Finding the Right Match: Keys to Patient Selection

"I say this a little tongue in cheek, but not totally. I do listen to the patient, but I don't trust that they know how they use their eyes."

"We're really just talking about improving someone's quality of life and trying to reduce the need for glasses after cataract surgery."

Hear Robert Weinstock, MD; and John Berdahl, MD, lay it all out-from deciding when to use a premium lens to managing unique cases. Tune into their candid conversation to learn how they match the right technology to the right patients.

HOST: Presbyopia Unlocked is an editorially independent podcast supported with advertising by Alcon. If you’re heading to the MillennialEYE Live meeting, be sure to stop by Alcon’s booth and attend the 3D lunch symposia.

HOST: Presbyopia…An ocular condition that affects so many.

John Berdahl: It's the rare patient that has perfect pristine eyes.

HOST: There have been significant advances in the management of this condition, but how does one decide the best course of action to treat the unique eyes of each patient?

Rob Weinstock: What a complicated topic that is … Not just choose the right patient as if it's black or white, but rather kind of steer the patient into what we think is gonna work best for them and what is the best refractive solution for them.

John Berdahl: What I really want my patient to know, and I think it's incumbent upon us as ophthalmologist, is they've got options.

HOST: With so many options, how do you find the perfect match? Dr. Rob Weinstock and Dr. John Berdahl will take you through the patient selection process.

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Rob Weinstock: Oh, thank you so much. So excited to be here doing this podcast. My name is Rob Weinstock. I am here with my amazing colleague and dear friend, Dr. John Berdahl. John, how are ya?

John Berdahl: I'm doing great, rob. Nice to hear your voice.

Rob Weinstock: Yeah, same to you. We've got a great, great, exciting topic today that we should kick around a little bit, John. We're starting to be the old guys. Well, at least I am a little bit. And when we first started in this amazing field of ophthalmology, refractive surgery meant something very different than what it means today. I think both you and I were getting our hands wet with LASIK like crazy a decade ago, or maybe two decades ago, and that was refractive surgery. And now we find ourselves almost 20 years later, where at least for me, the bulk of the refractive surgery I do is lenticular based. Have you also seen this shift?

John Berdahl: Yeah, so that's definitely the case for me too. And I do LASIK and PRK, and smile, and all that kind of stuff, but the most powerful refractive surgery we do is cataract surgery. There's no other refractive surgery that exists where you get a 25 diopter swing in a matter of seconds. And one thing I would like to touch on is I'm getting older too. And some of that gray comes from picking the wrong presbyopic IOL patient and trying to redeem ourselves from that. Tell me about the ideal patient that you pick, but then maybe even more importantly, tell me about the patient that isn't ideal, but you're willing to take a risk on for a presbyopic IOL.

Rob Weinstock: Yeah, what a complicated topic that is. And I wish there really was an easy answer, John. I think a lot of it comes with our gray hair, like you said, in our experience in how to choose the right patient. Not just choose the right patient as if it's black or white, but rather kind of steer the patient into what we think is gonna work best for them and what is the best refractive solution for them. And I think we learned that by making mistakes in LASIK and trying to choose good and bad candidates.

Rob Weinstock: I mean, the first and foremost thing is, I mean even before we get to the refractive component, we like to make sure the patient's ready for cataract surgery and actually wants to fix their vision. And once we've established that they're having trouble seeing and they truly want to see better, then it's a matter of examining the patient's situation, their eye, the health of their eye, and to determine whether you can use what you have to get them out of glasses. Not every patient comes in with a perfect macula, a perfect round cornea, and we can just slide a multifocal lens into. So in fact, that's the rare patient. So that's when we start to think about, well, what are the basic criteria?

John Berdahl: We're a mostly co-managed practice and so most patients that come in for a cataract eval, the vast majority have that cataract. And because they were seen by an OD outside of our practice first. And so it's pretty rare that they don't end up with cataract surgery. And so what we try to do before they get to our office is educate them that they have options.

