Increased premium cataract surgery options boost outcomes, conversions

The premium IOL landscape has expanded dramatically in recent years with the advent of new multifocal, trifocal, toric and accommodating lenses and, most recently, an extended depth of focus lens. Cataract surgeons now have more opportunities to maximize visual outcomes and increase the rate at which patients choose premium IOLs over standard monofocal implants.

Regardless of the type of implant used, patient satisfaction hinges on the accuracy of refractive outcomes, according to Uday Devgan, MD, Healio.com/OSN Section Editor.

“It has been shown in many studies that the No. 1 predictor of postop patient happiness, particularly with premium lenses but with any lens, is the ability to nail the specific refractive outcome, and usually that’s plano,” Devgan said.

Maximizing conversion rates depends on marketing and delivering optimal results, Jack T. Holladay, MD, MSEE, FACS, OSN Optics Section Editor, said.

“It’s basically marketing your practice. The clinic has to do an overhaul of the experience of the patient,” Holladay said. “The take-home message is that you have to market to that segment of the people that are candidates for premium IOLs. Then you have to be an ‘A’ surgeon in order to fulfill the promise that those people are going to be happy.”

Patient selection is critical, particularly with an increasing number and variety of lenses now available, according to Jeffrey C. Whitsett, MD.

Image: Jack Scully/Wills Eye Hospital

“The really cool thing for us is that we have fantastic options for patients,” Whitsett said. “The biggest challenge for us is finding the best technology for each individual patient.”

Audrey R. Talley Rostov, MD, said she has a conversion rate exceeding 75% because of a keen focus on patient selection.

“I try to select the right technology for the right patient,” Rostov said.

Multifocal, accommodating IOLs

In the U.S., leading multifocal IOLs include the AcrySof ReSTOR (Alcon) and the Tecnis (Abbott Medical Optics) with +4 D of near addition and new iterations with +2.75 D and +3.25 D near addition.

Various novel diffractive implants are available in Europe, such as the Lentis Mplus, a varifocal lens, the Lentis Comfort, with an addition of +1.5 D, and the Lentis LT (all Oculentis).

The Crystalens (Bausch + Lomb) is currently the only accommodating IOL approved in the U.S.

Novel accommodating IOLs outside the U.S. include the Synchrony dual-optic IOL (Abbott Medical Optics), FluidVision (PowerVision), Sapphire (Elenza), DynaCurve (NuLens), Lumina (Akkolens/Oculentis) and Juvene (LensGen).

Whitsett said that in his practice, the go-to presbyopic lens is the Tecnis low-addition multifocal IOL.

“When patients come in and their goal is to be glasses-independent, that’s pretty much our go-to lens. The challenge for that lens is finding the people that are the best candidates for that lens because not everyone is a candidate for a multifocal lens,” he said.

Rostov said she prefers the Tecnis multifocal ZLB00 +3.25 D, the Crystalens and Trulign toric (Bausch + Lomb) IOLs.

“I really like the ZLB00 (+3.25 D near add), which is kind of the mid-range,” Rostov said. “The [original] one had the really close near add. I find that people don’t enjoy that quite as much because it’s a little too much add.”

Rostov said she implants the ZLB00 in the first eye and asks the patient about his or her preference for second lens power.

“If they want a tiny bit more near, I can put in a ZMB00, the +4 D. Or if they want a little bit more intermediate, I can back it down and use a ZKB00. Most of the time, when I’m using a multifocal, they like the ZLB00,” Rostov said.

She urged caution in implanting presbyopic IOLs in patients with previous cornea transplant, radial keratotomy or LASIK.

Mitchell A. Jackson, MD, OSN Refractive Surgery Board Member, said he prefers the Tecnis low-add IOLs (ZKB00 and ZLB00), the Symfony and Symfony toric, the Crystalens and the Trulign IOL.

The next wave of IOLs will be truly accommodating lenses, according to Devgan.

“If you ask what’s in the pipeline now, there are very few multifocal lenses in the pipeline anymore,” he said. “If we can put a truly accommodating lens and nail plano, that’s literally the fountain of youth. That’s giving them back their youthful vision. No glasses. Nothing.”

