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Presbyopia Challenge | Mar/Apr '15

Look Before You Jump

At a recent meeting, I ran into a colleague who told me he was no longer implanting multifocal IOLs. Over the past couple years he had, on occasion, stopped to ask me my opinions on the technology, my recommendations on different platforms, and my “pearls for success” in using multifocal IOLs. It was like watching one of my children on the edge of the dock, filled with excitement and apprehension, testing the water over and over before finally jumping into the lake. Eventually, he jumped too. He called with that initial exuberance for the patient, who was thrilled to be spectacle-independent. But when I saw him recently, he explained that in a subsequent patient, the result was not as thrilling. The patient was irate with the results, complaining she could not read well and had significant halos, and demanded reimbursement for such a “poor” result. As a true empathetic physician, the patient’s disappointment was enough to keep him from “using the technology ever again.”

In our last segment, Daniel Chang, MD, wrote brilliantly about surgeons who choose not to offer patients a multifocal IOL to actually treat presbyopia at the time of cataract surgery. He points to concerns of increased chair time, quality of vision complaints, or side effects that may result with the implantation of this class of IOL technologies. While this is certainly true of multifocal IOLs, I would argue that the same is true for any treatment we offer in ophthalmology. Do we not spend an inordinate amount of chair time explaining to the emmetropic pseudophake with a monofocal IOL why he or she is completely dependent on readers? Do we not worry about the potential side effects of any medication we prescribe? I tell every patient I start on Restasis (Allergan) that his or her eye drops may burn, just as I tell every patient who has a multifocal IOL that he or she may see halos. I think the real issue comes down to the higher stakes involved in a procedure that requires significant financial investment from patients. As such, there needs to be an equally significant investment made by surgeons when utilizing technologies for presbyopic correction, and it relates to a foundation of knowledge.


The example from my colleague is all too familiar with many surgeons I’ve encountered. There was no regard for the absolute success achieved just months before this difficult encounter. For many, it seems to take just one unsatisfied patient to abandon the option of multifocal IOLs for so many that will follow. For others, it appears to be the apprehension of such an exchange that keeps them from even engaging in multifocal IOLs.

What surprises me about this “decision-making” is how contrary the concept is to everything we do as physicians. Very few treatments in disease offer 100% success. We see treatment failures in everything we do as ophthalmologists. Just look at trabs! Yet, despite the failures, we still come back to these treatments because, as physicians, we have a duty to maintain logic and reasoning in knowing the majority of patients will have success. That also comes with the responsibility to be educated enough to make calculated decisions as to which patient would benefit from treatment and what the potential negative effects might entail. Many of my scleritis patients might not need immune-modulating therapy, but those who do can benefit immensely, and I’m certain to explain to them that the side effects of treatments like cyclophosphamide can be grave. Similarly, we must be educated on when to use multifocal IOLs, how they affect a patient’s vision, and what to counsel them about regarding outcomes. And sometimes, just like with cyclophosphamide, we may even need to discontinue therapy due to a particular result.

My concern is for the surgeon who ignores this concept and maintains the attitude that turning the dial on the injector system is no different for a multifocal IOL than a monofocal IOL. I am equally concerned for the surgeon who refuses to adopt the technology simply out of fear. We need to be proficient in the optical effects of multifocal IOLs prior to using them; we need to develop skills to examine patients for the subtleties of concomitant disease that may negatively affect outcomes; we need to invest in technology that improves outcomes; and we need to learn from others with experience how to manage the nuances of postoperative care. As such, my hope is that this column can provide the necessary framework for those getting started with this complex technology to achieve personal success and improved patient care.