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Incorporating wavefront into practice requires education, planning
Patient education seminars will once again be an important part of marketing for this unfamiliar technology.
By June of this year, several wavefront systems may be approved for commercial use in the American and European markets. Experts say now is the time to plan how to incorporate this technology into your practice — if you have not done so already.
“Surgeons need to decide exactly how they will tell their patients about the technology, what they will say about it and what is the most optimal way of incorporating it into their practice,” said Richard L. Lindstrom, MD, chief medical editor of Ocular Surgery News and founder of Minnesota Eye Consultants in Minneapolis.
Daniel S. Durrie, MD, agreed that now is the time to determine how surgeons will integrate the new technology into their own centers.
“Once you’ve figured this is the way you want to go, start setting goals and guidelines to make the transition to wavefront-guided LASIK a smooth one,” he said.
“For most surgeons, incorporating wavefront-guided LASIK into their practice will be an incremental change, as it is an incremental addition to a refractive surgeon’s repertoire,” Dr. Lindstrom said. “The integration is similar to when we decided that every patient needed to be examined with topography; wavefront is just a little more advanced, but certainly necessary for a better quality of vision.”
Learn the technology
When deciding whether to offer this service in one’s practice, the surgeon must take a number of steps to ensure that physicians, technical support, staff and patients are well-informed.
“The first thing you want to do is get yourself educated,” Dr. Durrie said. “You can’t just do this by going to a weekend meeting. You need to spend time with someone who performs the surgery successfully in their practice.”
His practice, the Durrie Vision in Overland Park, Kansas, offers mini-fellowship programs for surgeons who are interested in learning more about a particular aspect of refractive surgery.
“People spend the day with us in surgery and in the clinic. We do didactic training and get them up to speed not only on custom ablation, but also on conductive keratoplasty and the IntraLase system,” Dr. Durrie said. In his wavefront-guided and standard LASIK procedures, he uses the IntraLase FS femtosecond laser to create the LASIK flap, “to increase the safety of the procedure,” he said.
“We encourage surgeons to invest time in getting to understand the technology. Ask the refractive surgeon questions about patient selection, procedure times, their experience and outcomes,” he said.
When visiting a clinic to observe wavefront-guided ablation and to consider offering it to patients, Dr. Durrie suggests that surgeons bring along their refractive surgery coordinators or business managers so that they, too, can get an idea of the way the new technology will affect your practice flow and business plan.
Educate staff
Staff education is the next step.
“Long before you do a marketing program and put an ad in the paper, you need to make sure that in addition to the operating room staff, the people answering the phones and seeing patients in the office know what wavefront is,” Dr. Durrie said.
He suggests training all staff members who come in contact with the public on the terminology of wavefront technology.
“Wavefront is a whole new language. We’re talking about Zernike polynomials, coma and spherical aberration, not about sphere and cylinder, so it takes a while to learn the new language,” he said.
When Dr. Durrie first began using the Alcon CustomCornea wavefront system as part of clinical trials, the management at his center held retreats for staff members to learn the basics of wavefront technology.
“We had about 10 meetings with our staff over time — lunch meetings, weekend retreats, discussions on what wavefront was about,” he said. “Remember that you have to pay your staff overtime to come in to these meetings and be away from their families.”
Educate patients
Steps to incorporate |
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Educate yourself
Educate your staff
Educate your patients
Rethink your business model
Start treating patients
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Once staff has been educated, surgeons must begin the process of educating potential patients.
“We hold seminars every week, or biweekly, that inform patients on the particulars of refractive surgery,” Dr. Lindstrom said. “Patients can learn not only about custom ablation but about other refractive procedures as well.”
“Make sure you have the seminars at the same time, same place every time you have them,” Dr. Durrie said. “Have it in your office instead of a hotel room, because patients prefer to go to a doctor’s office so they can see what the surgery experience might be like.”
During the seminars, surgeons should explain to patients the risks and complications of the surgery: what is good, what is bad and what is still not known about the technology.
Dr. Durrie advises that the operating surgeon attend all these seminars.
