IOL Counseling Primer
With the rapid rate of expansion and evolution of refractive correction technology, now is an exciting time for cataract surgery. New intraocular lens (IOL) technology — as well as the ever-increasing patient visual needs and desires — means taking a one-size-fits-all approach with cataract surgery is a thing of the past.
Effective education regarding these choices and setting accurate patient expectations for vision correction is critical for achieving the best visual outcomes for our patients. They can be confused about which is the best lens for them and need help understanding visual expectations of each technology specific to their lifestyle to so they can make the appropriate decision.
This education does not have to come only from the doctor, nor does it have to happen all in one sitting. In our experience, we have found it most effective for multiple staff members to be involved in the patient education about refractive cataract technology. We involve patient care coordinators, technicians, and nurses to help counsel and educate at multiple touch points throughout the patient’s time in our care.
To properly educate patients, you need to know the differences between the variety of available IOL technologies. Here is an overview of the available IOLs along with suggestions for how to make the most of preoperative counseling process.
Start by knowing your IOLs
There are multiple types of IOLs used for refractive cataract surgery, including toric, extended depth of focus and multifocal (see Table, page 26). To feel comfortable providing patient information on cataract technology, it is important to understand the basics on how each lens type functions and the level of vision it is expected to provide.
A limit of traditional cataract surgery is the inability to correct corneal astigmatism. Uncorrected astigmatism causes blur at all distances, and patients typically need full-time eyeglasses for their best vision after surgery.
A toric IOL is a monofocal, or single point of focus lens, with astigmatism correction. The lens is implanted in the capsular bag at the time of surgery and rotated to a specific orientation to correct the patient’s degree of astigmatism. Using a toric lens results in clarity at one distance. For example, if this lens is targeted for distance vision in both eyes, the patient would need to expect to wear eyeglasses for intermediate and near activities. A cataract educator may say “this lens will provide good vision at distance, but you will need eyeglasses for activities at arm’s length and closer.”
If a patient desires more near function than a monofocal IOL provides, a surgeon may consider a presbyopia-correcting lens technology. Extended depth of focus, accommodating, or multifocal IOLs are lenses that function to provide improved near ability.
Multifocal IOLs have ringed designs that use either refractive or diffractive optics that split light to provide two or more distinct points of focus for the patient. Multifocal lenses that provide two points of focus often come in multiple add powers for patient-specific customization. Trifocal lenses allow three points of focus for the patient: distance, intermediate, and near.
Extended depth of focus lenses function with either beam-shaping or diffractive optics to elongate the range of focus the lens provides. There are not distinct focus points like a multifocal; instead, they use an extended single focus point to increase the depth of focus.
An accommodating lens has flexible haptics that causes the lens to move forward, providing improved near acuity when the ciliary muscle naturally contracts to focus at close distance.
Understand the limitations
Depending on the specific type of presbyopia-correcting lens or targeting used, often a patient will still need some occasional glasses. To provide wider ranges of focus, there is inherently some compromise that may occur to the vision with these lenses. For example, some of these lenses have increased potential for glare or halo or potential for decreased contrast compared to a standard monofocal IOL. Patient education regarding presbyopia lenses should involve both the excitement of the improved range of focus a patient will experience as well as the limitations.
Before the office visit
Many patients are unaware that lens technology even exists or that they have a choice that impacts their outcome. In preparation for the time in our office, we have implemented a video conference with a care team, which can include a surgical coordinator, technician, or nurse, to counsel patients on expectations prior to their appointment. This helps to ensure they arrive with an open mind and a readiness to hear about options.
Learn about the patient
A good way to start this process of cataract education, whether virtually or in person, is to get to know the patient. Understanding the patient’s lifestyle as well as personality is integral to the decision-making process of refractive cataract surgery. It is important to learn the patient’s profession and hobbies. What distance or lifestyle activity is glasses independence most important? When would a patient be comfortable wearing glasses? Would they tolerate the potential for glare or halo? Could they tolerate some mild blur to get larger range of focus? Does the patient need the clearest night vision possible?
Having the answers to these questions enables the cataract technology education to be tailored to each patient. When patients have the broad understanding of the functionality of the IOL and can put the functionality into practical application for their lives, it empowers them to know how a lens may or may not work well for them.
Equally important to the introduction of options is the discussion of the financial responsibility for the patient — one cannot go without the other. Consider initiating this discussion prior to the surgical consultation, and include information on the amount insurance will cover and the amount the patient will be expected to pay, as well as any options the practice offers for financing the procedure, if appropriate. Being transparent with this information prior to the surgical consultation allows the patient to focus on what the doctor is recommending without the worry of “But how much will this cost?”
Patients often need time to digest new information and consider all options. Providing pre-consultation information or having multiple appointments can allow the patient to absorb all that is shared and have space away from the office to decide what may work best for them. The initial visit with the doctor can be a straightforward medical assessment of the eye and a discussion of options, followed by a conversation with a surgical counselor. At this time, insurance benefits and elective costs are reviewed, questions are answered, and a second visit for surgical planning and decision making with the doctor is scheduled.
It takes a team
Each patient has unique visual needs. Fortunately, cataract technology is expanding and providing more patients with the ability to have refractive correction with their cataract surgery.
With these expanding options, it is necessary for a variety of staff in the practice to understand and provide excellent education to patients regarding these choices. Patient care coordinators, technicians, and nurses are empowered to play a large role in this important decision in each patient’s cataract journey.