Surgeons considering premium IOLs must overcome fear of change, challenge

Premium IOLs offer high-quality refractive outcomes in addition to the visual benefits long expected by cataract patients.

These new IOL technologies may pose various clinical challenges and raise the bar in light of patient expectations, but the challenges may cause some surgeons to delay or even avoid making a transition to premium IOLs. Other surgeons say they have not adopted the technology because of reluctance by some patients to pay out of pocket for premium IOLs.

However, many surgeons and patients embrace toric, multifocal and accommodating premium lenses. Experts in the field say it is necessary for physicians to thoroughly educate themselves and their patients about premium IOL platforms, surgical alternatives such as limbal relaxing incisions, laser refractive enhancement and potential complications.

The reluctance of some surgeons to use premium IOLs stems from a general sense of anxiety about meeting patient expectations, Y. Ralph Chu, MD, said. Self-assessment is vital to conquering that anxiety.

Y. Ralph Chu, MD, said physicians need to learn about available technologies and assess their own capabilities. Image: Rory O’Neill Photo

“The first step is changing the mindset,” Dr. Chu said. “I think it depends on fear of change, fear of delivering the outcomes needed to meet patient expectations, then the difficulty of arranging your practice around handling these new expectations around new technologies.”

OSN Chief Medical Editor Richard L. Lindstrom, MD, also attributed trepidation to the overriding need to satisfy patients. The high costs of premium IOL implementation also raise patient expectations, he said.

“What surgeons fear is that they’ll have an unhappy patient,” Dr. Lindstrom said. “It’s magnified by the fact that the patient has paid a premium for a lifestyle lens implant or a premium lens implant that suggests a premium outcome.”

Physician and patient education

Physicians need to learn about available technologies and assess their own capabilities, Dr. Chu said.

“The first [thing] is to educate yourself about technologies and think about how that technology fits into your practice and your technique of doing surgery,” Dr. Chu said. “Some patients are more comfortable with multifocal platforms. Some surgeons are more comfortable with accommodating IOL platforms. I think it really depends on just how you engineer your practice to manage those patients.”

Patient education and surgical expertise are equally critical to ensuring success and patient satisfaction, David F. Chang, MD, an OSN Cataract Surgery Board Member, said.

David F. Chang

“Concise, understandable and effective communication about expectations is just as important as the ability to make a perfect capsulorrhexis,” Dr. Chang said.

Gauging patient expectations requires diligence.

“We measure corneal incisions to the nearest 0.1 mm, axial lengths to the nearest 0.01 mm and the foveal OCT thickness in microns, but we have no way to quantify or measure potentially problematic patient personality traits over which we have little to no control,” he said.

Surgeons must be prepared to openly discuss all premium IOL options with patients, John A. Hovanesian, MD, an OSN Cornea/External Disease Board Member, said. The discussion should include the strengths and weaknesses of each lens.

Effective patient education also hinges on surgeons trusting the technology they choose for their patients.

“If we don’t really, truly have an internalized belief that these lenses improve patients’ lives, we’re not going to give the patient the education about these lenses that they deserve,” he said.

Eric D. Donnenfeld

Eric D. Donnenfeld, MD, an OSN Cornea/External Disease Board Member, echoed Dr. Hovanesian’s comments.

“If you don’t believe in the technology, you should not be offering it to patients,” he said. “You can tell the patients about it, but you should not be recommending it.”

Diagnostics and imaging

Preoperative clinical assessment is essential to optimizing outcomes, Dr. Chu said. For example, topography is key to identifying irregular astigmatism and ruling out candidates for most presbyopic IOLs and many toric IOLs.

“A corneal topographer is critical because you have to be able to assess the type of astigmatism, not just that the patient has astigmatism based on keratometry,” he said. “I think that topography is essential to being able to assess the patient’s candidacy, let alone being able to deal with enhancements after surgery.”

Biometry is also a crucial component of preoperative evaluation, Dr. Chu said. However, despite the myriad available diagnostic technologies, refractive cataract surgery is somewhat of an inexact science.

“Because there is no perfect technology or perfect lens platform, I still think there’s a lot of art to delivering this technology,” Dr. Chu said. “There’s still a very human aspect to making these lenses successful in a practice.”

Optimal IOL placement is also essential to enhancing outcomes, Dr. Donnenfeld said. The ORange Intraoperative Aberrometer (WaveTec Vision) enables precise measurement, helps the surgeon avoid postoperative laser enhancement, and aids adjustment of a toric IOL or LRI to optimize outcomes, he said.

The next-generation ORange aberrometer will offer aphakic refraction, enabling surgeons to predict IOL power calculations in challenging cases involving previous LASIK or RK, Dr. Donnenfeld said.

Dr. Hovanesian agreed that the ORange Aberrometer is a promising technology but said it is limited by the availability of lenses in the operating room at the time of surgery.

