Extended-Depth-of-Focus and Accommodating IOLs

James Loden, MD; P. Dee G. Stephenson, MD; Vance Thompson, MD; and Blake Williamson, MD, join Marguerite McDonald, MD, to share insights into how they explain-and get patients' acceptance for-extended-depth-of-focus and accommodating IOLs. Listen to hear how this panel of experts recommends these advanced IOLs to patients.

Speaker 1:

Informed Consent, Getting to Yes, is editorially independent content supported with advertising by Allergan Eye Care.

Marguerite:

Welcome to our podcast Informed Consent, Getting to Yes. I'm Marguerite McDonald of the Ophthalmic Consultants of Long Island in Lynbrook New York. In this podcast, we interview key opinion leaders about how they tell patients what treatment or program they recommend and why, and get them to say yes. We want to hear what well-balanced words they use to quickly and efficiently cover all the important pros and cons, but still lead patients to accept the recommended regimen. Today our distinguished panel of guest ophthalmologists will be discussing how they explain, and get acceptance for, extended-focus and accommodating IOLs. So let's introduce our four guest physicians, beginning with Dr. Jim Loden, President of Loden Vision Centers in Nashville Tennessee. It's great to talk with you Jim.

Jim Loden:

Thank you so much Marguerite, always enjoy our times together.

Marguerite:

Next we have Dee Stephenson who is the President of the American College of Eye Surgeons and CEO and founder of Stevenson Eye Associates in Venice, Florida. Welcome Dee.

Dee Stephenson:

Thank you Marguerite.

Marguerite:

The esteemed Dr. Vance Thompson is also with us. Dr. Thompson is a Professor of Ophthalmology at the University of South Dakota, and Director of Refractive Surgery for Vance Thompson Vision, both in Sioux Falls, South Dakota.

Vance Thompson:

Thank you so much Marguerite, it's an honor to be here.

Marguerite:

And last but not least, we'll be hearing the valuable insights of Dr. Blake Williamson of Williamson Eye Center in Baton Rouge Louisiana.

Blake W:

Thanks Dr. McDonald.

Marguerite:

What a great panel. Why don't we start by finding out how everyone feels about the state of the EDOF and accommodating lens technology today.

Blake W:

I just think, what a great time to be a refractive cataract surgeon. I find that specifically the new generation multifocals and now the EDOF lenses have been fantastic in patients’ happiness.

Vance Thompson:

I feel like the companies have brought us absolutely amazing technology with the low-add multifocals and the extended-depth-of-focus implants. We still have also the accommodating implant and technology that's on the horizon. But right now our patient satisfaction levels have never been higher because of these technologies the industry has brought to us.

Jim Loden:

Well the technology has just exploded. We've seen the progress with the low-add multifocal lenses and extended-depth-of-focus lenses, and this is just a great increase in our capabilities.

Marguerite:

What about you Dee?

Dee Stephenson:

Well you know Marguerite, you and I have been doing this a long time, and it's an exciting time to be into ophthalmology. There have been some new lenses on the market recently, with the Symfony, the Symfony Toric, the low-add multifocal from Alcon, and of course the Trulign accommodating lens that is the same platform as the Crystalens platform. And I find that I have a place for just about all of these lenses.

Blake W:

You have to have the right personality for advanced IOLs as you know. You have to pick the right patients. We feel like we do a great job of that at Williamson Eye. We do a Dell Questionnaire. I have a chance to talk with every single patient preoperatively.

Marguerite:

The Dell Questionnaire is really terrific, can you tell our listeners a little bit more about it.

Blake W:

What's great is for the patients to have an idea what they want before you get into the room. And it's great because it gives you an idea of their personality. So what the Dell Questionnaire does, is it says are you more interested in near vision, or intermediate vision? Is driving at night critically important to you? If you had to wear glasses for one task what would it be? That sort of thing. And it gives you a sense of the patient's lifestyle, how they want to use their eyes after surgery. Everybody has a right to know how they can use their eyes after surgery. So the Dell Questionnaire kind of gets you in the frame of mind of what IOL this patient may want. At the very end it asks them to grade their personality. A lot of times some of them won't even circle whether they're a perfectionist or easy going, and those are the ones you have to kind of think about, "Oh I am sure this is really a good multifocal candidate?"

