ophthalmology-off-the-grid
Ophthalmology off the Grid
Episode 90

Trifocal IOL Lessons From Abroad

Cohost Blake Williamson, MD, MPH, invites Raymond Stein, MD, from Bochner Eye Institute in Toronto for a conversation about the PanOptix, a presbyopia-correcting IOL that was first approved by the FDA last year. Dr. Stein draws on his extensive experience and shares surgical pearls for US-based surgeons who are acclimating to this new technology.

Blake Williamson, MD, MPH: Open, outspoken. It's Ophthalmology off the Grid, an honest look at controversial topics in the field. I'm Blake Williamson.

Speaker 2: Today on Off the Grid, Dr. Blake Williamson invites Toronto-based ophthalmologist Dr. Ray Stein to speak on his extensive experience with a new trifocal IOL technology.

The PanOptix presbyopia-correcting IOL was first approved by the FDA last year and is the first and only trifocal lens approved in the United States. Listen as Dr. Stein shares surgical pearls for US-based surgeons who are acclimating to this new technology.

Coming up, on Ophthalmology Off the Grid.

Speaker 2: Support for Ophthalmology off the Grid comes from Diamatrix, supplying surgeons with innovative products like the X1 iris speculum. Its unique ability to simultaneously capture both iris and capsule makes this device a game changer, providing superior stabilization of the pupil, capsule, and anterior chamber. Visit diamatrix.com to learn more or request a sample.

Gary Wörtz: Hello, everyone. Gary Wörtz here. Before we begin this episode, I want to share a quick message with our listeners about what you can expect in future episodes of this podcast. Ophthalmology off the Grid has had great success highlighting physician stories and experiences. We love getting to know our guests beyond the OR and clinic and learning about the path that got them to where they are today.

Over the past few months, my cohost, Blake Williamson, and I took some time to focus our episodes on the COVID-19 pandemic, but now we're going to shift the focus back to personal themes. It's likely that stories related to the pandemic will come up in our future episodes, but for more focused content on returning to practice, be sure to subscribe to CRST The Podcast, which will feature a miniseries titled Back to Practice. The podcast miniseries will explore topics such as patient and staff safety protocols, patient co-management and referrals, and premium technology in the COVID era. Be sure to tune in.

Blake Williamson, MD: Hey everyone, welcome to another episode of Ophthalmology off the Grid. We've got a fantastic podcast for you today. I'm very, very excited about not only the topic, but especially the guest. Just this past year, a few months ago, Alcon released the first and only trifocal presbyopia correcting IOL here in the United States, and it's been something that many refractive cataract surgeons from coast to coast have been very excited about. The early outcomes have been terrific from the majority of surgeons I talked to. Certainly, my own outcomes have been good, and the FDA trial also was very promising.

We're all searching for that perfect presbyopia-correcting IOL, and there's actually a lot of good options on the market today, but Alcon has come through with the first trifocal that we have here in the United States. I was trying to figure out where do I position it, and what types of patients would most benefit from this, and what are the pluses and minuses of the lens, and a lot of the trade journals and a lot of people I was talking to were US-based surgeons who've only put in a handful. I said, "Well, this has been out, OUS, in Canada and in Europe for a long time. It might be cool if I tracked down the number one volume implanter on planet Earth. If I could somehow find the guy or gal who has put in more PanOptix literally than anybody on the planet, I'd like to track them down and have a conversation."

That's what we did today. I'm very happy to bring in our guest today, the one and only Dr. Ray Stein from the Bochner Eye Institute in Toronto. Ray, how are you?

Raymond Stein, ND, FRCSC: Oh, thank you very much for the kind invitation on a really hot topic that I'm really quite passionate about. I'm not a consultant for Alcon or any other company. I've been involved with refractive surgery over the past 30 years, and the technology that I use in different areas of my practice are ones that allow me to get a very, very high patient satisfaction with very limited chair time postoperatively, so very happy patients. So, I'm happy to speak on PanOptix today.

