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October 27, 2009

Who Should Implant Your Cataract Premium IOL?


There was an interesting presentation Sunday at the Annual AAO meeting in San Francisco given by Dr. Vinjay Shah.  EyeWorld Magazine summarized his findings:

Residents lacking in premium IOL, pediatric cataract procedure experience

Third year residents are not getting enough hands-on experience leading pediatric cataracts and implanting premium intraocular lenses (IOLs) according to Vinay A. Shah, M.D., University of Missouri, Kansas City, and his colleagues. Dr. Shah sent a survey to every third year resident accredited with the Accredited Council for Graduate Medical Education (ACGME) in the United States; 154 (35.5%) of the 434 residents completed the survey. Through this self-reported survey, residents responded that they were getting ample chances at extra-capsular cataract extraction (ECCE) with 40 residents having done more than 50 surgeries. But in terms of pediatric cataract surgery and premium IOL implantation, their experiences were lacking. For example, 102 residents never implanted a premium IOL, and all but seven residents had implanted premium IOLs in 10 patients or fewer. Similarly, 118 residents never performed a pediatric cataract surgery, and only three residents had done more than 10 procedures.

This interesting study leads me to ask two important questions:

  1. Should residents even implant any premium IOLs?
  2. Who should one go to if they want a premium IOL at the time of their cataract surgery?

Let me answer these two questions by first defining my goals of different surgical procedures:

  1. Cataract surgery is preformed on a patient when their cataracts are causing a decrease in vision that is interfering with their daily lifestyle.  The goal of cataract surgery is to improve the patient's best corrected vision.  If a patient has pre existing astigmatism, they will most likely still need distance glasses after cataract surgery.  All patients will also still need to wear reading glasses after cataract surgery, as the IOL does not focus for near objects.
  2. Many patients would like to decrease their dependence on glasses.  This is the goal of premium IOLs.  A toric IOL will decrease pre existing astigmatism and improve distance vision without glasses.  A multifocal IOL will allow one to read without glasses.  Uncorrected vision after cataract surgery may be further improved with LASIK surgery.

In my opinion any surgeon who is offering premium IOLs MUST have the following attributes:

  • Must be performing perfect, pristine cataract surgery, on a very consistent basis.  This only comes with experience and volume.  I would suggest going to a surgeon who does over 30 cataracts a month.
  • Must fully understand refractive surgery.  One of the biggest complaints I get from patients who see me for second opinions after premium IOL implantation is that they are unhappy with some aspect of their vision.  Most of these patients have a residual refraction in their eyes.  A simple LASIK procedure will usually correct this problem.  Many times, their operating surgeon does not offer this as an option, as they do not provide LASIK services.
  • Must have vast experience in premium IOL implantation.  There are many nuances that must be overcome to achieve success in the refractive cataract patient.  I would suggest going to a surgeon who does at least 20% premium IOL implantations of his cataract volume.

So, to answer the two questions I posed earlier:

  1. I do not believe residents should be implanting premium IOLs.
  2. If one is interested in reducing their dependence on glasses following cataract surgery, I would suggest going to a high volume surgeon with vast experience in both premium IOL implantation and refractive LASIK services.


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I agree with most of th posting but might split some hairs regarding what constitutes premium IOLs. One could argue that toric IOLs could be implanted by more surgeons than the strict criteria noted above. The surgeon still has to be excellent and relied upon to be consistent with the capsulorhexis but there are less patient satisfaction issues than with pseudo-accommodative or accommodative IOLs (neither of which I would touch myself!) I am a glaucoma surgeon with a high surgical volume for glaucoma but low for cataracts except in my glaucoma patients or ones 'dumped on me' with 1mm scarred down pupils. It is a pleasure, the rare times I get to implant a toric iol, to actually make someone able to see better!

I would have to mostly agree that there are more patient satisfaction issues associated with the presbyopia patients. Toric implants are generally easier to help a patient meet their goal of excellent distance vision without glasses, however, there is that occasional toric IOL patient who still has a residual refractive error who will only be happy with a LASIK touch up!

Thank you for your post. Do you think that the questions listed on the like below (sorry I didn't know how it would format if I copied them) are good questions to ask my Mom's cataract surgeon?

Are there more that I should ask? She has been told she has "ripe" cataracts and she hates her glasses....I am trying to figure out her options.



Interesting question. 5 year follow up questions are not relevant as all current lenses have been on the market for around 3 years.

I think the main thing a patient needs to discover is a suregoen's track record. What results can be expected? What will be done if there is a residual refraction? Does the surgeon specialize in LASIK fine tuning? Also, always good to ask for a number of patient refrences with similar issues.

Good luck!

"Interesting question. 5 year follow up questions are not relevant as all current lenses have been on the market for around 3 years."

This is misleading though, because they go through extensive clinical trials years before coming to market.

Thus, 5 year plus studies are there, if not publicly available.

I definitely agree and salute about the goal of cataract surgery it is to improve the patient's best corrected vision. Like your blog keep posting!


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