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Incorporating Premium IOLs Into Your Practice, Part 1: Laying the Groundwork
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When it comes to cataract surgery, we’ve found that one of the most important elements is laying the groundwork. Doing this effectively involves both patient education and a thorough corneal topography. In this article, we’ll look at how to provide initial patient education on cataracts and IOL options, plus the optics involved in ensuring premium IOLs yield the most satisfied patient possible.

Start with Education
In Dr. Melendez’s practice, the education begins when patients are sent a brochure on cataract surgery and IOL options prior to the visit. The patients are then asked to bring the brochure with them on their visit. The goal of the brochure is to assess their visual needs (i.e., do they want to see up close or far away with or without glasses).

Dr. Melendez’s practice also has a flat-panel TV in the waiting room that runs a video outlining what cataract surgery is, as well as lens options. When the technician meets with patients, he or she also assesses how knowledgeable each patient is about lens options. If the patient is not knowledgeable about the lens options, the technician will briefly share information about lenses before the physician enters the room. The physician then does his best not to discuss any lens options until he’s completed the eye exam, looking for corneal abnormalities and, if astigmatism is > 0.75 D, reviewed the corneal topography that is performed on every cataract consult patient.

The Importance of Corneal Topography
In the event your patient decides on premium lenses, you may choose to use presbyopia-correcting IOLs (presby-IOLs). Selecting an appropriate IOL for a patient involves more than simply evaluating the patient’s refraction and visual needs. Although these things are certainly important, the optics of presby-IOLs are much more precise than traditional monofocal IOLs. A fundamental understanding of optics is necessary in order to achieve satisfactory results with presby-IOLs. A monofocal IOL is much more forgiving of other abnormalities within the optical system, such as an irregular cornea, than is a presby-IOL.

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Despite the functional advantages that presby-IOLs may offer patients undergoing cataract surgery, and the remarkable technological advancements that have taken place in recent years, these lenses are used in a low percentage of cataract surgeries. A significant barrier to their adoption, of course, is the out-of-pocket cost for the patient. But a more significant barrier is the perceived difficulty in achieving success with these lenses.

Presby-IOLs and Patient Dissatisfaction
Surgeons accustomed to excellent results with monofocal lenses after cataract surgery are frequently perplexed by the level of patient dissatisfaction after surgery with a presby-IOL when there is no obvious cause. After ruling out traditional causes for poor outcomes after cataract surgery — such as maculopathy — the first impulse is to blame the patient and his or her personality. As a result, many surgeons avoid using presby-IOLs in patients with more discerning personalities and visual needs. This strategy is not ideal and reflects either a limitation in available technology or a limitation in the understanding of how to apply it.

The second impulse is to blame the IOL and its associated technology. Absent obvious pathology, such as corneal edema or scarring, surgeons rarely consider the cornea and anterior segment anatomy in the assessment process. However, as the optical precision of IOLs has become more refined (as in the case of presby-IOLs), the demand on the optical performance of the cornea has increased. Corneal abnormalities that traditionally would have been considered too subtle to be visually significant may, in fact, become major factors limiting the visual results of presby-IOL patients.

This phenomenon may be understood mathematically. For example, an IOL with a 6.0mm optical zone has uniform optics across the entire 6.0mm. In contrast, a ReStor IOL does not have uniform optics throughout, but rather has 5?m steps within its 3.6mm diffractive zone and, therefore, may be affected by optical aberrations as small as 5?m.

This difference in optical precision demonstrates the importance of a thorough evaluation pre-operatively, including detailed analysis of the corneal surface, tear film, stromal opacities and endothelial opacities or irregularities. Subtle findings on corneal topography that traditionally have been considered normal may, in fact, become visually significant in a presby-IOL patient. An understanding of this concept will enhance your ability to predict the likelihood of visual success with presby-IOLs, and allow you to recommend an appropriate IOL based on optical performance rather than relying on personality traits.

Next month: How to follow up on the groundwork you’ve laid with the right IOL recommendation.

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About the authors: Lance Kugler, MD, graduated from Case Western Reserve University School of Medicine and completed his residency in ophthalmology at the University of Nebraska. Dr. Kugler did his fellowship training in cornea and refractive surgery with Ming Wang, MD, PhD, at the Wang Vision Institute and the University of Tennessee in Nashville. He is also an adjunct clinical professor at the University of Nebraska Medical Center, serves on the YO Info subcommittee and is a graduate of the Academy’s Leadership Development Program (LDP).

Robert F. Melendez, MD, MBA, is a partner at Eye Associates of New Mexico, assistant clinical professor at the University of New Mexico in Albuquerque and section chief of ophthalmology for Lovelace Hospital in Albuquerque. Additionally, Dr. Melendez is author of Ophthalmology Buzzwords™, co-founder of the Juliette RP Vision Foundation, editor of YO Info and a graduate of the LDP. His contribution to the article is excerpted from a longer article that appeared Ophthalmology Business.

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