PRIMARY CARE OPTOMETRY NEWS  1/1/2007
IOL comanagement depends on surgeon’s skill, optometrist’s knowledge
The primary care OD has a unique perspective on a patient’s personality and refractive needs.
Jennifer Byrne

Primary care optometrists’ knowledge of their patients’ histories, refractive needs and personality types enables them to play a significant role in the comanagement of multifocal IOLs. According to some practitioners, the optometrist’s knowledge and background in refraction also makes IOL comanagement a natural fit for ODs.

“Optometrists are ideally suited for not only cataract comanagement, but comanagement of multifocal IOL patients,” said Christopher Quinn, OD, a Primary Care Optometry News Editorial Board member and president of Omni Eye Services, Iselin, N.J. “It’s natural; it’s what they do. Optometrists are comfortable dealing with the kinds of issues that might be encountered with IOLs.”

Discussing IOL comanagement

Dr. Quinn said when presenting the notion of comanagement to an IOL candidate, he takes the same approach he would with cataract surgery comanagement. “We make sure the patient understands that it is his or her choice of how they want to have that care provided,” he said in an interview with Primary Care Optometry News. “Most patients, when they understand that they do have that option, elect to have that care provided by their optometrist.”

According to Paul M. Karpecki, OD, FAAO, a Primary Care Optometry News Editorial Board member with Moyes Eye Center in Kansas City, Mo., said it is helpful to delineate for patients the areas of expertise involved in successful comanagement.

“We usually discuss the advantages of working with experts in both areas,” he told PCON. “In other words, the comanaging optometrist has a lot more insight into the patient, his or her personality needs and refractive stability, whereas the surgeon has his or her own specialty area.”

Brenda J. Wahl, OD, a refractive surgery consultant at Eye Surgeons of Indiana, Indianapolis, said she tells her patients that their optometrist can provide the majority of the postoperative care.

“Most patients have a good relationship with their optometrist and are more than happy to continue seeing him or her,” she said in an interview with PCON. “This enables the optometrist to not only monitor the postoperative process, but to be able to prescribe, if needed, the glasses for them as well.”

According to Thomas M. Chester, OD, FAAO, clinical director of the Cleveland Eye Clinic in Cleveland, Ohio, it is important to discuss the risks and benefits of the procedure, as well as any alternatives.

“Part of this discussion includes introducing the surgeon, providing an orientation of the surgery facility and discussing the opportunity to continue the postoperative care with the primary eye care provider,” Dr. Chester said in an interview. “For the patient, proximity to the doctor’s office and familiarity with the doctor and staff typically aid in managing the expectations for the postoperative period.”

Choosing a lens design

Deciding on the proper lens design for a given patient involves weighing the patient’s refractive and personality needs, according to Dr. Wahl. “When deciding on an IOL design or postoperative outcome, the first question I ask the patient is if he or she minds wearing glasses,” she said. “The answer to this question sets a precedent for the remainder of the conversation.”

Most patients do not mind wearing glasses and plan to continue wearing them postoperatively, she said. “If this is the case, the discussion is simple,” she said. “If a patient expresses interest in being less dependent on glasses/contacts, I will discuss the different options available.”

Options include monovision with monofocal IOLs and premium IOLs, she said. “Successful monovision contact lens patients most often elect to have monovision postoperatively with IOLs,” she said. “Low to moderate myopes are less likely in our practice to receive or choose premium IOLs. The near vision a myope enjoys without glasses simply cannot be replicated with current IOL technology.”

Dr. Wahl said a high myope may do well with a premium lens, because most of these patients are accustomed to wearing glasses full-time vs. the low myope who removes glasses to read. However, because high myopes tend to have long eyes, she said, they may be excluded from some of the premium lenses due to the IOL power available.

“Hyperopes tend to do very well with the premium lenses,” she said. “A hyperopic patient will gain vision both at distance and at near with these lenses,” she said.

It is also important to talk with the patients about their specific visual needs when deciding on an IOL design, Dr. Wahl said. “Patients who want good intermediate vision without glasses will not do well with diffractive multifocals,” she said. “These patients will do better with the refractive multifocal or accomodative designs.”

