Eyeworld

mium IOLs become a bigger part of the practice, many find that patients ap- preciate receiving educational materials before their visit so that they are pre- pared for their IOL decision. If recommending a premium lens, the ophthalmologist should explain why the recommendation is being made. If it is in the patient's best interest not to pursue surgery with a premium IOL, the discussion should include the reasons why this is not recommended. The patient's evaluation may start with a questionnaire to evaluate the desire for spectacle independence. Some surgeons also use a self-evaluation questionnaire to assess personality type and expectations following cataract surgery. As the patient continues with the appointment, and after the pre- liminary history and physical examination by the technician, the existence of different choices for IOLs may be introduced. A surgeon may choose to have this discussion. If it is a possibility that the patient may require cataract surgery, the pre-operative evaluation might include corneal measurements performed prior to intraocular pressure measurements and pupillary dilation. The additional benefit of having the pre-operative measurements before the physician's evaluation is that the surgeon can then assess the level of corneal astigmatism and any potential irregularity before counseling the patient about the IOL choices. After a thorough ocular examination, the ophthalmologist should be prepared to make a recommendation to the patient regarding selection of an intraocular lens. It is important to consider the patient's age, lifestyle, med- ical condition, and ocular health. It is always important to select the appropriate procedure for the appro- priate patient. Premium IOLs may not be recommended in patients with: • Corneal disease, particularly Fuchs' dystrophy and anterior basement membrane dystrophy • Macular disease • Diabetic retinopathy • Patients who do not desire spectacle independence • Patients with unrealistic expectations • Some patients with previous refractive surgery When selecting the first premium IOL cases for presbyopia correction, choose a patient with less than 0.5 D of corneal astigmatism and moderately dense cataracts. Patients with myopia who are accustomed to taking off their glasses to read may be more critical of presbyopia-correcting lenses. Toric lenses are well tolerated by most patients. Consider occupational needs, as well as hobbies, when deciding the type of IOL. The ideal initial presbyopia patient is: • A hyperope who requires spectacles for vision at all distances • A patient with minimal amounts of corneal astigmatism • A patient with visually significant cataracts • A patient who does not have critical visual requirements (such as a pilot) Surgical counselor Some surgeons conduct the entire lens discussion and decision process with the patient, while others make a lens recommendation and then have the patient visit with a surgical counselor or well-versed technician who can an- swer both technical and financial questions. The individual who does this should have a good understanding of the benefits of the premium intraocu- lar lens along with financing options. Surgical counselors should be able to provide information and answer questions. They should be cautioned not to encourage unrealistic expecta- tions. It is important to fully educate patients on the anticipated and poten- tial side effects of the recommended IOL so that they can make an informed decision. Patients are generally more accepting of imperfections explained to them before surgery than those discovered after surgery. The type of IOL should be determined by the surgeon, and a specific rec- ommendation should be made for each individual patient. Giving the pa- tient a list of options and asking him or her to choose one often leaves the patient in a quandary. How to start All cataract surgeons have the ability to implant premium IOLs. Pre-opera- tive planning does not require any additional equipment other than the standard, but accurate, measurements of axial length, corneal curvature, and topography. The surgeon must of course be able to provide the best possible vision after cataract surgery. This may include relaxing incisions and the use of an excimer laser. However, implementation of these IOLs is best accom- plished with a "team" approach to the patient. It is very desirable, therefore, to encourage the entire office staff, from the personnel who check-in and check-out the patient to all staff in between, to become acquainted with these lenses. Many patients will ask questions not only of the surgeon, but also of the technicians and surgical scheduling coordinator, so all involved should be able to field and triage their questions appropriately. A commitment to continual improvement in surgical technique and at- tention to detail will lead to quality surgery and satisfying outcomes in both standard and premium cataract IOL surgery. It is recommended that sur- geons become educated about all types of "premium" IOLs available and start by using one until they become comfortable with the process. Information about the various premium IOLs, including implantation techniques, is available from texts on the subject, through various courses at ASCRS and AAO meetings, as well as from the various manufacturers. Most sales representatives are well educated on the techniques and can serve as valuable resources, but will have a focused point of view. Deciding which lens to implant is probably the hardest question to answer for the beginning surgeon. There is no simple answer to this question. The best way to select a lens is to study the various lenses and seek the advice of trusted colleagues and mentors. Stick with one lens until you are comfortable with it. How to introduce premium lenses to patients For most ophthalmologists, the subject of premium lenses can best be intro- duced to patients after the diagnosis of a cataract has been made. As pre- Education As mentioned previously, the entire office staff should have some basic knowledge of premium lenses. Patients will have questions, and the staff should be sufficiently educated to answer the questions properly or triage the questions to the appropriate personnel. This can be achieved with an educational program in the office. Industry represen- tatives are often willing to provide this education onsite to your staff. Everyone in the office should understand the following: • Presbyopia • Cataracts • Astigmatism • Intraocular lenses (IOLs) • Presbyopia-correcting IOLs The technicians who interact with patients should also be familiar with IOL options for cataract patients: • No surgery • Surgery with a monofocal lens • Monovision • Astigmatism reduction with limbal relaxing incisions with toric IOLs • Surgery with a presbyopia-correcting lens • Bioptics with laser vision correction Teaching material, brochures, and DVDs are available from indus- try sources as well as from AAO. In addition, ASCRS has recently developed a patient education website geared toward patients who are interested in learning more about the variety of premium IOLs available, www.eyesurgeryeducation.com. May 2011 • 35

• Cover