Blake: Thanks, Ray. I appreciate it. I thought it was really cool and telling that the surgeon that's done more of these than anybody on Earth isn't even an Alcon consultant. That was refreshing to kind of hear or learn. I think many people know you. You've won several awards from the AAO and even the Innovator's Award from ASCRS. You've done over 200,000 eye procedures. So, people, especially refractive surgeons, know who you are. I've had a chance to meet you a couple of times at various Refractive Surgery Alliance meetings. But for those who don't know you, can you tell us a little bit about yourself, where you practice, where you trained, and kind of what your current practice is like now?

Ray: I did my medical training at the University of Toronto, then I went on to do an ophthalmology residency at the Mayo Clinic, and then I did a cornea external disease fellowship with Peter Laibson at Wills Eye Hospital and basically have been back in practice now for the last 30 years. My practice is mostly refractive. I got involved with laser vision correction in the early days in 1991 and have a very active cataract and refractive lens exchange practice, along with implantable contact lenses and the treatment of keratoconus with cross-linking and topography-guided PRK.

So, a variety of different procedures, very exciting technology that's continued to advance, but one of our biggest areas of growth in the last few years has been the presbyopic IOLs, both for cataract surgery and refractive lens exchange. What we're finding is a significant number of patients coming in in their late 40s, 50s, and 60s, they're typically low hyperopes, they never used to wear glasses, and the first thing that went was their reading ability. Now their distance is getting blurrier and blurrier.

These patients are very, very motivated to do something. Certainly, we could offer laser vision correction with monovision or just give them the best distance vision and have a pair of reading glasses. But almost everybody today wants to be able to see their cell phone, see their computer, and drive comfortably at night. The presbyopic IOLs, in the form of the trifocal lens, has made a huge difference in our practice. In fact, I've been involved with the PanOptix for the past year and a half, but the past 3 or 4 months, over 80% of the lens implants we're implanting are the trifocal lens. We have no hard sell in our office. We just share patients with the concept of either getting the best distance vision or to try to get the full range of vision, and most patients today are choosing that full range of vision.

Blake: Yeah, right. That's great. I think, obviously, with the volume that you do, certainly you have a unique setup and unique surgical practice. Can you walk us through what your typical surgical week is like? Do you operate 2 days a week or 3 days a week? How many cases are you usually doing, and, of those, how many are PanOptix? I'm trying to understand what you're…

Ray: Sure. I do have a relatively unique surgical practice in that I put in a 5-day week, but 4 days of the week, I'm in the operating room. Two days, I'm doing cataract or refractive lens exchange, and 2 days a week, I'm doing excimer laser treatments with PRK or SMILE. For cataract or lens exchange, we're doing around 50 cases a week, and I would say that now pretty close to 80% of those implants are the trifocal implant from Alcon.

Blake: It's interesting, because the whole point of finding you is because people who do a large volume—I also do a large volume of cataract surgery, I'll sometimes do 30 to 40 cases in one day, and when you start doing that high of volume, especially with advanced IOLs, you start to learn all kinds of things that you might not otherwise learn if you were just doing one of these lenses per week. So, I'm kind of curious, with the PanOptix, when did you place your first one, and what kind of cases did you choose? Sort of, what was your early experience? Were you surprised by anything?

Ray: We started about a year and a half ago and started very, very slowly with the PanOptix. I've been involved in so many presbyopic IOLs over the years, including ReSTOR +4.0 and Tetraflex and Crystalens and ReSTOR +3.0 and +2.50 and the Tecnis Multifocal and the Mplus and the Symfony and the FineVision. There were some positive features about many of these lenses and some negatives, but we started slowly, and I never believe things that I hear or that I read. I need to start very slowly with safe technology and make sure the patients are doing as well as I think that they're going to do.

We chose some patients for refractive lens exchange that were relatively low hyperopes to give them distance and reading, and we treated cataract patients that definitely had clear corneas, no irregular stigmatism, and OCT evaluation showed no evidence of an epiretinal membrane or macular degeneration. So, basically, these patients have healthy eyes, and the cataract patients obviously just have lens opacities, but nothing else going on.

