Educating Patients About Their IOL Options

Alice Epitropoulos, MD; P. Dee G. Stephenson, MD; Eric Donnenfeld, MD; Russ Fumuso, MD; and Quentin B. Allen, MD, speak with Marguerite McDonald, MD, about how to efficiently, ethically, and honestly get their patients to accept recommendations for a multifocal IOL. Listen as this extensive panel of surgeons discusses communication strategies for different lens options and learn how to gain patients' trust and confidence in your surgical recommendations.

Announcer:

Informed Consent: Getting to Yes. Is editorially independent content supported with advertising by Abbott?

Marguerite M.:

Welcome to Informed Consent: Getting to Yes. I'm Marguerite McDonald of the Ophthalmic Consultants of Long Island, otherwise known as OCLI in Lynbrook, New York.

Ranna Jaraha:

I'm Ranna Jaraha.

Marguerite M.:

In this podcast we talk to key opinion leaders and successful high-volume surgeons about what they say efficiently, ethically and honestly to get their patients to accept their recommendation regarding a procedure, drug or something else that they think should be a part of the patient's regimen.

Ranna Jaraha:

In today's episode, that something is a multifocal IOL.

Marguerite M.:

That's right. Our four guests will tell us how they talk to patients about their vision preferences and how they educate their patients about the various lens options.

Ranna Jaraha:

And get buy-in.

Marguerite M.:

Yes, but also when they may have to talk the patient out of one because of contraindications.

Ranna Jaraha:

Getting to 'yes' about a 'no'.

Marguerite M.:

I guess that's right. Let's introduce our guests. Beginning with the ladies, we have Dr. Alice Epitropoulos, founding partner of the Eye Center of Columbus and clinical assistant professor at the Ohio State University in the department of ophthalmology. Welcome Alice.

Dr. Alice E.:

Thank you Marguerite. Thank you for having me.

Marguerite M.:

Next is Dr. Dee Stephenson, founder and CEO of Stephenson Eye Associates in Venice, Florida and at the time of this recording the sitting president of the American College of Eye Surgeons. Welcome Dee.

Dee Stephenson:

Thank you Marguerite.

Marguerite M.:

Also contributing to the discussion today is Dr. Eric Donnenfeld, a founding partner of the Ophthalmic Consultants of Long Island and clinical professor of ophthalmology at NYU. Glad to have you sir.

Eric Donnenfeld:

Thank you Marguerite. It's good to be here with you.

Marguerite M.:

Finally from OCLI we have Dr. Russ Fumuso, senior founding partner and director of office design and development. Russ is a very high-volume, successful cataract surgeon with a large word-of-mouth and referral practice. He gets many complicated cases from other ophthalmologists. Thanks for being with us Russ.

Dr. Russ Fumuso:

Oh, thank you very much Marguerite.

Ranna Jaraha:

Finally we have the Quentin B. Allen who will introduce himself.

Quentin Allen:

I'm Quentin B. Allen, M.D. I'm in a group practice in the treasure coast are of Florida, comprising between Port St. Lucie and West Palm Beach. We have five offices. We have six surgeons. Still, a comprehensive practice but my practice has evolved into primarily refractive and cataract surgery over the last five to ten years.

Marguerite M.:

Let's begin. Why don't we start by talking about your general approach to communicating with patients about multifocals. Alice?

Dr. Alice E.:

Communication with our patients is very important. The way in which we explain the treatment options and the wording that we choose becomes critical. I personally like to include a very detailed discussion of the patient's prognosis, any pre-existing conditions, risks and possible complications along with their IOL options. This is an absolute must in today's litigious society. It's a given that the average patient is unlikely to remember much of what we say, so I try to make sure that a family member or a friend is in the room. A second set of ears is much more functional than those of a stressed-out patient.

Eric Donnenfeld:

When I talk to patients I usually have three key areas.

Ranna Jaraha:

This is Eric Donnenfeld.

Eric Donnenfeld:

Number one is: Are they ready for surgery? Number two is: How do they want to see after the procedure? Number three is: How do they want the surgery performed? When it comes to number two, which is probably the most important concept, how do they want to see, I give them three different choices: You can see far away without glasses, you could wear glasses all the time or you could try and reduce your demand on glasses and try to wear glasses the least amount of time, including reading. If when I speak to them they think that they would like to have reduced dependence upon glasses, then my conversation shifts to a multifocal IOL or an extended-depth IOL, such as the new Symfony lens.

