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Presbyopia Challenge | Sept/Oct '16

Don’t Discriminate, Accommodate

Just 1 year ago, I was in residency, performing cataract surgery at the local VA. I was lucky to be at an institution with tremendous potential for surgical volume; however, as in most residency training programs, access to premium IOLs was limited. At that time, my main objective was simple: to complete a safe procedure in the handful of cases I was given for the day and avoid complications. Fast forward 12 months, and life couldn’t be more different. I am now a fairly high-volume refractive cataract surgeon, routinely performing 20 to 30 phaco procedures every surgery morning. With a 70% conversion rate to presbyopia- and astigmatism-correcting technologies, my current objective has a little more riding on it than simply performing safe surgery—these patients expect perfect outcomes.

Young surgeons who are interested in having a premium practice using presbyopia-correcting IOLs need to understand that delivering a 20/happy result begins with the patient consultation. Identifying the best candidates for premium lenses, setting appropriate expectations, performing precise testing, and managing the ocular surface play a huge role. The surgeon’s confidence in his or her IOL recommendation and the care taken to perform a perfect surgery are also paramount to success. You must follow through from beginning to end, like a good golf game.

Dispelling myths associated with accommodating IOLs.


Two lenses I’ve had great success with in my first year of private practice are the Crystalens and the Trulign (both Bausch + Lomb). The aspheric lens design and aberration-free optics of the Crystalens provide superior visual quality and contrast sensitivity over a broader range of vision compared with a traditional monofocal IOL. I like that the optical performance is pupil independent, with uniform power from the center to the edge of the optic. Add in the ability to correct nearly 2.00 D of cylinder at the corneal plane with the Trulign, which our practice has found to have among the best rotational stability of all toric IOLs, and you have some highly effective lens technologies that can lead to reduced spectacle dependence for the cataract population. 

Currently, I am in the process of collecting data on my first 50 accommodating IOL cases. So far, I have found that, at 1 month, 82% of patients achieved an uncorrected distance visual acuity (UDVA) or 20/20 or better, and 100%, of 20/25 or better. For uncorrected intermediate visual acuity (UIVA), 91% were 20/20 or better and 100% were 20/25 or better. Interestingly, 13 of the 50 cases were post-RK or post-LASIK patients, and, of those, only one did not achieve 20/20 UDVA; all had 20/20 UIVA. Patients in the post-refractive surgery cohort actually saw better than those in the general cohort, which speaks to how forgiving the lens can be in this setting. I’ve also had no case to date in which a laser revision or touchup was needed. Despite these satisfying outcomes, perhaps what I love most about these IOLs is that just about everyone is a candidate and any postoperative issue, albeit rare, is usually a simple refractive error that can be fixed with an excimer laser. In contrast, with multifocal lenses the potential candidate pool is smaller, and postop intolerance issues may result in explantation.  

It is important to note that I have had great success with the new generation of low-add multifocal IOLs. In good candidates with realistic expectations and a solid understanding of the potential side effects, these lenses have been game changers for patients who seek freedom from readers after surgery—a reality I never discuss with my Crystalens patients. Thanks to my meticulous patient selection, I have had no unhappy multifocal IOL patients or explants. Rather than championing one company or technology over another, I would encourage young surgeons to consider both multifocal and accommodating lenses as tools in their armamentariums if they are looking to offer premium IOLs.

Despite increases in the market share of accommodating IOLs (up to 32% of all presbyopia-correcting IOLs in the first quarter of 2016, per Market Scope1), few of my young colleagues are attempting to place them in patients desiring more spectacle independence. Older, more experienced surgeons are implanting them, while younger surgeons sit on the sidelines. When I share the early success I’ve had with my peers and inquire as to why they are not offering these lenses, what I hear most is that (1) they never placed any in residency, so they are not comfortable doing them now; (2) they heard from an attending or senior surgeon that they do not work and that patients routinely require readers; or (3) they heard they can lead to severe postoperative complications such as Z syndrome.  

I’ll address these issues and myths below by offering my five keys to getting started with accommodating IOLs as a young surgeon.

1. See for yourself. Don’t blindly adopt the biases of your residency program attendings and/or senior members of your practice. Instead, commit to trying a technology for yourself. It is important to get comfortable exploring new treatment options if you want to stay on the cutting edge and offer the best solutions to your patients. As a resident, I heard many faculty members say that accommodating IOLs didn’t work, yet I knew that there were thousands being implanted worldwide and many skilled surgeons having success with them—my own father (Charles Williamson, MD) being one. If they didn’t work, why would reputable surgeons be implanting them? I refuse to believe it’s simply for financial gain; not only does that go against everything we stand for as physicians, but also simple logic suggests that if these IOLs didn’t work, patients would be unhappy and would tell their friends and family, who would, in turn, not go back to that surgeon. That is a practice killer, and the practices of the top surgeons implanting these lenses are the opposite of dead: They are thriving. I realized as a young surgeon that this didn’t add up, and, at the very least, I needed to try out these lenses for myself.

2. Be a sponge. Find a mentor who is successful with accommodating IOLs and absorb his or her insights. Texas is about 3 hours west of me, so I decided to go on a surgery tour after residency and do a micro-fellowship with five of the highest-volume refractive cataract surgeons in the Lone Star State. They all had different lens preferences, technologies, and approaches; however, the common theme was that they were all successful. Many were implanting accommodating IOLs quite regularly, and, for some, it was their lens platform of choice. If you think accommodating lenses don’t work, I’d challenge you to sit in surgery with Jeffrey Whitman, MD, in Dallas. Or, take I-35 200 miles south to Austin and visit Dr. Steven Dell’s operating room. That is what I did. Watching master surgeons allows you to learn the nuances of a technology, including where it excels and where its shortcomings lie. This, in turn, sets you up for success in your own implementation of the technology, both in terms of setting appropriate patient expectations and fine-tuning your surgical technique.  

