Eyeworld

EW REFRACTIVE 30 February 2019 YES connect by Liz Hillman EyeWorld Senior Staff Writer Patient considerations for advanced technology IOLs I n 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 " 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 There are several factors to think about when selecting candidates for presbyopia- correcting IOLs I s there a way to predict who is going to be happy with ad- vanced 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 Ad- vanced 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 presur- gical refraction, the health of the ocular surface, preexisting astigma- tism, 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 mul- tifocal 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 dyspho- topsia. "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 astig- matism, 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 expec- tations. 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 correct- able 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 experi- ence 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 chanc- es 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 motiva- tion," Dr. Holz said. Dr. Holz finds that his patients often come in knowing about multi- focal and EDOF IOLs, but he thinks it's his duty to bring up these lenses upon consultation, even if the pa- tient 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

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