Quentin Allen:

I think it's first just important to take a step back, Marguerite. Like you, I like to kind of ask some questions and gain the trust of the patient, but we don't want to spend too much time in the lanes.

Ranna Jaraha:

Quentin Allen is speaking.

Quentin Allen:

After we've decided that the cataract is indeed visually significant and the patient is interested in surgery, then the question is asked: Were you hoping to reduce your need for glasses as a part of this procedure? It's kind of an open-ended question and patients are usually a bit prepared for that, as you know. The patient may say, "Well yes, I was hoping to be out of my reading glasses ..." or oftentimes they'd say, "Well, you know I'm happy with my glasses." I think sometimes or too often the surgeon will make the assumption at that point that there's really not a need to discuss the limitations of monofocal lenses or the technology options that are available.

I've been very passionate over the years that it's incumbent upon me to stress to the patient what the limitations of monofocal lenses are and to be certain that the patient is properly educated about the options available.

Marguerite M.:

You have to explain to them: You will need your reading glasses to eat your food. That, I think, makes it so clear. To see the peas and the rice individually, you're going to have to have glasses on. All of a sudden the nickel drops, they get it.

Quentin Allen:

Kind of like the hand gesture going from my face kind of out to computer range just showing that depth of focus that a monofocal lens does not provide. Once that is kind of understood, then we start about options. We've got strong lenses that can really give you a lot of reading power, multifocal lenses that can potentially get you out of glasses altogether, but you will have some halos or rings around lights when you drive at night. If the answer at that point is, "Well, I don't really drive that much at night ..." then they've almost self-assigned them into that higher add multifocal category in my mind. I'll kind of reiterate that point and say, "Well, great. If you don't mind having the rings around lights. Probably not terrible. They're not too distracting. Some patients do find them to be concerning, but if you're not a big night driver and your main goal is to be out of glasses then we can absolutely do that."

Ranna Jaraha:

Now Dee Stephenson.

Dee Stephenson:

I have one spiel that I give, but I also customize it to the age of my patient, their previous or their current profession and their current activities or hobbies or lifestyle that they lead. You also need to talk to the patients differently if they had a previous refractive procedure such as LASIK or RK or PRK or enhancements of those as well. The technology has changed so much that you have some options for all of these patients and if they have macular degeneration. The biggest change I see that has happened in my practice is the correction of astigmatism.

Dr. Alice E.:

If the patient is deemed appropriate for a premium lens, whether it be a toric implant or a multifocal implant or an extended depth of focus lens, I try to get an idea what the patient's goals are, what their goals of their surgery is.

Ranna Jaraha:

Alice Epitropoulos.

Dr. Alice E.:

If they have a desire to reduce their dependence on corrective lenses, then I present these options. Some patients basically voice the fact that they prefer to wear glasses or they don't mind wearing glasses, but I do spend a fair amount of time discussing some of the options that are available in today's technology.

Dr. Russ Fumuso:

I ask them what they do. Are they retired? Are they working? What are their requirements? Are they on the computer all day long? Then I ask them, "What would you like? Do you mind wearing reading glasses? Would you like to be relatively spectacle-free?"

Ranna Jaraha:

This is Russ Fumuso, chiming in on a running theme of spectacle independence.

Dr. Russ Fumuso:

I use the word 'relatively'. I never promise anyone's going to give up their glasses. I feel them out. Some people are very interested in not wearing glasses most of the time. Other people are really just like, "Well, I've worn glasses most of my life. I really have no problem wearing them afterwards." Toric lenses, which I use and I really enjoy using them and I think I have a very good success rate with them, people with astigmatism who have worn glasses their whole life, they like the idea that possibly in the future after cataract surgery not wearing anything for distance or even with a bit monovision, they're very enthused at that. I think I have a high success rate converting people to torics actually than multifocals.