Marguerite:

That seems useful. Particularly because the patient's lifestyle and expectations are so critical in picking the right IOL.

Dee Stephenson:

I think it's probably the best questionnaire. There are some things that I have reworded a little bit for the type of patient, but I think it's an excellent thing.

Marguerite:

I think I'm going to start using the Dell Questionnaire. What sort of person would you recommend an accommodating IOL versus multifocal or extended-depth-of-focus Vance?

Vance Thompson:

Well even more, since I don't have a true accommodating implant, I can use what I call a pseudo-accommodating implant with the Crystalens. I have a tendency to reserve that for a fairly highly aberrated cornea. Because really what I'm trying to do is not create reduced contrast or contribute further to reduced contrast in a patient that maybe having some nighttime glare issues even before they developed the cataract. So I have a tendency more to lean real heavily on low-add multifocals and extended-depth-of-focus as long as they have a fairly clean cornea and there's not a lot of high order aberrations coming from their cornea. I'm doing 40% of my patients in cataract surgery with low add multi-focals and extended-depth-of-focus.

Jim Loden:

I encountered this exact question just this week when my optometrist came to me and said, "I need you to interview this patient." And that's what it really comes down to. Doing an in-depth interview, and I sit down with the patient and I say, "Share with me what you do at work and what you like to do on a recreational basis." The woman I was thinking of was an analyst. So she runs two large computer monitors, she has an iPad or a laptop computer with her, and she's working on spreadsheets. So this is a more difficult patient to work with, because we're working with three zones of vision continuously. So we counseled her as to what the low-add multifocal would do, it can probably get her reading her spreadsheets, the optimum range would be somewhere between 18 and 20 inches for looking at her near vision and her computers. But her larger computer, she may have to increase the font size on. The other option is to maybe even do a mix and match with an extended-depth-of-focus lens in the dominant eye to give her more of that intermediate arm's length vision where she was showing me her monitors were at arms length. So it's really about taking the time to interview the patient and find out what their personal needs are.

Marguerite:

So Dee, pretend I am Mrs. Smith, I am the perfect EDOF candidate. I have a healthy cornea, I have almost no dry eye, I don't have a bizarre angle kappa. So how would you explain EDOF to me and get me to say yes?

Dee Stephenson:

Well, first of all you've had an exam and you knew coming in that's what you wanted. So basically, I have a little spiel, but my biggest person is my surgical counselor. But I have a spiel, and I do say, "I have more experience with these lenses, and less experience with these," but we've learned over time that not all these premium lenses are created equal, and that intermediate is so important to them. But I also want to talk to them about driving. Because driving at night, I'm not sure that the extended-depth-of-field Symfony or Symfony Torics are for them, because they do have halos and glares albeit less than with the current technology and the new low-add Alcon lens, they have less halos and glares. But that's a big issue, but how do I convince the patient? The technology probably doesn't matter to the patient at all. It's what their outcome's going to be.

I try to encourage them to know a little bit about the lens and know about the down sides of it, but at the same time ... a lot of times the patient has their mind made up, it's usually not very hard to convince them to do something different if it's what I choose, but a lot of times they're telling me what they want. That's where I have an issue, so I just have to say, "Well remember," and I have them sign something that tells them that we've discussed this, so they actually sign it, I sign it, date it, and I give it to them, I keep a copy and they keep a copy. So I'll always go back and say, I only promised you this at near, and this is what you circled, so if you're J3 and you circle and you come in and you're J1, I've given you more. So I always undersell it, I always undersell it and go for the lower.

Speaker 1:

Informed Consent, Getting to Yes is editorially independent content supported with advertising by Allergan Eye Care.

Marguerite:

I'm a nice, normal candidate for an EDOF lens, I've got great topography. I don't have severe dry eye. How would you explain it to me? How would you get me to yes? What would you say?

Blake W:

I'll tell you exactly how I do it. Before I enter the room the first thing that my technician tells me, they need to tell me two things, I only want to know two things before I enter the room. The first thing is, what else is wrong with the patient's eye besides the cataract? And the second thing is, do they have any astigmatism? And if so where is it? We know that second question can be quite loaded. We want to make sure that our topo and our IOLMaster and everything's matching. But the reason I do it like that is because if the patient has some dry eye, if the patient has some AMD or something, which they invariably do, I always position that as the primary problem, and since it's chronic, there's no cure for that, only treatment.

