ISRS/AAO Web Site: www.isrs.org
Original URL:
|
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 FEATURE CLINICAL UPDATES ISRS/AAO INFORMATION INDUSTRY NEWS CALENDAR CLINICAL UPDATES 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 ISRS/AAO INFORMATION 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 INDUSTRY NEWS 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
FEATURE Current and Future Roles of Phakic IOLs Rick Milne, MD: The Eye Center, Columbia, SC Why is custom matching IOLs important? 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 Is intermediate vision important for older patients? In 1998:
Bucci Study Results Bilateral Intermediate Vision Outcomes 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. Near Vision Explantation 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. Education 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 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. Surgical Planning During a surgical consult, I recommend the following: 1. Listen. Allow the patient to speak first and fully. Determine their desires, expectations and fears. Typically my approach is to implant the ReZoom lens in the first eye with a post operative goal of -.25 sphere. Sequencing 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. Intermediate Exam 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:
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. References: 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 hmilne@aol.com
|
