Elizabeth Yeu, MD

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I have long been an advocate of giving patients the best possible uncorrected distance vision with toric IOLs.

Recently, my results with a toric extended depth of focus (EDOF) lens have led to a dramatic increase in my presbyopia-correcting IOL rates, from about 7% of all my cataract procedures to nearly 25%. I've found that Symfony toric lenses (Johnson & Johnson Vision) provide reliable correction of astigmatism and the same acuity and quality of vision that we are accustomed to with the Tecnis toric, with the added benefit of improving near and intermediate vision.

That has made me much more comfortable talking to patients and referring optometrists about toric EDOF. I even chose this implant for my mother-in-law when she underwent cataract surgery. 
 



I reviewed one-month results for 102 consecutive eyes of 72 patients implanted with Symfony toric IOLs.  The cases were nearly evenly split between right and left eyes (52 OD/50 OS), with a majority of the patients (63%) being female. 

All four of the available toric powers were implanted in this case series. The majority of eyes received the ZXT150 lens (62%); while 25% were implanted with a ZXT225, 9% with the ZXT300, and 4% with the ZXT375.  Most eyes (55%) were targeted for emmetropia; 45% were targeted for slight myopia ranging from -0.25 to -1.00 D.

At one month postoperatively, mean uncorrected distance visual acuity was 0.11 ± 0.15 LogMAR (20/25.8 Snellen). More than three-quarters of the eyes were seeing 20/25 or better.  The manifest spherical equivalent (MSRE) was -0.25 ± 0.47 D, with nearly eight in 10 patients enjoying an MRSE within 0.50 D of emmetropia.  Patients were quite satisfied with their near vision after surgery: 72% of eyes implanted with the Symfony toric were J2 or better and 93% were J3 or better.

Residual cylinder was very low, at 0.30 ± 0.33 D. In all, 88% of eyes had ≤ 0.50 D of residual cylinder and 63% had ≤ 0.25 D. 

Less than 2% of eyes (2/102) required a lens rotation postoperatively. Both of these eyes were high WTR astigmatic eyes implanted with high toric power IOLs. We know that any rotation in a higher astigmat can have a greater impact on vision so repositioning is more common in these cases.  One of these patients also had a long, 27-mm axial length eye, along with her 3.50 D of with-the-rule (WTR) astigmatism.
I am now more likely to place a suture or use ReSure sealant (Ocular Therapeutix) in larger eyes like this to prevent any egress of aqueous that can lead to an imbalance in pressure in the anterior chamber and potentially contribute to lens rotation.


Many factors go into success with any toric IOL, including the Symfony toric.  Particularly during one's early experience with the lens, it is important to choose candidates with regular, stable astigmatism, average axial length (22-25.5), and a healthy cornea and retina.  Initially, I would recommend avoiding patients with very low (<1.0 D) or very high (>3.0 D) astigmatism and anyone with poor zonular or capsular support. 

Many people are concerned about the impact of toric IOL rotation on outcomes in astigmatic patients.  However, postoperative rotation is only one potential cause of residual refractive error after toric IOL implantation-and, I would argue, the least likely, especially in normal eyes.  Errors in preoperative measurement of the axis and magnitude of astigmatism are far more likely to be responsible for a suboptimal outcome.

In selecting the cylinder power and axis I like to ensure that at least two preoperative keratometry measures are in agreement.  I always compare measurements from the Lenstar (Haag Streit), Cassini (i-Optics), and a Placido topographer-either the OPD Scan (Nidek) or the Atlas (Carl Zeiss Meditec).

In post-refractive eyes, I also obtain Orbscan topography (Bausch + Lomb). The Cassini device is helpful in understanding posterior corneal curvature.  We know that anterior corneal topography measurements tend to slightly underestimate total corneal astigmatism in eyes with against-the-rule (ATR) cylinder, and that those with ATR are more sensitive to small amounts of residual error, so it is important to be more aggressive in correcting all the astigmatism in ATR eyes.

Appropriate power calculation is also important.  For average eyes, I'm very comfortable with my Holladay 1 calculations, but I always do Barrett Universal and the newest version of the Hill-RBF calculator, as well.

Patients with dry eye (or any other corneal pathology) are likely to have more keratometric variability, so it is also very important to evaluate and treat the ocular surface before surgery.  This should include evaluation of the lid margin and diagnostic meibomian gland expression, because the majority of cataract patients present with some degree of meibomian gland dysfunction, and often are asymptomatic.  Ideally, the ocular surface management would begin with the referring primary care doctor.

