal of residual refractive error exists, my preference is to address this prior to second eye implantation. Based upon this data, a custom IOL is chosen.
For example, if a ReZoom patient’s post-operative near vision is good and their refraction is a -.50, I would select a ReZoom IOL for the second eye, with a post-operative target of plano.
If distance and intermediate vision is good but near vision is limited, I tend to use the ReStor IOL in the second eye and clearly explain my decision to the patient.
After deciding to use a different lens, I explain to patients that:
- There are existing limitations;
- We have a complementary lens that performs well in this area of vision;
- We are intentionally making their eyes perform a little differently to provide more capabilities over a wider range of visual situations.
In the absence of a tangible product, it’s important to help patients understand exactly what it is that they are purchasing. After the purchase, find ways to illustrate that the patient received exactly what they purchased.
Once both eyes have been successfully implanted and all post-operative refractive errors have been addressed, I celebrate the success with that patient, asking the patient to demonstrate their improved distance and near vision, which reminds them of the limitations of their pre-operative vision.
In most cases patients leave with the joy of knowing that they have received exactly what they hoped to purchase. I thank them for promoting both their excellent results and the excellent care received at our office. Most pleased patients will then engage in what is now called “viral marketing,” spreading the word of their good visual outcome and educating others about the benefits of IOL implantation. Internal marketing has been launched with another satisfied patient.
1. AARP Aging Indicators Study, 2005; U.S. Bureau of the Census, Current Population Survey, Internet and Computer Use Supplement.
Dr. Rick Milne, of Columbia, S.C., is a board certified ophthalmologist and corneal surgeon specializing in Refractive Surgery--CK, PRELEX, LASIK, LASEK, PRK, as well as Corneal Transplant and Cataract Surgery. Dr. Milne may be reached at firstname.lastname@example.org
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