Blake: Yeah, I think it's a good pearl that you just shared. If you're kind of trying to pick your first few cases, really with every presbyopi9a lens that I've used just about, but especially with this one, choose your low hyperopes. Choose patients that have a relatively dense cataract, where they're going to be happy no matter what you do. So, I think that makes good sense. Ray, is there anything that's really stood out to you? You mentioned all the other presbyopia-correcting IOLs you've been a part of. Is there something about PanOptix that kind of stands out or is different than, say, the other ones that you've tried that's something that you really like about this PanOptix trifocal?

Ray: I had required a lot of chair time with many of the other multifocal implants, whether they didn't have satisfactory reading vision the first few days out or they had a higher chance of glare and halos at night. So, I used to see these patients on a frequent basis postop, but the PanOptix has changed this all for me. Most patients are delighted on the first day postop. They're able to read their phone. They're able to read the computer. For me, J1 is not important. If the patients are able to see J3, they're usually just delighted. However, many patients with PanOptix see better than that.

But I get very, very few complaints in terms of glare and halos at nighttime. The proper patient selection…one of the important things that we learned, and we've learned this with other lenses as well, is angle kappa is important. If the patient has a very high positive angle kappa where their line of fixation is closer to the nose, it's very difficult to position this lens on the line of sight. So, basically, the center of the lens is de-centered relative to the line of sight, and these patients have a higher incidence of glare and halos.

So, the number that we tend to use is about 0.5 mm. If the patients have under 0.5 mm, then they usually have very good quality of vision during the day and night. Between 0.5 and 0.6, there's a little higher chance of some glare and halos, and certainly over 0.6, a much higher incidence. So, for me and my practice, it's generally an absolute contraindication over 0.6, and 0.5 to 0.6, we counsel the patients.

But we're very careful. We, as you probably do too, we administer a questionnaire before we see the patient, and we ask a variety of questions. One is, “Would you tolerate some glare or halos at night as it occurred,” how much driving do they do during the day and night, and how they would rate their personality from an easygoing to a perfectionist scale. So, someone who rates their personality as a perfectionist that does a lot of driving at night, I probably wouldn't select this as an ideal candidate for PanOptix, but in general, we're seeing that 80% or more patients seem to fall into the good category for patient selection.

Blake: So, Ray, one of the things that you talked about was trying to select patients based off their angle kappa. I'm curious what device you're using to measure that, whether it's an OPD or something else. Are you doing anything surgically to kind of account for that? I know some surgeons will actually nudge the IOLs when the center button is a little bit more nasal. Do you ever do anything like that or modify your surgical technique based off that, and what are you using to assess the angle kappa?

Ray: Those are very good questions. We use the OPD, although there are a variety of instruments that allow you to detect angle kappa. By far and away, the myopic patient has a low angle kappa. It's usually the high hyperopes that have the positive angle kappa that is high, and so we do an OPD evaluation on each patient. That helps us with the counseling tremendously, because sometimes we see patients with +6.0 diopter hyperopes that has a very high angle kappa, and we don't recommend a trifocal lens in these patients.

But at the time of surgery, I spend a lot of time at the very end of the case to try to move the optic to the line of sight. I have a…ring with a red fixation light that the patient looks at. However, you don't really need this. You can have the patient look at the microscope light. Sometimes there are two lights. Sometimes there are three lights. We have the patient look in between those lights, and that's extremely helpful. Most of the time, you can nudge the implant to the line of sight.

Very important surgically is make sure that you take all the viscoelastic out from behind the lens. Otherwise, the viscoelastic can come out after and shift the lens, and then we tap down on the implant to make sure it's secure. To our surprise, and this was a big surprise for me, the lens, wherever I left it at the time of surgery, it tends to be in that same position postoperatively. So, that was a really nice feature with this trifocal lens.

Blake: I think that's a really good tip. A lot of times, people think about taking out the posterior viscoelastic with toric IOLs, but it makes sense to do the same thing with your presbyopia-correcting IOLs, especially if you're trying to line them up on the coaxial light using the Purkinjes. So, I think that's a really good tip.

