Patient Selection, Co-management With Premium IOLs

Kerry K. Assil, MD, Assil Eye Institute, Santa Monica and Beverly Hills, CA.

Kerry K. Assil, MD, is medical director and CEO of the Assil Eye Institute in Santa Monica and Beverly Hills, CA. One of the world's foremost experts in cataract and refractive surgery, Dr. Assil was honored with the prestigious Jules Stein Living Tribute Award in 2005. He has written more than 100 books, textbooks and articles on refractive surgery and is an editor or reviewer for numerous scientific journals. His educational forums include featured lectures at Harvard University, Johns Hopkins University and Tokyo University. Dr. Assil received his undergraduate degree from the University of California, Los Angeles, and his medical degree from the University of California in San Diego.

Our practice is a multispecialty group of two MDs and three ODs in southern California. We provide consulting and co-management services for a wide range of MDs and ODs. Our mission is to offer the best refractive solution for the lifestyle of the patient.

When I'm considering the candidacy of a patient for a premium IOL rather than a monofocal lens, I look for an otherwise healthy eye. Upon determining this, I think through which premium IOL would best suit that patient, taking into account the referring optometrist's recommendation based on the lifestyle, work habits and visual needs of the patient.

Unless the patient has had previous corneal refractive surgery for hyperopia and has a steep central cornea (similar in topographic shape to early keratoconus) — or an extremely small pupil (a photopic pupil smaller than 2.3 mm or 2.4 mm), most likely I'll select a Tecnis^® multifocal lens (Abbott Medical Optics, Inc., Santa Ana, CA.).

Conversely, if the patient is post-hyperopic LASIK and/or has an exceptionally small pupil, or has any mild macular pathology, such as mild epiretinal membrane or macular drusen or mild diabetic retinopathy, then I may select the Crystalens^® accommodating IOL (Bausch & Lomb, Rochester, NY).

In patients of all pupil sizes (except those that are very small) and in those who have flat or average corneal curvatures and a healthy macula, I prefer the Tecnis^® multifocal lens, which isn't pupil dependent.

On occasion, if I have a patient who's averse to halos and glare, but insists on being able to read without eyeglasses, then I might place a Crystalens^® in the distance-dominant eye, aiming for plano, and the Tecnis^® multifocal in the nondominant eye.

When co-managing patients, I often rely on the experience and degree of comfort the co-managing optometrist has during the early postoperative period. I know some optometrists who prefer I see the patient for 3 months post-op and then return the patient to the practice, while others assume the postop care after the initial post-op exam.

The choice of follow-up depends on both the enthusiasm of the referring optometrist and the degree to which I'm comfortable with the optometrist's capabilities for diagnosing and recognizing certain conditions. Of course, I perform the first post-op exam, looking for inflammation and making sure everything else looks good for the expected surgical outcome.

At the 1-week visit, I expect the co-managing optometrist to be comfortable with establishing and determining if the patient has achieved best-corrected visual acuity (BCVA). Thereafter, the OD should monitor the BCVA, so it remains at that level and rule out any early cystoid macular edema (CME).

During the first month, the co-managing optometrist performs a dilated fundus exam, again to ensure the absence of CME, but more importantly, to examine the peripheral retina for small tears or other pathology. The optometrist should be comfortable monitoring and possibly managing intraocular pressure.

During the first 3 months, the co-managing optometrist should be comfortable with assessing the patient. If the Crystalens^® was implanted, the optometrist should determine if any fibrosis is pushing the lens anteriorly and creating a myopic shift. In the case of the Tecnis^® multifocal IOL, the assessment should include ruling out posterior capsular opacification, which would cause blur or glare. If the co-managing optometrist recognizes any of these conditions, he should be prepared to promptly refer the patient back for Nd:YAG laser capsulotomy in either case.

Lastly, I want optometrists to assess patient satisfaction with the new IOL and call our office if the patient is less than superbly satisfied. Optometrists also should be comfortable with tapering the post-op medications, recognizing that the antibiotics should be discontinued at the end of 1 week, the steroids tapered over the course of 1 month and the non-steroidal anti-inflammatory drugs continued for 1 month in low-risk patients and for 2 months in high-risk patients.

I'm familiar with my network of co-managing optometrists and their comfort levels in diagnosing and treating pathology. I relinquish patient monitoring after the first post-op exam to those who are most comfortable serving in this role. Most optometrists prefer to have me follow up with patients for a slightly longer period of time.

After the third month, if all is well, patients return to the referring doctor with the recommendation that they have annual exams to monitor their ocular health. In all cases, doctors should alert patients to all of the signs and symptoms of an early retinal tear: floaters, flashing lights, showers of floaters, a cobweb over their vision, or a curtain or veil over any part of their vision.

Co-management covers a broad spectrum of comfort. Some optometrists prefer I see the patient for the entire global period. Some take over immediately, while others are somewhere in between.

Optometry's Emerging Role in Cataract Surgery and IOL Selection

Before the development of premium intraocular lenses (IOLs), the refractive options for patients undergoing cataract surgery depended on the surgeon's preference and the availability of monofocal IOLs in inventory at an ambulatory surgery center. Optometric management was focused on patient visual acuity expectations, while co-management primarily was concerned with postoperative refraction and clinical monitoring of the ocular surface.

Spectacle lenses and/or contact lenses corrected the residual refractive error of the IOL and compensated for the loss of accommodation following removal of the crystalline lens. The procedure was considered finished.

Over time, advances in surgical technologies, such as tissue protective instrumentation and a wide variety of viscoelastic agents for ocular protection, gave rise to improved surgical techniques. Advances in refractive technologies, such as premium IOLs (multifocal and accommodating IOLs) provided more refractive choices.

The primary care optometrist, who sees the patient routinely and usually knows the patient's lifestyle and visual needs, began to educate the patient about premium IOLs while consulting with the surgeon to determine the best IOL for the individual patient. This altered and strengthened the co-management relationship. The standard of care evolved as well.

As primary care practitioners, we need to recognize premium IOLs and refractive procedures as state-of-the-art refractive considerations for patients, similar to the selection of contact lenses, eyeglasses and treatment for ocular abnormalities. The primary care practitioner who regularly examines the patient is extremely important in the referral process and in the selection of refractive technologies for providing optimal patient outcomes.

Be proactive, educate your patient and develop your co-management skills. It's in the best interest of the patient!

Sincerely,
David W. Hansen, OD, FAAO (DipCL)
Global Professional Services
Abbott Medical Optics