Cataracts – Part 2: Why Choosing The Right Lens Is So Important!
In our last newsletter, we discussed how to determine the right time to proceed with cataract surgery, because a reduced acuity threshold as the barometer is just too simplistic. We need a better yardstick to measure with. We need to look at the patient more holistically. What are their needs, wants, desires, etc., and is the cataract interfering with their ability to function or enjoy the things that they love to do?
In this newsletter, I want you to think beyond the referral itself and think about what IOLs would be the best fit for your patient. While cost is a definite consideration (and we will get to that), stop for a moment and ask yourself this most basic question… “If cost were irrelevant, what would be ideal for this patient?” I think this is a foundational approach to beginning the process of IOL selection.
Monofocal IOLs (Base IOLs) are good lenses with a long track record, but they have their limitations. The foremost limitation is the inability to target the variety of visual needs that we all have of seeing at multiple distances (far, intermediate, near). For some, having surgery and still being dependent, full-time or part-time, on some form of glasses is perfectly acceptable. For others, it is completely unacceptable. This is why establishing the patient’s needs and wants is so incredibly important. Once that is done, setting proper expectations and then delivering on that promise can be the difference between a happy patient and an unhappy patient. There is nothing wrong with looking at cataract surgery as a form of refractive surgery and establishing expectations for the outcome and then tailoring a solution to address that patient’s goals. We do this every day.
Aspheric and Toric IOLs (Intermediate IOLs) are more advanced than standard Monofocal IOLs and can deliver better outcomes and better targeting of overall refractive error, especially when trying to correct astigmatism. There are some great IOL choices in this category, but we still find ourselves limited in addressing a patients visual needs across the entire spectrum of distance, intermediate and near, without targeting some form of monovision. I always explain to patients that monovison is a compromise and not everyone can visually or mentally adapt to having a refractive imbalance. I think it is reasonable to say that 50% of patients like monovision, 20% tolerate monovision, and 30% can’t, or won’t, tolerate it. Thinking about it this way translates to monovision being about 70% successful. Decent… but not great odds. If possible, trialing monovision helps to determine if your patient is in the 70% camp who likes it, or the 30% camp who doesn’t. Either way, it is a compromise and patients need to understand its limitations.
Multifocal and Extended Depth of Focus IOLs (Premium IOLs) have improved dramatically over the years, but they are not for everybody. Older multifocal designs had their fair share of limitations. Many patients complained of induced glare and halos, especially at night and near vision that didn’t live up to their expectations. Thankfully, this category of lenses continues to improve, and currently, our favorite multifocal IOL is the PanOptix by Alcon. It has been stellar for us. In a study done by Alcon, 99% of people with the PanOptix lens would choose the same lens again, and 98% would recommend it to family and friends. That is impressive data which lines up well with our experience. Lately, while doing cataract post-op exams, I have found myself being envious of the results that these patients are achieving. This is weighing heavily in my desire to have these lenses implanted myself. (That could be a newsletter topic all its own!)
If you’re a student of the methods for determining what IOL is appropriate for any given patient, then you’ve seen multiple methodologies applied (personality typing, surveys, questionnaires, etc.) that attempt to dumb this down and make it seem cookie cutter. There is not a one-size fits-all approach, so talking openly and honestly about the Pros and Cons of each IOL choice with every patient is the best way to navigate these waters and land at a favorable destination. Every IOL has its Pros and Cons and each patient is unique, and by unique, I mean that we need to think about their physical (health, optical system, biometry, capabilities, etc.) and emotional (wants, needs, expectations, etc.) states, as well as their financial situation. Unless forced to do so, choosing an IOL based solely on what insurance covers is a very ‘nearsighted’ approach. A better approach is to present the facts, explain the differences and help the patient make a decision that they can feel good about. Please keep in mind that the IOL chosen will be the lens that carries them through the rest of their life! This decision should not be taken lightly. My goal is to match up each patient with the best IOL and then meet their expectations, give them a great experience and send them out the door at the end of the healing process loving us and bragging about us to their friends and family. Below is the latest graphic that we use to explain what is included with each IOL category. It is important to note that older patients do very well with PRK enhancement. PRK is an excellent way of fine tuning a result to help our patients achieve their best outcome. We hope that you are clearly seeing why you can refer to us with confidence!
Until next time!
George Goodman, OD, FAAO
Director of Cataract and Refractive Services
EyeCare Associates of South Tulsa
10010 E 81st St #100, Tulsa, OK 74133
O: 918.250.2020 | C: 405-245-9333 | F: 918.250.8910
Service-oriented, comprehensive eye care in a timely fashion.
Please send your comments and suggestions to DrGoodman@southtulsaeye.com
or call Dr. Goodman at (405) 245-9333 (cell).
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