Ray, many of the surgeons that listen to this podcast are here in the United States, and they may have had more experience with the ReSTOR +3.0 and ReSTOR +2.5 ACTIVEFOCUS from Alcon. Did you have any experience with those? Is there anything that really stands out about this PanOptix lens versus those other two lenses that they may have more experience with?

Ray: To our surprise, the quality of distance vision is excellent, and, in my mind and experience, better with the trifocal lens. They seem to have better intermediate vision, and they seem to have very good close vision. So, quality of vision, low incidence of night glare or halos, and more of the full range of vision has been very positive compared to some of the other lenses, like those ReSTOR lenses that we used in the past.

Blake: Yeah. It's interesting. The ReSTOR +2.5 ACTIVEFOCUS, the central button, we're supposed to be dedicated all to distance, but like you, I've found that this lens has every bit as good of distance vision as that lens did. Here in the States, you can get the yellow version or the clear version. Which one do you prefer, and also do you have any concerns about glistening, things like that, long term?

Ray: In Canada, we just have the yellow tint. I would welcome a clear lens. I'm not sure that the yellow tint is really necessary. So hopefully, down the road, we'll have access to that technology. Certainly, we were concerned about glistenings before with other Alcon lenses, and Alcon did make some manufacturing change, and the lens has a lower incidence of glistenings, but it's not 100% reduced. So, there's always that concern, long term, of some glistenings, but even the patients that I treated with the ReSTOR lens many years ago when we started, and some of them for sure had significant glistenings, it was very rare for those glistenings to interfere with the quality of vision.

Blake: Yeah. So, those patients are still very, very happy. Ray, you talked about sort of starting slow, and I like what you said. Any time you're evaluating a new technology, you're going to not just believe what you read or hear. You do it for yourself, which I think everyone listening to this podcast hopefully feels the same way about adopting new technology. But you kind of start slow, and you put it in the right kind of patient. What about...at this point, I mean, you've literally done more of these than anybody in the world, over 1,000, I assume. Are there some instances where you feel more comfortable now that perhaps you wouldn't before? Because we're always talking about at these meetings, "Well, can you put it in post-RK if the topography looks good and post hyperopic or myopic LASIK...” Are these technologies that you're putting there, or, being that you're in Canada and you might have access to other lenses, are you using other lenses in those scenarios?

Ray: Those are good questions. I have a very active excimer laser practice over the past 30 years. So, we have many patients that I operated on when they were in their 20s and 30s. Now, 20, 30 years later, they're interested in improving their sight further. So, we see patients that we did LASIK or PRK on that are coming in and asking about reading or that group is coming in because they've developed cataracts. Almost in 100% of these cases, they're very interested in gaining both the distance and the reading vision. These patients are tremendously motivated. They were interested years ago in improving their distance, and now they want the full range of vision.

We've been very successful in treating these patients with the trifocal lens. One of the caveats is that we always ask them what their quality of vision is, certainly before they develop any cataracts, post-LASIK or PRK. What is the quality of vision like at nighttime? If it's raining, if it's snowing, if the leaves are falling, can they see well? If they have a very good quality of vision from their previous LASIK or PRK at nighttime, then I feel very comfortable going ahead with the trifocal lens.

Yes, there are a variety of measurements. You can measure higher order aberrations. But, the most effective means of patient selection we've found is just to ask patients what their vision is like at nighttime. If they're doing well, then we do well with the trifocal lens. A very high percentage of the patients that we did previous refractive on are opting for trifocal lenses and are doing very, very well.

Blake: Very cool. Sort of the reverse to that question is, now that you've had so much experience, are there some clinical scenarios which you thought it would be a slam dunk and maybe it's not so much? Maybe you're trying to use a different IOL or not a presbyopia IOL at all.

Ray: We thought initially that the RK patients would probably not be great candidates for a trifocal lens, and I would say the vast majority are not because a lot of them have starbursts at nighttime, and I certainly don't want to increase that for them. But there are different situations. Everyone's a little different. Some patients don't do any driving at night or even during the day, and those patients could actually have a trifocal lens, even though they have some starbursts at nighttime.

