Who Should Implant Your Cataract Premium IOL?

There was an interesting presentation Sunday at the Annual AAO meeting in San Francisco given by Dr. Vinjay Shah.  EyeWorld Magazine summarized his findings:

Residents lacking in premium IOL, pediatric cataract procedure experience

Third year residents are not getting enough hands-on experience leading pediatric cataracts and implanting premium intraocular lenses (IOLs) according to Vinay A. Shah, M.D., University of Missouri, Kansas City, and his colleagues. Dr. Shah sent a survey to every third year resident accredited with the Accredited Council for Graduate Medical Education (ACGME) in the United States; 154 (35.5%) of the 434 residents completed the survey. Through this self-reported survey, residents responded that they were getting ample chances at extra-capsular cataract extraction (ECCE) with 40 residents having done more than 50 surgeries. But in terms of pediatric cataract surgery and premium IOL implantation, their experiences were lacking. For example, 102 residents never implanted a premium IOL, and all but seven residents had implanted premium IOLs in 10 patients or fewer. Similarly, 118 residents never performed a pediatric cataract surgery, and only three residents had done more than 10 procedures.

This interesting study leads me to ask two important questions:

1. Should residents even implant any premium IOLs?
2. Who should one go to if they want a premium IOL at the time of their cataract surgery?

Let me answer these two questions by first defining my goals of different surgical procedures:

1. Cataract surgery is preformed on a patient when their cataracts are causing a decrease in vision that is interfering with their daily lifestyle.  The goal of cataract surgery is to improve the patient’s best corrected vision.  If a patient has pre existing astigmatism, they will most likely still need distance glasses after cataract surgery.  All patients will also still need to wear reading glasses after cataract surgery, as the IOL does not focus for near objects.
2. Many patients would like to decrease their dependence on glasses.  This is the goal of premium IOLs.  A toric IOL will decrease pre existing astigmatism and improve distance vision without glasses.  A multifocal IOL will allow one to read without glasses.  Uncorrected vision after cataract surgery may be further improved with LASIK surgery.

In my opinion any surgeon who is offering premium IOLs MUST have the following attributes:

• Must be performing perfect, pristine cataract surgery, on a very consistent basis.  This only comes with experience and volume.  I would suggest going to a surgeon who does over 30 cataracts a month.
• Must fully understand refractive surgery.  One of the biggest complaints I get from patients who see me for second opinions after premium IOL implantation is that they are unhappy with some aspect of their vision.  Most of these patients have a residual refraction in their eyes.  A simple LASIK procedure will usually correct this problem.  Many times, their operating surgeon does not offer this as an option, as they do not provide LASIK services.
• Must have vast experience in premium IOL implantation.  There are many nuances that must be overcome to achieve success in the refractive cataract patient.  I would suggest going to a surgeon who does at least 20% premium IOL implantations of his cataract volume.

So, to answer the two questions I posed earlier:

1. I do not believe residents should be implanting premium IOLs.
2. If one is interested in reducing their dependence on glasses following cataract surgery, I would suggest going to a high volume surgeon with vast experience in both premium IOL implantation and refractive LASIK services.

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