The Artemis 3 VHF digital ultrasound arc scanner (ArcScan) will enable more precise measurement of the crystalline lens capsule, accommodating IOL sizing and IOL power calculations, Dr. Donnenfeld said.

Surgical technique and astigmatism management

Sound surgical technique is also critical to dispelling fear and maximizing outcomes, Dr. Donnenfeld said.

“You have to be able to do a good capsulorrhexis, a good phacoemulsification, center the lens well and have an astigmatically controlled procedure so that you can minimize some of that fear,” he said.

“One of the unknowns with refractive cataract surgery is where the IOL sits relative to nodal points, and that will affect the results very significantly,” Dr. Donnenfeld said. “A real pearl is that probably the greatest control we have over getting perfect refractive outcomes is to do a capsulorrhexis that is just a little bit smaller than the lens, and that holds the lens in place. That dramatically reduces the variability of our IOL position and gives much tighter results.”

Staged implantation and custom matching are appropriate in some cases, Dr. Lindstrom said.

“I still do some staged implantation with custom matching, but not everybody likes to do that and not everybody has all the lenses,” he said. “But it works quite well. I start with a Crystalens HD (Bausch & Lomb), and if the near [vision] is weak, think about a near-dominant multifocal in the second eye. That can give you a nice outcome.”

“With the higher expectations that these products promote, one must certainly have confidence in achieving emmetropia,” Dr. Chang said. “Beyond expertise with biometry and IOL formulae, this also requires the ability to manage astigmatism, either with LRIs at the time of surgery or with laser vision enhancement postoperatively.”

Physicians should be willing and able to handle astigmatism, Dr. Donnenfeld said.

“If you don’t feel comfortable resolving these problems, you’ll never be successful with refractive IOLs,” he said. “The easy problems to overcome are things like capsular opacities and ocular surface disease, but the challenge for most physicians who have not jumped into refractive IOLs is their ability to control astigmatism.”

Astigmatism is commonly associated with multifocal and accommodating lenses, Dr. Lindstrom said.

“Astigmatism degrades the outcome significantly with both multifocal and accommodating IOLs,” he said. “Astigmatism degrades multifocal a little more than accommodating.”

Dr. Lindstrom said he typically performs laser enhancement but may resort to piggyback IOLs, mini-RK or conductive keratoplasty in some cases.

Role of toric IOLs

Toric IOLs are a good starting point for surgeons who want to implement premium IOLs, Dr. Donnenfeld said.

“We kind of do things backwards in that we started using presbyopic IOLs, which are a lot more difficult to start with than toric lenses,” he said. “Now that toric IOLs are there, I think it’s a great starting place. If you’re a member of that 29% of doctors who are not doing refractive IOLs, start there and then work your way up to some of the presbyopic IOLs afterwards.”

LRIs and toric IOLs are both appropriate for refractive cataract surgeons aiming to treat astigmatism, Dr. Chang said.

“Both LRIs and toric IOLs are certainly an excellent starting point,” he said. “Unlike with myopia, astigmatism provides no optical benefit to patients, and even if you only reduce, not eliminate, it, the patient will be better off. By offering astigmatism procedures, the physician and staff can transition to discussing non-covered, self-pay benefits that enhance lifestyle and convenience, rather than health.”

Toric IOLs are becoming the “go-to” tool for astigmatism management, Dr. Chu said. “Torics are a growing part of the practice. Some of it is economics because there’s a cost difference between the lenses themselves.”

Dr. Lindstrom offered a different perspective on toric IOLs and astigmatism management.

“I’m not quite as big of an advocate of this toric story,” Dr. Lindstrom said. “I offer my patients who want to pay extra for reduced dependence on glasses the chance of seeing well at all distances. If you’re willing to do the work, I think you can achieve that goal in most patients. … I’m doing 10-to-1 accommodating vs. toric. I only very occasionally use a toric.”

John A. Hovanesian

Many surgeons resort to toric IOLs only in cases involving high astigmatism, Dr. Hovanesian said.

“Most refractive cataract surgeons I know who are comfortable with LRIs still use toric lenses but they use them only for cases of very high astigmatism who can’t be otherwise treated,” he said.

A surgeon may not be comfortable performing LRIs or laser vision correction, Dr. Donnenfeld said, but both procedures are important to a successful practice.

“To be a refractive cataract surgeon, you have to do both,” he said. “Unless you or someone in your practice has the capability and the availability of these technologies, you’re never going to be successful with most refractive IOL surgery.”

Refractive enhancement and complications

Laser enhancement is sometimes necessary to fine-tune premium IOL outcomes, Dr. Chu said.

“Postoperatively, having access to laser vision correction … is essential to finishing the job,” he said. “Being able to get the patient the refraction that they need, which is essentially plano in most cases, is necessary to let the patient achieve the maximum benefits from these technologies.”

Surgeons who use multifocal lenses should be prepared to tackle residual refractive errors and complications.

