Offering premium lenses to patients for cataract surgery or refractive lens exchange is simple. I use one premium implant in all patients—irrespective of visual demands, age, or occupation. Postoperatively, all of my patients have UCVA of 20/20 or better, near and intermediate UCVA of 20/20 equivalent or better, no significant postoperative visual problems, and no loss of BCVA or contrast sensitivity. In short, the return on each and every IOL I implant is 100% satisfaction.

Or so the dream goes . . .

In reality, we—the surgeons who assess, recommend, and perform surgery; the manufacturers of premium IOLs, which continue to proliferate; and the patients who crave the visual freedom these lenses promise—can only aspire to a situation like the one depicted above. The truth is that there is no definitive structure that works for all surgeons and all patients. Therefore, each surgeon must develop his or her own structure, keeping in mind the variables that influence outcomes, the greatest of which is the inherent variability among patients' responses to the same treatment.

It is also true that there is no longer a distinct separation between the refractive surgeon and the cataract surgeon. As much as technology has improved, these advances are matched by increasing patient awareness and expectations. If we want to offer the greatest potential for achieving desirable outcomes, we must be able to provide both cataract and refractive services. Yes, it is true that most times we can satisfy patients' needs with one or the other of these, but having both in our armamentarium maximizes the number of patients to whom we can provide personalized, precise, and perfect outcomes.

THE FAMILY RULE
A structured approach to patient selection is essential to maximize satisfaction after surgery. My personal simple structure for patient and procedure selection is based on what I call the family rule: At every step I consciously ask myself, “If this were my family, is this what I would recommend or do?” If the answer to this question is no, then I will not offer the treatment, always preferring a good night of worry-free sleep instead.

Before considering the patient, you must know what technology you are comfortable using. With a vast (and growing) array of premium IOLs available, life is simpler if you master a select few as your core offerings. Choose a monofocal, a multifocal, and an accommodating IOL that you are comfortable implanting, giving consideration to incision size, asphericity, and toric correction. Research the literature during this process; gaining from the experiences, wisdom, and pearls of your mentors will reinforce what lenses you feel confident with. The projection of that confidence in your preferred choices will be a strong influence on your patients' perceptions and their decisions to proceed with a procedure.

Currently, I use the following IOLs: the monofocal Akreos MI60 (Bausch + Lomb, Rochester, New York), the accommodating Crystalens AO (Bausch + Lomb), the multifocal AT.LISA (Carl Zeiss Meditec, Jena, Germany), and, as of recently, the multifocal Lentis Mplus (manufactured and distributed by Oculentis GmbH, Berlin; and Topcon, Rotterdam, Netherlands). Both multifocal IOLs are available in toric variants.

NARROW YOUR SELECTION
Once you select your core procedures and technologies, you can determine patient suitability for any procedure and then decide which procedure or IOL you will use. Identifying a good patient for a premium IOL requires increased chair time, during which you should make a reasonable assessment of personality type, quantify visual needs and demands, and determine the physical health of the eye. The nature of the conversation and the preoperative approach will naturally be influenced by whether the patient is exploring surgical options for the treatment of cataract or as a candidate for refractive lens exchange (RLE)—the former carrying a significant element of need, rather than just desire for a surgical procedure to correct vision.

The best candidates for premium IOLs are optimistic but realistic. They understand that surgery is about reducing, not eliminating, dependence on spectacles; they comprehend that all surgical outcomes involve some type of compromise compared with the vision they had as a 20-year-old; and they accept that this treatment has the potential to provide better results than other options.

Poor candidates for premium IOLs are the pessimistic perfectionists—those who would not be happy with anything less than 20/20 for distance and near equivalent (and sometimes not even then), and those who will not accept a change in visual quality. However, the poor candidate for premium IOLs with RLE may evolve into a good candidate once cataract develops. This group often contains patients who still have some accommodation. I often encourage these patients to wait until accommodative loss has greater subjective impact on their lives, at which time I reassess them as potential candidates for a premium IOL procedure.