John Berdahl: We're not trying to talk anybody into anything. And I actually have a pet peeve with the word conversion rate, because it feels like I'm converting somebody from something they didn't want into something, or something that they, yeah, didn't want into something now that they're going to get. And I prefer the phrase adoption rate. But what I really want my patient to know, and I think it's incumbent upon us as ophthalmologists, is they've got options. You can have regular cataract surgery and maybe not need glasses, but likely will. Certainly for up close. We can try and get you good distance vision and you'd wear some readers and not need distance glasses as much. Or we can try to use lenses that have a built-in bifocal and hopefully get you out of glasses for almost all your activities.

John Berdahl: And I want patients to start thinking about that before they get into our practice so they can make a good decision, a good informed decision when they're here. Because how many of us can make a multi-thousand dollar decision, especially about something as precious as our vision on the spot. And that's something that really is helpful for us. And I tell patients that aren't good candidates. Listen, you may have a friend that got these, this technology, and I want you to know I've thought about it for you, but it's not in your best interest and I wouldn't be a good steward of your trust or your dollars if I put one in. So I have that conversation both ways.

Rob Weinstock: Yeah, John, that's such a great point. And you bring up that that important concept of educating the patients about the opportunity to reduce their dependency on glasses. And even though not everybody might be a candidate, if they at least know that's an option, they're thinking about it.

Rob Weinstock: I think that there's a big missing gap where we're really instead of talking about premium cataract surgery, we're really just talking about improving someone's quality of life and trying to reduce their need for glasses after cataract surgery. Whether it's 100% of the time, 50% of the time, or a quarter percent of the time. We have such amazing tools these days with different lenses, whether they're monofocals or torics or lasers that correct the astigmatism on the cornea or a multifocal optic or even a trifocal optic that's in the near future. We have all these choices and it's getting challenging, but if you do your homework and you think through it and are thoughtful and methodical, you really can help these patients achieve amazing independence and they appreciate you for it.

John Berdahl: Okay, so Rob, let's talk about some of these more challenging patient selection discussions. We all know that with a pristine eye, we're going to have a pretty good shot, not foolproof, but pretty good shot. And we've had our conversation and educated the patient about the pros and cons. And you've got a patient that's really hoping to be able to see well without glasses, wants a presbyopic IOL, but they've got real dryness. What are you doing?

Rob Weinstock: Those are challenging cases because a lot of times you're right. These people, they don't think they have dry eyes. To them, they don't feel dry. But we look at the topography and we look at the tear film, and we can tell it's irregular and it's gonna affect the quality of the optics, especially with multifocal optics. So there's no question that we really use topography in the clinical exam to identify these patients and really treat the ocular surface first. Make sure we have a stable topography, no irregular astigmatism. And we watch out for that subtle Map-dot-fingerprint dystrophy. And we're cautious to avoid patients who have significant corneal pathology because you can get into trouble. But certainly like you mentioned, everybody should do a good analysis on the tear film and the health of the ocular surface, the stability of it.

John Berdahl: So if you're like me and you've not, you made a mistake and you put some, put a multifocal in somebody who you didn't think the dryness was gonna be a problem, how do redeem that? What do you do?

Rob Weinstock: Well, you have to really make that effort to heal the ocular surface and then follow that up with a little PRK, if needed, or a little bit of a limbal relaxing incision if there's irregular sill that's hanging around. You ultimately have to make that call. If somebody’s not happy and is having trouble vision, why is it not good? Is it the Macula? You got an OCT, is it PCO? And some of these decision trees are kind of a final, so if you do the Yag, you're kind of committing to keeping that lens in the eye. So if you have a very unhappy patient, you've done everything you can and the patient is generally dissatisfied. I've had the rare case where I've explanted the lens before I did the Yag, because I could just tell that's where it was going and I didn't want to cut off my ability to have that option by doing the Yag.

