CEDARS/ASPENS Debates

Expect challenges, demands from former refractive surgery patients with cataracts

Patient education goes a long way in managing expectations for IOLs and increasing satisfaction, two surgeons say.

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

The use of presbyopic IOLs for patients who have previously undergone corneal refractive surgery is always a challenge. Not only does the surgeon have to deal with more complicated methods to determine appropriate IOL power and decreased precision of the calculations, but an even greater challenge is dealing with the potential of postoperative visual aberrations. IOL selection methods and patient education are critical to surgical success and patient satisfaction.

This month, Douglas A. Katsev, MD, and Lisa M. Nijm, MD, JD, discuss their methods for using presbyopic IOLs for postrefractive patients. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

Success with accommodative IOLs hinges on patient education

Douglas A. Katsev, MD
Douglas A. Katsev

It is not uncommon in my practice for a patient to come in for cataract surgery after they have already had refractive surgery. These patients are different from most cataract patients, and the numbers are increasing — they may make up 25% of an average cataract day for me. The interesting thing is that the conversion to premium IOLs is much higher in these patients, probably greater than 80% in my office. However, the previous refractive surgery creates a challenge with IOL calculation and lens choice.

On a standard cataract patient with a normal topography, I am all over multifocal IOLs (Tecnis multifocal and Tecnis Symfony by Johnson & Johnson Vision and now PanOptix by Alcon). The discussion of glare is important, but I find with good informed consent on the front end, these patients are extremely happy. Of course they are suitable for every occupation or personality, but it is uncommon these days to produce an unhappy patient with a virgin cornea.

I have to break postrefractive patients into different groups — RK, high myopic LASIK and hyperopic LASIK — and in the LASIK group there is further separation — standard vs. custom treated. I may present a different option based on the group. The most important thing is a happy patient in the end, and although we all want a high conversion rate, your future patients depend mostly on your past patients’ results.

Surgeons who use only a multifocal lens and avoid accommodative IOLs are hurting their conversion rate and satisfaction in these postrefractive patients.

I have been able to achieve my intended results in RK patients often with an infrequent need for a piggyback IOL. These patients are not easy, but when they understand the few potential issues, they can be extremely pleased and often able to see without glasses for everything. They already have a multifocal cornea, so I do not need to add extra issues. These patients need to know that, unlike the normal cataract patient, their initial result will usually not be stable, and they need to wait a few weeks for the cornea to stabilize. I often say if they are perfect the day after, that may not be a good sign, so this discussion can buy you a couple weeks before they get anxious.

For low-corrected myopes or some higher-corrected custom-treated post-LASIK patients, a multifocal lens can work with proper informed consent. For those non-custom and higher myopic-treated LASIK patients who want to pay more, an accommodative IOL with slight monovision can get you to the finish line with a happy patient. The multifocal corneas that many of them have can often produce great distance and near with a Trulign or Crystalens (Bausch + Lomb) without the issues that a multifocal will produce.

As far as hyperopic-treated LASIK, which is far less common, the accommodative lens can get you to an acceptable result with a good preop discussion. I have found out the hard way that it is not easy to achieve a good result with a multifocal IOL.

A touch-up will be necessary with all premium IOLs, but one of the best things about the accommodative IOL is when you place a piggyback lens for residual hyperopia there is a lot of space, and the lenses continue to perform well with a low add LI61AO (Bausch + Lomb) type lens in the sulcus

Getting these postrefractive patients happy will be a big boon to your practice. Making a bad choice can hurt your referral base as well as your happiness in the office.

Disclosure: Katsev reports he is a consultant to AMO, Bausch + Lomb and Novartis and a stockholder of TrueVision (part of Alcon).

Calculations, low myopia, expectations are crucial

Lisa M. Nijm, MD, JD
Lisa M. Nijm

Patients who have enjoyed sharp refractive surgery outcomes years ago may have higher expectations than the average cataract patient. Not surprisingly, they often present to the office with the notion that they will be able to see well without glasses, much like their experience after LASIK.

Because of this, it is important to pay close attention to preoperative planning in these patients, especially in areas such as education, setting appropriate expectations and lens implant choice.

One of the greatest advances in the last decade has been the wide array of presbyopia- and astigmatism-correcting options now available. Being a postrefractive patient is not an automatic cause for exclusion from one of these advanced technology lenses; however, several important factors need to be considered.

I will contemplate using a presbyopia-correcting lens in a postrefractive patient if three basic criteria are met: Having adequate tools available to estimate the power of the lens implant carefully; postmyopic LASIK with treatment under –4 D, well-centered ablation and minimal coma; and a patient who has appropriate expectations.

