Kerry K. Assil, MD, is medical director and CEO of the

Assil Eye Institute in Santa Monica and Beverly Hills,

CA. One of the world’s foremost experts in cataract

and refractive surgery, Dr. Assil was honored with the

prestigious Jules Stein Living Tribute Award in 2005.

He has written more than 100 books, textbooks and

articles on refractive surgery and is an editor or

reviewer for numerous scientific journals. His educa-

tional forums include featured lectures at Harvard

University, Johns Hopkins University and Tokyo

University. Dr. Assil received his undergraduate degree

from the University of California, Los Angeles, and his

medical degree from the University of California in

San Diego.

Our practice is a multispecialty group of two MDsand three ODs in southern California. We provideconsulting and co-management services for awide range of MDs and ODs. Our mission is tooffer the best refractive solution for the lifestyle ofthe patient.

When I’m considering the candidacy of a patientfor a premium IOL rather than a monofocal lens, Ilook for an otherwise healthy eye. Upon deter-mining this, I think through which premium IOLwould best suit that patient, taking into accountthe referring optometrist’s recommendationbased on the lifestyle, work habits and visualneeds of the patient.

Unless the patient has had previous cornealrefractive surgery for hyperopia and has a steepcentral cornea (similar in topographic shape toearly keratoconus) — or an extremely small pupil(a photopic pupil smaller than 2.3 mm or 2.4 mm), most likely I’ll select a Tecnis® multifocallens (Abbott Medical Optics, Inc., Santa Ana,CA.).

Conversely, if the patient is post-hyperopicLASIK and/or has an exceptionally small pupil,or has any mild macular pathology, such asmild epiretinal membrane or macular drusen or

mild diabetic retinopathy, then I may select theCrystalens® accommodating IOL (Bausch &Lomb, Rochester, NY).

In patients of all pupil sizes (except those thatare very small) and in those who have flat oraverage corneal curvatures and a healthy mac-ula, I prefer the Tecnis® multifocal lens, whichisn’t pupil dependent.

On occasion, if I have a patient who’s averse tohalos and glare, but insists on being able toread without eyeglasses, then I might place aCrystalens® in the distance-dominant eye, aim-ing for plano, and the Tecnis® multifocal in thenondominant eye.

When co-managing patients, I often rely on theexperience and degree of comfort the co-managing optometrist has during the earlypostoperative period. I know someoptometrists who prefer I see the patient for 3 months post-op and then return the patientto the practice, while others assume the post-op care after the initial post-op exam.

The choice of follow-up depends on both theenthusiasm of the referring optometrist and thedegree to which I’m comfortable with theoptometrist’s capabilities for diagnosing andrecognizing certain conditions. Of course, I per-form the first post-op exam, looking for inflam-mation and making sure everything else looksgood for the expected surgical outcome.

At the 1-week visit, I expect the co-managingoptometrist to be comfortable with establishingand determining if the patient has achievedbest-corrected visual acuity (BCVA). Thereafter,

Before the develop-ment of premiumintraocular lenses(IOLs), the refractiveoptions for patientsundergoing

cataract surgery depended on thesurgeon’s preference and the avail-ability of monofocal IOLs in inventoryat an ambulatory surgery center.Optometric management wasfocused on patient visual acuityexpectations, while co-managementprimarily was concerned with post-operative refraction and clinical moni-toring of the ocular surface.

Spectacle lenses and/or contactlenses corrected the residual refrac-tive error of the IOL and compen-sated for the loss of accommoda-tion following removal of the crys-talline lens. The procedure was con-sidered finished.

Over time, advances in surgicaltechnologies, such as tissue protec-tive instrumentation and a wide vari-ety of viscoelastic agents for ocularprotection, gave rise to improvedsurgical techniques. Advances inrefractive technologies, such as pre-mium IOLs (multifocal and accom-modating IOLs) provided morerefractive choices.

The primary care optometrist, whosees the patient routinely and usuallyknows the patient’s lifestyle andvisual needs, began to educate thepatient about premium IOLs while

Patient Selection, Co-management With Premium IOLsKerry K. Assil, MD, Assil Eye Institute, Santa Monica andBeverly Hills, CA.