“Multifocal IOLs are quite unforgiving of any residual refractive error, poor centration and any slight degree of concomitant ocular abnormality, whether a small epiretinal membrane or a poor ocular surface,” Dr. Chang said. “Even if the ophthalmologist performs technically superb surgery, there is still the disquieting possibility of an emmetropic patient who says, ‘Things just aren’t that clear.’”

Still, some unexpected refractive results are inevitable.

“There are still surprises that happen, despite our best attempts with devices like the Pentacam (Oculus), the use of topography with advanced formulas like the Holladay II and Warren Hill’s formula, and the others,” Dr. Hovanesian said.

Dr. Lindstrom cited a large meta-analysis of studies on post-LASIK patient satisfaction that showed refractive error and ocular surface disease as the leading causes of patient dissatisfaction. Additionally, the study showed that 95.4% of patients were satisfied with their outcomes.

“It’s almost exactly the same with premium IOLs,” he said. “The patients are dissatisfied because they have residual refractive error. We can fix that with an enhancement.”

Residual refractive error is a common complication of premium IOL implantation, Dr. Lindstrom said.

“All the premium IOLs are extremely sensitive to even small amounts of residual refractive error,” he said. “You have to get the patient near plano or the target, which occasionally can be a small amount of myopia or hyperopia, depending on the lens.”

Postoperative ocular surface conditions such as dry eye and blepharitis are the second-leading cause of patient dissatisfaction and are generally treatable, followed by night vision symptoms such as glare, halo and starbursts, Dr. Lindstrom said.

Diminished quality of vision and posterior capsular opacity can be managed in most cases. However, cases involving macular disease can be particularly challenging.

“If we operate on a patient who has macular problems, they can also sometimes have unrealistic expectations, whether we do a premium IOL or a standard IOL,” he said.

Growing preference for premium IOLs

Despite some of the challenges surgeons face entering the premium IOL market, the number of U.S. ophthalmic surgeons offering theses lenses is growing. According to a survey of cataract and refractive surgeons reported by Market Scope, 71% of U.S. surgeons are offering premium IOLs, up from about 59% in 2007. Market Scope also reported that about 420,000 presbyopia-correcting IOLs were implanted worldwide in 2008, up from about 301,000 in 2007. In the U.S., that number was expected to increase from 153,000 to 210,000.

In the 2008 member survey of the American Society of Cataract and Refractive Surgery, 40% of members preferred premium IOLs and 23% preferred LASIK for high myopes. Additionally, 14% of responding members approved of bilateral premium IOL implantation, compared with 11% in 2006.

“I’m surprised we don’t have even more penetration of premium IOLs into the marketplace right now,” Dr. Donnenfeld said. “I really think that the comprehensive cataract surgeon will be doing refractive IOLs as routine surgery within the next couple of years, and there will be almost 100% penetration.”

Cost is a concern, particularly amid the current recession and the potential advent of federal health care reform, Dr. Donnenfeld said.

“In the new era of medicine here in the United States, I think you have to be comfortable asking patients to pay out of pocket for new technology that will deliver better outcomes,” he said. “Patients are more than happy to receive the benefit of these IOLs. We have to be comfortable telling them about it.” – by Matt Hasson

In terms of outcomes and risks, is laser-based or cornea-based refractive surgery or premium IOL implantation a better value for patients?

References:

• Freeman W. Global demand for presbyopia-correcting IOLs grows. Market Scope. 2008;24(3):300-305.
• Duffey RJ, Leaming D. U.S. Trends in Refractive Surgery: 2008 ASCRS Survey. http://duffeylaser.com/physicians_resources.php. Accessed Sept. 23, 2009.
• Mahdavi S. SM2 Strategic Web site. A Survey of Consumer Demand for Premium Cataract Surgery. http://sm2strategic.com/files/200920Mar%20-%20Premium%20Channel%20-%20Consumer%20Survey%20by%20SM2.pdf. Accessed Sept. 23, 2009.

• David F. Chang, MD, can be reached at 762 Altos Oaks Dr. Suite 1, Los Altos, CA 94024; 650-948-9123; fax: 650-948-0563; e-mail: dceye@earthlink.net.
• Y. Ralph Chu, MD, can be reached at Chu Vision Institute, 9117 Lyndale Ave. South, Bloomington, MN 55420; 952-835-0965; fax: 952-835-1092; e-mail: yrchu@chuvision.com.
• Eric D. Donnenfeld, MD, can be reached at OCLI, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com.
• John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; 949-951-2020; fax: 949-380-7856; e-mail: drhovanesian@harvardeye.com.
• Richard L. Lindstrom, MD, can be reached at Minnesota Eye Consultants, 9801 DuPont Ave. S, Suite 200, Bloomington, MN 55431; 952-888-5800; fax: 952-567-6182; e-mail: rllindstrom@mneye.com.