Bonus Playbook: Helping Patients Choose their IOL

LiveseySolar created this playbook as a comprehensive guide for refractive surgeons to navigate the nuanced process of co-selecting the most appropriate lens for patients undergoing lens replacement surgery (cataract or refractive). It underscores a participative-medicine, patient-centred approach, weaving lifestyle considerations, vision needs, and technological options into the decision-making process, from pre-consultation preparation to post-surgery follow-up. We have consulted with Arthur Cummings, medical director, owner, and consultant ophthalmologist of Wellington Eye Clinic, who has generously provided medical advice for this public playbook.

The steps outlined here ensure complete patient information, engagement, and satisfaction with their lens selection. They emphasize the importance of understanding patient lifestyles, using visual aids and real-life scenarios to educate on lens options, and setting realistic expectations for surgery outcomes. 

Additionally, the playbook calls for continuous education for surgical teams to keep up with advancements in lens technology and patient communication strategies. Following this guide, refractive surgeons will enhance their consultation processes, making them more efficient and effective and ultimately improving patient satisfaction and vision outcomes.

You can use a video like this (used with permission) at any stage of the patient onboarding process to explain the lens types, compromises, and chances of needing glasses after surgery.

Video Transcript

  1. 1

    Pre-Consultation Preparation

    • Send the patient a detailed lifestyle and vision needs questionnaire before the appointment.
    • Provide educational materials on lens options, including videos or brochures, to familiarize patients with their choices.
  2. 2

    Initial Patient Consultation


      • Review the completed lifestyle and vision needs questionnaire with the patient.
      • Identify the patient's primary vision zones: 
        • Distance (e.g. looking out a window), 
        • Intermediate (e.g. looking at a computer screen), and 
        • Near (e.g. looking at your phone or a book).
      • Communicate the compromises
        • Standard Vision (0): For distance vision without glasses. Key point:
            
          "Glasses are required for intermediate and near zones."
           
        • Blended Vision (-1): One eye for distance, one for intermediate. Key point:
            
          "You will require glasses for reading."
           
        • Blended vision (-2): One eye for distance, one eye for reading. Key point:
           
          "You may need to move closer to the screen for intermediate tasks in order to use the -2 eye."
  3. 3

    Lens Options Education

    • Explain monofocal IOLs corrected for distance vision (with reading glasses for near) and blended vision.

    • Discuss when and where glasses may still be required with the above options. 
  4. 4

    Advanced technology / Presbyopia-correcting IOL Discussion

    • Describe FROF and IROF lenses, highlighting peaks, troughs, and the absence/presence of halos.
    • Use third-party stories to illustrate patient experiences with these lenses.

    Sample items to note:
    • FROF Lenses key points:
      • "Recognize they have peaks for Distance, Intermediate, and Near vision."
      • "Be aware of potential halos around lights."
      • "Ideal for those valuing reading vision over night driving."
    •  IROF Lenses:
      • Option 1: Lenses set for Distance in both eyes. Key point:
        "You will need glasses for up-close activities."
      • Option 2: Set one eye for distance and intermediate vision (target emmetropia) and the other for intermediate and near vision (-0.50 or -0.75D). Key point: 
        "You will experience minimal glare and halos while greatly improving your range of vision. However, you will still need glasses to read very small print or in low-light conditions."
  5. 5

    Lifestyle and Vision Priorities

    • Discuss the patient's night driving and reading habits to personalize lens recommendations.
    • Present visual simulations or demonstrations to show potential vision outcomes with different lenses.

    Sample items to note:

    If you're a night driver (e.g., taxi driver), consider your need to see road signs, dashboard, and phone clearly. IROF lenses may be preferable for minimal glare and halos.
    
    If night driving isn't a priority and you desire a complete range of vision - FROF lenses could be the best fit.

  6. 6

    Choice point - Is the patient suitable for blended vision?


    • Assist the patient to reflect on their daily experience and vision priorities.
    • Simulate the blended vision experience for the patient using one or more of three steps:
      1. Full refractive correction using the phoropter to emmetropia for both eyes. This is full correction and becomes the reference for the patient of "100% vision." Defocus the non-dominant eye to -1.50 and ask the patient to rate the vision compared to the reference 100%. If the patient rates the vision as 80% or more of the 100% reference, the odds are close to 100% that they will accept blended vision. (99% for myopes and 98% for hyperopes in our experience over 25 years of using this method). Demonstrate the reverse to the patient, i.e. the non-dominant eye corrected to distance and the dominant eye corrected to -1.50D. Sometimes, this is preferred to the first demonstration. Select the option that the patient prefers. This is based on sensory dominance.
      2. Trial frames -Trial frame: If the phoropter test outlined above does not yield a conclusive result, conduct a trial frame test for at least ten minutes in the clinic with the patient using the trial frame to view all distances. Compare 0/-1.50 to -1.50/0. Most often, this trial frame test will provide a conclusive answer.
      3. If step 2 remains inconclusive, proceed to a contact lens trial for a few days so that the patient can experience blended vision at home and at work in their real-world environment. 
    • Why blended vision?
      • It costs less than the alternative (AT-IOLs)
      • Glasses can correct any glare symptoms or range issues if required.

    • Summarize the pros and cons of each lens type based on the patient's lifestyle and vision needs.
    • Assist the patient in making an informed decision by answering any remaining questions.
  7. 7

    Plan to replace the lens in the non-dominant eye with a monofocal IOL targeting reading and a distance IOL in the dominant eye

    Remember, this is based on "sensory" dominance.
  8. 8

    Plan to replace the lens in the non-dominant eye with an FROF lens

  9. 9

    Consent and Expectation Setting

    • Schedule a final consent meeting to confirm the patient's lens choice.
    • Set realistic expectations about the surgery, recovery, and potential need for glasses in certain activities.

    [OPTIONAL] You could save 30 minutes of chair time per patient by sending a video like this in advance of your final consent appointment with the patient: 

    youtube.com/watch?v=buV6kOigN2Q
  10. 10

    Post-Surgery Follow-Up (1 week later)

    • Conduct a follow-up consultation to assess satisfaction and address any vision concerns.
    • Collect feedback on the lens performance in various vision zones and daily activities.
  11. 11

    Choice point: Custom Match

    Now, Custom Match is a very Innovative approach where you first place a full range of focused lenses in the non-dominant eye, and then one week later, you reassess.
  12. 12

    Place the same (FROF) lens in the dominant eye

    90% of people love the lens. They are not disturbed whatsoever by the halos that they don't have and, hence, want the same lens in the other eye. So, both eyes now have a full range of focus lens with a full range of focus, and they can function everywhere.
  13. 13

    Place an IROF lens in the dominant eye

    The 10% who are disturbed by the glare and halos at night in the non-dominant eye then get an IROF lens in the dominant eye. So now both eyes can see far. Both eyes can see intermediate. You can still read with a full range of focus lenses, giving you very good reading, and the increased range of focus lenses adds to that. You now have a very functional range of vision, and you can easily drive at night with no glare and halos, given that the dominant eye does not have glare and halos.
  14. 14

    Continuous Education and Training for Staff:

    • Organize regular training sessions on the latest lens technologies and patient communication strategies.
    • Ensure all team members have up-to-date knowledge to support patient education effectively.
  15. 15

    End