In regard to the first criterion, as we all know, refractive surgery changes the power of the cornea, and much of the literature has been devoted to calculations for these patients. We are learning more about the best methods for performing these calculations, but it is still not an exact science. I find IOLMaster 700 (Carl Zeiss Meditec), with modern formulas, to be most useful, and that has greatly improved my measurement of the postrefractive cornea.

In postrefractive cases, I also will confirm the readings at the time of surgery with intraoperative aberrometry (ORA, Alcon) — be sure to check the box on the ORA indicating that the eye is postmyopic LASIK. Each surgeon will have his or her own preferences on what works best in their hands, but if you are going to consider using a presbyopia-correcting lens in a post­refractive patient, you must have the tools available to appropriately calculate the power of the lens implant.

My second criterion is preferably a postmyopic correction of less than –4 D, with a well-centered ablation and minimal coma. One study showed intolerable dysphotopsia after implantation of diffractive multifocal IOLs in the presence of anterior corneal coma greater than 0.32 µm.

Optically, we know that postmyopic ablations result in increased positive spherical aberrations. Logically it would follow that lenses with negative spherical aberrations seem to work best to counterbalance that effect.

Given that understanding, my preference in these cases is generally an extended depth of focus lens (Tecnis Symfony, Johnson & Johnson Vision), which tends to be more forgiving and allows for tolerance of some residual refractive error. There may be some possibility for mixing and matching or using multifocal IOLs that can be determined on a case-by-case basis. If there are minimal higher-order aberrations, the patient will likely be a much better candidate to have a presbyopia-correcting lens.

It may still be possible to use an extended depth of focus IOL in posthyperopic and RK patients. However, these eyes generally have negative spherical aberrations, so we may see better results with accommodating IOLs or monofocal IOLs, such as the enVista or Crystalens from Bausch + Lomb.

My third criterion is a patient who has appropriate expectations. This remains the most crucial of the three criteria. Understanding the patient’s personal goals for surgery and having frank discussions about the technology available is one key to success in implanting these lenses. Patients should be made aware that these are IOL power estimations, not exact calculations, as well as understand the risks and benefits of each lens option. Patients should also be aware that there is a higher-than-average risk for residual refractive error and the options that are available for correcting that after the initial surgery.

Implanting an advanced technology lens in postrefractive patients requires careful planning, but with appropriate preparation, you can offer these patients a whole new world of vision with presbyopia-correcting IOLs.

Disclosure: Nijm reports she is a consultant to Akorn, Alcon, Allergan, EyePoint, LacriScience, Kala, Novartis, Ocular Therapeutix, Omeros, Johnson & Johnson and Zeiss.

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

The use of presbyopic IOLs for patients who have previously undergone corneal refractive surgery is always a challenge. Not only does the surgeon have to deal with more complicated methods to determine appropriate IOL power and decreased precision of the calculations, but an even greater challenge is dealing with the potential of postoperative visual aberrations. IOL selection methods and patient education are critical to surgical success and patient satisfaction.

This month, Douglas A. Katsev, MD, and Lisa M. Nijm, MD, JD, discuss their methods for using presbyopic IOLs for postrefractive patients. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

Success with accommodative IOLs hinges on patient education

Douglas A. Katsev, MD
Douglas A. Katsev

It is not uncommon in my practice for a patient to come in for cataract surgery after they have already had refractive surgery. These patients are different from most cataract patients, and the numbers are increasing — they may make up 25% of an average cataract day for me. The interesting thing is that the conversion to premium IOLs is much higher in these patients, probably greater than 80% in my office. However, the previous refractive surgery creates a challenge with IOL calculation and lens choice.

On a standard cataract patient with a normal topography, I am all over multifocal IOLs (Tecnis multifocal and Tecnis Symfony by Johnson & Johnson Vision and now PanOptix by Alcon). The discussion of glare is important, but I find with good informed consent on the front end, these patients are extremely happy. Of course they are suitable for every occupation or personality, but it is uncommon these days to produce an unhappy patient with a virgin cornea.

I have to break postrefractive patients into different groups — RK, high myopic LASIK and hyperopic LASIK — and in the LASIK group there is further separation — standard vs. custom treated. I may present a different option based on the group. The most important thing is a happy patient in the end, and although we all want a high conversion rate, your future patients depend mostly on your past patients’ results.

Surgeons who use only a multifocal lens and avoid accommodative IOLs are hurting their conversion rate and satisfaction in these postrefractive patients.

I have been able to achieve my intended results in RK patients often with an infrequent need for a piggyback IOL. These patients are not easy, but when they understand the few potential issues, they can be extremely pleased and often able to see without glasses for everything. They already have a multifocal cornea, so I do not need to add extra issues. These patients need to know that, unlike the normal cataract patient, their initial result will usually not be stable, and they need to wait a few weeks for the cornea to stabilize. I often say if they are perfect the day after, that may not be a good sign, so this discussion can buy you a couple weeks before they get anxious.