John Berdahl: Yeah, me too. It's only taken me getting burned a few times to say, let's pause, let's slow down the process and make sure we get that dryness treated as well as possible beforehand. And then know that there's a little higher risk that you may not love this lens, but I also don't want to rob people or, and this is going to sound too strong, but condemn them to absolute Presbyopia for the rest of their life when they would have had a shot at a more spectacle independent life.

John Berdahl: And so I think it's incumbent upon us to slow the process down when we meet these folks. And you touched on something that I think is a conundrum that we face all the time. Subtle ABMD, advanced ABMD we're gonna put, do a PTK or superficial Keratectomy first, but subtle ABMD, the topography's not quite right. This person wants some Presbyopia correction. Are you doing a superficial Keratectomy first? A PTK first? Are you putting in plugs and treating the dryness and hoping that a new, a better ocular surface is gonna help, or saying no multifocal at all for that person? What are you doing? Because it's common, 10% of people have ABMD, at least subtle ABMD.

Rob Weinstock: Yeah. I think a lot of it even backs up to their personality. If they have a super dense cataract and a little mild ABMD, and they're not even complaining that much about glare or about the vision being that terrible, but they're starting to have trouble, I think you can get away with it in a subtle case. But anybody with significant, significant disease, even if I'm going to be using a monofocal, I'm going to treat that first because I want that patient to be after the cataract surgery. I want them to have the best possible vision immediately. I want that to be the wow factor. The cataract surgery. I don't want the wow factor to be the superficial Keratectomy so I'm going to do my best to bit if I think the cornea is one or two lines of vision affecting in part the whole system and it's going to give them only 20/25 or 20/30 best corrected even with a monofocal. I'm going to treat that first, for sure.

John Berdahl: Yeah. I have gotten more aggressive doing PTK and superficial Keratectomy before surgery. And so I am in the same spot, and it's two reasons. One, afterwards, what are you going to do with that patient with irregular astigmatism? You can do PRK, but it's going to be less predictable because they've got an irregular epithelium that you're unmasking with your PRK, and it's going to be harder to get a predictable PRK, and you could do LASIK and it's going to be more predictable, but you still have the irregular epithelium on the top.

John Berdahl: So I really have gotten more aggressive about treating the epithelium before surgery. And the other thing that I'll share is that I think the most underused diagnostic test in ophthalmology is a gas prim over refraction. So you've got that 20/40, 20/30 cataract that isn't seeing quite as well as they'd like, and you put a gas prim contact lens on and all of a sudden they see crisply. We know that's not the cataract, that's the cornea. And let's get that cornea polished first. And that's something that my partner, Vance, taught me. And boy has that saved my bacon a number of times.

Rob Weinstock: Yeah. Nice, John. So let me ask you a couple of pointed questions about your interaction with patients.

John Berdahl: Lay it on me.

Rob Weinstock: So when you see a patient, things look good, they definitely have cataracts best corrected, say 20/30, 20/40 cataracts, and pretty much used to wearing glasses, progressives for the last 10 years or so. Motivated to get cataract surgery, healthy eyes, low amounts of sill, everything's looking good. How do you in a short amount of time assess whether you should give them a, or whether you think they're going to tolerate multifocal optics and that's a good path. Or whether you should just stick to say bilateral distance, correct the sill with a laser and just keep it a little more simple, and have them wear over the counter readers. How do you kind of, what do you ask them that kind of steers you into what you recommend?

John Berdahl: Yeah, I ask them how they want to use their eyes. And I ask them this question, do you want to wear glasses all the time? And I don't, do you mind wearing glasses? Because in the upper Midwest, nobody minds anything. Everybody's happy to, if people minded things up in the upper Midwest, they wouldn't live here because the winters are rough. And so they'd live down by you in Florida. So we have a bunch of hardy stock up here.