Dr. Alice E.:

Speaking slowly is very important trying to explain in simple terms what their refractive error is and what we have the ability to do post-operatively. Sending them visual aids prior to their visit, for example sending them information on femtosecond cataract surgery, sending them information on presbyopic implants basically introduces the technology to patients so that when they come into the office they're a little bit more educated and a little bit more informed so that it's not totally new to them.

I tell them that when we take a cloudy lens out we always put an implant in and we can put one of a couple different types of implants: A monofocal lens will correct one distance and typically you'll still need to wear some glasses postoperatively. We also have presbyopic implants which allows for a little bit more range of vision, reducing and possibly eliminating the need for glasses.

Marguerite M.:

There's many things that you ask but mostly about what they want. A lot of patients actually use their glasses, not only as a coverup of their wrinkles, as women that have those awful wrinkles. They take their glasses off and they look in the mirror and they go, "Oh my gosh. I never want to be without my glasses ..." so they use it as a prop. I always say to them, "That's fine. You can wear your glasses for everything you want, but I want you to be ... How would you like to be independent when you got up to go to the restroom in the middle of the night and you wouldn't have any trouble seeing to get around?"

Dr. Alice E.:

I think it's important that we tell patients that there is a cost associated with some of these upgrades in technology. Again, I explain to patients that your insurance will pay for cataract surgery, they'll pay for a monofocal lens but they don't typically pay for the upgrade to remove your astigmatism or to reduce your dependence on glasses with the presbyopic implants.

Marguerite M.:

How do you describe the difference between the "classic multifocals" and extended depth of focus, or do you think that's too much technical information for the average patient?

Eric Donnenfeld:

For the average patient I don't really discuss that so much. What I talk to patients about is if they want to have reduced dependence upon glasses, I tell them that there are essentially four different types of lenses that can give you distance and reading and they give you different amounts of reading. Some give you very, very close reading, that would be like a four diopter add lens. Some give you a little bit less, like a 3.25 or 2.75, and there's the Symfony, which is about the same as a 2.75.

Quentin Allen:

You can throw in whatever verbiage you want at that point, whether it's an accommodating lens or a low-add multifocal or an EDOF lens. At that point, that category of lenses is what you're discussing, saying now you've minimized the nighttime driving issues, you've expanded the depth of focus. A lot of people tend to like that category of lenses and they nod their head in agreement and say, "Well yeah, I'd be okay with reading glasses or a weak pair of reading glasses." You're telling them they're going to get two out of three things: Good night driving and expanded range of vision, but they still might need a weak pair of reading glasses. That's kind of what most people have in their 40s, mid-40s and if they ask me I'll say, "Well we can't dial you back to 20 or 25 but I can dial you back to 40 or 45 where you may need reading glasses for dim light or fine print but you'll have a much greater depth of focus, more like what you had back in your 40s until now where you need reading glasses and even glasses for the computer.

Marguerite M.:

We used to describe the different types of platforms but now it's just more confusing to patients. The biggest thing for me is, I talk to them about their lifestyle. If they sew, if they do needlepoint, if they do counted cross stitch, I want them to have a good platform that gives them ... If they want to be without glasses, I want them to have a good platform that allows them to see well up close. If it's a piano player or they sing in the choir and they need to see everything at arm's length, I want to make sure that their intermediate is really, really good and they don't mind putting reading glasses on to read a medicine bottle.

If they're avid sportsmen, they're fishermen, they're golfers, they want to see quite well at distance, they want to see very well at distance, but they'd like to be able to read their scorecard on the golf cart without putting their reading glasses on because they're hot and sweaty, if you will.

Eric Donnenfeld:

I explain to patients that with any lens that gives you additional reading, there's also a price you pay and that is that their distance vision may not be quite as good. I explain that if they want to have really, really close vision up close that they're going to have less quality vision at distance, they'll have more glare and halo. If they're willing to have good intermediate and moderately good up-close vision, that the low-add lenses, like the 2.75 Tecnis, the 2.50 Restore or the Symfony lens all give very good reading up close, wonderful intermediate vision and they degrade the distance vision very minimally. The incidence of glare and halo with these low-add lenses is significantly better than with the high-add lenses. I explain that that's a fundamental difference between the different lenses.

