The OD as IOL Matchmaker

Reality TV has opened our eyes to matchmaking as an exciting, vibrant career option. Although most of us missed the opportunity to become matchmakers by investing in becoming optometrists in our 20s, that doesn’t mean we can’t still play in the sandbox. Confused? I’ll explain.

I recently sat down with my colleague and friend, Brian M. Shafer, MD, an expert in cataract surgery and intraocular lens (IOL) technology. He has championed the concept of being an IOL matchmaker for years, and with an ever-growing armamentarium of options, the job becomes more interesting by the month. The reality, as he explained to me, is that the discussion of visual goals for a patient is best initiated by the visual system expert (ie, the optometrist). After all, we are the gatekeepers who work with patients for years optimizing their individual vision goals. If we educate ourselves on the available IOL options, then we are uniquely qualified to make informed recommendations about how to set the patient’s vision following surgery (Figure). So, what does optometric IOL matchmaking involve?

Figure. Flow chart for IOL selection.

A REVIEW OF THE PROCEDURE AND THE OPTIONS

To kick things off, a fundamental understanding of cataract surgery is crucial. The procedure, which involves breaking up the natural clouded lens and replacing it with an artificial one, has been improved and perfected with nuances to surgical technique and the use of lasers.

Femtosecond Laser-Assisted Cataract Surgery

For more than a decade, femtosecond laser has been available to assist in certain steps of cataract surgery. Typically, the laser can be used to make incisions, perform the capsulorhexis, and fragment the lens. Although these steps should be comfortable in the surgeon’s hands, certain patients prefer to have technology available to them. The ability to perform nomogram-enhanced limbal relaxing incisions (LRIs) with the femtosecond laser is the only true step that is superior to manual surgery from an outcome perspective.

LRIs

For patients with low levels of astigmatism, an LRI can be performed by the surgeon either preoperatively with a femtosecond laser, intraoperatively with a blade, or postoperatively in the office. While typically less accurate and precise, it is still helpful to debulk the astigmatism as much as possible. Along with these changes to the surgery itself, IOL technology has evolved significantly, and there is now an impressive assortment of IOLs from which to choose, each with unique features designed to meet varying needs.

Monofocal IOLs

The most commonly implanted IOLs are monofocals, which have a single point of focus. Consequently, patients still require reading glasses or bifocals after surgery because of presbyopia. Think of monofocal IOLs as the single-vision lenses of the IOL world. Patients who receive monofocal lenses can expect the sharpest, most uncompromised vision at distance or at a chosen focal length. The tradeoff, of course, is the need for spectacles to correct presbyopia, defocus, and astigmatism. Patients who have become accustomed to monovision in their daily wear contact lenses may consider a mini-monovision when selecting an IOL. Newer monofocal IOLs, such as the Tecnis Eyhance (Johnson & Johnson Vision), may allow better blended vision with enhanced depth of focus.

Toric IOLs

For patients with greater than 1.25 D of with-the-rule astigmatism or 0.75 D of against-the-rule astigmatism, toric IOLs are an excellent choice. A patient’s visual quality and experience tends to be better when their astigmatism is corrected with an IOL rather than with spectacles. Think about when a patient has their astigmatism corrected with spectacles versus contact lenses. There’s no concern about the optical center of the spectacle lens or “swim” effect when looking peripherally through the lens when a contact lens provides visual correction at the corneal plane. As long as the contact lens is aligned, there will be no loss of visual quality when the patient turns their head or looks peripherally. Both of these problems (contact lens alignment and spectacle distortions) are eliminated when a toric IOL is implanted correctly and superior vision is provided. Toric IOLs can also be combined with multifocal, trifocal, or extended depth of focus (EDOF) technology to provide a broader range of clear vision.

Multifocal and Trifocal IOLs

Multifocal and trifocal IOLs, such as the AcrySof IQ PanOptix Trifocal IOL (Alcon) or the Tecnis Synergy IOL (Johnson & Johnson Vision), provide multiple points of focus at near, intermediate, and far. These lenses use diffractive optics to divide light entering the eye into separate focal points, enabling patients to function without glasses for most activities. Although these IOLs provide considerable convenience, they can sometimes lead to optical side effects, such as halos around lights at night. This is the most important piece to counsel patients on. There is no free lunch, and, in the case of trifocals, the photic phenomena are real. When patients are not counseled properly, they can become quite distressed with their dysphotopsias, which can eat up considerable chair time and affect their overall satisfaction. Therefore, patient lifestyle and preferences should be considered when recommending these lenses. In my experience, the best patient for trifocal technology is a low-key retiree who does not do much night driving.

EDOF IOLs

EDOF IOLs represent a middle ground between monofocal and multifocal IOLs. They expand the range of clear vision using advanced optical design, resulting in fewer optical side effects than multifocal IOLs. EDOF IOLs may be an optimal choice for patients seeking more independence from glasses with fewer visual compromises. EDOF IOLs are most analogous to aspheric or extended range contact lenses that deliver functional vision, except that patients can expect to require cheaters to read very small print. Examples of EDOF IOLs include the Clareon Vivity IOL (Alcon) and the Tecnis Symfony OptiBlue IOL (Johnson & Johnson Vision).