John Berdahl: And so I say, "Would you rather not wear glasses?" And they say, "Yes." And then we talked through it and if their eyes are pristine, I really would prefer to correct it all with one surgery and not come back and do a LASIK enhancement unless we need to. Now, I tell them it's a three-step process that we might do that, but I have, I would rather do it all with the lens. And then the decision of, distance or distance and near, really comes down to how they want to use their eyes. Are they willing to trade some flexibility in their vision for a little bit of decreased quality with a multifocal? And, and then the financial part of it.

John Berdahl: One other question I have for you on patient selection that comes up commonly is mild glaucoma and ocular hypertension. Are you willing to put a multifocal in somebody that has high eye pressures or let's say mild glaucoma, meaning by the AAO definition, no visual field change, but they do have a little change on their optic nerve head appearance or OCT, but no visual field change. Can that person get a multifocal from you?

Rob Weinstock: It's circumstantial, but I definitely have had patients that have had incredibly stable glaucoma with very, very slowly marching optic nerve changes over decades that are in their late 70s, were diagnosed in their early 60s, and they have been completely healthy and stable, followed well, treated well. It's safe to say that that demographic is not going to progress unless something weird happens and I'm comfortable with those, especially with the newer generation multifocals. If I think that they have a family history or it's looking more like we're getting to where it's starting to have some significant changes in the optic nerve fiber layer. I'm going to be more conservative. So it's circumstantial, but I would say if you're really comfortable with it, it's okay. Especially with the newer technology.

John Berdahl: And do you do it in combination with the MIGS on those patients?

Rob Weinstock: Yeah, I mean with the newer generation MIGS, it's certainly reasonable, especially with something that's a little bit more simple and easy to use with less likely risk of hemorrhage or damage, or any hemorrhaging in the angle. Something like an iStent inject. That's a real more simple, basic kind of entry level so to speak, procedure. I like to keep things somewhat simple. At the end of the day I want to do no harm and I want to make sure the patient is happy. If they are motivated for multifocality and total freedom, I'm going to work hard to do that. But if the patient says to me, "Hey, I don't mind wearing readers." You know what, I'm not going to push for a multifocal lens." I'm going to fall back on a monofocal with astigmatism correction. I'm going to listen to the patient and what their desires are.

Rob Weinstock: I will, fight for them, but I'm not going to talk them into anything. And I'm gonna also always try to give them my most conservative recommendation on their situation.

Rob Weinstock: So John, when you're thinking about targeting for a patient and you're really doing your best to try to give them a full field of vision, we have a lot of options now to choose from. Are you like myself where you tend to use say one, say either extended depth of field lens or say a lower power multifocal lens, in say the first dominant eye that you do, and then the second eye maybe go with a higher power reading point or the stronger multifocal? Because that's kind of what I've fallen into a really successful pattern with. What are you doing?

John Berdahl: Yeah, I do almost exclusively right now, mix and match. And so I'll use a lower power multifocal or extended depth of focus in the typically dominant eye, and then a medium powered multifocal in the non-dominant eye. And I tell you, Rob, I say this a little tongue in cheek but not totally is that I do listen to the patient but I don't trust that they know how they use their eyes. So I'll have patients who will say, "I don't read. That doesn't matter to me." And I put in bilateral low-power add or extended depth of focus lenses and they come back and they say they can't read their pill bottle.

John Berdahl: And I say, "Well that's your fault. You told me you didn't read." When I know every patient reads. And so, people want to see distance, intermediate, and near. And so I have a tendency to do almost exclusively mix and match. I know a lot of people offset that non dominant eye, but I haven't had as much success with that because of the glare and the nighttime driving difficulties. So I'm almost, over 95% mix and match. And that's one of the reasons I'm excited for trifocal technology in the future.

Rob Weinstock: Yeah, I couldn't agree more. I mean, I've come to the same conclusion by learning things the hard way just like you. And I hear many surgeons that have been doing this for awhile come to the similar conclusion. And like you said, even though after that first eye, patients might say, "Oh, this is perfect, I'll be able to be just fine like this. Let's just do the same thing in the other eye." That's what I was doing for awhile and I had the same thing happen.