Dr. Chester said in addition to physiological traits such as refractive status, pupil size and retinal health, he has his patients fill out the Cleveland Eye Clinic’s Quality of Life Card, which provides educational information to the patient about what they can expect.

“Upon reviewing this material, the patient can take ownership in choosing which IOL may be the best fit,” he said. “For example, the card demonstrates that one particular IOL is better suited for road signs or movies, while another may be better for computer use, while still another may be best for reading newsprint or needlework.

“By allowing the patient to choose which activity is most important to him or her, the management of surgical expectations through IOL selection is clarified,” Dr. Chester continued.

Dr. Karpecki said it is also important for optometrists to be fully aware of the technologies and IOL designs available.

“Being aware of those options gives your patient the chance to get the newest technology,” he said. “For example, there are new light-blocking IOLs. Some block violet light, which is the most harmful light in the visual spectrum, without blocking blue, which might affect scotopic vision. For a patient with a family history of age-related macular degeneration or with AMD, this is something to consider.”

Dr. Karpecki said that for a patient who flies a plane or does a lot of night driving, the best choice might be aspheric IOLs. However, for a person who is willing to tolerate some halos at night and does not perform such tasks, a multifocal or accommodating IOL might be preferable. Otherwise, monovision with an aspheric lens may provide the best depth of field with quality of vision.

Dr. Quinn said while it is important for the optometrist to consider the patient’s personality, the patient should also be involved in the decision. “It helps for you to be able to make some decisions about what’s best for patients, given your understanding of their history and personalities, but it is important not to prejudge them.”

Dr. Quinn also emphasized the need to inform patients that they do, in fact, have multiple options. “ODs should not be intimidated by the surgeon’s preference when educating patients,” he said, “especially if they are working with a surgeon who is not offering all the available options. The patient should be informed of the options and that this particular surgeon does not believe in x, y or z. That way the patient has the knowledge to decide if he or she still wants that surgeon.”

Communicating with surgeons

Dr. Quinn said it is important for the optometrist to communicate what he or she knows about the patient’s refractive and personality needs to the surgeon. “This can be done when you request a consultation for cataract evaluation. Or, if there is a strong preference one way or the other, get on the phone with the surgeon when the patient is being seen,” he said. “In our practice, sometimes patients come in here, and we don’t know them as well as their primary care optometrist does. We’ve had situations where the patient might express interest in, for example, a multifocal lens, and then we get a call from the referring doctor saying that this is the worst patient in the world for a multifocal lens.”

In this way, Dr. Quinn said, the surgeons in his practice gain knowledge that they would not normally have about the patient. “It is so important to have that open communication,” he said. “I think sometimes ODs abdicate their responsibilities in that regard, because they’re intimidated. It should be a collaborative effort using the skill of the surgeons and the communication and knowledge of the optometrists.”

Dr. Karpecki said the optometrist should be prepared to discuss and recommend technologies when dealing with surgeons.

“IOL selection goes along with the surgical portion, so I’m not going to tell the surgeon what to do,” he said. “The surgeon has to decide what’s best for the patient. However, I do think that it’s important to be able to discuss these technologies and obtain the surgeon’s opinion. In the end, the OD is obligated to do what is best for the patient.”

Dr. Wahl said in her practice, she works very closely with surgeons. She said she will typically see patients first and will discuss their goals and IOL options before the consultation with the surgeon. “I go over the benefits of each technology and try to answer all the patient’s questions,” she said. “Before I leave the room, the patient has a reasonably good idea of which technology he or she is leaning toward. I will then write my recommendations in the chart or communicate my opinion to the surgeon.”

She said the surgeon then sees the patient and makes a final decision about the procedure and design.

Postoperative protocols

Dr. Karpecki said due to recent research on cystoid macular edema (CME), which suggests a 3% to 5% or higher incidence in all normal patients, he has changed his perioperative protocols slightly.