I say, "The cataract is something I can fix, but you're still going to have these other issues." And then I bring in the astigmatism component, and I say, "Here's something that we can fix, and by the way, you're going to have to fix it one way or the other. Either after surgery with spectacles or if you prefer, since you're already on the table there, we can use my femtosecond laser or we can use this specialty advanced lens to fix your astigmatism and get you seeing better." And when I say it like that, patients are much more agreeable, because they say, "Okay, I have this, this, and this which can't be fixed but treated, but I have these things which can be fixed. Of course I want to fix those." So in terms of what I say to talk about a multifocal IOL such as a TMF or a Symfony lens, what I tell them is, "The lens that you choose for your eye is the most important decision you're going to make for your vision for the rest of your life."

And the reason I say it like that is because it's almost like putting in a heart valve in the sense that it's never going to come out, I'm never going to do this again, you're never going to have cataract surgery again, so it's in there forever. So it's very important that you think critically about how you want to use your eyes, not only now, but 10 years from now. And when I kind of frame it like that, the patients are understanding the finality of cataract surgery and having a lens implant in there. I found by doing that, we were able to get more conversions.

Jim Loden:

One of my favorite questions to ask is, "If I gave you great distance vision without glasses, driving at night without glasses, watching TV, going to a sporting event, but you still had to wear readers for up close and computers, would that be acceptable or unacceptable?" That question gives me a lot of insight into the patient's expectation and what they're really wanting. When they tell me, "That's not really what I want," that's when I really start going in to the extended-depth-of-focus or multifocal lenses. Then I ask questions, "If you could have great distance vision, dashboard of the car really clear, looking at a computer monitor, looking at price tags in the store, going through a grocery store looking at the shelf prices, but you still had to wear some plus one readers for fine print, would that be acceptable or not?"

That gives me insight as to whether the EDOF lens is going to work well for them. If they say, "No, I really want to read," like an English teacher I did surgery on recently. I said, "What do you do?" And she says, "I read a novel a week." Well I'm going to do a little bit higher-add multifocal lens on that patient. She says, "I don't play sports anymore, I do a little bit of nighttime driving but I'm not doing a lot." This is a true multifocal lens candidate in my practice.

Vance Thompson:

I'm also looking at the patient, and I'm looking at how long their arms are, where they're probably going to enjoy reading. Sometimes I even ask them to show me at what distance they want to read and do they use a computer a lot? And when they really are talking to me about, "Hey, I want to be able to do the majority of what I do without glasses, at distance intermediate and near." If I'm going to do that with a lot of confidence, I have a tendency to drift towards a low-add multifocal. Somewhere in that 2.75 add, the 3.25 add range, and I'll even mix and match, sometimes using the 2.75 add in the dominant eye and the 3.25 in the nondominant eye. If there's someone who says, "You know, I do a lot of nighttime driving, and I really want to maximize my contrast sensitivity but I don't want to do monovision. I really want to not have to use glasses at distance and intermediate. And hey, if I need to sometimes put on a pair of readers for near, I'll be okay," then I'm drifting towards extended-depth-of-focus in those situations. Because the low light image quality has been so impressive.

Marguerite:

So I'm Mrs. Smith. I'm going to tell you that I'm still working and I do everything on a digital device, everything. I almost never pick up a hardcover book.

Jim Loden:

So I would say Ms. Smith, I really feel like an extended-depth-of-focus lens is going to be the premier product for you. My expectation for you postoperatively is you're going to be able to drive without glasses, you're going to be able to see the dashboard of your car, you're going to be able to look at a computer monitor, you're going to be able to read a kindle or iPad as long as you hold it out about 20 or more inches and use a little bit larger font size. It's going to be a really good product for you. But you're in a dark restaurant, if you're trying to work real small figures, balancing your checkbook, looking through accounts, you're probably going to need some plus one reading glasses, would that be acceptable for you?

And if they say, "Yes, that's acceptable," then I'm immediately going to go into the EDOF technology and schedule the patient for that. If they say, "No, that's not really,” if she said, "Dr. Loden, I know I said I don't read that much, but I really want to go to a dinner and be able to read the menu without my glasses," then I'm going to go more toward the low-add multifocal at that point. I feel like it's really important to discuss this preoperatively with them to set their near points, even go over what size print that I expect them to be able to read, what size print I don't expect them to be able to read, and the distance that's going to be necessary to facilitate the best visual outcomes.