Dr. Alice E.:

I think it's also important to explain to patients that there's no perfect lens out there. There is a possibility that they still may need to wear glasses afterwards, or contacts. There is a chance that they might experience some photopsias or glare and halos at nighttime or difficulty driving at nighttime. Again, I think it's important to be very transparent and talk about both the advantages and disadvantages of this technology.

Dee Stephenson:

What I try to get away from is telling the patient that this is the lens that I'm going to use, I'm going to use the Symfony or I'm going to use the Crystalens. I try to get away from that. I say, "We have several options and once I get you to the operating room and do aura, then I will refine what I do." I give them kind of an idea so it's in my package and I will give them details about the technology, but not all patients need to know all of that or want to know all of that.

Marguerite M.:

I agree. I don't use any trade names at all. You just want to introduce the concept. I've never had a patient say to me, "Who makes that lens ..." or "Who makes that laser?" Not one.

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Informed Consent: Getting to Yes is editorially independent content supported with advertising by Abbott.

Marguerite M.:

I'm intrigued by the three packages. Could you tell us in a little more detail about the three levels?

Ranna Jaraha:

This is Dee.

Dee Stephenson:

Sure. The premium level is the Forever Young package. It's a premium lens and I either pick ... I decide whether they're a multifocal candidate, whether it be multifocal toric, multifocal just a regular low-add multifocal, the new low-add multifocal, or a Crystalens or a Trulign. Those are all in my package for premium and I just determine ... What's included in that is femto and aura, so that's the premium. I take care of astigmatism and I take care of presbyopia correcting so I make them very glasses-independent. The second package is for toricity so there are some extended depth of field toric lenses so they get the near vision thrown in there, however ... My second package is a little less money but it includes the femto and aura and it includes toricity. My bottom package is just a monofocal lens with either LRIs, either made by a femto or made by hand, so an AI with a femto or an LRI with a diamond knife, and they get aura and femto. Those are my three packages and I've been pretty darn successful with it.

Marguerite M.:

Besides sort of a lifestyle assessment, do you want to be free of glasses, et cetera, how about what conditions you would find under examination that would make you think this is not a multifocal candidate?

Ranna Jaraha:

Russ Fumuso.

Dr. Russ Fumuso:

Well certainly. If they ... I've had post-LASIK, which there's always a question about decreased contrast with certain series' of lenses. [Intracorneal 00:17:54] disease, Fuchs' dystrophy, certainly that's an issue, anything involving the cornea. Of course, there are other intraocular issues as well, any idea that there is any maculopathy, any diabetic retinopathy, any sort of maculopathy whatsoever, I certainly would not use that lens at all. I'd like to see an eye that's very healthy with a clear cornea and very good posterior segment.

Eric Donnenfeld:

You want to start with the ocular surface, making sure the ocular surface is in good shape. If it's not in good shape can you convert it to a good ocular surface?

Ranna Jaraha:

Eric Donnenfeld.

Eric Donnenfeld:

If you can, then they become candidates for a presbyopic IOL. If you think the cornea is going to be a problem regardless, then I would eliminate those patients. Posterior segment problems including glaucoma, are a very strong relative contraindication. Patients with significant glaucoma are absolute contraindications. I look at the retina as well, and while in the past an epiretinal membrane was a contraindication, now it's a relative contraindication depending upon the severity of the epiretinal membrane and certainly the same thing for macular degeneration and Drusen. When you see Drusen, that's a small relative contraindication. When you have overt macular degeneration then that becomes a very strong contraindication to a presbyopic IOL.

Marguerite M.:

Do you ever say to yourself, "The premium IOL is going to work as long as this person continues to take the following four things I put them on, but if they start to lose it a little bit and their dementia manifests itself, they're going to hate this multifocal IOL. Do you ever find yourself in that position?

Dee Stephenson:

Sure. You bet I do. I live in Florida and my average patient has gotten younger but my average patient is about 85, and they're young 85s. Yes ma'am, absolutely. The one thing that is ... I feel obligated many times to talk patients out of the premium package and they want to know why. I say, "Because I can't tell you ... If you do all these things and it's a great day and the stars are aligned, your dry eye will be under very good control and you will see excellent with this lens. However, if you're in a different atmospheric condition, if you're in a different temperate weather, if you're out in a dry part of the country, you're going to have difficulty waxing and waning of your vision. If you can tolerate that and you know why, that's great, but if not I think that you would have a better chance of seeing well most of the time with this package.