“I am present at every seminar to answer questions and discuss options,” he said. “Patients really appreciate the extra attention, and this makes them a lot more inclined to opt for the surgery at your center.”
Cover your bases
According to Dr. Durrie, it is important to thoroughly explain all aspects of the surgery.
“You have to be consistent throughout the seminar,” he said. “You have to know all the answers to the questions asked so patients don’t get clouded or confused. You don’t want them to get misleading or outdated information.”
Additionally, Drs. Durrie and Lindstrom said, surgeons should be conservative when discussing outcomes.
“Try to be careful not to get expectations out of line,” Dr. Durrie added. “We aren’t promising super-vision, 20/10 or anything specific, other than just quoting the data from clinical trials.”
Dr. Durrie said it is “extremely important” that surgeons in the United States cite only the outcomes that are detailed in wavefront product approvals from the Food and Drug Administration. For example, for the Alcon wavefront system, which was approved for low to moderate myopia by the FDA, 14% of patients in clinical trials showed an improvement in halo and glare at night, he noted.
However, Dr. Lindstrom explained, while this small percentage of patients reaped clinically significant benefits, a much larger portion of patients reported a subjective improvement in night vision problems.
“To avoid problems, stick to the FDA data,” Dr. Durrie said. “If your patient decides to opt for the custom ablation — based on the potential benefits of nonclinically significant reduced night vision issues — this is their choice,” Dr. Durrie said.
“In my practice, I try to be open with patients about our level of knowledge,” said Dan Z. Reinstein, MD, MA, FRCSC, of the London Vision Clinic, London, England. “So far, there is little conclusive data, and I like to provide my patients with data. I’m trying to steer my patients away from what we have been hearing, which is a lot of hype that is at risk of setting unrealistic expectations.”
Deal with expectations
Dr. Lindstrom said surgeons should be especially sensitive to patients with unrealistic expectations when addressing the benefits of wavefront-guided ablation, especially for patients who have previously had an unsatisfactory result from previous refractive surgery.
“We have to watch out for the unhappy patient,” he said. “Just in the United States, there are 60,000 eyes — 1% of the 6 million LASIK cases — of patients who are dissatisfied with their results from standard LASIK. These patients are very vocal,” Dr. Lindstrom said.
Many of these dissatisfied patients have spent a long time on waiting lists, waiting for the availability of custom ablation, he said.
“The reality is that many of them have been overpromised by a lot of surgeons as to the potential of custom ablation,” he said. “A lot of patients will come in expecting a miracle cure to fix their vision problems, and the truth is, customized ablation just isn’t going to cure them.”
Dr. Lindstrom said physicians should be particularly cautious with this group of patients and spend a lot of chair time counseling them.
“I am sure we will be able to help some of these patients incrementally. But I’m a little more concerned about the unrealistic expectations of this unhappy patient than I am concerned about the unrealistic expectations of a happy patient, or new patient, whom we can properly counsel,” he said.
He added that the current capabilities of custom ablation for “fixing” previous refractive surgery problems do not reach beyond treating a patient who is happy but has a little residual refractive error, spherical aberration and mild astigmatism. For patients with complicated errors and significant higher-order aberrations, other refractive options might be more beneficial, he said.
Waiting for wavefront
Many patients who stand to benefit from wavefront-guided LASIK are on waiting lists for surgery in practices around the country.
At Minnesota Eye Consultants, Dr. Lindstrom has many patients on a waiting list for custom ablation.
“There is nothing wrong with having a waiting list,” he said. “It’s like building a future annuity.”
In his practice, Dr. Lindstrom and colleagues are using the Visx WaveScan diagnostic wavefront system, Tracey Technology’s corneal ray tracing system and the Bausch & Lomb Zywave diagnostic wavefront system to identify patient aberrations. The wavefront-guided customized ablation technologies from Visx and Bausch & Lomb are pending FDA approval.
“We think we will have these devices available to us by summer 2003 for patients up to –7 D, with 2 D of astigmatism,” he said.