Blake: Yeah. So, I think that that kind of hits on…you need to talk to the patients. It's not all about just taking measurements. You need to understand how they're using their eyes and how they want to use their eyes after surgery as well. So, Ray, you mentioned that the majority of presbyopia lenses that you're using is PanOptix, but are you using any other presbyopia IOLs, and, if so, what types of patients are getting those lenses?

Ray: I am not using any other presbyopic IOLs. I certainly put in probably a few thousand Symfony lenses and certainly liked the material of the Tecnis platform, but we found that many patients didn't have satisfactory reading vision. If we left one eye slightly myopic, yes, they could read better, but there was a higher incidence of aberrations at nighttime. So, if patients are not a good candidate for a trifocal lens, then I will go with a monofocal lens, often a toric lens, if they have about 0.75 diopters of astigmatism or greater.

Blake: OK, great. Yeah, I'm still doing a good number of Symfonies. I really like the defocus curve and then it's a little bit more forgiving. So, I have several clinical scenarios that I use it in, but I'm with you. Especially for the low myopes, I've found that PanOptix is just superior for near vision. Another opportunity would be kind of mixing and matching. If you are going to use a Symfony lens with a more traditional multifocal, there's EK or ZL.

Ray: I should just bring up one kind of interesting scenario. We have many patients that had a monofocal lens in one eye that come in with a second cataract in their other eye. We do talk about the trifocal lens with them. Certainly, we didn't do this when we started the trifocal lens, but we learned pretty quickly that it can be very successful in this scenario in allowing both eyes to have good distance vision and one eye to have good reading vision. So, this is another option that's very reasonable.

Blake: Yeah, I've done that routinely, and one of the things I like about that scenario is you have the opportunity to kind of undersell the patient on the front end because you say, "Hey, listen, this is going to give you depth of focus, and you'll have some reduced freedom from glasses, but maybe not complete freedom, because, remember, you only have this in one eye." Lo and behold, you do the PanOptix, and next thing you know, they're at J1 and J2, and they're not using readers at all. So, I think it’s a great opportunity to sort of overdeliver.

So, again, with this high number that you've done, I mean, not everybody's going to be happy. If you do enough surgery, like you and I do, you're going to run into some unhappy people. You're going to have to do some touch-ups. You may have to do an explant here and there. Can you talk about some of the early signs of dissatisfaction with this lens and maybe some signs…for a lens exchange and if there's anything that we can do as surgeons, besides preoperative testing and counseling, anything that we can do to reduce the chances of having to do a lens exchange?

Ray: Yeah. Well, over the last year and a half, I haven't had to do one lens exchange with the trifocal implant. So, I've been very, very pleased about that. But I try my best to make the patient happy and try to identify why they have some complaints, if they have some. Obviously, if someone has a loss of best corrected acuity, it's imperative that you do an OCT to rule out cystoid macular edema. It can be very subtle. Patients can have 20/25 vision and can have significant cystoid and have a decrease in their intermediate vision. So, OCT evaluation is critical.

If the patient has even a mild or moderate capsule fibrosis, that can knock the quality of vision down, give them some glare or halo. You obviously have to be careful with doing a capsulotomy because doing a lens exchange after is potentially complicated. But so far, in the capsulotomies that I've done in the right patients, we haven't seen anybody that didn't improve, that required a lens exchange, which would have been more complicated.

I think if you're going to get involved in premium IOLs, you need to be able to refine the refractive outcome, whether you do this yourself or you partner with a refractive surgeon, but we have found that if patients certainly have a diopter of residual astigmatism or +0.75 on their sphere, they may not be delighted. They may have more aberrations. They may not be able to read as well, and so usually 3 months postop, when refractive error is stable, we will offer either PRK or LASIK with a very high incidence of very happy patients afterwards.

