EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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98 EW FEATURE February 2011 Cataract/IOLs, femtosecond cataract March 2013 A decade later, premium IOLs still viable option by Erin L. Boyle EyeWorld Senior Staff Writer AT A GLANCE • Since the first premium IOLs were approved a decade ago, physicians have learned how to best select lenses. • Implanting a premium lens is a "process" that is more than simply implanting the lens. • Educating patients is crucial to success. • Patients are knowledgeable, so they should be presented with all options available. Choosing the appropriate candidates for premium IOLs can improve patient satisfaction T he first premium IOLs on the market were approved some 10 years ago, and since then, a great deal has been learned about not only the lenses, but also the psychology behind implanting them, including the best patient selection and education. "The lenses now are basically modifications of what was first introduced," said Stephen S. Lane, M.D., clinical professor of ophthalmology, University of Minnesota, Minneapolis. "The majority of the original advanced technology (AT) lenses, first introduced 10 years ago, are no longer available in the form that they were. There's been this evolutionary change that has occurred with incremental improvements over the years." Lenses The range of IOLs for the treatment of presbyopia includes multifocal, and accommodating lenses, and toric IOLs to correct astigmatism, each addressing specific visual needs. The accommodating lens Crystalens (Bausch + Lomb, Rochester, N.Y.) received market approval in 2003, the multifocal AcrySof ReSTOR IOL (Alcon, Fort Worth, Texas) received approval in 2005, and the AcrySof Toric (Alcon) was approved in 2005. Other lenses that have gone through iterations include the Tecnis multifocal (Abbott Medical Optics, AMO, Santa Ana, Calif.) and the STAAR toric IOL (STAAR Surgical, Monrovia, Calif.). Though the years, physicians have learned, by trial and error and good clinical studies, how best to implant these lenses. Dr. Lane said a symbiotic working relationship between the medical community and industry has developed AT lenses into the options now available. "I think that we have a better perspective of the problems that can arise, as we have identified over time the areas where patient satisfaction was not achieved. As patient issues have come to light, companies have tried to address these issues with modifications in the lenses. Incrementally, we now have better lenses that are giving patients better results. They're not totally solved, but we clearly have a better product than 10 years ago," he said. Jay Pepose, M.D., founder and medical director, Pepose Vision Institute, Chesterfield, Mo., and professor of clinical ophthalmology, Washington University School of Medicine, St. Louis, said that despite advances in the field and the many improvements in existing lenses, there remains no perfect lens for all patients. Managing patients' expectations, then, is vital to the best outcomes, he said. Also, informing patients about the "process" of gaining desired vision is necessary. "It's important to tell patients on the front end that we may not hit the target. Even in our best efforts, we may not 100% hit the target. It would be like a baseball player getting up to bat expecting to hit a home run every time. It's just not going to happen, no matter how skilled we are," Dr. Pepose said. "Patients need to be aware that there could be additional steps required. They could need a YAG capsulotomy, they could need LASIK or a laser vision enhancement to get to where they want to be. It's important for people to know that on the front end because otherwise they're disappointed, they lose confidence in the surgeon, they say, 'Why didn't they tell me this before?" It's important to set the stage and explain to patients, 'We're going to get you where you need to be, but it could take more than one step to get there,'" he said. Patients do not do well with multifocal IOLs if they have with highly aberrated corneas, as shown here by the large amount of vertical and horizontal coma at a 6 mm zone using Atlas topography. Source: Jay Pepose, M.D. Now, then When asked how, if at all, their use of premium IOLs has changed since they began using them in the early 2000s, a group of physicians had varied responses. Dr. Lane said his use of presbyopia-correcting lenses has changed—he is more confident now. "You have to gain a certain amount of experience using them and [knowing] how to deal with patients expectations and how to choose patients," he said. "I think that I'm better at selecting patients that will do better with presbyopiacorrecting lenses than I was when I first started using them 10 years ago or so. I have better discussions with patients as to the pros and cons in terms of their particular needs and a better handle on the types of issues they may encounter after implantation. Finally, I think that the presbyopia-correcting lenses, particularly the multifocal lenses that are available now, are better than the original multifocal refractive and diffractive lens that were available when we first started using them." Douglas D. Koch, M.D., professor and the Allen, Mosbacher, and Law Chair in ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, said he has been cautious with presbyopia-correcting premium IOLs and has only modestly increased his use of them through the years. "My level of use is relatively low and has grown only minimally," he said. "I have a greater level of confidence now with patients not being terribly bothered by glare and halos with either of the two lenses, the ReSTOR or the Tecnis, but I have a great appreciation for how finicky the issues are, with regard primarily to astigmatism, but also the accuracy of the spherical correction." If the refractive outcome is correct, patients are "extremely happy," he said, but that can be difficult to obtain. "I warn patients of that in advance and if they seem like they are not going to be tolerant of a 'process' in treating their presbyopia, rather than an immediate result, I tend to back away," Dr. Koch said. "Conversely, I am doing much more monovision than before, aided by the outstanding results we see with toric IOLs." According to Dr. Pepose, he uses the lenses with the same approach as when he began using them in approximately 2004. He now uses multifocal, accommodating, and toric lenses in "varying degrees." "There's no one size fits all," he said. "I try to find out from patients what's the most important thing for them—in other words, are they going to be disappointed if they need reading glasses, are they going to be disappointed if the computer distance isn't good? What is it that they want to maximize?" After Dr. Pepose determines what patients are seeking in a premium IOL, he obtains clinical infor-