Good marking technique (whether with a radial marker and ink, a femtosecond laser, or other method) is important to positioning the IOL on the correct axis intraoperatively.  Surgeons need to make a consistent entry wound to avoid surgically induced astigmatism and achieve a round capsulorrhexis that overlaps the lens optic evenly.

When all of these factors are handled with care, it is possible to achieve excellent toric outcomes and, with new toric EDOF lenses, to offer patients better uncorrected near and intermediate vision at the same time.

Articles

Where a toric EDOF lens fits in this surgeon's practice

,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The views expressed in these blogs are those of their respective contributors and do not represent the views of 

	In this collaborative blog post, learn how building rapport and sharing like-minded philosophies benefits your practice and your patients. Five ophthalmologists share how to make the most of a co-managed relationship for smoother patient handoff, improved preoperative experiences, and better postoperative outcomes.

Dr. Donnenfeld“The most important aspect of co-management is that both parties collaborate in providing the best possible care for the patient,” said Eric Donnenfeld, MD, who practices with Ophthalmic Consultants of Long Island and Connecticut, and is clinical professor of ophthalmology, New York University.

	One of the ways this plays out in his practice is making sure patients arrive ready for surgery.

	“We have emphasized to our optometric network the importance of managing the ocular surface in patients coming in for cataract and refractive surgery,” he said. 

	Previously, if patients arrived for a surgical evaluation but their ocular surface was not optimized, clinicians had to defer surgery. Now, the optometric network manages ocular surface disease before referring patients.

	“The patient comes in and has already been treated appropriately, whether it be with an immunomodulator, a steroid, omega-3 supplements, or LipiFlow thermal pulsation,” he said. “It is so helpful when the patient comes in for a cataract or LASIK evaluation with the best ocular surface possible.”

	Dr. Donnenfeld noted the importance of the optometrist’s recommendations.

	“A doctor who has been taking care of that patient for a decade is going to know a lot more about that patient’s personality, history, and vision care experiences than I can learn in a short consultation, so their counsel becomes very important in my decision as to what lens the patient should receive,” he said.

2. Look for partners who share your philosophy 

Dr. KontosWhen building a successful co-management network, ophthalmology practices should seek out and nurture relationships with like-minded partners. 

	“We look for optometrists who are progressive, engaged in continuing education, and who are always looking to learn more about what is happening in eye care,” said Mark Kontos, MD, who is in private practice with Empire Eye Physicians, Spokane, WA, and Coeur d'Alene, ID.  The practice has co-management relationships with about 75 optometrists.

	“A fundamental theme in our practice is that we want to be on the cutting edge of innovation in ophthalmology,” Dr. Kontos said.

	For example, his practice likes to use advanced technology lenses to correct astigmatism and presbyopia, but that can be a source of conflict if the referring optometrist has little interest in or knowledge about the technology.

	“We feel that new lenses like the extended-depth-of-focus IOLs [Tecnis Symfony, Johnson & Johnson Vision] are beneficial to patients, and so it is important that we are on the same page with our referring doctors,” he said.

	To keep co-management partners up to date, his practice presents a large education event each year. Speakers discuss new technology and the latest research in ophthalmology. 

	In addition, ophthalmologists in the practice also meet with co-managing partners during dinner and lunch meetings once or twice a month to discuss issues related to patient care and to maintain strong lines of communication.

	“If they can spend a half day in the practice, that gives them an opportunity to see surgery and us a chance to educate them about what we are doing in our practice,” he said. “We also can get valuable feedback from the optometrists on what patients are saying about the combined care we are providing.”

3. Establish relationships based on best practices

Dr. Chang“With co-management, you have to be really careful from a documentation standpoint,” said Daniel H. Chang, MD, who is in private practice at Empire Eye and Laser Center, Bakersfield, CA. To ensure thorough documentation, his practice uses a five-form process that includes consent for co-management, requiring signatures from the patient, surgeon, and co-managing optometrist.

	Prior to surgery, he sends a surgery appointment schedule to give the referral optometrist an idea of the anticipated course of treatment. After surgery, he sends a co-management operative report with relevant details about the surgery.

	After surgery, he documents appropriate transfer of care. When Dr. Chang examines the patient postoperatively and determines that he or she is doing well, he sends the transfer agreement to the optometrist, as well as a pre-labeled transfer response.

	This way, the optometrist can confirm that the patient returned for continued follow-up and report the postoperative findings from that visit.

	“These forms demonstrate an open communication between the surgeon and the co-managing optometrist,” he said.

	About 10% to 20% of his cases are co-managed. To enhance his collaborative relationship with community optometrists the decision was made not to include an optical shop at his new practice location. This reduces the concern from referring optometrists that he may not return their patients and may even represent unwelcome competition for spectacle sales.