3. Never apologize for the technology. Know what these lenses are and are not made to do. I must credit Paul Singh, MD, and Mitchell Jackson, MD, for teaching me this great pearl, which has helped me justify what I offer to patients and how I explain their premium lens options. As it relates to the Crystalens and Trulign, the perceived “issue” of these platforms not providing consistent freedom from readers at near is really a nonissue in my mind. This is because the words “near vision” never leave my mouth when counseling patients on the Crystalens or Trulign. In my experience, this technology is not a J1 lens like multifocal IOLs can be, and that’s OK. I tell patients that these lenses are not made to do that. 

Instead, we talk about intermediate vision and increased range of vision and depth of focus compared with a monofocal lens. I explain that today we live in an intermediate world with iPads and smartphones, and this technology shines in that space. I offer all patients who choose an accommodating lens the option of building in some mini-monovision to try to achieve excellent intermediate vision (still avoiding the word near) if they read or use the computer frequently. Interestingly, 50% of patients decline and say they are happy wearing readers for closer tasks and prefer to be “matched up” at distance and intermediate between eyes. In my experience, the idea that patients will be unhappy postoperatively if they are in readers is a myth as long as you take the necessary time to counsel them preoperatively. 

4. Be meticulous with the preoperative consult. Inform and educate, then motivate and recommend. Your preoperative consult and workup are vital to achieving 20/happy postop patients. In addition to the standard workup, every patient I see for a cataract evaluation undergoes macular OCT and topography, sometimes with multiple devices if I observe any irregularity in astigmatism. I look closely at angle kappa, coma, root mean square, and pupillometry, as this information assists me in making my IOL recommendation. All patients get tear osmolarity and MMP-9 testing if they have any dry eye complaints, and I don’t hesitate to start tears and/or topical cyclosporine when warranted. I look closely for meibomian gland dysfunction and blepharitis, and, if found, I schedule the patient for what I call lid physical therapy, in which BlephEx (RySurg) and MiBo Thermoflo are performed preoperatively by our eyelid hygienist. 

I have patients fill out a Dell questionnaire, which informs me about what lens fits their lifestyle and goals, how they want to use their eyes after surgery, and whether freedom from glasses is important to them. If they are more interested in learning about the Crystalens, I am careful to explain all pertinent details, including the fact that they will need light readers for reading up close. I realize that many actually will not need them, as I have seen plenty of patients who are J2 and happy 5 years postop. But I decided from the start that if I had even one patient who was unhappy with the Crystalens because he or she had to wear readers, then that would be too many. As such, I undersell and over-deliver. I take what I learned from Kurt Weir, MD, and start every consultation with the phrase, “Nothing I’m going to offer you in terms of lenses will be as good as what God gave you—meaning, I can’t make you 22 years old again.” This immediately puts the patient in the frame of mind that there will be some compromise. Then, they are pleasantly surprised when they can read their iPad and watch the news without glasses for the first time in years. As you start seeing outcomes like this, you will grow more confident in the technology and feel more natural when motivating patients who inquire about premium IOLs.

Some of my young colleagues have told me that they have problems converting patients to premium IOLs and question how to boost their conversion rate. My advice is to focus on patient education and messaging. First, ask the patient what he or she likes to do and whether doing those things without glasses is of interest. If the patient says yes and that he or she loves driving his or her convertible, then I might mention the idea being able to see not only the highway and street signs but also the gearshift and radio without glasses if he or she is considering a Crystalens. This will resonate more with the patient than a discussion about focal lengths or the contraction of the ciliary muscle. People love to pay for things they want and hate to pay for things they need. It’s why I cringe when I pay my water bill each month (which is nominal), yet I’m the first in line when a new iPhone comes out (which is expensive), despite the fact that my current iPhone works just fine. Understanding this simple fact and having confidence in the technology has helped me shape my conversations with patients and drive conversions.

5. Start implanting and stick with it! As with any new technology, there will be a learning curve for accommodating IOLs, although, for me, it was fairly short. In fact, my first case in private practice was a Crystalens implantation, and my second, a Trulign. I was eager to dive in, having acquired many surgical pearls on my Texas surgery tour and at home watching my dad operate. To be succinct, I’d say a nice curvilinear capsulorhexis that covers both haptics and the edge of the optic for 360°, meticulous cortical cleanup of the anterior and posterior capsules, confirmation that the lens is seated properly and not vaulting forward, and a watertight seal of the wound are the keys to success intraoperatively.

Postoperatively, patients should be followed carefully, and YAG capsulotomy should be performed immediately if capsular opacification is seen to prevent capsular fibrosis syndrome. Given this approach, the incidence of Z syndrome is extremely rare in our practice. With careful patient consultation, meticulous surgical technique, and close postop monitoring, complications should be few and far between. When they do occur, it is important to identify why, correct any mistakes, stick with the technology, and use what you have learned from the experience to improve your technique moving forward.


This has long been our approach at Williamson Eye, and we have improved the sight and lives of many patients as a result of this pioneering philosophy. It is this mindset that I am working to carry on as I get started and move our practice into the next generation.

Blake Williamson, MD, MPH
Blake Williamson, MD, MPH