Blake: Yeah. It's one of those things. You can get them all the way to the 5-yard line, but you've got to get them into the end zone. It's the difference between someone being 20/happy and someone being 20/heck yes, because 20/ecstatic is very different from 20/happy. So, I think the ability to touch up even small amounts of residual refractive error really is key.

What about that patient that comes in, you do their first eye, and they're mostly happy, but they kind of talk about, "Oh, I feel a little bit off-balance, and I don't know about this other eye," and you're thinking, "Well, it's probably because you still have the cataract in the other eye. We need to go ahead and do the other eye?” How do you handle that conversation? Have you had a patient like that that says, "Wait. I want to hold off for a while until this lens heals," when you know that all they really need is just to have the same lens technology in both eyes?

Ray: Well, you bring up a good point, and there are certainly patients like that, where they're really off-balance with two different levels of vision. We certainly don't want to ever push anybody into surgery, but we certainly encourage them to have the second eye done. Most of the time, with time, the patient will come back, have their second eye done, and they're very happy.

I just want to bring up one other point, and that is ocular surface disease. Now, we don't see a lot of patients for refractive lens exchange or cataract surgery that have significant ocular surface disease that makes us concerned, but it's not uncommon postoperatively as a reaction to maybe the betadine, reaction to preservatives in the medication that we give patients, that they do develop some toxicity and punctate keratitis and the quality of vision goes down.

So, we are very aggressive with preservative-free lubricating drops postop, and sometimes it takes a number of months for the best quality vision to be achieved in that small percentage of patients that may be symptomatic. Sometimes, we just need to encourage them, and if they have meibomian gland problems, we'll often do the LipiFlow procedure free of charge for the patient. If they have a mild residual refractive error, I will pay for their glasses. I will encourage them to get a pair of glasses to help them maybe with nighttime vision, and they will send me their receipt, and I'll reimburse them. All these goodwill things are really helpful for patient management.

Blake: I think that's a fantastic point, and the surgeons who may hear this may say, "Gosh, I don't want to be buying patients’ glasses," but the reality is, I bet you the percentage that you have to do that for is actually extremely small…

Ray: Yeah, it's very rare.

Blake: Yeah, exactly. But being able to do that and really make sure that you control their experience and keep them happy is great, and also waiting a few months before you have to do a touch-up or otherwise, we always tell patients, "It took a long time for your vision to get this bad. It's going to take a little while for it to get a little better," and they seem to understand that.

We've talked a lot about how this lens fits into your practice and what your experiences have been. I'm kind of just curious to pick your brain on the future. I mean, I don't think that we're going to be doing trifocal or any type of multifocal lens, necessarily, 50 years from now. Are there lenses on the horizon, not necessarily certain types of lenses, but at least using certain mechanisms for presbyopia correction that you're looking forward to using? I'm wondering where you see presbyopia-correcting IOLs going in the future.

Ray: Well, it would be nice if we had a lens that would be super easy to take out if the patient wasn't happy, although I haven't had any experience like that with the trifocal. But one lens that I'm very excited about is the implantable contact lens. Staar Surgical is developing a presbyopic ICL. This has great potential, especially for refractive lens exchange patients. These are patients in their often later 40s or 50s or 60s with crystal clear lenses that, rather than take the lens out, we can insert a lens into the sulcus that can refine their distance vision and give them reading vision.

In addition, we know that the ICL is a fantastic sulcus lens and can be used post cataract surgery to refine refractive outcome, to correct hyperopia, myopia, or cylinder. So, with a presbyopic ICL, theoretically, the millions of patients that are out there that have monofocal lenses or toric lenses, we may be able to offer them this presbyopic option by inserting a lens into the sulcus to, one, refine their distance outcome if it's not perfect and to give them better reading vision. So, very, very exciting technology.

Blake: That's excellent. I can't tell you how many patients come back to me a year, 2 years later, after we've already perhaps done a YAG capsulotomy, that say, "Doc, I wish I had gone with that nice lens that gets you out of reading glasses." So, I think that would be a remarkable tool to have, and the ICL is so important to have in our toolkit as refractive surgeons.

