In the cover story of this issue of Ocular Surgery News, we explore the value of OCT scanning in preoperative cataract surgery evaluation. Indeed a useful tool, OCT allows us to see subclinical epiretinal membranes and other disease that can foil our expected surgical outcomes.
But when we find imperfect eyes, are at least some of them candidates for presbyopia-correcting implants? Multifocal and extended depth of focus lenses in particular can degrade contrast and lead to unsatisfactory results in significantly impaired eyes, but if we restrict these lenses to only perfect patients, we are missing an opportunity to achieve spectacle independence in a large number of patients who desire it but have other problems.
Market research has shown that as many as 80% of patients are interested in refractive cataract surgery if they understand its value. Interestingly, about the same percentage of patients in the cataract age group also have significant dry eye, causing a disruption in the ocular surface. About 20% of the population have significant corneal irregularity for other reasons, 12% have maculopathy, and as many as 20% may have borderline glaucoma. If all of these are exclusions from presbyopia-correcting lenses, there are very few candidates left.
Experienced and successful refractive cataract surgeons know that getting it right in these patients depends on three important factors: choosing the right patient, using the right technology and always doing the right thing.
Choosing the right patient
Certainly, advanced forms of any of these comorbidities would rule out a presbyopia-correcting implant. Those with moderate disease deserve great caution, but those in the category of mild dry eye, corneal irregularity, macular disease or glaucoma may well be good candidates for premium cataract surgery. Naturally, patients need to fully understand their limitations, but assuming there is some benefit to the individual in a presbyopia-correcting lens, the decision may best be left to the patient.
One more worry about treating imperfect eyes with presbyopia-correcting lenses is that the disease may progress over time and make the multifocal implant a liability rather than an asset. Last year we published a study of patient satisfaction measured 5 years after refractive cataract surgery with both accommodating and multifocal lens implants. The groups studied included many imperfect eyes, and we found that 90% of patients were satisfied with their surgical outcome. Also, 90% of patients were likely to refer their friends or family for the same procedure.
In other words, we should certainly be cautious in our approach, but patients are very willing to accept and are very satisfied with these technologies when they are used.
Using the right technology
It makes sense in imperfect eyes to use implants that are least likely to degrade quality of vision. Certainly, the accommodating Crystalens (Bausch + Lomb) is in this category. Also, low-add lenses like the ReSTOR with ActiveFocus from Alcon and the EDOF Symfony lens from Johnson & Johnson Vision have performed well in less than perfect eyes. Our own studies have shown that these lenses lead to fewer glare and halo symptoms than their higher-add predecessors, making them an appropriate consideration with proper cautions.
Doing the right thing
This is the most important category that hopefully requires the least explanation but the most judgment. Would we offer the same technology to a family member or other loved one if they were similarly motivated and interested in paying for the technology? If the answer is no, our path is clear. If yes, we owe the patient a discussion.
One of my partners is fond of saying, “Nobody is perfect. Except of course me and you, and I’m not so sure about you.” Indeed, we all have limitations, just like our patients, but most of us enjoy the best things in life. Don’t many of our patients deserve the same?
Disclosure: Hovanesian reports he is a consultant to Alcon and Bausch + Lomb.