Cataract Surgery Report

Teacher, teacher: Staff and physicians’ roles in positioning premium IOLs

Education is key in in cataract surgery with astigmatism. Biometry is a teaching tool.

By R. Bruce Wallace III, MD, FACS; Robert T. Crotty, OD

	About the Authors: R., Bruce Wallace III, MD, FACS, is founder and Medical Director of Wallace Eye Associates in Alexandria, La. He is clinical professor at Louisiana State University and Tulane Schools of Medicine, both in New Orleans.
	Robert T Crotty, OD, is clinical director of Wallace Eye Associates.

The key word in converting cataract patients from selecting traditional IOLs to the more lifestyle-oriented premium IOLs is education. We divide this principle into three groups: education of the patient, education of the staff and education of the doctor. Reliable biometric readings play an important role in all three phases of this process to enlighten patients about premium IOLs.

EDUCATING THE PATIENT

A successful refractive surgery program depends on a well-informed patient. Our goal is to help our patients feel comfortable with the cataract procedure, as well as their refractive options, before they ever meet with one of our doctors.

Before each patient’s initial appointment, our practice sends out informational material to help educate her or him on the cataract procedure and the variety of implant choices available. Astigmatic, accommodative, multifocal IOLs and contrast sensitivity are all important terms that patients need to be familiar with.

Before the appointment, a staff member who is well versed in the cataract procedure calls patients to confirm they have received their informational packets and answer any questions they may have about their IOL options.

Most patients are already aware that today’s cataract surgery can reduce their dependency on glasses. Our team counsels all patients to help them understand that selecting a standard or traditional monofocal IOL typically results in the need to wear glasses for reading purposes after surgery.

STAFF AS TEACHER

When the patient arrives at the office, the staff should seamlessly continue the education process. The technician performing the initial patient work-up assesses the patient’s condition and expectations. The tech also answers questions the patient may have and makes suggestions about items the patient may want to bring up with the surgeon before the operation.

Our team includes select technicians who work specifically with cataract patients. They are well versed in the surgical procedures and can clearly explain what each lens and surgical option offers — helping the patient choose the best option for his or her personal vision needs.

Staff engagement

Achieving good refractive results is important. Tracking outcomes, sharing that data with the staff and encouraging the staff to share our patients’ excitement during their postoperative visits helps achieve this goal. The cataract team should feel partial ownership of the surgical results and a desire to continually improve patient satisfaction. Staff members who perform above and beyond should be recognized and rewarded.

TEACHERS’ TOOLS

Reliable biometry is key

Accurate and easy-to-perform biometry is another key component for achieving great visual results after cataract surgery. Keeping current with the newest biometry equipment and ongoing staff training are major factors in a practice achieving superior refractive outcomes. Our current optical biometer is the IOLMaster 500 (Carl Zeiss Meditec, Dublin, Calif.) with version 7.5 software.

The IOLMaster 500 helps our team record all necessary IOL calculations in one sitting. The speed of the IOLMaster 500 is patient and staff friendly. The machine is fully automatic and includes a “stop light” feature for ease of use. The “stop light” shows red/yellow until the proper position is obtained. Once the light turns green, it automatically takes the patient’s measurement.

Accurate and easy-to-perform biometry is another key component to achieving great visual results.

Technician has options

If needed, the technician has the option of changing from automatic to manual mode. For axial length, the IOLMaster 500 takes five measurements. If all five have a high signal-to-noise ratio, then it proceeds to the next measurement. However, if a patient’s cataract is very dense, the technician is able to switch to the manual mode and “defocus” the center light to obtain those more difficult scans.

With the Holladay II program now included in the IOLMaster, the calculation process is much quicker. The technician no longer has to input the data from the IOLMaster to the Holladay IOL Consultant, saving time and reducing the chance of human error. We also use the Humphrey Atlas corneal topographer and the Hoya I-trace on all surgery candidates.

LRIs or Toric IOLs

Refractive cataract surgeons cannot ignore the importance of surgical correction of corneal astigmatism. For many multifocal IOL patients, problem astigmatism may require corneal reshaping.

One recent multicenter study demonstrated that the quality of vision is significantly diminished when 0.75 D or greater of corneal astigmatism persists after multifocal IOL implantation.¹ Limbal relaxing incisions (LRIs) have a long track record of safety and effectiveness.² Our general rule is if the patient has a small degree of astigmatism (up to 1.50 D), then LRI is recommended.

Femto reinforces need for LRIs

The emerging popularity of femtosecond laser cataract procedures reinforces the effectiveness of LRIs to reduce unwanted corneal cylinder. Our team regularly serves as LRI wetlab instructors. We have observed, with some concern, that misconceptions and/or complicated methods and instrumentation often discourage surgeons form performing LRIs.

We have designed a set of LRI instruments to improve and simplify these procedures (no financial interest). (A demonstration, including a do-it-at-home wetlab video, is available at youtube.com and eyetube.com. Type in “Wallace LRI”.) For patients with astigmatism greater than 1.50 D, we typically recommend a toric IOL over an LRI.

When to recommend premium IOL

For patients whose overall eye health is good — that is, they have very little astigmatism, no pathology or previous corneal surgeries — we recommend multifocal IOLs (MIOLs) or accommodative intraocular lens (AIOLs). Patients who enjoy an active lifestyle — activities such as fishing, sewing, playing golf, just to name a few — do well with MIOLs.

Patients choosing MIOLs typically return to our office for a follow-up assessment. During this extra visit, we take additional measurements to rule out other ocular pathology. Also, we conduct an in-depth review of the type of premium lens the patient has chosen (toric, accommodative or multifocal).

We pay special attention to helping the patient understand the benefits, as well as the possible adverse events each of these technologies may present. As part of our lens assessment, patients and their family members watch education videos on the different lens styles.

DOCTOR’S ONGOING EDUCATION

Keeping abreast of the latest lens and surgical technologies and understanding the nuances of cataract surgery and biometry are very important for doctors working in the clinic. A pristine ocular surface is a must for good outcomes; any anomalies need to be recognized and taken into account.

Some of these patients will require pretreatment. There may also be a need to postpone surgery to achieve the desired outcome. Understanding astigmatism also is important; not only anterior corneal astigmatism but posterior corneal curvature as well.

Doctors need to be prepared to handle the more difficult post-refractive patients. A certain percentage of patients who have premium IOLs are going to need enhancements, and the surgeon has to be willing and able to perform these procedures. Fine tuning a patient’s vision after surgery, whether with limbal relaxing incisions or laser vision correction, is an important role that the refractive cataract surgery team needs to explore together.

With the proper team approach, a patient’s surgical experience can be transformed into a life-changing event – one that improves her or his lifestyle, inspires practice staff and energizes the surgeon. OM

References

1. Zheleznyak L, Kim MJ, MacRae S, Yoon G. Impact of corneal aberrations on through-focus image quality of presbyopia-correcting intraocular lenses using an adaptive optics bench system. J Cataract Refrac Surg. 2012;38: 1724-1733.

2. Wallace RB. Limbal relaxing incisions. In: Hovanesian JA. Premium Cataract Surgery: A Step-by-Step Guide. 2012. Thorofare, NJ: Slack Inc.