Rob Weinstock: So, I literally almost exclusively put a higher ad in the second eyes so they really get that pop on the reading. Now, that being said, there's another strategy that I believe you use almost as much, if not more than multifocal or EDOF optics, and that's monovision. I have so many patients that are either natural myopes or that have done monovision, and contact lens wearers or myopes that take their glasses off to read. And I'll take the first eye and just nail the distance with a monofocal and the vast majority of those low myopes, they do amazing by leaving the second eye near. Do you do that as a strategy too? You look hard to find the monovision patients.

John Berdahl: All right. This is where it's gonna get fun cause I don't love monovision in cataract patients. I love it in LASIK, but I haven't had the success that you've had with cataract patients, and I wonder with light adjustability around the corner if that may change because I can for sure nail the distance eye every time and I can dial in the non dominant eye. But unless they've gotten to absolute, or close to absolute presbyopia, so a 65 plus year old person that's done well with monovision, I feel like my monovision patients aren't as happy. And so I really only reserve it for older patients that have done well. And I know that I'm in the minority here. A lot of people have great success with monovision. I just, my experience hasn't been as good as others. So what am I doing wrong?

Rob Weinstock: Well, I don't think you're doing anything wrong. I just think that you're very good and found a sweet spot with the newer technology lenses, and especially the ability of a low ad and a higher ad multifocal. A lot of these, you are right in one fact, and I've had rare patients with monovision where they somehow had a little bit of depth of field with their near eye. This is what I run into the most. And there they feel like they can't have as much range of vision as they had with their own natural lenses or their contact lenses as they do with like say a fixed monofocal. So I mean there are caveats to monovision just like there are to multifocal optics and that's what comes down to picking the right patient. And I know it's hard to do and there's some amazing tools out there like Dell's questionnaire and we don't use that cause it's kind of cumbersome.

Rob Weinstock: It takes a long time for us to go through. But I gotta tell you there's a real gestalt that I use when I talk to patients that I tried to get a sense of how easy going they are, whether they're going to tolerate things that are not perfect and understand that there is no perfect solution here, that we're trying to find the best technology we have that they're going to be the happiest with. And I've had patients that I can just tell are, they're going to be challenging, and the way they ask questions or their attention to detail, or even the mildness of the cataract is not in line with the degree of their vision loss subjectively. I just know that it's gonna be hard to make them happy. How do you weed out some of these tough ones, John? Personality wise?

John Berdahl: Yeah, I ask them if they're a picky patient. And I just ask it really point blank, are you visually picky? And then I look at them but I'm also paying attention to their spouse and if their spouse is nodding their head big time, that's a pretty big warning sign to me. And I follow that question up with, when you get a new pair of glasses, do you have to have them remade frequently? And if they have to have them remade frequently, that's a watch out for me with multifocality. And then if I am going to push the limits a little bit on an eye that isn't pristine with a multifocal IOL, I make sure to tell them that there is a small but real chance that they might not like this lens and we have to come back and take it out.

Rob Weinstock: Great pearls, John. And to add to that, sometimes when you start talking to patients about either distance vision, astigmatism correction, multifocal lenses, and they start prodding with more and more questions, you start to realize that this person perhaps is so detail oriented and so worried about things that all of this is almost worrying them too much and sometimes I'll just take a step back and say, "Listen, sometimes less is more. Sometimes you need to just go with your gut instinct of what you know is the most reasonable approach for you that you're going to be happy with. So you don't get yourself into a situation where you're questioning what you're doing." I don't want my patients questioning whether they made the right decision. I want them very confident that they made a good decision or we made it together and they're going to go down the road positively.

John Berdahl: I love that. I love that, Rob. And I find that sometimes people almost feel bad that they chose a monofocal and I've got to reassure them that no, that's some of the best vision you can possibly get is with today's modern monofocal lenses and a good pair of glasses afterwards. That's fantastic vision and they shouldn't feel bad about that decision at all.

