This article is more than 5 years old. Information may no longer be current.
Going the extra mile for patient outcomes
Click Here to Manage Email Alerts
Surgeons discuss the possibility of enhancements after premium IOL implantation.
The need for enhancements after premium cataract surgery is common because patients’ expectations are extremely high. Therefore, it is important to recognize which patients may need “touch-ups” postoperatively and to determine which procedure will be most effective.
“We know that reducing cylinder and sphere to the lowest possible level increases the quality of vision and patient satisfaction with all IOLs, but especially with multifocal lenses,” Eric D. Donnenfeld, MD, said. “I am very quick to perform enhancements when I feel it’s safe and effective and in the patient’s best interest.”
Common enhancements
The types of postoperative enhancements performed are highly dependent upon the surgeon’s preferences and the patient’s individual needs.
According to Carlos Buznego, MD, YAG capsulotomy is one of the most common enhancements used in his practice; however, first ruling out other points of patient dissatisfaction, such as ocular surface disease and active cystoid macular edema, is key.
“Before you embark upon a surgical enhancement, you want to make sure it’s not something that can be managed medically,” Dr. Buznego said. “Once we have excluded those two major issues … YAG capsulotomy is a low risk for the patient and [requires] a minimum amount of effort from the ophthalmic surgeon.”
In the practice of Karl G. Stonecipher, MD, between 7% and 8% of patients usually require touch-ups because the patient is not seeing as clearly as he or she would like due to a residual spherical refractive error. This presents three surgical opportunities, according to Dr. Stonecipher: a surface procedure, such as PRK; a LASIK procedure; or an IOL procedure, such as an IOL exchange or a piggyback procedure.
“If the patient is significantly off the mark, or if they don’t like the multifocal lens and you’ve given enough time for neuroadaptation, an IOL replacement is probably the best option,” he said. “Otherwise laser vision correction is usually the most commonly performed procedure in my practice.”
Choosing patients carefully from the start, particularly those who will receive multifocal IOLs, is critical to limiting the number of enhancements needed, according to Thomas W. Samuelson, MD, who avoids implanting these lenses in patients with significant comorbidities.
When necessary, however, “I tend to do my enhancements with the excimer laser in the form of IntraLase LASIK (Abbott Medical Optics) or, on occasion, surface ablation PRK,” Dr. Samuelson said. “I prefer that over corneal incision enhancements, such as limbal relaxing incisions or astigmatic keratotomy, and [have found] using the IntraLase LASIK or surface ablation to be quite stable over time, extremely accurate and well-accepted by patients.”
Pre-educating patients
In all cases, discussing the potential need for postoperative enhancements with patients before surgery is a must.
“Whenever a patient is coming in for premium cataract surgery, or any cataract surgery, I explain to them that refractive enhancements are a part of the procedure and that manual cataract surgery is not as precise as laser surgery,” Dr. Donnenfeld said. “[I tell them] there’s a possibility they will need an enhancement, and if they do need an enhancement, [I say] these are the possibilities of things we might have to do.”
Dr. Samuelson has found that informing patients from the start that their surgery may be a two-step process is helpful, particularly in cases in which the enhancement is more likely, such as pre-existing high astigmatism or with post-LASIK IOL calculations.
“Surprise enhancements are much less satisfying,” he said. “But if you maintain a positive demeanor with the patient, [you can] explain that the beauty of modern ophthalmic surgery is that we’ve got all these fantastic tools available if there is a surprise refractive outcome or if we need to fine-tune the spherical component of the outcome.”
These details should be explained at multiple levels throughout the practice, according to Dr. Samuelson, with everyone from the surgeon to the surgical coordinators being able to consistently reinforce the patients’ education.
Dr. Stonecipher and his partners utilize technology such as the iPad for educational purposes, using animations and short videos to explain to patients what they can expect from the lenses, as well as what potential enhancements may involve afterward. Additionally, printed materials play an important role in showing patients exactly what is included as part of the premium procedure.
Postop charges
Whether to charge patients additional fees for postop enhancements remains a highly debated topic and one that is currently determined by each practice.
“We have built [enhancements] into the price, knowing we’re going to have a certain finite level of enhancements,” Dr. Buznego said. “It would be a little difficult, once we’ve discussed a premium procedure with a premium price, to request additional payment. Although it’s not the surgeon’s fault, it’s not the patient’s fault, either.”
Within a 2-year period after premium surgery, Dr. Donnenfeld’s practice will correct any residual refractive error at no charge to the patient regardless of the type of procedure needed, unless the patient initially presents with an unusual visual problem in which an enhancement will likely be necessary.
“In these cases, I charge the patient for the laser visual correction preoperatively, but I will refund them the money if an enhancement is not needed,” Dr. Donnenfeld said.
Alternatively, a number of practices charge an additional but reduced fee to patients who require touch-ups. In the practices of Dr. Samuelson and Dr. Stonecipher, for example, a nominal fee is set to cover the costs of using the laser equipment and paying the surgical staff; however, the surgeon does not receive an additional fee.
“There’s a legitimate argument that if you’re only enhancing 10% of the population, you can’t charge the other 90% for a service you’re not rendering them. That’s why we’ve elected to go with a nominal fee for that service,” Dr. Stonecipher said. “[Patients] know that these are $400,000 to $500,000 laser systems and that there’s staff you have to pay. They just want to know it on the front side.” — by Cara Hvisdas
Carlos Buznego, MD, can be reached at Center for Excellence in Eye Care, Baptist Medical Arts Building, 8940 North Kendall Drive, Suite 400-E, Miami, FL 33176; 305-598-2020; email: cbuz@comcast.net.
Eric D. Donnenfeld, MD, can be reached at Ophthalmic Consultants of Long Island, Ryan Medical Arts Building, 2000 North Village Avenue, Suite 402, Rockville Centre, NY 11570; 516-766-2519; email: eddoph@aol.com.
Thomas W. Samuelson, MD, can be reached at Minnesota Eye Consultants, 9801 Dupont Avenue S., Bloomington, MN 55431; 952-888-5800; email: twsamuelson@mneye.com.
Karl G. Stonecipher, MD, can be reached at TLC Laser Centers, 3312 Battleground Ave., Suite 102, Greensboro, NC 27410; 877-852-2020; email: stonenc@aol.com.
Disclosures: Dr. Buznego is a clinical investigator for AMO. Dr. Donnenfeld is a paid consultant for Alcon, Allergan, Bausch + Lomb. Dr. Samuelson is a consultant to Alcon and AMO. Dr. Stonecipher is a paid consultant and does travel and research for Alcon, Allergan and Bausch + Lomb.