Recent developments within ophthalmology have led us to approach cataract and presbyopic patients differently than in the past. New lens technologies are available such as the Rezoom (Advanced Medical Optics, Inc., Santa Ana, CA), Acrysof Restor (Alcon Laboratories, Inc., Fort Worth, TX), and Crystalens (Eyeonics, Inc., Aliso Viejo, CA). In addition, the Centers for Medicare & Medicaid Services ruled last year that patients may pay a premium to receive presbyopia-correcting IOLs.
These changes combined with many middle-aged and older individuals' desire to enhance their quality of life as they age has prompted my colleagues and me to adjust how we present information to patients. This article offers tips on tailoring discussions to the patient's perspective and visual needs.
Keep conversations simple with cataract surgery patients. For example, I ask them if, after the surgery, they would like to see without glasses. If a patient demonstrates little enthusiasm, I drop the subject and schedule him for cataract surgery.
However, if a patient shows an interest in being free of glasses postoperatively, I discuss with him the availability of multifocal lenses and accommodating IOLs and how they can provide binocular vision. Additionally, I explain that the patient will see some halos, but not many patients are dissuaded by that fact.
It is important not to refer to a presbyopia-correcting IOL as a better lens. Patients who cannot afford a new-technology IOL or who choose a standard monofocal lens should not feel that their decision was wrong or that paying the premium would have gotten them better surgery. Instead, try to focus your conversation on lifestyle improvements. This idea also helps patients understand premium surgery. Medicare patients are not used to paying out of pocket for medical benefits, but they are increasingly familiar with spending money to better their lives.
Conversations with ametropic and presbyopic patients differ from those with cataract patients. First, you need to educate presbyopic patients about the loss of accommodation associated with age. Second, discuss cataracts with these patients, because they typically are already experiencing some early lenticular changes. In my practice, I use the analogy of a dirty windshield to explain how the crystalline lens becomes opaque with time.
Many patients are already familiar with the excimer laser treatment, but you still need to explain that excimer laser correction will not fix the source of their problem, which is the growing inflexibility of their crystalline lens. Discuss how their natural lens can be replaced with a new one that can provide binocular vision. Further explain that, if they have LASIK, they will quite possibly require cataract extraction in the future. A conversation about postoperative halos is always necessary before implanting multifocal IOLs. Although the halos often diminish with time, they may be noted for 1 year or longer. Once the second eye is treated, the halos may lessen more rapidly.
Last, although I am cautious in recommending refractive lens exchange to presbyopic myopes, I will consider the procedure for patients with early cataracts, provided a retinal specialist has conducted a meticulous examination of the peripheral retina and ruled out an unacceptably high risk of retinal detachment.
We need to reestablish our traditional roles when dealing with privately paid procedures. First of all, patients need to understand that any clinical recommendation is based on their eye health, visual needs, and lifestyle—not how much money they have. I recommend not discussing money with patients at all. Instead, make them aware of the in-practice counselors who are available to discuss financial matters.
Surgeons need to be closely involved in patient care pre- and postoperatively, because older patients are used to having a relationship with their physicians. These patients will not tolerate not meeting their surgeons, especially when they are paying a premium for the procedure.
Surgeons implanting presbyopia-correcting IOLs must strive for excellent outcomes. Careful preoperative screenings are a must, meaning that no patient should have macular disease or other ocular pathology, and lens subtypes (Rezoom, Acrysof Restor, or Crystalens) should be selected to match the patient's physiology and lifestyle. Moreover, the surgeon should disqualify candidates who seem prone to unrealistic expectations or who have an underachieving personality. Tight surgical protocols should ensure the implantation of the correct lens for a specific patient's dioptric range. In addition, the ophthalmologist should have access to an excimer laser and be prepared to perform a refractive enhancement via LASIK or Epi-LASIK, a lens exchange, a piggyback IOL, an Nd:YAG capsulotomy, etc.
Prudent patient selection, coupled with proper care and communication, will help ensure that patients receiving presbyopia-correcting IOLs are happy with their visual results postoperatively. Good news spreads quickly from the mouths of satisfied patients. Although we have not been implanting this types of lens for very long, my colleagues and I have already had patients refer their friends to us.
Kerry K. Assil, MD, is Medical Director of the Assil Eye Institute in Santa Monica and in Beverly Hills, California. He is a paid consultant for Advanced Medical Optics, Inc. Dr. Assil may be reached at (310) 828-2082; firstname.lastname@example.org.