comanagement

Effectively Comanage IOL Patients

Constant patient education and practitioner involvement ensures successful outcomes.

MARC BLOOMENSTEIN, O.D., F.A.A.O., SCOTTSDALE, ARIZ.

Whereas the success of intraocular lens (IOL) implantation, and other refractive surgeries, is contingent on the patient's perceived outcome, it's essential we manage these patients' expectations by providing constant education and remaining active in their care. (See "Currently Avaliable IOLs" below.)

Patient education begins with enlightening the patient on his unique visual requirements, so the both of you are on the same page in terms of IOL category selection and then, postoperative outcomes. To provide the patient with adequate education, you must perform a thorough pre-implantation evaluation. This is comprised of an examination of his visual acuity (VA), refractive error and corneal health — should the patient benefit from any refractive surgical options, such as LASIK or a limbal relaxation incision (LRI), to improve his post-surgery vision. Then, you must discuss the advantages and disadvantages of each individual lens option within the IOL category that best suits him. Remember: Surprised patients are dissatisfied patients.

From there, perform a thorough post-implantation evaluation, and discuss your findings with the patient. The evaluation is comprised of an examination of the patient's VA, anterior inflammation, corneal health, IOL position, posterior capsule for opacification, intraocular pressure (IOP), the presence of any white blood cells in the anterior chamber and iris-released flare.

Remaining active in the IOL patient's care starts with addressing ocular inflammation both pre- and postoperatively, as inflammation can negatively affect the patient's visual outcome. Two concerns that I feel need to be addressed: dry eye, or ocular surface disease, and retinal swelling.

I've discovered that cyclosporine pre- and postoperatively combined with the hourly use of artificial tears for the first few days and postoperatively tapered to q.i.d. for the first four to six weeks has provided many of my ocular surface disease patients with a few added lines of vision on the Snellen acuity chart. The reason for this: I've found that when you treat the refracting surface and cornea of these patients the same way (i.e. concomitant use of cyclosporine and artificial tears) as you treat the refracting surface and cornea of refractive surgery patients, the IOL patient quickly achieves a more stable VA.

I aggressively treat lid disease (i.e. blepharitis or meibomianitis) by prescribing lid scrubs b.i.d., a low dose of tetracycline (20mg) b.i.d. (for heavily inflamed meibomian glands or the presence of seborrheic blepharitis-induced frothy tears) and the addition of topical macrolide antibiotic suspended in an thick mucoadhesive to help kill the bacteria and provide anti-inflammation. In addition, I prescribe warm compresses b.i.d. with massage to express the thick secretions blocking the glands. And I continue the cyclosporine, as it works synergistically with tetracycline and the macrolide to further quell the inflammation in these patients.

Continue the dry-eye patient on the aforementioned appropriate therapies until his VA is stable. This may take weeks to months depending on the severity of the pre- and postoperative condition. The goal: To provide the patient with a stable refractive endpoint.

To prevent post-IOL implantation retinal swelling, or cystoid macular edema (CME), and to decrease the potential for pain, I prescribe the prophylactic use of a non-steroidal anti-inflammatory drug (NSAID) in combination with a fourth-generation antibiotic and steroid. I have the patient use the NSAID and antibiotic 48 hours prior to surgery and the antibiotic for one week following surgery. Slowly tapering the steroid and NSAID through the next four to six weeks alleviates any potential for rebound inflammation.^1,2 Preventing and/or controlling CME becomes particularly important for any patient who has had CME in the past (Irving Gass syndrome) or is diabetic. The presence of diabetes increases the likelihood of leaking capillaries and, thus, can lead to CME.

Now that I've discussed the all-inclusive care of IOL patients necessary to meet their expectations, let's discuss the needed patient education and practitioner involvement related to each IOL category.

Spherical IOLs

Educate these patients (i.e. those with cataracts who either choose this option, or have no other option as the result of corneal and/or medical insurance limitations) that these standard monofocal IOLs only treat one focal point. And, that as a result, you'll have to provide the patient with spectacles or contact lenses postoperatively in order for them to achieve optimum vision.

Toric IOLs

Educate the candidate (i.e. patients with corneal astigmatism greater than 1.50D, post-refractive surgery-induced astigmatism, keratoconus and pellucid marginal degeneration) that this lens doesn't correct presbyopia. It provides general correction, implying that some patients may experience residual refractive error post-implantation. Then, explain to the patient that you're going to use a lens power that is "closest" to correcting his astigmatism to give him an excellent chance at optimum vision.

Further, discuss with the patient that should he experience any residual refractive error postimplantation, you're going to use the results of his pre-operative corneal exam to select the best form of further refractive correction (i.e. refractive surgery, LASIK, spectacles or contact lenses). Recommending spectacles and contact lenses is the best course of action for patients who have thin corneas or topographic anomalies, such as inferior steepening. This is because refractive surgery on these patients has the potential to create an unstable and uncorrectable VA.

Leave no stone unturned in the pre-operative discussion, especially when it pertains to postoperative outcomes. Patients are paying a premium for these lenses, and they want a return on their investment.

