The premium preoperative evaluation sets the tone for the premium postoperative outcome in premium IOL patients. There are 6 key components including the preop history, the ocular surface, corneal topography, IOL calculations, macular assessment, and the final patient discussion about premium IOL selection.
The preop history can be streamlined with a good patient questionnaire that asks about previous refractive surgery (RK, LASIK, PRK, ICL), about systemic conditions (immune diseases, diabetes, depression), about systemic/topical medications (flomax, imitrex, antidepressants, antihistamines), and about vocational/recreational needs (truck driver, avid reader, IT specialist, seamstress, pilot).
A previous corneal refractive patient may not be able to undergo more refractive surgery as an enhancement tool with premium IOLs if needed; many immune diseases and medications will contribute to dry eye and tear film instability in the postop patient causing fluctuation in vision; a multifocal IOL might be more suitable for the seamstress but accommodating IOL might be advantageous in the truck driver.
The ocular surface is highly underrated and if not pristine preoperatively to enhance capturing of accurate diagnostic data and/or postoperatively to prevent blurred vision, pseudo-refractive error, and/or discomfort will spell disaster. Studies have shown TBUT to be as high as 62% in patients undergoing cataract surgery. Diagnostic drops such as Fluramene (EyeSupply) provide simultaneous fluoroscein and lissamine staining of the conjunctiva and corneal surfaces to allow for rapid ocular surface assessment pre and postoperatively.
Corneal topography is essential to be sure the cornea can be used as an enhancement tool post premium IOL implantation. Epithelial dystrophy patients such as map-dot-fingerprint most likely will benefit from PRK over LASIK if needed. Evidence of keratoconus or like conditions if not detected preoperatively will usually result in IOL exchanges.
Formulae for IOL calculations such as the Haigis-L as part of the IOL Master version 5.4 or 500 are useful in post-LASIK cataract procedures and without emmetropia within 0.5 D of target, enhancement with LRI, LVC, and or piggyback IOL will be commonplace reducing profitability and word-of-mouth referrals.
Macular disease must be assessed and OCT to rule out epiretinal membranes/macular holes/early AMD changes is an excellent tool to prevent unhappiness postoperatively. OCT is also helpful in gauging withdrawl of topical steroids/NSAIDs in terms of macular edema postoperatively.
Lastly, the surgeon has the ultimate responsibility in the final discussion with the patient’s decision to upgrade. Avoid brands with patients because all the patient really cares about is seeing not if a diffractive or apodized or aspheric IOL is put in their eyes. The patient’s expectation is to see without glasses and proper patient selection, expectation, and preop evaluation will bring the patient closer to that premium goal and premium visual outcome.
Watch for managing astigmatism in the next blog in this 10 part series.
Blog #2 of 10: Managing Preoperative Evaluation
