14 EyeWorld Asia-Pacific | March 2025 CATARACT From there, Dr. Donaldson said that she tries to acquire imaging (topography, biometry, and macular OCT) before performing the slit lamp exam. This helps her determine which lenses the patient might be a candidate for. “Once I determine their candidacy with the exam and review of imaging, I discuss the patient’s goals for their surgery. I assess their visual needs by learning about their occupation, their pastimes and by assessing their potential desire for spectacle freedom,” she said. While she and the patient might discuss different lens options, Dr. Donaldson said she always ends the consultation with a concrete lens recommendation, clearly stated in the patient’s chart. “This is very important for my staff who will take the conversation to the next level. It delivers a singular message to the patient, despite who they may be interacting with in the office. My surgical coordinator will then discuss scheduling and finances in more detail, following our office visit. If the patient calls with additional questions after our visit, staff can refer back to my notes and specific recommendations to ensure consistency with our message as a practice, and to avoid causing patient confusion,” Dr. Donaldson said. When Dr. Donaldson started practicing 20 years ago, she said there were basic monofocal lenses, one multifocal lens, and one accommodating lens. The discussion involving lens selection at this time was short, and most patients chose a monofocal lens. Soon two new multifocal lenses joined the pack, but Dr. Donaldson said these and the other lenses that tried to offer more spectacle independence had significant dysphotopsias (associated with high near-add powers). “For the most part, we were not very savvy explaining dysphotopsia profiles, and surgeons quickly became frustrated with unpredictable visual side effects,” she said. “We had many happy patients, but just a single unhappy patient could be devastating to clinic flow and to surgeon confidence. This limited the penetration of premium lens technology into the market. “Today, we are very fortunate to have a plethora of lens options with much-improved dysphotopsia profiles,” she continued. “However, lens discussions can consume a great deal of chair time. In larger, high-volume premium practices, specialized staff may whisk the patient away for a full review of the lens options, but it is still the doctor’s responsibility to help the patient decide what best suits their ocular health and their lifestyle. In most practices, this is one of the most time-consuming responsibilities of the typical cataract surgeon.” Looking forward, Dr. Donaldson said she thinks AI and realistic vision simulators will play a role in lens selection. “AI could combine patient lifestyle information, desires for spectacle freedom, and financial concerns with clinical data (including macular health, astigmatism, and degree of myopia or hyperopia) to produce a lens recommendation. The more information input into the system, the more robust the algorithm would become,” she said, adding later that “improved patient educational tools, including realistic simulators, could help provide an opportunity to trial various lens options before surgery. This would increase surgeon and patient confidence with lens choices. It would also help patients better understand potential dysphotopsias.” ‘There is an art to this’ Jonathan Rubenstein, MD When it comes to making an IOL recommendation to the patient, informing the patient to select their best option is, according to Dr. Rubenstein, “a combination of art and science.” “There is an art to this. You have to try to figure out what the patient’s needs are. There are two ways to look at this: one is to ask ‘what does the eye require’ and the second is ‘what does the patient require’,” he said. It starts with what the eye needs. Does the patient have astigmatism? Do they have a current comorbidity (ocular surface disease, a problem with the macula, glaucoma, previous refractive surgery)? “You have to assess the eye because that will narrow down your IOL choices right there,” Dr. Rubenstein said.
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