Finally, educate the patient that there's a chance the lens may rotate in the capsular bag, but that, as in the case with the lens power, you have a plan to correct it. Namely, you're going to follow-up with him once a week for the first few weeks post-implantation, so you can immediately identify this outcome and refer the patient back to the surgeon for lens repositioning in a timely manner. Toric IOLs have etchings at the three o'clock and nine o'clock positions. If the lens rotates greater than 20°, immediately refer the patient back to the surgeon within the first month to preclude any further capsular fibrosis or contraction prior to the repositioning of the lens.

Aspheric IOLs

Wavefront technology has demonstrated that the treatment of aberrations can significantly enhance a patient's quality of vision. In fact, studies have revealed that the reduction in positive spherical aberration (SA) helps to improve the visual quality of IOL implant patients.³ Currently, these lenses have either aspheric or modified prolate surfaces to better imitate the curvature of the cornea and, thus, reduce aberrations.

Educate the candidate for this lens (i.e. patients who want to enhance their quality of vision, especially those who have spherical aberration) that these lenses, as in the case of spherical IOLs, correct one focal point, meaning the patient will still require reading and/or distance spectacles post-implantation.

Further, explain to the patient in layman's terms that a post-implantation complication of the negative SA aspheric IOL is significant reduction of contrast sensitivity that is equal to decentered spherical IOL implantations, particularly at higher spatial frequencies, due to the negative SA aspheric IOL's decentration or tilt. And, that this reduction may occur, in part, because of induced second- and third-order aberrations, such as astigmatism and coma. Then, assure the patient that should you identify this rare outcome via your several postoperative follow-up visits, you will immediately refer him back to his surgeon for lens rotation in the capsular bag, which will help alleviate the distortion.

Presbyopic IOLs

Educate the candidate for this lens (i.e. patients age 40 and older who have difficulty focusing on close objects, due to a loss of flexibility in their crystalline lens) that compromise is the key to success in any one of the three currently available lenses. This, of course, is easier said than done, as these patients "want it all," — something that's simply not possible in this category of IOL.

To effectively manage this population's expectations, first determine where, specifically, the patient is willing to compromise. Do this by asking him about the visual requirements of his profession and his hobbies. Once you've determined his visual needs, educate him on the IOL you feel will best meet those needs and the specific compromise(s) needed to achieve a successful outcome in that IOL. Presbyopic-correcting IOL compromises include neural adaptation, subjective glares and haloes at night and the possible need for spectacles to strengthen near and intermediate vision.

A clinical pearl: Because these patients are hard to please, follow their "mental acuity" (i.e. psychological response to surgery) as closely as their VA via several postoperative follow-up visits (i.e. typically one-week, one-month and six months) to ensure they become satisfied with the ultimate outcome.

Phakic IOLs

Educate the candidate for this lens (i.e. non-cataract myopic patients who desire a refractive change that LASIK may not be able to provide) that sometimes the sutures the surgeon places at the large incision for the "one-size-fits–all" PMMA design (an anteriorly placed IOL not flexible through a small incision) may break and cause discomfort.

Assure the patient, however, that you're going to carefully monitor the incisional sutures through several follow-up visits (typically one week, four weeks, three months and one year), and that if the sutures break or the patient experiences discomfort, you're going to remove the sutures. Also, inform the patient that this large incision may cause corneal steepening that may induce astigmatism. Educate the patient that should his postoperative refraction reveal this outcome, you're going to treat the astigmatism with other surgical modalities, such as a LRI.

Further, educate the phakic IOL candidate that the posterior chamber IOL design rests very close to the crystalline lens, slightly increasing his likelihood of cataract formation. (The reported incidence is 0.6%.⁴) Inform him that should you note any cataract formation through follow-up visits, that you'll immediately refer the patient back to his surgeon for removal of the current IOL and replacement with another lens option.

The IOL landscape is sprouting new designs regularly. (In fact, as this article goes to press, a new aspheric IOL has entered the market.) Finding the best lens to meet our patient's expectations, however, is only a small portion of our job. We must also continue to educate ourselves as to strategies that will help our patients achieve satisfaction with their vision. Don't give up on your frustrated patients. Continue to work with them to achieve the best results. OM

1. Roberts CW, Brennan KM. A comparison of topical diclofenac with prednisolone for post cataract inflammation. Arch Ophthal. 1995 Jun;113(6):725-7.

2. Roberts CW. Pretreatment with topical diclofenac sodium to decrease postoperative inflammation. Ophthalmology. 1996 Apr;103(4):636-9.

3. Mester U., Dillinger P, Anterist N. Impact of a modified optic design on visual function: clinical comparative study. J Cataract Refract Surg. 2003 Apr;29(4):652-60.

4. Sanders DR, Vukich JA. Incidence of lens opacities and clinically significant cataracts with the Implantable Contact Lens: comparison of two lens designs. J Cataract RefractSurg. 2002 Nov-Dec;18(6):673-82.

Dr. Bloomenstein is director of optometric services at the Schwartz Laser Eye Center in Scottsdale, Ariz. He' a founding member of the Optometric Council on Refractive Technology and president of the American Optometric Charitable Foundation. E-mail him at drbloomenstein@schwartzlaser.com.