Most of the patients on Dr. Lindstrom’s waiting list were potential candidates to undergo standard LASIK ablation or a LASIK enhancement, but they were told to wait because their root mean square calculations were 0.4 µm or greater.
“If you are going to do an enhancement and more than 20% of the residual refractive error is higher-order aberration, we feel you should think about putting these patients on a waiting list for customized ablation,” he said.
Treating complicated cases
Dr. Reinstein said it will be patients with postop complications and high-amplitude higher-order aberrations who stand to benefit most from wavefront-guided custom ablation.
“The main function of wavefront-guided treatment is not going to be for treating normal eyes, which are going to do extremely well with the newer aspheric Aberration Smart Ablation Profiles (ASAP), such as are incorporated into the MEL80 from Carl Zeiss Meditec,” he said. “Wavefront guidance is going to be for the surgical improvement of visual complaints after LASIK, ie, for enhancements. This is where it’s really going to come in handy.”
In his practice, Dr. Reinstein uses the MEL80 excimer laser from Carl Zeiss Meditec with an aspheric ablation platform that greatly reduces the induction of aberrations. The WASCA aberrometer linked to the MEL70 excimer laser has been available outside the United States for over 2 years.
He called the WASCA wavefront system “the most accurate and most precise aberrometer system available.” Dr. Reinstein is an investigator for Carl Zeiss Meditec and is currently conducting studies developing their CRS-Master platform, which will incorporate WASCA aberrometry into the treatment profiles of the MEL80.
Dr. Reinstein recently presented outcomes using the MEL70 and WASCA for the correction of postop visual complaints at the winter meeting of the European Society of Cataract and Refractive Surgeons. He said preliminary data showed that in 15 eyes with severe postop visual disturbances, wavefront-guided ablation with the WASCA and MEL 70 effectively produced subjective improvement in patient complaints.
“Visual complaints were reported to improve by at least 70% in 80% of eyes. The system was highly effective in reducing or eliminating monocular multiple images,” he said.
These early results led Dr. Reinstein to believe the WASCA wavefront system will be effective for such therapeutic enhancements.
Starting little by little
When Dr. Durrie began incorporating wavefront technology into his practice, he did it gradually.
“I decided to go extremely slow with introducing this technology into my practice,” he said.
First, he began performing wavefront-guided LASIK on patients who had been measured over the previous 2 years with significant higher-order aberrations, patients who had been on waiting lists for primary surgery.
“I just did their dominant eye, because I felt the wavefront correction would be best to try in a distance eye before we tried to adjust the eye for any monovision or blending of the eyes. This gave me more experience with the patient who had one custom and one conventional eye,” he said.
Dr. Durrie next expanded to a group of patients who had heard about the technology and “were looking for the best possible vision,” he said.
“Athletes and other people who were interested in high-quality vision had heard of custom ablation and wanted it,” Dr. Durrie said.
Third, he offered the surgery to patients who had previously undergone surgery and wanted to be “upgraded” to the new technology.
“Patients like the term ‘upgrade’ because it’s something they understand. It’s like upgrading to a faster computer, camera or television,” Dr. Durrie said.
Financial remodeling
Like with a new computer, camera or television, upgrades cost money.
“There is an added cost to retrain your staff, pay for marketing and invest in new equipment,” Dr. Durrie said. “This is going to carry over into the cost of wavefront-guided ablation. Some surgeons are going to have to rethink their business models.”
The going rate for conventional ablation in the United States and the United Kingdom falls in a large range, from discounted procedures at $500 per eye up to $2,700 per eye and above.
“Depending on the clinic, the price can rise and fall for discounted LASIK – which may not offer a lot of safety and postoperative care – and for premium-priced LASIK, which can be over $3,000 per eye,” Dr. Durrie said.
At the London Vision Clinic, Dr. Reinstein charges a supplemental fee for previous patients treated by conventional LASIK, who may benefit from WASCA wavefront-guided LASIK enhancement. They currently charge the same fee for wavefront-guided and the new aspheric ASAP MEL80 LASIK, as the added benefit of wavefront-guided treatment over and above the new aspheric ASAP LASIK is not completely proven.
