Custom matching IOLs is key to managing patient satisfaction

The needs of our patients are a strong driver of innovation and adoption of solutions that address their demands. Nowhere is that more pertinent and important than when it comes to IOL selection for lens-based surgeries.

Many of our patients are extremely well informed with access to a lot of information about vision correction, meaning they have high expectations, even if they think they don’t. They want a spectacle-free life, with great vision at all distances, minimal dysphotopsias and importantly, a solution that fits in with their busy schedules.

How do we best address the expectations of out patients? Back in 1998 I wrote a chapter on multifocal IOLs for Buratto and colleagues' renowned textbook, Phacoemulsification Principles and Techniques. In that chapter I first talked about the concept of custom matching IOLs to achieve the best outcome for my patients. I also presented the approach the following year at the Ophthalmological Society of South Africa meeting in Durban, South Africa. I prefer the term “custom match“ to mix and match.¹

Spoiled for choice

There is no such thing as a universal approach and all IOLs have their limitations; in the book, I described combining the distant dominant Array IOL (Abbott Medical Optics Inc) in the dominant eye and the True-Vista IOL (Bausch + Lomb) in the non-dominant eye, neither of which are available today (Figures 1 and 2). This was a truly personalised approach to surgery. With today’s vast array of IOL choice and new techniques over the years, I have been able to hone my approach to custom matching, resulting in happy patients and a successful practice. Here, I share my learnings,

In our practice we start with a thorough assessment and understanding of our patients’ ocular history, health and ocular comorbidities as well as their visual goals, lifestyle, personality, profession and hobbies, all of which are critical to optimise outcomes and meet the high expectations of patients.²

When it comes to choosing the IOLs, not only do we need a deep understanding of the optics of the IOLs we are considering, but we need a meticulous selection process that includes an objective assessment of patient-specific
ocular characteristics including:

• corneal astigmatism
• health of the ocular surface
• angle kappa/alpha
• pupil size
• previous LASIK, higher-order aberration (HOA) and other ocular comorbidities

Getting patient selection right

Preoperative patient counselling is a critical step in the assessment process; it requires a clear and comprehensive discussion in language that patients understand. It should be remembered that whilst the majority of patients will not know the difference between an extended depth-of-focus (EDOF) and monofocal lens, they may have spoken with someone who has undergone similar surgery, they will likely have looked online and may have even visited industry websites.

When we undertake counselling with our patients, we cover what is involved in the surgery, including what to expect before, during and after the surgery; the type of anaesthesia we use and what to expect in the recovery period, including postoperative do’s and don’ts.

We also ensure that we cover the benefits of the proposed surgery as well as impact on quality of life postoperatively. Part of that discussion will include a frank, but empathetic discussion on expectations versus reality and a discussion around the incidence of halos and glare and how they may impact quality of life. We already have a good idea of our patients’ lifestyle and daily activities, but we will discuss IOL choice with these factors in mind. Finally, as part of informed consent, the risks and potential complications of the surgery will always be discussed.

A case study

The following case study highlights the benefits of a custom match approach that addresses the functional needs of our patient as well as their subjective needs. Our patient was a 56-year-old woman who wanted to be spectacle free. Her preoperative refraction was:

• OD: –2.00/ –2.25 x 170
• OS: –2.75/ –2.25 x 178
• Keratometry readings: OD, 44.44 and 45.86; OS, 44.88 and 46.18
• Axial length: OD, 23.53; OS, 23.63
• Nuclear lens sclerosis: grade 1 OU

Based on this refraction, preoperative assessment and her desire to be spectacle independent, we implanted a Vivity Toric in her dominant eye. This is a non-diffractive EDOF lens designed to simultaneously correct presbyopia and astigmatism, offering functional vision from far to intermediate distances.

I implanted a Clareon PanOptix in the patient's non-dominant eye. The PanOptix IOL is a trifocal lens designed for presbyopia correction, offering spectacle independence and good vision at all distances, with features including diffractive optics and aspheric biconvex design for improved visual performance. The iTrace (Tracey technologies) is a valuable tool for surgical planning. It differentiates between lenticular and corneal astigmatism and indicates the alignment (Figures 3 and 4).

Postoperative results and patient satisfaction were excellent:

• Uncorrected distance visual acuity (UCDVA) OU: 20/20
• UCVA intermediate at 60cm: 20/25
• UCVA near at 40cm: 20/20

I am also combining the Vivity EDOF IOL in the dominant eye and the Panoptix Trifocal IOL in the non-dominant eye. I have found implanting the trifocal IOL in both eyes reduces glares and halos.

When to skip custom match

In my hands, success rates with a custom match approach have been high;
however, patient selection is critical. There are situations where I would not recommend a custom match approach:

• Cornea is not suitable (e.g., irregular): HOA greater than 0.3
• Severe dry eyes not managed with topical drops
• Retinal pathology, e.g., age-related macular degeneration
• Contra-indications for trifocal lenses
• Sensitivity to halos
• Angle kappa bigger than 500 µm (more of an issue post-LASIK) (Figures 5 and 6)
• Pupil smaller than 3.5 mm or larger than 4.5 mm
• Not in decentred ablations in post-LASIK patients

Imperfect surgery

When a patient demands a full range of vision, a custom match approach is an excellent strategy. No one lens is perfect, but with the myriad options we have today, this approach means we can better meet the exacting demand of today’s patients. I find this approach far superior to mini-monovision where patients are complaining of distance vision clarity, poor near vision and glare at night. Patients have fewer haloe with this approach and they usually disappear within 3 months.

References

1. Kruger JA. Avoiding and managing patient dissatisfaction after intraocular lens implantation after cataract surgery. In: Buratto L, Apple DJ, Werner L, Zanini M, eds. Phacoemulsification: Principles and Techniques. 2nd ed. Slack Incorporated; 2003.

2. Yeu E, Cuozzo S. Matching the patient to the intraocular lens: preoperative considerations to optimize surgical outcomes. Ophthalmology. 2021;128(11):e132-e141. doi:10.1016/j.ophtha.2020.08.025

Johann Krüger, MD | E: drkruger@eyelaserclinic.co.za

Krüger is an internationally renowned eye surgeon in private practice in Cape Town for 32 years. He is a fellow of the College of Ophthalmology South Africa, Royal College of Surgeons Edinburgh and a fellow and founding member of the World College of Refractive Surgery and Visual Sciences.