Optometry’sEmerging Role inCataract Surgery andIOL Selection

June 2009Visit us online at: www.abbottmedicaloptics.com

Clinician’s Update

continued on page 2

continued on page 2

0609_OMAMO399-17.qxd:AMO 5/26/09 12:57 PM Page 1

Q: The Tecnis® multifocalIOL is relatively new to themarket. How soon will weknow how well it functionsunder real world, ratherthan clinical trial, condi-tions?

A: Since late 2007,Tecnis® multifocal IOLs have been distrib-uted outside the United States in morethan 50 countries requiring regulatoryapproval, including Japan, China, Korea,Taiwan, the European Union and Canada.More have been distributed in countrieswithout regulatory requirements. As ofMarch 2008, approximately 60,000

Tecnis® multifocal lenses have been soldoutside the United States.1 The Tecnis®

multifocal IOL has a good track record inall of the countries in which it has beenlaunched, with high rates of patient satis-faction.

Q: What is a premium IOL and how does thatdiffer from a monofocal IOL?

A: The term “premium IOL” refers to IOLsthat provide visual function over andabove standard monofocal IOLs. In thiscase, the term is applied to multifocalintraocular lenses because of theextended range of vision available com-pared to monofocal IOLs.

Q: A recent report came out on LASIK andpatient satisfaction. What was the outcome?

A: A research team from Storm EyeInstitute did a comprehensive search ofthe worldwide clinical literature and iden-tified 19 peer-reviewed, well-designedstudies specific to patient quality of lifeand satisfaction after primary (original)LASIK.2 All were randomized, controlledclinical trials, or cohort or case-controlledstudies. The studies covered the periodfrom 1995 to 2003 and included 2,198subjects. The review found an overallpatient satisfaction rate of 95.4% (2,097of 2,198 subjects), ranging from 87.2% to100%. This is an elective procedure, so

the OD should monitor the BCVA, so itremains at that level and rule out anyearly cystoid macular edema (CME).

During the first month, the co-managingoptometrist performs a dilated fundusexam, again to ensure the absence ofCME, but more importantly, to examinethe peripheral retina for small tears orother pathology. The optometrist shouldbe comfortable monitoring and possiblymanaging intraocular pressure.

During the first 3 months, the co-managingoptometrist should be comfortable withassessing the patient. If the Crystalens®

was implanted, the optometrist shoulddetermine if any fibrosis is pushing thelens anteriorly and creating a myopic shift.In the case of the Tecnis® multifocal IOL,the assessment should include ruling outposterior capsular opacification, whichwould cause blur or glare. If the co-managing optometrist recognizes any ofthese conditions, he should be prepared topromptly refer the patient back for Nd:YAGlaser capsulotomy in either case.

Lastly, I want optometrists to assesspatient satisfaction with the new IOL andcall our office if the patient is less thansuperbly satisfied. Optometrists alsoshould be comfortable with tapering the

post-op medications, recognizing that theantibiotics should be discontinued at theend of 1 week, the steroids tapered overthe course of 1 month and the non-steroidal anti-inflammatory drugs contin-ued for 1 month in low-risk patients andfor 2 months in high-risk patients.

I’m familiar with my network of co-manag-ing optometrists and their comfort levels indiagnosing and treating pathology. I relin-quish patient monitoring after the firstpost-op exam to those who are mostcomfortable serving in this role. Mostoptometrists prefer to have me follow upwith patients for a slightly longer period oftime.

After the third month, if all is well, patientsreturn to the referring doctor with the rec-ommendation that they have annual examsto monitor their ocular health. In all cases,doctors should alert patients to all of thesigns and symptoms of an early retinaltear: floaters, flashing lights, showers offloaters, a cobweb over their vision, or acurtain or veil over any part of their vision.

Co-management covers a broad spectrumof comfort. Some optometrists prefer I seethe patient for the entire global period.Some take over immediately, while othersare somewhere in between.

Ask Dr. Nick Tarantino: Premium IOL and Refractive Technology Options

Patient Selection, Co-management With Premium IOLs (continued)

Optometry’s EmergingRole in Cataract SurgeryAnd IOL Selection(continued)consulting with the surgeon to determinethe best IOL for the individual patient. Thisaltered and strengthened the co-manage-ment relationship. The standard of careevolved as well.