“I don’t feel comfortable charging a supplemental fee unless I can statistically show the patient what the added benefit will be. As we found definite improvements in postop visual complaints using the WASCA and MEL70, we feel comfortable about charging a supplemental fee for WASCA custom ablation,” he said.
Surgery fees
In Dr. Durrie’s practice, where he has performed wavefront-guided ablation on 100 eyes since the CustomCornea approval in October 2002, a pricing system for wavefront-guided LASIK has already been implemented.
“We charge $500 more per eye for custom LASIK than standard LASIK. I have a standard rate for LASIK that includes IntraLase, advanced flying-spot lasers and separate sterilized equipment, which costs $2,200 per eye. We charge $2,700 for custom LASIK,” Dr. Durrie said.
“We tend to start on the high end, cost-wise, because we don’t think that prices for refractive surgery tend to go up,” Dr. Lindstrom said. Once the wavefront systems he is using receive premarket approval, he said, he too plans to ask for an additional $500 per eye for wavefront-guided ablation.
“Classical retailing tells you to charge two to three times what your costs are. So if it costs you $200 extra per eye to perform the surgery, to cover advertising, time, training and technology, you should be charging your patient $400 to $500 per eye extra,” he said.
For enhancement and re-treatment procedures, Drs. Durrie and Lindstrom have similar pricing plans. Dr. Durrie charges $100 for enhancements up to 1 year after surgery. Dr. Lindstrom charges $150, but if the patient was a patient for primary surgery the fee is half price. Similarly, in Dr. Durrie’s practice, if the patient wishes to have an “upgrade” or re-treatment and is a former patient of the practice, the patient is charged half the fee.
Dr. Lindstrom urged caution in pricing.
“Surgeons need to figure out what they are going to charge for enhancements and re-treatments to former refractive surgery patients and new ones. But whatever you do, be careful about doing it for free. This could be enough to bankrupt a practice,” he said.
Future resistance?
With the current economic climate, financial recovery after September 11, 2001 and the war in Iraq, Dr. Lindstrom said he believes that patients will be less eager to undergo elective surgery.
In fact, he said, if the economic climate stays as it is or worsens, it will take most practices 6 years to reach the prosperity they may have enjoyed with LASIK before 2001.
“We will be happy if we see a 12% growth in LASIK surgeries per year, and hopefully in 6 years we will be back to where we were in 2000,” he said.
While many patients may be hesitant to undergo any form of LASIK for financial reasons, patients who are focused on achieving better vision will not be dissuaded by the increase in cost, Dr. Durrie said.
“I have seen virtually no resistance to the increase in price,” he said. “Your patients will understand that if it costs you more to do the surgery, if will cost them more to have it.”
Dr. Lindstrom agreed.
“My colleagues who are performing custom ablation with Alcon’s CustomCornea said there is almost no resistance to paying the extra fee. The patient perceives it as a meaningful procedure, taking more time, and so it should cost more,” he said.
He said that once wavefront-guided ablation is approved, he believes he will be performing it in his practice nearly 100% of the time.
For Your Information:
- Richard L. Lindstrom, MD, can be reached at Minnesota Eye Consultants, 710 E. 24th St., Suite 106, Minneapolis, MN 55404; (612) 813-3600; fax (612) 813-3660; e-mail: rllindstrom@mneye.com. Dr. Lindstrom is a paid consultant for Visx and Bausch & Lomb.
- Daniel S. Durrie, MD, can be reached at Durrie Vision, 5520 College Blvd., Suite 200, Overland Park, KS 66211; (913) 491-3737; fax: (913) 491-9650; e-mail: ddurrie@hunkeler.com. Dr. Durrie is a paid consultant for Alcon.
- Dan Z. Reinstein, MD, MA, FRCSC, can be reached at London Vision Clinic, 8 Devonshire Place, London W1G 6HP, UK; (44) 20-1224-1005; fax: (44) 20-7681-1233; e-mail: dzr@londonvisionclinic.com; Web site: www.londonvisionclinic.com. Dr. Reinstein is a paid consultant for Carl Zeiss Meditec.