Presbyopia correction: Where are we now, 1 year after the CMS ruling?

ASCRS course attendees illustrate that surgeons are poised to begin presbyopia correction.

Issue: May 1, 2006

ByWilliam F. Maloney, MD

William F. Maloney

The annual meeting of the American Society of Cataract and Refractive Surgery is always an important opportunity to take the pulse of our profession. This year, presbyopia is on our minds as never before. Although less than 10% of U.S. surgeons are currently performing presbyopia corrections, there is no doubt in my mind that the percentage is about to increase significantly.

The strong impression that I took away from our ASCRS course, “Presbyopia correction: Keys to success,” is that surgeons are now poised to begin presbyopia correction in earnest. The overflow crowd was a clear indication of the strong interest. This annual presbyopia overview has been well attended since its inception in 2004, but the atmosphere was tangibly different this time. The lively question-and-answer segment centered on practical how-to issues that come to the fore only after surgeons have taken the full measure of a new procedure and are ready to act.

We covered a wide variety of topics relating to presbyopia correction, from an objective assessment of the technology to related techniques, such as astigmatic keratotomy, to the new financial realities. Here is a summary of what in my view were the highlights.

$Lens-Based Refractive Surgery [logo]$

1. There is no off-the-shelf presbyopia solution.
Surgeons have obviously taken a clear-eyed look at each of the presbyopia-correcting IOLs, and they now seem to understand that none is an automatic solution. Surgeons have moved beyond the marketing mantras and rightly view each presbyopia-correcting IOL approach for what it is — a specific set of capabilities and compromises. They now see that their primary challenge will be to match each presbyopia candidate with an IOL approach that is best suited to meet his unique reading goals while minimizing the impact of its inherent compromises. This central issue has been illustrated using the focus zone chart.

We do not have a presbyopia-correcting IOL that will reliably deliver all five focus zones, in particular both the zone 1 and zone 2 reading that most presbyopia candidates want. Because there is no single IOL solution, there must be more involvement and creative planning by the surgeon. Those who are ready to act have come to understand and embrace this new role.

2. Presbyopia surgeon as architect.
The successful presbyopia surgeon recognizes today’s need to design each one-of-a-kind procedure in close collaboration with each candidate. This represents an important preoperative extension of the surgeon’s traditional intraoperative role. First, the surgeon must understand the candidate’s lifestyle, hobbies, and reading and computer needs through a preop questionnaire and assessment. Then, he must know the specific capabilities and compromises inherent with each of the four presbyopia alternatives: crystalens (eyeonics), ReZoom (Advanced Medical Optics), ReSTOR (Alcon) and the conventional IOL. The final element of this preop design process involves some form of creative manipulation to extend the resulting uncorrected focus range closer to the full five zones. Most often this takes the form of binocular blending.

3. Binocular blending.
Binocular blending typically utilizes varying amounts of myopic defocus in one or both eyes to creatively enhance a given fixed accommodative range. Seasoned crystalens and ReZoom users often employ 1 D of myopic defocus in the nondominant eye to achieve full zone 1 focus, for example.

We have recently seen another creative iteration of binocular blending utilizing complementary pairs of fixed-range IOLs such as the ReZoom-ReSTOR combination that seeks to blend the ReSTOR’s consistent zone 1 focus capability but relative lack of zone 2 with ReZoom’s typical zone 2 range.

Binocular blending is also the basis of the conventional IOL approach to presbyopia correction. Here, each eye typically is targeted for a different degree of myopic defocus, for example, –0.35 D for distance and –1.90 D for near. The pseudoaccommodation inherent in all conventional IOLs contributes an additional 1 D of accommodative effect to this equation. This particular IOL pairing is therefore capable of delivering both zone 1 and zone 2 reading with minimal if any compromise to distance focus, especially for cataract patients who typically do little zone 5 night driving. This is a good example of the preoperative creative design at work to tailor the procedure to each candidate’s presbyopia profile.

4. Conventional IOL approach has wide appeal.
I have said in this column before that I suspect more presbyopia corrections have been done utilizing the conventional IOL approach than the other three presbyopia-correcting IOLs combined. That tendency was evident among those at this course, where the conventional IOL approach was clearly a topic of interest for a majority of attendees.

Special training and purchase quotas are important considerations, but the additional cost of a premium presbyopia-correcting IOL seems to be the main issue for surgeons who are ready to act. The uncovered refractive surgery cost for a conventional IOL presbyopia correction typically ranges from $1,100 to $2,200 per eye. This cost to the patient increases substantially — about $1,000 per eye — if one of the three premium IOL approaches is used. If it becomes increasingly clear that there is no off-the-shelf solution providing automatic presbyopia correction, the additional cost of a premium presbyopia-correcting IOL will be an increasingly scrutinized element in the presbyopia financial equation.

That brings me to perhaps the biggest surprise of this course. Many attendees were unaware that they were entitled to charge the patient for presbyopia correction using a conventional IOL. We have dealt with this issue previously in articles by billing consultant Kevin Corcoran and attorney Alan Reider.

Presbyopia correction is the most important innovation in ophthalmic surgery since phacoemulsification. During the remarkable revolution that unfolded between 1985 and 1995, phacoemulsification usage increased from 9% to 95% among U.S. surgeons because the benefits of small-incision surgery were just too compelling to ignore. To patients, the benefits of a successful presbyopia correction are much more apparent, and surgeons are again ready to act.

For more information:

William F. Maloney, MD, is head of Eye Surgery Associates of Vista, Calif., and a well-known teacher of cataract and lens-based refractive surgery techniques. He can be reached at 2023 West Vista Way, Suite A, Vista, CA 92083; e-mail: maloneyeye@yahoo.com. In the interest of objectivity, Dr. Maloney has no financial interest in any ophthalmic product and has no financial relationship with any ophthalmic company.

Lens-based Refractive Surgery Column Mission Statement: To educate readers on all aspects of lens implant refractive surgery including presbyopia correction, refractive cataract surgery, refractive lens exchange and phakic IOLs.