As primary care practitioners, we need torecognize premium IOLs and refractiveprocedures as state-of-the-art refractiveconsiderations for patients, similar to theselection of contact lenses, eyeglassesand treatment for ocular abnormalities.The primary care practitioner who regular-ly examines the patient is extremelyimportant in the referral process and in theselection of refractive technologies for pro-viding optimal patient outcomes.

Be proactive, educate your patient anddevelop your co-management skills. It’s inthe best interest of the patient!

Sincerely,

David W. Hansen, OD, FAAO (DipCL)Global Professional ServicesAbbott Medical Optics

0609_OMAMO399-17.qxd:AMO 5/26/09 12:58 PM Page 2

patient satisfaction is an important meas-urement of whether the patients’ physi-cal, emotional and financial expectationswere met.

Q: Is the cost of multifocal IOLs really worth it?

A: Yes, according to research reported inthe November 2008 issue of the Journalof Cataract and Refractive Surgery.3 Atotal of 495 patients participated in acost-benefit study, 339 with multifocalIOLs and 156 with monofocal IOLs. Thenet benefit for the multifocal group, after

the cost of two multifocal IOLs, was$11,670 compared to $155 for the mono-focal group. Eighty percent of the 495participants were willing to pay at least $5a day to be spectacle independent,although multifocal vision was considerednot medically necessary by third-partypayers. As fair-balance, the researchersdidn’t include any postsurgical complica-tions, which would be expected to besimilar with multifocal and monofocallenses, or a comparison with monovision,which approximates depth of vision butisn’t multifocal vision.

Nicholas Tarantino, OD, FAAO, is head of global

clinical research & development at Abbott

Medical Optics, Inc.

References

1. Tecnis® multifocal intraocular lens, package insert, 2009.

2. Solomon KD, Fernández de Castro LE, Sandoval HP, et al.

LASIK world literature review: quality of life and patient satis-

faction. Ophthalmology. 2009;116:691–670.

3. Maxwell WA, Waycaster CR, D’Souza AO, Meissner BL,

Hileman K. A United States cost-benefit comparison of an

apodized, diffractive, presbyopia-correcting, multifocal

intraocular lens and a conventional monofocal lens.

J Cataract Refract Surg. 2008;34:1855–1861.

■ Blink® Tears Lubricating Eye Dropsclinically proven to improve tear film sta-bility and provide longer-lasting relief.More effective than Systane® Drops when

used concomitantlywith Restasis® Dropsand has significantlyless blur and ocularburning. Patients sig-nificantly preferredBlink® Tears vs.Systane® Drops withgreater than 60-minute retention time.

■ Blink GelTears®

Lubricating Eye Dropsprovides all theadvantages of Blink®

Tears in a more vis-cous formula. This for-mula providesenhanced comfort formoderate-to-severe dry eye with

greater than 70-minute retention time — forday and nighttime use. Clinically proven toshow superior comfort vs. Refresh Liquigel®

Lubricant Eye Drops.

■ Blink® Tears Preservative-FreeLubricating Eye Drops ideal for the pre-and postcataract and refractive surgerypatient and for those patients with sensi-

tive eyes.

Ask Dr. Nick Tarantino: Premium IOL and Refractive Technology Options (continued)

P R O D U C T S P O T L I G H T :

Tecnis® Multifocal IOL and Blink® Tears — Premium Technologies The Tecnis® multifocal IOL is the firstand only pupil independent, non-apodized fully diffractive aspheric lensdesigned to correct the two highest-order aberrations, spherical and chro-matic. Reducing these aberrationsimproves image quality and restoresyouthful vision.

■ Superior near vision and readingspeed compared to other presbyopia-correcting IOLs.

■ Exceptionally high spectacle inde-pendence, with nearly 9 out of 10patients reporting that they never weareyeglasses after surgery

■ High-quality vision for near, far andintermediate distances, day or night.

■ High patient satisfaction — Over 94%of study patients would choose theTecnis® multifocal lens again.1

■ Delivers a predictable and consistentfull range of vision.