Marguerite:

Of the presbyopia-correcting IOLs that are available, would you consider putting any of them in someone with say a well centered myopic or hyperopic laser vision correction of PRK or LASIK.

Blake W:

Sure. Obviously an accommodating IOL would be absolutely reasonable in those cases. You know what I found, is that these EDOF lenses have actually worked very well, not setting as well. I know a lot of people who have been doing this, and I've had some success doing it. And the Symfony has been just a really a windfall in terms of freedom from glasses and less nighttime symptoms than our traditional multifocals. I've put them in a fair amount of post refractive patients. As you mentioned, topography is very important, but I think that it's possible to try some EDOF lenses in the post refractive setting. Multifocals, I just hadn't gone there. Just because really I hadn't needed to. If you have a great option like an accommodating IOL in a patient like that, and now the EDOF, I don't know that you really have to go to a multifocal, but I do know that some people are doing it successfully.

Dee Stephenson:

I'm getting so many post refractive patients now. The baby boomers are back with cataracts, and they want the same results as they got with their refractive procedure. It's all about toricity for me. Happy patients are different today than happy patients were 25 years ago, or 28 years ago when I started. Patients come in and have an idea of what they want. Whether they want to ... they don't mind wearing reading glasses or task glasses, but they want to see perfect far away. There's several options for them, accommodating, multifocal, and extended-depth-of-field lens. So you have to really look at the eye and the pathology of the eye.

Marguerite:

But what exactly do you say to that kind of patient Vance?

Vance Thompson:

A situation like that where patients had previous refractive surgery, there's a very high chance they want to do a lot without glasses. And then if they have a fairly aberrated cornea, but at the same time she maybe was pretty happy with that 16-cut RK. Because I find that sometimes people will go to blaming the RK for nighttime glare, when before they had a cataract they didn't have a ton of nighttime glare, they were happy with their image quality. And if she said she was happy with her image quality before RK, I'm going to talk with her about both EDOF and I'm going to talk with her also about the accommodating implant. But if I see a fair amount of high order aberrations, or for sure if she always felt like she had nighttime glare prior to cataracts developing, I'm going to do the accommodating implant.

And I'm going to tell her that the principle of the accommodating implant is such that we typically will get real good distance, real good intermediate, sometimes actually quite good near. Especially if it's in both eyes. And we get even better near if they allow for a little bit of mini-monovision. We'll go for plano typically in the dominant eye, and around -1 in the nondominant eye. And it's amazing, we can make a lot of patients happy that way, especially if they don't mind a little pair of glasses for nighttime driving, and occasionally reading. But the expectations to go into this with is, "Hey, if we can get you doing 90-95% of what you do without glasses, will you be happy?" And they say yes, I know I can help that person be happy with that technology.

Marguerite:

Great. And do you ever use percentages, like you told me, like hey, you know 90% of the time, I actually love using percentages because they can really wrap their brain around it.

Vance Thompson:

Yeah, I do. I feel comfortable, especially saying 90-95% when I feel the majority of the time I'm going to be able to achieve their expectations. I'm trying to leave in that 5-10% expectation so they know pre-experience that they're not going to be 100% spectacle independent. I love saying, "We're not here to rid the world of glasses. What we're here to do is rid the world of spectacle dependency."

Marguerite:

I'd like to know how you counsel patients about night vision.

Jim Loden:

I tell everybody that any of these products have the potential to give them some light phenomena. Even when we look at monofocal lenses, if you look at the package inserts, 3-5% of patients typically have some photopsia described in the FDA clinical trials with monofocal lenses. So I'm very up front that we do expect some photopsias with any of these products, and it's just a matter of what they can manage.

Marguerite:

I know that we could keep this going, but we've covered a lot of ground about your methods of getting to yes on extended-depth-of-focus and accommodating IOLs. So thank you all so much.

Jim Loden:

Absolutely Marguerite, anytime.

Vance Thompson:

Thank you so very much Marguerite.

Dee Stephenson:

Thanks Marguerite for everything.

Blake W:

Thank you for the opportunity, this is great.

Marguerite:

What a great discussion. But with guests like these it always is. So please join us for the next Informed Consent, Getting to Yes.