“One of these changes is the implementation of medications prior to cataract surgery, perhaps starting the patients 3 days prior to surgery on a steroid and an NSAID [nonsteroidal anti-inflammatory drug],” he said. “The NSAID is the important one now, because it blocks prostaglandins, and prostaglandins may play an important part in CME.”

Dr. Karpecki said he recommends an antibiotic for a week and maintains the NSAIDs and steroids for 3 to 4 weeks. “That’s fairly new as well; we used to start tapering right away, but now we realize it is important to have both the steroid and the NSAID for 3 to 4 weeks,” he said.

Dr. Wahl said the majority of the patients in her practice are seen by either herself or the surgeon for the initial postoperative visit. “At that point, if a second surgery is planned, I see that patient at 1 week after the first eye, to check the progress, and also to review the plan for the second eye,” she said. “After the second surgery is performed, the patient is again seen at our practice for the initial 1-day postop.”

She said at that point, the patient either comes back 2 to 3 weeks after the second surgery for the final postoperative visit. “If, at any point, a problem occurs, the patient always has the opportunity to return to our practice to see either me or the surgeon,” she said.

According to Dr. Chester, it is important in a postoperative cataract visit to complete the comanagement documentation form provided by the surgeon.

“The postoperative form typically includes acuity, refraction status and intraocular pressure measurements, as well as documentation of the IOL and ocular health status,” he said. “Postoperative visits typically occur 1 day after surgery, 1 week after surgery, 1 month and 3 months after surgery, as well as any time in between if the patient is unsure of his or her progress or has developed any unusual findings.”

Dr. Chester added that it is extremely important that these patients have access to postoperative care after hours in case of emergency.

Comanaging crystalens

Dr. Wahl said her comanagement approach for the crystalens is the same as for traditional IOL patients. “I may check them more frequently postoperatively, to make sure they are healing well and that the lens is in the proper position,” she said. “Also, any residual refractive error needs to be addressed.”

Typically, Dr. Wahl said, this is treated with laser vision correction at about 3 months postoperatively. Once patients are happy with their distance vision, she said, they can benefit from exercises to strengthen near vision.

“Eyeonics has a set of word-search puzzle books, which start with large print and progress to small print,” she said. “We tell patients to do one workbook per week, making sure they are working the puzzles without glasses.”

Each week the print becomes progressively smaller, Dr. Wahl said, making it more challenging to the patient. This, in turn, helps re-engage the ciliary muscle and results in better uncorrected near acuity in most cases.

“We have found 1% pilocarpine to be helpful as well,” she said. “It will not only cause ciliary contracture, but also constrict the pupil size. A small pupil gives a pinhole effect, which is beneficial for near vision.”

Dr. Chester said he recommends crystalens if the patient prioritizes intermediate vision (at the potential cost of slightly compromised near vision) through the Quality of Life Card.

“The postoperative regimen is similar to other IOLs, with the exception of stressing no accommodative stimulus for the first 2 weeks after surgery,” he said. “This allows the lens to settle into the right position and provides the patient with the best potential for achieving accommodation in the future.”

Dr. Chester also emphasized that during the postoperative period, it is important to manage patient expectations. “It is not uncommon to have the patients return for additional visits to monitor progress,” he said.

For more information:

• Christopher J. Quinn, OD, FAAO, can be reached at Omni Eye Services, 485 Route 1, Ste. A, Iselin, NJ 08830-3009; (732) 750-0400; e-mail: cqod@comcast.net.
• Paul M. Karpecki, OD, FAAO, can be reached at 10815 W. 140th Terrace, Overland Park, KS 66221; (913) 681-1925; e-mail: paulk-Vc@kc.rr.com.
• Brenda J. Wahl, OD, can be reached at 8102 Clearvista Parkway, Indianapolis, IN 46256; (317) 845-9488; e-mail: brenda.wahl@esi-in.com.
• Thomas M. Chester, OD, FAAO, can be reached at 2740 Carnegie Ave., Cleveland, OH 44115; (216) 621-6132; e-mail: tomchester@verizon.net.