AOA 2024: Exploring options in premium IOLs and refractive surgery

Commentary
Video

Nick Bruns, OD, FAAO, talks refractive surgery, from premium IOL options for patients with cataracts to EVO ICL for patients seeking elective corrective surgery.

At AOA 2024, Nick Bruns, OD, FAAO, discusses the evolving landscape of premium intraocular lenses (IOLs) and refractive surgery in his upcoming talk. He emphasizes the importance of listening to patients to understand their visual needs and lifestyle, ensuring the best lens match and managing expectations. Bruns highlights the success of EVO ICL, a game-changing option with minimal complications and excellent visual outcomes, particularly for patients not suited for LASIK or other procedures. He advocates for considering a range of refractive surgery options beyond LASIK to provide optimal patient care.

Video transcript

Editor's note: This transcript has been lightly edited for clarity.

Nick Bruns, OD, FAAO:

Yeah, I'm Nick Bruns, I practice at Summit Eye Care in Milwaukee, Wisconsin. Yeah, so tomorrow I'm gonna be giving a talk on premium IOLs, kind of the changing landscape in premium cataract and refractive surgery. And so we're gonna cover a lot of different things about kind of how there's more of a trend towards refractive outcomes. I mean, back decades ago, it was a standard monofocal lenses, and patients were understanding that they'd wear glasses. But now, today's patient in 2024 no longer is accepting, you know, wearing glasses or needing glasses full time. So we're going to talk about different lens options, the pros and cons of every one, how we try to maximize these outcomes to really meet our patient's changing lifestyle. Everybody's got different visual demands. It's kind of a weird thing to think about: How do you use your eyes? And so everybody's very different. And so every lens, trying to fit that lens to the right patient is a really important thing that optometrists really have a huge key part.

So I think the biggest tip I have for trying to make that proper match is really listening to your patient. You really have to get down to what do they want to do? What are their hobbies? What are their lifestyles? Are they a big reader? Are they very active? Are they skiers or golfers? Each lens has different, you know, different priorities and different things that it can maximize. And so trying to maximize what the lens can do to match what that patient needs is really, really important in trying to get to know your patient. So I think there's really an interpersonal relationship between doctor and patient that has to be kind of taken to the next level to match that appropriately. Number one takeaway, I think, is really listen to what your patient is telling you.

Yeah, so if patients come back, and we'd like to think that every one of our patients is just super happy and super thrilled with their their outcome and their vision, but inevitably, unfortunately, we're forced to deal with some challenging situations because not every match is perfect. We're not 100%. And so when you get that patient back, and they're just not thrilled with their outcome, we want to do a couple things. Number one, we want to advocate for our patients, we want to make sure that we're listening to what it is they're complaining about. Is it a problem with the optics of the lens? Is it a problem with maybe visual or optical discomfort? Is there any pain or dry eye sort of symptoms? Or is it more of a buyer's remorse situation? Because remember, we're taking these patients now and turning them into consumers. There is an out of pocket expense for these procedures. So they have really high expectations.

And so again, it goes back to listening. That is the number one takeaway of the entire lecture; it's going to be listen to your patient, try to hear exactly what it is. And don't run away from it. You don't want to be defensive. You know, if there's a patient complaint, it's not personal. You've got to be a teammate with your patient and try to work together to find a solution, if there is one.

And sometimes time is the best medicine. Neuroadaptation really takes weeks to months; it can take years. And so sometimes time is the best medicine. You don't have to rush to the OR or rush to the YAG laser to do a YAG capsulotomy.

So EVO ICL has been a huge game changer for us. So we've worked in Milwaukee with the Visian ICL for a long time, had fantastic outcomes. But back in 2022, when EVO was introduced, it really has opened up this whole world of refractive candidates. So the complication rates have plummeted. There's rarely any complications with EVO ICL. The visual outcomes are just impeccable. I mean, we're actually gaining lines of visual acuity from contact lenses or glasses because of where we're correcting. We're correcting vision at the nodal point of the eye, which is right at the anterior plane of the crystalline lens.

So the optics are fantastic. The complications are slim to none. And so we're really able to capture this whole portion of patients who are searching for options when maybe LASIK is not a good option, or maybe PRK is not a good option or SMILE because there are reasons that those procedures aren't 100% available for certain patients. And so we have EVO that really can open up this other subset of patients. So EVO, we kind of think of it as our more high myopic patients subset, but in reality, we have really good outcomes with mid to moderate myopes that really compete with the outcomes of LASIK. And the cool thing about EVO that patients love is that it's completely reversible. So if patients aren't really happy, never had anybody come back and ask us to take the lens out, but if they want it out, we could do it.

I think there's been a slower adaptation of it in the surgical space because of the complications that that existed with the Visian. There were complications; we saw them. There were things that did happen and they were less than, you know, fun things to go through from a clinician standpoint and a vision standpoint, obviously. And so I think there's still this sort of hesitation. Surgeons are aware of those complications and they're just a little bit gunshy. EVO has completely eliminated those complications. We don't see secondary glaucoma anymore. We don't see premature cataract formation anymore. It just the inclusion of the central [KS-]AquaPORT has eliminated all of it. A simple inclusion of a 360 micron hole has completely taken those complication risks away. So I think there's still a little bit of gunshy but if you actually look at the trends that is becoming much more and more, I think the gunshyness is going away. And so you're gonna see EVO, a lot more prevalent in the next couple of months to years. It's not going away.

My only recommendation, one of my recommendations would be to not think of refractive surgery as LASIK. Sometimes I think especially newer doctors, think of refractive surgery and LASIK as being synonyms. They are not. LASIK is a subset of refractive surgery, but there's a whole bunch of different options. EVO ICL is one of the, in my opinion, one of the best, the safest, and visually advantageous options that we have.

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