	“We still have optical patients at our original location, and they remain a welcome part of our practice,” Dr. Chang said. “But referred surgical patients never know that we sell glasses.”

4. Build rapport with your co-management partners

Dr. IrshadStrong co-management relationships are especially important in rural areas, where patients may need to travel long distances to see an ophthalmologist. When forging a bond in these wide-open spaces, however, Farhan A. Irshad, MD, with Wallace Eye Associates, Alexandria, LA, found that it helps to go the extra mile.

		When he was new to the practice and the community, Dr. Irshad said it was most effective to visit practices to introduce himself.

		“It meant a lot to them that I traveled the distance to their location and could see their office, meet their staff who I would also be working with, and see their equipment,” he said.

		“With every first-time referral, I actually called the doctor after surgery in addition to sending a letter,” he said. During the conversation, he detailed his findings from the examination, the treatment plan, and why he chose that plan.

		Practice services also support these relationships. For example, his practice sends billers and coders to assist the optometrists’ teams with co-managed cases.

		“With the changes in rules and regulations, some of them are not familiar with the nuances of medical billing because it’s not something they do on a regular basis,” Dr. Irshad said. “Sending our team in to help has gone a long way to building a solid partnership.”

Dr. YeuWhether ophthalmologists receive referrals from an optometrist associated with a corporate chain or private practice, they need to understand how each practice functions so they can better serve that practice.

		That begins with some mechanism to organize information about each practice.

		“We created an Excel spreadsheet of preferences, contact information, and available diagnostic and imaging tools,” said Elizabeth Yeu, MD, assistant professor, Eastern Virginia Medical School, and partner, Virginia Eye Consultants, Norfolk, VA. “Just like there is such a breadth of MD practices, there is a breadth of OD practices.”

		“We find out from each co-managing partner exactly how they would like their patients to be managed,” Dr. Yeu said.

		For example, some expect patients to be returned as soon as possible, whereas others may ask the ophthalmologist to take care of the patient throughout the postoperative period or for everything related to glaucoma, for example, and just return the patient for glasses and contact lenses.

		“This is how you are going to create a successful network,” Dr. Yeu said. “Not all referring practices are created equal, so you have to customize your specific relationship with the specific practice that is referring to you, but you need to begin with an organized process.

		Daniel H. Chang, MD
		P: (661) 325-3937; E: 


		Dr. Chang is a consultant to Johnson & Johnson Vision.


		Dr. Donnenfeld is a consultant to Allergan, Bausch + Lomb, Johnson & Johnson Vision, Kala, RPS, Shire, Sun, TearLab, and TearScience.

		Mark Kontos, MD
		P: (509) 928-8040; E: 


		Dr. Kontos is a consultant to Johnson & Johnson Vision.

		Elizabeth Yeu, MD
		P: (757) 622-2200; E: 


		Dr. Yeu is a consultant to Johnson & Johnson Vision. 

Five ophthalmologists share how to make the most of a co-managed relationship for smoother patient handoff, improved preoperative experiences, and better postoperative outcomes.

Five secrets to success with co-management

There are a number of ways to improve near vision for presbyopes, including multifocal intraocular lenses (IOLs)–traditional or low add–and pseudoaccommodative IOLs. It has been well documented that a small pupil and higher order aberrations, such as spherical aberration (SA) or coma, can increase depth of focus.

In combination with some degree of monovision, this may enable some patients to have good near vision with a monofocal IOL or a corneal refractive treatment. However, there may be tradeoffs in terms of visual quality.      

The ophthalmic industry is beginning to see a new category of extended depth of focus (EDOF) IOLs that are designed to provide a continuous range of focus with fewer limitations than multifocal IOLs or the pseudoaccommodative options described above. These include the Tecnis Symfony IOL (Johnson & Johnson Vision/AMO), which relies on diffractive echelette optics to elongate the focal line, and the small-aperture IC-8 IOL (AcuFocus), which is not yet available in the United States, as well as other designs in development.

The EDOF category offers two advantages over traditional multifocal IOLs. First, it offers a natural range of vision, rather than one or two “sweet spots.”

This can be easy to explain to a patient who has worn bifocal or trifocal spectacles. They understand that each portion of their spectacle lens has a limited range, beyond which there is a blur. While patients can adapt to spectacles or multifocal IOLs with distinct focal points, the idea of having a broader field of clear vision with an EDOF lens is attractive. 