QUALITY AND PERFORMANCE
I focus on two key elements—visual quality and visual performance—when reviewing the potential implants and their respective qualities with patients. I divide the IOLs into two groups, monofocal and accommodating IOLs in one group and multifocals in the other.

Monovision can provide as complete a solution as any of the premium lenses at reduced cost to the patient. It can provide the highest quality of vision, without the halos or glare associated with multifocal IOLs and with the same degree of spectacle independence. The catch is that patients must be comfortable with a monovision strategy, and therefore a monovision contact lens trial before surgery is crucial. For some patients, this trial is enough to convince them that monovision is not a viable strategy.

No accommodating lens will restore the level of accommodation of a prepresbyopic individual. The Crystalens AO typically provides approximately 1.00 D of accommodation. Although its monofocal optic provides the best quality of vision, including excellent distance vision and almost certain intermediate vision, it only offers variable near-vision levels. Patients whose visual demands are primarily focused on distance quality, such as for driving at night or flying, are great candidates for an accommodating IOL. However, they must accept the greater possibility of needing reading glasses compared with either monovision or multifocal IOLs.

With multifocal IOLs, the obvious trade-off is image quality. Glare and halos are fairly universal, although they tend to improve with time. The advantage of multifocal designs is the more definitive achievement of excellent distance and near vision; however, intermediate vision may be more variable. I choose the appropriate multifocal IOL primarily on the basis of the patient's near demands; the AT.LISA has a 3.75 D near add and the Lentis Mplus a 3.00 D add (also available with a 1.50 D add). The optics system of the Lentis Mplus, which has a single surface-embedded near segment rather than the multiple rings of the refractive- diffractive AT.LISA, appears to result in less glare and halos and possibly less loss of contrast sensitivity. With the option of mixing the 3.00 and 1.50 D adds in fellow eyes, this lens has tremendous potential for great distance, intermediate, and near vision outcomes.

As a basic rule, the best choice for patients with glaucoma or any suggestion of macular compromise is a monofocal or an accommodating IOL. These patients already have some contrast sensitivity loss, and a monofocal optic will maintain the maximum quality of vision. A multifocal IOL will always exaggerate the loss of contrast sensitivity. Again, the optical principles of the Lentis Mplus may make this lens a more feasible option in such patients; however, it should be considered with caution.

PATIENT EXPECTATIONS
With any surgery, it is important to manage patient expectations. I always aim to under-sell and over-deliver, and I aggressively manage preoperative issues such as dry eye (even mild) because they can significantly affect early postoperative satisfaction. Additionally, I warn patients that immediate postoperative results may not be optimal and that they will notice significant improvements after the second eye is done, typically 1 week later. I always counsel patients that there is a 5% to 10% chance refractive enhancement will be necessary, and I frequently perform limbal relaxing incisions for low levels of corneal astigmatism. If a patient wants an accommodating IOL but has high corneal astigmatism, I counsel a two-step approach, IOL implantation followed by refractive laser treatment 3 to 6 months later.

With so much information transfer, I always encourage patients to be accompanied by a family member. Despite the use of educational videos, literature, and support staff, much of the information will not be retained by the patient alone. Prior to surgery, I offer a further opportunity for questions and clarification of expectations.

There is no perfect solution—no solution that fits all—nor do I believe we will ever have one. But with the application of simple and consistent principles, careful assessment, consideration of factors relevant to the individual, and diligent education, the available technology (which is still improving) enables us to provide a satisfactory solution to most patients who wish to be considered for a vision correction procedure.

Saj Khan, MB BS, FRCSEd(Ophth), is a Consultant Ophthalmic Surgeon, Centre for Sight, East Grinstead, West Sussex, United Kingdom. Dr. Khan states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +44 1342 306020; fax: +44 1342 306039; e-mail: skhan@centreforsight.com.