Cataract and refractive surgeons Daniel H. Chang, MD, and Gary Wörtz, MD, initially bonded over mutual interests in chromatic aberrations and basketball, but their greatest commonality is their shared commitment to taking the best possible care of their patients and making a positive difference in their lives.
As both strongly believe in adopting an interventional mindset and encouraging others to do the same, they are using this forum to identify and remove some of the barriers blocking surgeons from utilizing presbyopia-correcting intraocular lenses (PCIOLs).
Dr. Chang’s primary focus—as well as passion—is vision correction and he constantly strives to develop a deeper understanding of the science behind patient satisfaction in the optics arena.
His strategy is fourfold and includes patient education, behind-the-scenes preparation, performing a stellar surgery, and working with individuals within the industry to help develop better devices. This article delves a bit into these first three areas.
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The dangers of not correcting presbyopia
Dr. Wörtz admits that, not so long ago, he was not eager to add PCIOLs to his armamentarium, mainly because of the possibility of potential post-surgical complications and follow-up visits from disappointed patients looking for full spectacle freedom.
Dr. Chang lists this, along with not wanting additional chair time and being uncomfortable upselling IOLs, as the most common reasons surgeons may not want to implant presbyopia-correcting lenses.
However, Dr. Chang points out that the value in surgically correcting presbyopia is more than a matter of patient satisfaction—it is a matter of patient safety. He stated, “We, as surgeons, should be more geared toward safety than necessarily convenience and money.”
A study on the toll of falls in bifocal-dependent elderly people
Commonly, after monofocal cataract surgery, individuals could be prescribed bifocals or progressive lenses as default solutions for vision correction. Data on the topic reveals bifocals are a major culprit in falls in bifocal-dependent people over 65 years of age.1
A 2014 report by the Centers for Disease Control and Prevention (CDC) states that in a single year, 29 million people fell, resulting in 2.8 million emergency room visits, 800,000 hospitalizations, and 27,000 deaths, which accounts for a higher incidence in elderly people than breast cancer and prostate cancer.2
The majority of these patients might never make the connection between their bifocals and the accident and, therefore, never mention the fall to their eyecare provider (ECP). For this reason, Dr. Chang suggests specifically asking older cataract patients about recent falls to determine if they would benefit from PCIOLs.
Avoiding communication pitfalls with presbyopia-correcting IOLs
Before focusing on adding PCIOLs to the armamentarium, the surgeons offered advice on pitfalls—and patients—to avoid. First and foremost, Dr. Chang warns against overpromising, especially to individuals who are prone to unrealistic expectations.
To circumvent this, it is recommended to make certain the patient understands that, though they will see improvement in most aspects of their vision, they may still have to wear glasses in certain situations or undergo a presbyopia-correcting enhancement following their initial surgery.
Further, it is imperative to educate and prepare patients in the event they may experience nighttime halos, glare, and starbursts.
Other qualities that may make a patient difficult include:
- Myopia, especially in the -2.50 range or beyond.
- A visually demanding profession (e.g., photography, architecture, engineering, etc.)
- Dense, cortical, or posterior subcapsular cataracts
- Ocular surface disease
- Macular conditions
- Glaucoma
Starting with a patient with a relatively healthy eye, aside from the cataract, can increase the surgeons’ likelihood of success, which helps build assuredness as they build experience.
Clinical pearl from Dr. Chang: For -3.00 myopes, determine how often they remove their glasses for tasks throughout the day. If they profess to never remove them and assert they cannot see without them, consider proceeding with PCIOLs.
Selecting an appropriate lens for the patient
When deciding whether an extended depth of field (EDOF) or a high-add or low-add multifocal lens would be best for a specific patient, Dr. Chang keeps three things top of mind: visual quality, depth of field, and night vision symptoms. It is a matter of balancing out the patient’s needs with the technology's capabilities and knowing that compromise is inevitable—more range typically translates to more halos and glare.
The key is being confident in what the lens can do and conveying this to the patient. Dr. Chang prioritizes providing the best vision possible with the fewest night vision symptoms—this may mean they are not 100% spectacle-free.
Dr. Wörtz has found patients are still amenable to the improvement offered by an EDOF, even when informed they will likely still need reading glasses or bifocals for certain activities. He finds most cataract patients are quite content with the J2 to J3 chart range they achieve, which is often an improvement from their prior vision.
Who should build refractive surgery skills
With PCIOLs, the goal for the surgeon and the expectation of the patient would be to eliminate or minimize the use of glasses. In the past, it has been a common practice for cataract surgeons to refer dissatisfied patients to a refractive specialist in their geographic area (or within their practice) for adjustments.
But, for patients who have already developed a rapport and level of trust with their original surgeon, this can be unnecessarily stressful. An interventional mindset encourages surgeons to develop their refractive skills with procedures—primarily laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK)—for greater patient confidence and convenience.
Dr. Wörtz asserts there is a feeling of greater control in being able to “take them to the finish line” by completing both their initial surgery and any subsequent “touch-ups.”
In conclusion
For both surgeons, at the end of the day, choosing an EDOF or multifocal lens is a matter of patient safety and satisfaction. Establishing self-assuredness in the procedure and an in-depth knowledge of the available devices is paramount to progress.
But, if you approach presbyopia correction with transparency and realistic expectations on all sides, it offers the opportunity for patients to potentially enjoy better vision with some level of spectacle independence.