Rob Weinstock: I agree. And sometimes it's funny, you'll have a patient who says, you'll mention a lens that corrects all the vision with multifocal optics. And they'll say, "Oh no, no, no, no. My friend had that and they didn't like it. I don't want that." That's a tricky situation, right John? Because if you, even though the lens is probably better, the one you're going to put in, because the newer generations are better. If anything isn't perfect, you know that's always going to be in the back of their mind if you try to talk them into that technology. So it's a slippery slope, but then again, you don't want to cut off their chances. But honestly a lot of times I'm not going to push it. I'm going to say that's totally fine. I think we should still correct your astigmatism. I think we should still try to get you at least out of glasses for distance vision. And most of the time they say, "Hey, that's great. I'll just wear readers. I'm totally fine with that."

John Berdahl: I think that that's perfect, Rob. And the other thing that I would say here is I think there's a really good solution to that type of patient, and that's for us to listen. And I am terrible at that. And when you, I think that there's a study out there that shows how long doctors let patients talk and it's like 12 seconds. And I bet that I'm right there with them. And if we can just listen to what patients want, then we can help match the right technology to them.

Rob Weinstock: Totally agree. They sometimes, they really let you know because a lot of times they've already done some research and they've already formulated in their head what they want. Now sometimes you have to tell them no. Like if they have AMD and they come in thinking I want a multifocal, you're going to have to say, "Hey, I get it. But that's not safe in your eye." But most of the time what they're thinking about, they've gotten comfortable with it. Just like when a patient finally decides they want to get LASIK, you can't really talk a patient into LASIK unless they've already decided that they're ready to do it. And the same goes with some of these lens selections. People have already decided how they want their vision to be and you have to follow their lead a little bit.

John Berdahl: Totally agree. And then when there is that patient that hasn't done great, and I bet they're going to talk on talk about this and one of the exciting podcasts to come, but bring them close, don't stiff arm them. What people want to know is that we care about them and we care about their vision and so we bring these people close and we let them know we're going to be shoulder to shoulder and then you actually do care, and you work hard to solve their problem.

Rob Weinstock: Absolutely, because it's never perfect and we all know that it's not a failure to have to do a touch up or enhancement on these patients and you can't abandon your patients or you're going to have unhappy patients out there that you're not seeing that are going to be seen by somebody else. You have to keep these refractive cataract patients close to the vest, as much as it may cost your practice, as much time it may take, even if it's not you. You have to have a trusted individual optometrist or technician that is keeping their arms around these patients because when you have the patient that's not satisfied, whether it's objectively accurate or not, you have to be there to help that patient get to where they need to be or it's going to affect your reputation down the road.

Rob Weinstock: So that's part of the game. And I think that there's a lot of cataract surgeons that don't really want to play in that game or that arena, but you have to be prepared for that and that has to be part of your responsibility. Just like with the LASIK patients and we all learned a lot through LASIK, that it's not just do the LASIK and you never see them again. You have to be available to help the patients when they need it.

John Berdahl: I agree, Rob. And you know, maybe my parting thought is this, as surgeons, it's incumbent upon us to provide our patients with options. They should know what the technologies can do and we as surgeons should know what the technologies can do, and which patients to put them in.

Rob Weinstock: It’s amazing we're in two different parts of the country and we're trying to do the same thing for our patients. And everybody's got their own little twist on it. But those people that are successful in refractive cataract surgery and premium cataract surgery are passionate doctors like yourself. And that they're not just trying to take medical care of the medical side of cataracts. They're trying to really improve patient's quality of life. And they look at every patient that comes in as a refractive patient and try to give them the opportunity to really live a high quality of life and reduce their need for glasses or contacts after their procedure. So John, thank you so much for spending the time and yeah, we'll do this again soon. I'm sure.

HOST Thank you to Dr. Weinstock and Dr. Berdahl for sharing their pearls on patient selection. And thank YOU for tuning in. Presbyopia Unlocked is an editorially independent podcast supported with advertising by Alcon. Be sure to Subscribe and tune into the next episode on patient communication.