Reference

1. Tecnis® multifocal foldable acrylic intraocular lens, package

insert; Santa Ana, CA., Advanced Medical Optics, Inc.

To read this newsletter online or sign up to receive the newsletter via email, please visit

lwwvisioncare.com/emails/amo/newsletter05/issue14

Three visco-adaptive formulas from the company that brings you Healon®

0609_OMAMO399-17.qxd:AMO 5/26/09 12:58 PM Page 3

The more doctors explain to patients about why they need a par-ticular medication, the more likely patients will be compliant.Patients are far less compliant when doctors don’t explain whythey should take a certain medicine and how the medicine works.Compliance is probably linearly proportional to the patient’s under-standing of how a medicine works and what can happen if theydon’t take it as prescribed.

— Kerry K. Assil, MD, Assil Eye Institute, Santa Monica, CA.

Assessment of Systemic MedicationsAs part of the patient assessment, be sure to ask for the patient’ssystemic medications. Does the patient keep a list of multiplemedications? Does he or she understand why a drug was pre-scribed? When was the drug started? What are recent changes?Who prescribed the medication? Who’s monitoring the patient’svarious drugs — oncologist, internist, family physician, other alliedphysicians or multiple practitioners? This is important for assess-ing the patient’s health, level of compliance with medical therapyand possible visual needs for reading the drug labels.

— David W. Hansen, OD, FAAO (DipCL)

Clinical PearlsCompliance With Medical Treatment

Blink, Blink GelTears, Healon and TECNIS are trademarks owned by or licensed to AbbottLaboratories, its subsidiaries or affiliates. Systane is a registered trademark of Alcon.RESTASIS and Refresh Liquigel Lubricant Eye Drops are registered trademarks of Allergan.

Published June 2009

© 2009 Abbott Medical Optics Inc.

2009.04.28-CN989

Abbott Medical Optics Inc., 1700 E. St. Andrew Place, Santa Ana, CA. 92705 800.347.5005

Published June 2009The e-mail version of this newsletter is available at: lwwvisioncare.com/emails/amo/newsletter05/issue14/

Optometry’s MeetingWednesday, June 24, 2009Course #1004 3 pm – 5 pmRedefining Quality of Vision: NewTechnologies Influencing Vision CareLecturers: T. Kislan, ODP. Karpecki, ODW. Trattler, MDT. Varnell, ODReception to follow: 5:00 – 6:30 pm (Event is free to course attendees.)

Free Courses in the new CompleteRefractive Solution TheaterThursday, June 25, 2009Course #T133 4:30 pm – 6:30 pmChallenging Cases in Presbyopic IOL SurgeryLecturers: M. Bloomenstein, ODD. Geffen, ODJ. Owen, OD, MBA

Friday, June 26, 2009Course #T236 10:30 am – 11:30 amKeeping Your Patients and PracticeCurrent in Refractive SurgeryLecturer: J. Owen, OD, MBASponsored by: AMO and TLC

Course #T237 12 noon – 1 pmAdvancements in Dry Eye: Pre- and Post-Surgical ManagementLecturer: S. Morris, OD

Course #T238 1:30 pm – 2:30 pmContacts in 2009: Cutting Through theConfusionLecturers: B. Gaddie, ODS. Schatz, OD

Course #T239 3 pm – 4 pmRedefining Customized Laser VisionCorrectionLecturer: A. Morganstern, ODSponsored by: AMO and TLC

Course #T240 4:30 pm – 5:30 pmLaser Vision Correction Today: NewFemtosecond ApplicationsLecturer: P. Karpecki, OD

Saturday, June 27, 2009Course #T334 12:30 pm – 1:30 pmNew Technologies in Cataract SurgeryLecturers: M. Bloomenstein, ODJ. Owen, OD, MBA

Visit AMO at Booth #1601or www.AbbottMedicalOptics.com

Please check the on-site directory for function locations.

Take advantage of the FREE courses in the new Complete Refractive Solution Theater!

American Optometric Association

0609_OMAMO399-17.qxd:AMO 5/26/09 12:58 PM Page 4