In this session of Interventional Mindset, Dr. Blake Williamson offers a practical four-step approach to getting started with presbyopia-correcting intraocular lenses (IOLs).
As of 2020, there were 1.8 billion people worldwide aged 40 to 59.1 The majority of these individuals will experience the loss of accommodation, known as presbyopia, during this timeframe. However, today’s aging population is loath to accept spectacles as their only defense against diminishing vision. Presbyopia-correcting IOLs (PCIOLs) can offer a solution.
For ophthalmologists just entering the realm of PCIOLs, Dr. Williamson offers four keys to equip yourself for a successful start.
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1. Pick the proper patients.
When getting started with PCIOLs, Dr. Williamson suggests surgeons go for “the low-hanging fruit,” meaning they choose individuals who present as little risk as possible until they achieve a greater level of confidence with the procedure.
According to Dr. Williamson, patients who make the best candidates might have:
- Virgin corneas that have NOT undergone any refractive surgery (e.g., photorefractive keratectomy [PRK], laser in situ keratomileusis [LASIK], radial keratotomy [RK], astigmatic keratotomy [AK], etc.)
- No retinal pathologies (e.g., epiretinal membrane [ERM], age-related macular degeneration [AMD], diabetic retinopathy [DR])
- A healthy ocular surface
- Hyperopia: Individuals who already have issues with both near and far vision are likely to be highly satisfied with their results
- Realistic expectations, as there will very likely be some level of dysphotopsia
Note: He also points out that with today’s advanced technology lenses, it is possible to place a PCIOL in some of the classes of patients listed above, but it is not advisable until the surgeon has reached a level of proficiency through practice.
2. Screen appropriately.
Having patients undergo a thorough pre-operative screening is essential.
Dr. Williamson recommends the following be performed for each patient:
- Topography
- Biometry: When managing astigmatism, make sure the corneal power (K) in the patient’s biometry matches those from their topography
- Optical coherence tomography (OCT): Macular OCT scan
- Corneal staining: Check specifically for epithelial basement membrane dystrophy (EBMD) and neurotrophic keratitis (NK)
- Lid exam: Lift the lid to look for Salzmann's nodules, EBMD, and signs of dry eye
- Diagnostic testing: Point-of-care (POC) dry eye testing, such as osmolarity and matrix metalloproteinase-9 (MMP-9)
3. Master the conversation.
During the initial conversation about PCIOLs, one of the most important things to do is set appropriate expectations. Dr. Williamson’s philosophy is to “undersell dramatically, so you can overdeliver magically.”
To manage expectations, Dr. Williamson covers four pivotal talking points with each patient prior to the PCIOL procedure.
Improvement, not perfection
Though this surgery might significantly improve a patient’s vision, it will not reverse ocular aging by making the eyes what they were at 20 years old. Dr. Williamson makes certain patients understand that “nothing I can do for you is as good as what God gave you.”
No rings, no read
“No pain, no gain” is a common saying with the implication that every advancement requires a bit of sacrifice. Dr. Williamson puts an ophthalmic spin on the phrase by explaining to patients, “No rings, no read.” This translates to the fact that, along with improved visual acuity, patients should also expect some starbursts and halos and can likely not have one without the other.
Don’t throw away your readers
It's important to explain to patients that you cannot guarantee they will no longer need reading glasses for any occasion. Dr. Williamson addresses this by stating, “This is not about ridding the world of reading glasses; it's just about dramatically reducing your need for them, which I think that we can do with modern technologies.”
To illustrate the level of improvement they can expect, he refers to the near vision chart and informs them they will very likely be able to read at the J5 to J3 level, knowing that 95% of individuals will reach J3 or better.
Cost considerations
In Dr. Williamson’s experience, people have two primary concerns during their cataract evaluation: Will the surgery be painful, and what will be the cost? Many doctors feel uncomfortable discussing the financial component of surgery, but it is imperative to become adept at discussing cost considerations.
At the least, the surgeon should be able to:
- Quote the approximate cost after insurance
- Quote the out-of-pocket price
- Be informed on financing options (e.g., CareCredit, GreenSky, ALPHAEON, etc.)
Note: Presenting this information yourself in the exam room weeds out patients who cannot or are not willing to pay for this procedure and, thereby, saves your practice’s financial counselor time and disappointment.
4. Performing a successful surgery.
The final piece in the PCIOL puzzle is performing the “perfect” surgery. Dr. Williamson offers a few pearls to ensure optimal results.
Surgical pearls for implanting PCIOLs
- Make certain there is a well-centered 5mm capsulorhexis to overlay the 6mm optic.
- Avoid any tilt that can induce astigmatism and/or cause corneal coma.
- Center the corneal light reflex on the central button; if nudging the IOL is necessary, do so nasally.
- Remove all the posterior viscoelastic; this is especially important with toric presbyopia IOLs.
- Achieve a watertight wound seal.
- Providing the patient is satisfied and not experiencing high levels of dysphotopsias, perform the YAG capsulotomy early, as presbyopic IOLs can be sensitive to even mild posterior capsular opacification (PCO).
In closing
Ongoing growth as a physician with a commitment to ever-increasing patient care is the cornerstone of the interventional mindset.
By following these steps and incorporating the included surgical pearls, you will be on your way to adding one more tool to your armamentarium.
