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Cover Stories | Mar 2006

An Algorithm for Presbyopic IOL Patients

Tuning in to patients' needs.

Things used to be so much simpler. Ten years ago, a patient would present with a cataract. After a discussion of the risks, benefits, and alternatives, the ophthalmologist would remove the cataract with generally excellent results. If the patient required spectacles for distance vision postoperatively, the prescription usually was small, and the absolute presbyopia of pseudophakia was accepted as a necessary drawback of the surgery.

Then came presbyopia-correcting IOLs. With the variety available, I found myself yearning for a wavefront LASIK consultation with a litigious optical engineer suffering a panic disorder rather than another cataract and refractive lens exchange consultation. Any discussion of these IOL technologies could devolve into a circular conversation of every possible lens and combination thereof. Because I have achieved successful outcomes with the Crystalens (Eyeonics, Inc., Aliso Viejo, CA), Rezoom (Advanced Medical Optics, Inc., Santa Ana, CA), and Acrysof Restor (Alcon Laboratories, Inc., Fort Worth, TX) IOLs, the discussions were becoming highly convoluted. For patients contemplating off-label refractive lens exchange, conversations also covered LASIK, PRK, customized versus standard procedures, monovision, and everything else imaginable.

In many cases, patients arrived with completely unreasonable expectations, possibly based on the usual ability of refractive surgery to produce spectacle independence. Some patients had heard daily marketing messages guaranteeing 20/20 visual acuity and assumed that anything less is a failure. Many did not grasp the concept of presbyopia, despite detailed explanations.
In a nutshell, when I began offering new lens technologies, I found myself spending a lot of time in the clinic explaining presbyopia and the options for its correction and working to downgrade patients' unrealistic expectations. I determined that I needed a short questionnaire that would quickly steer me toward the best technology for any given patient.


I wanted to base my questionnaire upon the excellent preoperative evaluation forms designed by William Maloney, MD.1 I wanted the form to be concise (one page long) and its results to be easy for me to decipher.

My first goal was to determine the postoperative result desired by each patient. I therefore designed this questionnaire to force patients to delineate clearly the types of visual tasks they hope to perform without spectacles. Patients may desire a refractive outcome that is completely contrary to their surgeon's assumptions. For example, I have had presbyopic emmetropes who have simply wanted to be moderately myopic in both eyes.

Questions 1 and 2 (Figure 1) simply ask patients to indicate whether it is important to them to see well at distance and near, respectively, without spectacles. A negative response to both questions ends the discussion of presbyopia-correcting IOL technology. Adapted from Dr. Maloney's work, questions 3 and 4 ask the patient to pick the three contiguous zones of vision they value the most. Although premium IOLs may be able to deliver much more, I need a sense of patients' priorities. Question 4 in particular forces respondents to identify the activity (reading, using a computer, or driving) for which they would be most willing to use spectacles postoperatively.

Next, I sought to determine what types of unwanted visual phenomena the patient might be willing to tolerate after surgery. Question 5 is designed to screen out poor candidates for multifocal IOLs. These lenses are probably ill suited to patients who indicate an unwillingness to risk the possibility of halos at night. Similarly, question 6 is designed to help determine patients' candidacy for the Crystalens. Although the IOL provides strong distance and intermediate vision, approximately -0.50 to -0.75D of monovision is required to achieve high-grade near acuity. Otherwise, the patient may require glasses to read the finest print.

Finally, question 7 asks patients to assess their own personality by rating themselves on a spectrum from easygoing to perfectionist. In my experience, people are generally frank in their self-assessments. Perfectionists certainly may be candidates for any of these lenses, but they must realize that their expectations are higher than those of the typical patient.


The questionnaire itself alters patients' expectations. The queries subtly convey that I cannot magically perfect their vision for all distances under every lighting condition. Patients begin to understand that all surgical options involve a compromise, and they have much more appropriate expectations by the time we meet for a consultation.

Perhaps the biggest surprise has been what I learn about patients' personalities from the style in which they fill out the form. For questions that require only one answer, some patients will still demand all options, and others will mark up the form in a fit of indecision. Some patients demonstrate their inability to understand the questions. A few point out tiny imperfections (eg, an X that should mark the center of a rating scale but is off center). It is valuable to identify detail-oriented patients prior to selecting an IOL.

The questionnaire allows me to discuss presbyopia-correcting IOLs in the context of the patient's desired outcome. In my experience, patients want their surgeon to identify the right IOL for them, even if this choice is not as clear-cut as they imagine. No single IOL will be right for all patients, and the surgeon should be able to choose the best of multiple available options for each individual. This form helps make that process manageable. With appropriate expectations and adequate preoperative counseling, these patients can be some of the happiest in the ophthalmologist's practice.

Steven J. Dell, MD, is Director of Refractive and Corneal Surgery at Texan Eye Care in Austin, Texas. He is a consultant to Eyeonics, Inc., and Advanced Medical Optics, Inc. Dr. Dell may be reached at (512) 327-7000; sdell@austin.rr.com.

1. Maloney WF. Presbyopia success depends on comprehensive preop evaluation. Ocular Surgery News. Available at: http://www.osnsupersite.com. Accessed: January 25, 2005.
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