When considering Premium IOLs as a surgeon, there are a number of items that must be taken into account. There are a deluge of articles written in the magazines, but it is still very important to review the basics.
Some implants are simpler to start with, but my strongest recommendation is to either do refractive surgery yourself for these patients, or form an alliance with a refractive surgeon. Many of your local refractive surgeons would be happy form a relationship of mutual respect, where they work with you to achieve the best results for your patients. It is best that this relationship be formed PRIOR to your embarking on premium IOLs so that full details of cost and expectations are addressed.
Category of the Implants
The only currently approved accommodative IOL is the Crystalens. The Synchrony lens is in the pipelines to arrive. These implants are monofocal in nature and as such they behave similar to other standard implants.
The current models approved by the FDA in US are ReZoom, Tecnis Multifocal and the ReSTOR family. The implants behave differently due to their design. I would not recommend these implants for patients that have had Radial Keratotomy or Hyperopic LASIK in the past. In the Radial Keratotomy patients, the glare and halos are further amplified. In patients with prior Hyperopic LASIK/PRK, the central cornea is further steepened and the prolate nature of the cornea has greater spherical aberration. These implants, when combined with such higher order aberrations, further amplify the glare and the halos.
Patients that have had prior Myopic LASIK/PRK actually do very well with these implants. The biggest issue is accurate lens calculation in post refractive eye and possible need for enhancement. Before the cataract surgery with the Multifocal implants in these patient, the question of "can these patient have and enhancement?" must be answered by the LASIK surgeon.
One important note about these implants is that they perform optimally only when complete emmetropia has been achieved. That basically means there is very little room for calculation mistakes. More on this later on the page.
Toric IOLs are basically standard monofocal implants with a modified surface that accounts for correction of astigmatism. These implants require precise pre-operative measurements of the corneal astigmatism. The correct axis of astigmatism is a challenge as different instruments give different readings specially when patients end up moving their head and also when the patient lies down for surgery their eye may cyclotort. Additionally surgical manipulation of the eye will also further cyclotort the eye. There are many challenges in this regard. Placing pre-operative markers on the eye in a seated position, may alleviate some these issues, but still remain challenging.
Many cataract surgeons have never been faced with the issues of such extreme accuracy in the past. LASIK surgeons learn very early on that an absolute must in pre-operative consultation is discussion of "enhancements." Even though LASIK is extremely accurate, there is still a small percentage of patients (typically less than 5%) that will need an enhancement with the modern Custom laser treatments. If we held cataract surgery to the same standards, the current most optimized formulas would achieve a rate of better than 70% within +/- 0.50 D and 90% within +/- 1.0 D. If cataract surgeons head such results, it would behoove them to practice with discussion of "enhancements" as a standard topic of discussion for cataract surgery.
Enhancement can be achieved by either doing a lens exchange or doing a LASIK surgery once the eye has healed from the cataract surgery. I strongly advocate for LASIK surgery as it is going to provide by far the most accurate results and finalize the care for the patient. I typically do LASIK for about 10% of my premium IOL patients (planned or un-planned). As a standard, I advocate for evaluating all Premium IOL patients as LASIK patients; ATLAS corneal topography and pachymetry at a minimum. Additional testing such as macular OCT and specular microscopy are urged.
If the patient is not a good candidate for LASIK, they should not have Multifocal IOLs. Accommodative and Toric IOLs may be considered only if fully discussed with the patient that emmetropia may not be achieved.
The cost of enhancement should also be discussed; failure to do so, can cause significant stain on a relationship with an already suboptimal result. Alternatively, a surgeon may raise their complete fee and build the cost of the enhancements into the new fee, so there is no need for discussing costs later.
It is important to be completely frank with the patient about the Premium IOLs. With Multifocal IOLs, discussion of glare and halos is a must. Many of the Multifocal IOLs still have a tendency to behave as a bi-modal implant where there are definite "sweet spots" where the patient is in best focus. With Toric IOLs, presbyopia must be addressed, as well as options of monovision. Lack of accommodation with "accommodative" IOLs is an important topic as well.
As a Stockton cataracts, cornea and refractive surgeon, I must profess how exciting these new technologies have been. The patients have enjoyed tremendous freedom with these implants and are very happy. Although it may seem daunting before starting with these implants, having a good refractive surgeon as your back-up / mentor may prove to be very comforting and rewarding.