PAGE BREAK

For low-corrected myopes or some higher-corrected custom-treated post-LASIK patients, a multifocal lens can work with proper informed consent. For those non-custom and higher myopic-treated LASIK patients who want to pay more, an accommodative IOL with slight monovision can get you to the finish line with a happy patient. The multifocal corneas that many of them have can often produce great distance and near with a Trulign or Crystalens (Bausch + Lomb) without the issues that a multifocal will produce.

As far as hyperopic-treated LASIK, which is far less common, the accommodative lens can get you to an acceptable result with a good preop discussion. I have found out the hard way that it is not easy to achieve a good result with a multifocal IOL.

A touch-up will be necessary with all premium IOLs, but one of the best things about the accommodative IOL is when you place a piggyback lens for residual hyperopia there is a lot of space, and the lenses continue to perform well with a low add LI61AO (Bausch + Lomb) type lens in the sulcus

Getting these postrefractive patients happy will be a big boon to your practice. Making a bad choice can hurt your referral base as well as your happiness in the office.

Disclosure: Katsev reports he is a consultant to AMO, Bausch + Lomb and Novartis and a stockholder of TrueVision (part of Alcon).

Calculations, low myopia, expectations are crucial

Lisa M. Nijm, MD, JD
Lisa M. Nijm

Patients who have enjoyed sharp refractive surgery outcomes years ago may have higher expectations than the average cataract patient. Not surprisingly, they often present to the office with the notion that they will be able to see well without glasses, much like their experience after LASIK.

Because of this, it is important to pay close attention to preoperative planning in these patients, especially in areas such as education, setting appropriate expectations and lens implant choice.

One of the greatest advances in the last decade has been the wide array of presbyopia- and astigmatism-correcting options now available. Being a postrefractive patient is not an automatic cause for exclusion from one of these advanced technology lenses; however, several important factors need to be considered.

I will contemplate using a presbyopia-correcting lens in a postrefractive patient if three basic criteria are met: Having adequate tools available to estimate the power of the lens implant carefully; postmyopic LASIK with treatment under –4 D, well-centered ablation and minimal coma; and a patient who has appropriate expectations.

PAGE BREAK

In regard to the first criterion, as we all know, refractive surgery changes the power of the cornea, and much of the literature has been devoted to calculations for these patients. We are learning more about the best methods for performing these calculations, but it is still not an exact science. I find IOLMaster 700 (Carl Zeiss Meditec), with modern formulas, to be most useful, and that has greatly improved my measurement of the postrefractive cornea.

In postrefractive cases, I also will confirm the readings at the time of surgery with intraoperative aberrometry (ORA, Alcon) — be sure to check the box on the ORA indicating that the eye is postmyopic LASIK. Each surgeon will have his or her own preferences on what works best in their hands, but if you are going to consider using a presbyopia-correcting lens in a post­refractive patient, you must have the tools available to appropriately calculate the power of the lens implant.

My second criterion is preferably a postmyopic correction of less than –4 D, with a well-centered ablation and minimal coma. One study showed intolerable dysphotopsia after implantation of diffractive multifocal IOLs in the presence of anterior corneal coma greater than 0.32 µm.

Optically, we know that postmyopic ablations result in increased positive spherical aberrations. Logically it would follow that lenses with negative spherical aberrations seem to work best to counterbalance that effect.

Given that understanding, my preference in these cases is generally an extended depth of focus lens (Tecnis Symfony, Johnson & Johnson Vision), which tends to be more forgiving and allows for tolerance of some residual refractive error. There may be some possibility for mixing and matching or using multifocal IOLs that can be determined on a case-by-case basis. If there are minimal higher-order aberrations, the patient will likely be a much better candidate to have a presbyopia-correcting lens.

It may still be possible to use an extended depth of focus IOL in posthyperopic and RK patients. However, these eyes generally have negative spherical aberrations, so we may see better results with accommodating IOLs or monofocal IOLs, such as the enVista or Crystalens from Bausch + Lomb.

My third criterion is a patient who has appropriate expectations. This remains the most crucial of the three criteria. Understanding the patient’s personal goals for surgery and having frank discussions about the technology available is one key to success in implanting these lenses. Patients should be made aware that these are IOL power estimations, not exact calculations, as well as understand the risks and benefits of each lens option. Patients should also be aware that there is a higher-than-average risk for residual refractive error and the options that are available for correcting that after the initial surgery.

PAGE BREAK

Implanting an advanced technology lens in postrefractive patients requires careful planning, but with appropriate preparation, you can offer these patients a whole new world of vision with presbyopia-correcting IOLs.

Disclosure: Nijm reports she is a consultant to Akorn, Alcon, Allergan, EyePoint, LacriScience, Kala, Novartis, Ocular Therapeutix, Omeros, Johnson & Johnson and Zeiss.