Avoiding Unhappy Premium IOL Patients

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6 min read

In this installment of Interventional Mindset, Dr. Epitropolous discusses how to avoid an unhappy premium intraocular lens (IOL) patient.

In this episode of Interventional Mindset, Dr. Alice Epitropoulos reviews top pearls for improving treatment outcomes with premium intraocular lenses (IOLs). Investing time and energy into patient education is key to providing a well-informed and positive treatment experience for the patient.

Interventional Mindset is an educational series that gives eye physicians the needed knowledge, edge, and confidence in mastering new technology to grow their practices and provide the highest level of patient care. Our focus is to reduce frustrations associated with adopting new technology by building confidence in your skills to drive transformation.

Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.

Managing patient expectations around premium IOLs

To start, Dr. Epitropoulos highlighted that when implanting premium IOLs, an ounce of prevention is worth a pound of cure, and one of the first steps is to talk and listen to the patient to understand their expectations and vision goals. She recommended that all patients would benefit from being told about premium IOL options, even if they are not a candidate. This way, they understand the broad offerings of IOLs available and can make an educated decision.
She noted that some patients don’t mind wearing glasses after surgery, so they might not feel the need to spend out-of-pocket costs on advanced technology lenses. Other patients whose occupation requires significant night driving may also not be ideal candidates for multifocal IOLs. Further, Dr. Epitropoulos mentioned that surgeons shouldn’t be afraid to tell patients how and why they are not ideal candidates for specific lenses. It’s critical for surgeons to set realistic expectations for the patient, because it’s always better to underpromise and subsequently overdeliver on the treatment results.
One case scenario that Dr. Epitropoulos highlighted was for myopes who rely on reading fine print without glasses. These patients will likely need more guidance since, despite having a presbyopia-correcting lens, their uncorrected near vision may not be as optimal as it was pre-operatively. Subsequently, they might need to wear low-power reading glasses following the procedure. It is essential to let patients know these details pre-operatively to prevent an unexpected interpretation of the given surgical outcome.

Bringing up potential adverse effects caused by premium IOLs

It’s also imperative to explain to patients that a certain percentage of them may experience bothersome glares, halos, cobwebs, or starburst at night. While discussing treatment options with patients, Dr. Epitropoulos recommended surgeons explain to patients that there is no perfect IOL in existence, so occasionally, compromises need to be made. The goal of the advanced technology IOLs is to reduce the dependence on corrective lenses, but there isn’t a guarantee that the IOL will eliminate their need for glasses.
She also noted that investing in extra chair time with these patients prior to the procedure is very helpful in making sure they understand any potential risks. Also, having a patient’s family member present during these appointments to listen to the surgeon’s commentary as a second set of ears can reinforce what has been explained to potentially prevent miscommunication.

Patient selection for premium IOLs

Careful patient selection is critical for successful treatment outcomes. Dr. Epitropoulos advised that clinicians should screen patients for pre-existing ocular conditions that might make them a poor candidate for premium lens technology. She recommended that surgeons screen for ocular pathologies such as macular pathology, irregular astigmatism, dry eye disease (DED), and Fuchs endothelial corneal dystrophy (FECD), among others.
The best candidates for these lenses, especially for surgeons who recently started implementing premium IOL technologies, would be patients (aged 50+) with hyperopia who consistently need their glasses. These patients likely have some form of a significant cataract that could be treated and ideally are motivated to reduce their dependence on spectacles at distance and near.

Pearls for implanting premium IOLs

For surgeons new to premium IOLs, Dr. Epitropoulos suggested avoiding potentially challenging anatomies during surgery, such as small pupils, pseudoexfoliation syndrome (PXF), and post-refractive patients.
Additionally, accurate biometry and control/management of astigmatism are essential to maximizing surgical outcomes. Multifocal implantation requires the same precise surgical technique as conventional monofocal cataract surgery; however, the optics of presbyopia-correcting IOLs requires precise centration. This necessitates a well-centered capsulorhexis with good zonular support to achieve the best results.
Finally, Dr. Epitropoulos encouraged surgeons to track post-operative results and personalize their A-constant to refine the surgical outcomes. She noted that an appropriate target for post-operative astigmatism would be to reduce it to less than half a diopter, and for unhappy patients with astigmatism greater than this, laser vision correction or limbal relaxing incisions (LRI) may be required. The patient should be told about this risk pre-operatively by informing them that they may need an additional procedure following the IOL implantation to reach their visual goal.


There are a broad variety of techniques available to ophthalmologists to improve vision in patients with presbyopia-correcting lenses. Dr. Epitropoulos highlighted that it’s important to investigate and treat organic problems before assuming that neuroadaptation will resolve patient complaints. Assure patients by letting them know that you will work with them to try to resolve any issues they might be experiencing.
Pay attention to the patient’s ocular surface, residual refractive error, and if necessary, evaluate for cystoid macular edema (CME) or posterior capsular haze. With these factors in mind, surgeons new to premium IOL technologies will become more successful cataract refractive surgeons and will minimize the number of unhappy premium IOL patients.
Alice Epitropolous, MD, FACS
About Alice Epitropolous, MD, FACS

Alice T. Epitropoulos MD, FACS is a board-certified ophthalmologist who specializes in refractive and cataract surgery. She is a native of Columbus, Ohio and is passionate about improving the vision of her neighbors in Central Ohio. Her practice is focused on refractive cataract surgery with premium intraocular lenses and laser technology. She also has a Dry Eye Center of Excellence. She is a founding member and proud to be a part of The Eye Center of Columbus, an innovative affiliation of more than 80 ophthalmologists located in the Arena District in Downtown Columbus. Dr. Epitropoulos also serves as a clinical assistant professor in the Department of Ophthalmology at The Ohio State University and as an editor for the Journal of Refractive Surgery.

Dr. Epitropoulos serves as one of the team physicians for the Columbus Blue Jackets. She also served as a member on NBC-4 Health Team for 10 years

Dr. Epitropoulos has been voted as one of the top refractive surgeons by fellow physicians in the Central Ohio Area (“Docs Rate the Docs”). She has also been recognized as one of America’s Best Doctors.

Alice Epitropolous, MD, FACS