Eric Donnenfeld:

Of course you have to be concerned about ocular surface disease and if it's a very severe ocular surface disease that you can tune up as you described, I think it's an informed consent decision with the patient and you give them the pluses and minuses that yeah, this is going to work for you but if down the line the dry eye becomes uncontrolled, then it becomes more of an issue and you may not like this type of a lens. I always make a recommendation to my patients. I listen to what they want, I examine their eyes and I look at their different risk factors that I see, and then when it's all done I give them a recommendation.

"I think you're a candidate for this and this is what I recommend based on what I've heard from you, however if you want to go to something different, like a multifocal IOL in this case, I'm willing to do it as long as long as you're willing to understand that there are additional risks in your specific case." I allow patients to help make the decision because at the end of the day what we're really here to do in the informed consent process is to empower our patients to allow them to make smart decisions with your guidance.

Marguerite M.:

Do you ever take the son or daughter out of the room and just say, "I see your mother is on Aricept for dementia or I detect a small amount of dementia and I don't think the multifocal is going to work because they have severe dry eye?"

Dee Stephenson:

Yes, I do. There's a few markers on our charts that we look at. Of course for men the Flomax anti-Alzheimer's medications or Parkinson's medications, those are big red flags that we have so the girls know the right things to ask. Yes, we'll say, "Let's have your husband come in ..." or, "Let's have your wife come in ..." or, "Let's have your daughter come in." I have that conversation but I have the conversation with the other person in the room and we document that.

Quentin Allen:

I think you're right. The ocular surface regimen may not be as easy to maintain, especially in an assisted-living facility or something like that ...

Ranna Jaraha:

This is Quentin Allen.

Quentin Allen:

... But the trade-off of not needing to hunt for glasses or ambulating wearing bifocals, which increases the fall risk, so that's another point to discuss with the patient and their family is that we really want to reduce their risk of falling and breaking a hip, et cetera, and bifocals and reading glasses, which people either forget to take off when they're walking around or they don't put them on at all and they lose them and leave them somewhere. Multifocal lenses can have an advantage in that setting too.

Marguerite M.:

In your informed consent do you ever mention the small chance that if they're unhappy they might have to be ex-planted?

Dr. Russ Fumuso:

Yes. That's part of what I explain to any patient with cataract surgery. I tell them that nothing is 100%. It is one of the safest operations done in the United States with a high success rate. I say, "But like anything in life, nothing is guaranteed." I say, "There's always a small chance that the lens may have to be taken out if they cannot tolerate it or for any other reason." To date I've yet had, I've not had to do that but certainly I do mention that up front and that is brought to the patient's attention.

Marguerite M.:

With torics, do you mention that there might, in a very small percentage of cases, there might be the need to go back to make an adjustment to the position, the axis?

Dr. Russ Fumuso:

Yes, I do. Absolutely. I try to have people ... A well-informed patient who understands everything about the surgery, when there is a surprise if they've been told about it ahead of time that it might occur, it's a much different situation, especially if they know that it could occur, it's rare. If it does occur I just say, "You know, you're one of those rare people. Even though it might be one in five hundred, it doesn't matter if you're that one, but we knew this was a possibility and we're just going to take care of it." Most people are on board with that and understand.

Marguerite M.:

I think that about does it.

Ranna Jaraha:

We covered a lot of ground.

Marguerite M.:

We did. Thanks to all of my great guests.

Dee Stephenson:

Thank you Marguerite. It's always an honor and a pleasure to do anything with you.

Dr. Alice E.:

Thank you so much. I appreciate the invitation.

Dr. Russ Fumuso:

Thank you very much Marguerite.

Eric Donnenfeld:

Thanks for inviting me Marguerite. It's always a treat to be with you.

Quentin Allen:

Thanks for having me Marguerite.

Marguerite M.:

You're all very welcome. Thanks to you, the audience, for listening. I hope you heard some things you can use in your own practice. Please join us again for the next episode of Informed Consent: Getting to Yes.

Announcer:

Informed Consent: Getting to Yes is editorially independent content supported with advertising by Abbott.