Light Adjustable IOL

For the overly scrutinizing patient who is constantly returning for a glasses checks, the Light Adjustable Lens (LAL; RxSight) is the way to go. This IOL is implanted just like all the other IOLs, except that, postoperatively, it can be adjusted without having to reintervene surgically. This means that when a patient is unhappy with their residual refractive error, they can achieve emmetropia without an IOL exchange or laser finetuning, which is a gamechanger for postrefractive patients and engineers.

ASSESSING THE HEALTH OF THE EYE

Although advanced technology is attractive to most patients, there are situations in which a simple monofocal IOL is the best choice. Take, for example, the patient with keratoconus and unstable, irregular astigmatism. Implanting a toric IOL in this patient may not effectively neutralize the cylinder. Now, postoperatively, if we need to opt for a scleral or rigid gas permeable lens again, the fit becomes much more difficult, with multiple diopters of internal astigmatism.

As another example, consider the patient with a central scotoma due to exudative age-related macular degeneration or retinal disease. When light is split through a trifocal, less photons are available for the already compromised fovea. This is not a good use of advanced technology. In addition, ocular surface disease is easily overlooked and is one of the most amenable conditions that can lead to improved outcomes.¹ Because we know that pre-existing dry eye is a risk for worsening dry eye postoperatively,² it’s important to treat the ocular surface aggressively to ensure accurate IOL selection at the time of surgical evaluation.

UNDERSTANDING YOUR PATIENTS

The selection of an IOL is as individual as the patient themselves. Understanding their lifestyle, hobbies, occupation, and overall expectations from the surgery is vital in guiding their decision. Some may prioritize independence from glasses, while others may be more concerned about potential side effects. Understanding these factors allows us to provide tailored advice. Identifying patients with unreasonable expectations can avoid unsatisfactory postoperative outcomes by helping patients reframe their anticipated results.³

Additionally, beware of the moderate myope. These patients absolutely love the superpower of taking off their glasses to read. That said, it can be distressing to patients when they lose this superpower; therefore, it is critical to gently remind the surgeon of the patient’s preference for near vision. As the patient’s optometrist, you’ve likely had this conversation with them many times; therefore, you are uniquely suited to be the person making the recommendation.

Communicating Options and Managing Expectations

Presenting available options to patients is a balancing act. It’s essential to offer adequate information without overwhelming them. Patients should understand the benefits and trade-offs of each lens type in order to make an informed decision. Transparent communication about potential outcomes and the possibility of needing glasses for some tasks after surgery is key to managing expectations. The IOLs available on the market, with the exception of the LAL, are not tailor-fit lenses. In fact, most IOLs come in 0.50 D spherical and 0.75 D cylinder increments. Even with the most advanced IOL formulas, it is not uncommon to have residual refractive error. The key is to emphasize to the patient that we are not removing all of their refractive error, but rather minimizing it.

The Role of Technology

Continued innovation in diagnostic technology is another invaluable tool in our IOL matchmaking process. Devices such as optical biometers, corneal topographers, and OCT enhance our understanding of the eye’s structure, which helps to further guide our IOL choice. As we move forward, embracing these technologies is vital to providing optimal patient care. In fact, without corneal topography or OCT, it is not possible to accurately recommend advanced technology IOLs, such as trifocals.

In other words, if we discuss with a patient that doesn’t suit their eyes, they may face disappointment if the surgeon then paints a picture about their candidacy for certain IOLs. Diagnostic technology helps better identify these patients, and we should alter our discussions accordingly.

BE THE BEST IOL MATCHMAKER YOU CAN BE

As optometrists, we have a unique opportunity to play a critical role in guiding our patients through their cataract surgery journey. Just like a relationship matchmaker, the goal is to find the ideal IOL for each patient’s individual needs and lifestyle. In the end, isn’t that what matchmaking is all about—securing the perfect match to ensure the best possible outcome?

The world of optometry is no different. By becoming experts in IOL technology, we can play a significant role in our patients’ lives, providing them with informed choices and the best possible vision following their cataract surgery. So, let’s roll up our sleeves, dive into the sandbox, and embrace our role as IOL matchmakers.

1. Trattler WB, Majmudar PA, Donnenfeld ED, McDonald MB, Stonecipher KG, Goldberg DF. The prospective health assessment of cataract patients’ ocular surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430.

2. Gupta PK, Drinkwater OJ, VanDusen KW, et al. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. 2018; 44:1090-1096.

3. Rudalevicius P, Lekaviciene R, Auffarth GU, et al. Relations between patient personality and patients’ dissatisfaction after multifocal intraocular lens implantation: clinical study based on the five factor inventory personality evaluation. Eye (Lond). 2020;34:717-724.