Additionally, because EDOF lenses do not split light among focal points the same as a multifocal IOL, there is minimal-to-no loss of distance clarity and contrast acuity. Since patients do not have to suppress the second (blurred) focal point, they are less likely to experience ghosting, haloes, or “waxy” vision. It also lowers my level of concern about the impact of a presbyopia-correcting IOL in the context of other anterior segment conditions.

Because of this, I will consider an EDOF lens for post-refractive eyes (with regular corneal astigmatism and a well-centered ablation bed) and for patients with early Fuchs or mild-to-moderate dry eye disease that responds to treatment. I still do not recommend any presbyopia-correcting lens, including EDOF, for patients with any evidence of macular pathology. 

The addition of an EDOF lens to our practice has significantly changed the way I talk with patients about advanced technology IOLs. The lens has more than doubled the share of presbyopia-correcting lenses that I implant–from about 10% of all my cataract procedures to 20% to 25% (See Figure 1). 

Figure 1: EDOF IOLs have more than doubled the share of presbyopia-correcting lenses that Elizabeth Yeu, MD, implants in her practice - from about 10% of all cataract procedures to 20% to 25% of all cases. Courtesy of Elizabeth Yeu, MD

We took a careful and pragmatic approach to launching EDOF lenses that some might find unusual. We expected that EDOF lenses would probably not provide the very close near vision that higher-add multifocal IOLs do.

My experience in the past, particularly with the Crystalens pseudo-accommodative IOL platform (Bausch + Lomb), was that if the lens was promoted for “reading vision” or “distance and near” vision, patients expected to see everything at near without reading glasses, no matter what caveats I offered to manage expectations. 

Therefore, we position EDOF IOLs within a new refractive package, called “distance-and-computer” vision, and priced it 

 than the “distance-and-reading” vision package (See Figure 2).    

This approach helps educate patients about the strengths of EDOF IOLs, while avoiding unrealistic expectations. We were comfortable pricing a new IOL lower than the multifocal IOL package because early data demonstrated that EDOF lenses are more tolerant of residual sphere or cylinder, so there was less need to build in coverage of laser vision correction enhancements. 

Figure 2: Elizabeth Yeu, MD, positions EDOF IOLs within a new refractive package called “distance-and-computer” vision. The practice prices it 

 than the “distance-and-reading” vision package.

After three months and 65 cases, patients are achieving excellent distance and intermediate vision, so they are able to drive and use their computer, tablet, and navigation system in the car without glasses. A pleasant surprise has been that the near vision seems to be consistently between J2 and J5.

Most patients can read newspaper print (J3) unaided, particularly if I give them a - 0.25 D offset in the nondominant eye. This makes patients happy because we have exceeded their expectations.

Initially, the three-tiered pricing is an excellent way for surgeons to introduce the lens and gain experience with the EDOF category and what it can deliver for patients. I plan a more detailed review of the near-vision results after 100 cases. At that point, I may eliminate the middle package and charge the same for multifocal or EDOF.  

We try to provide a thorough educational experience when patients come in for a cataract evaluation. Their time starts with specific questions that help the surgeon figure out how to customize IOL options to patients’ needs:

·      What reading needs do you have? 

·      What do you typically do from 8 a.m. to 5 p.m.?

·      How much night time driving do you do? 

Patients are surprised by these questions. When I explain why I am asking, patients appreciate that I am taking the time to learn about their visual needs.

Their answers allow me to customize a solution to what patients really want from their vision after surgery. I am implanting fewer multifocal IOLs and toric monofocals because most patients who want a refractive correction are best served by an EDOF lens.

There is some impact from the pricing approach. Business executives refer to this as the “goldilocks effect,” in which consumers are likely to avoid the “extremes” and feel that the middle price (the distance/computer package, in our case) is the one that is “just right” for them.

It is also encouraging to know that if there is any dissatisfaction after implanting an EDOF lens in one eye, we can choose a monofocal or multifocal for the fellow eye.

It is exciting that the industry is getting closer to having presbyopia-correction options that truly meet patients’ need for a full range of uncorrected vision. The EDOF lenses have fewer of the night vision symptoms that were sometimes problematic with earlier multifocal IOLs. 

1.    Yeu E, Wang L, Koch DD. The effect of corneal wavefront aberrations on corneal pseudoaccommodation. 

Dr. Yeu is assistant professor of ophthalmology, Eastern Virginia Medical School and in private practice at Virginia Eye Consultants, both in Norfolk, Va. 

Dr. Yeu is a consultant for J&J Vision/AMO, Alcon Laboratories, and B + L.

Elizabeth Yeu, MD

Articles

Where a toric EDOF lens fits in this surgeon's practice

Five secrets to success with co-management

New IOL category offers more natural range of vision