I'm looking forward to adjustability myself. We just got the light-adjustable lens. I'm looking forward to that, and down the road, more biomimetic approaches, lenses that actually simulate accommodation as it naturally happens, but it seems to be that at least those are a few years away.

So, Ray, in your experience, we all want happy patients, and we all want patients to know that we care about them, regardless of what technology they choose, and we know that sometimes the patients that choose technology that they have to come out of pocket for, sometimes there's a little bit more handholding that goes on than is necessary. Are there any things that you do with your patients to kind of get that buy-in and sort of build that rapport between you and the patient?

Ray: Yes. I want to make sure that I'm available to all my patients, and so on the first day post-op, after I examine them, I give every patient, every surgical patient, my card with my personal email, and I handwrite my cell phone number down on it. Now, I'm sure most surgeons are almost fainting listening to this, but since I've been doing this over the last year, I get very, very few phone calls. I just want to make sure if a patient is having some concern and they can't get through to the receptionist or they don't get the message that they want, they have access to me. Most of the time, it's either just a quick email that I respond or a text message, and it makes patients very comfortable that they have access to their surgeon.

Blake: That is such an amazing pearl. Anybody listening to this should really, really store that. This is someone who does a tremendous volume of surgery, Dr. Stein, and still is giving out your personal number. I do something similar with all my cataract patients. I actually call them on the night of surgery. So, after I've operated that morning, I will go through and personally phone every single one. It doesn't matter how many cases I did. I'll call them all. I spend probably less than 40 seconds on the phone, but it means so much to them, and they all comment on it. For my LASIK post-ops, I will text them. I'll give them a text message with my cell phone directly from me, and you're right, 80% of them don't even text back, or they just text back a thumbs-up, but just that little bit to show that you care is important, because they don't care how much you know until they know how much you care.

To kind of finish up, I thought I'd ask you the final question just about...Talk a little bit about your motivation for correcting presbyopia in the first place. I mean, I think that if you look at the market here in the United States, it's still relatively flat. I don't think that enough of our cataract surgeons, in our country at least, I'm not sure about Canada, but they don't necessarily think about this in terms of the, not only lifestyle benefits…but also the safety benefits, all the falls that are attributed to bifocal glasses each year. That's not really top of mind for them. I don't know that they really think of presbyopia as a disease. Can you talk a little bit about that?

Ray: Well, you bring up falls and bifocal or trifocal glasses, and one of the really nice features of this trifocal lens is that patients can hold printed material down below, straight ahead, and up above. So, their quality of near vision is excellent and very large range. The one thing that I've noticed over the years is, especially with trifocal lenses, I get a lot fewer patient complaints when I give them the full range of vision than patients that I do a monofocal lens and they can't see their phone, they can't see their computer, they can't put their makeup on easily. So, really, patients have been really guiding me toward doing more and more trifocal lenses.

Blake: That's an interesting comment. It's so true. I mean, your happiest patients are literally the ones that choose the best technology, these presbyopia-correcting IOLs. When I talk to surgeons, I mention that all the time. Those aren't the ones in my office complaining. It's the ones that didn't choose the presbyopia-correcting IOL, now they're having to use reading glasses and everything like that.

So, Ray, I know that you're a very, very busy guy, obviously, and I can't tell you how much I appreciate you coming on the podcast and sharing the knowledge that you have with this new PanOptix lens.

Ray: Well, thank you very much. I hope that surgeons will find this a worthwhile. It's an exciting part of practice, mainly because patients are happy.

Speaker 2: Thank you to Dr. Stein for joining this episode of Off the Grid, and thanks to our listeners for tuning in.

This has been Ophthalmology off the Grid. Until next time.

Speaker 2: Support for Ophthalmology off the Grid comes from Diamatrix, supplying surgeons with innovative products like the X1 iris speculum. Its unique ability to simultaneously capture both iris and capsule makes this device a game changer, providing superior stabilization of the pupil, capsule, and anterior chamber. Visit diamatrix.com to learn more or request a sample.

7/14/2020 | 40:07

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