A meta-analysis published by Rosen and colleagues in the Journal of Cataract and Refractive Surgery earlier this year showed that “multifocal IOLs are an effective means of correcting presbyopia and remain an invaluable tool for ophthalmologists to meet the needs of both post-cataract and [refractive lens exchange] patients who must be carefully selected before implantation.”

Extended depth of focus

The Tecnis Symfony extended depth of focus IOL (Abbott Medical Optics) has a CE mark in Europe and was approved by the FDA in July.

“I think extended depth of focus lenses are a benefit. I’m glad we have access to them, but in essence I think they’re a stopgap measure to tide us over until we have that new generation of accommodating lenses available,” Devgan said.

Whitsett, who was an investigator in FDA clinical trials for the Symfony, said the lens surpasses other lenses in terms of visual outcomes and vision quality.

“It’s an innovative lens because of the extended depth of focus perspective and the ability to limit chromatic aberrations. This should give us some of the highest quality of vision that we’ve had for patients for distance and intermediate and, depending on how you set it, even for near,” Whitsett said.

The Symfony may also have an effect on post-refractive residual error.

“We’re hoping with the Symfony that that’s going to be a little kinder for the post-refractive as far as residual refractive error, particularly the post-hyperopics, which are the most challenging. But that’s still to be seen because, obviously, through the FDA trials we weren’t able to do any post-refractive patients,” Whitsett said.

Mark H. Blecher, MD, performed one of the first U.S. implantations of the Symfony IOL at Wills Eye Hospital in late August.

Early outcomes were encouraging, Blecher said.

“On their day 1 postops, their distance vision was excellent, as it should be and usually is with any of the Tecnis lenses,” he said. “The intermediate was starting to come around, but I’ve learned from the multifocal that it takes a little while for the eye to settle down and to get some of that intermediate and near vision, so I’m looking forward to seeing that. Also, we all know in using these lenses that binocularity really helps, so getting the second eye in so you get binocular summation of the image.”

Blecher said the Symfony had positive results in the FDA clinical trial and impressive early results reported by surgeons in Europe, Canada and Latin America.

“People are raving about visions and patient response to the extended depth of focus. I’m very excited about that,” he said.

Although some surgeons are switching from traditional multifocal IOLs to the Symfony, Blecher said traditional multifocals may be appropriate for some patients.

One option may be implanting a Symfony lens in one eye and a traditional multifocal in the other eye, he said.

“Obviously, they didn’t do that in the clinical trials. It has just been approved in the U.S., and none of us has gotten far enough along to even contemplate that,” Blecher said. “But I can definitely see thinking about it and probably working with that and seeing if that doesn’t enhance the functionality that we might get with the lens.”

Toric IOLs

Toric IOLs currently on the market in the U.S. include the Tecnis toric, Trulign and Tecnis Symfony toric.

Models on the market or in development in Europe include the Light Adjustable Lens (Calhoun Vision), Lentis LT toric, enVista (Bausch + Lomb), AcrySof IQ and AcrySof IQ ReSTOR multifocal toric.

The Trulign is based on the Crysta-lens platform.

“In the marketing, the Trulign toric does not have the FDA word ‘accommodation’ in the title of it. The Crystalens did. If that’s on the same platform, how is that the case? People have theorized that perhaps it’s the FDA being a little bit more stringent in the way they use that word ‘accommodation,’” Devgan said.

Rostov said she prefers the Tecnis toric and Trulign toric for cylinder correction.

“The thing I like about the Trulign is it’s a very stable lens,” she said. “It gives really good astigmatism control, and you also get a better range of vision.”

Jackson said he prefers for astigmatism correction the Tecnis Symfony toric and Trulign toric IOLs. He also performs astigmatic incisions with the Lensar femtosecond laser with Streamline astigmatism planning software and the Cassini corneal shape analyzer (i-Optics) for astigmatism up to 1.6 D.

In a presentation at the 2016 American Society of Cataract and Refractive Surgery meeting in New Orleans, Cynthia Matossian, MD, reported that the Trulign toric IOL improved uncorrected distance and intermediate visual acuities, reduced refractive cylinder and showed high rotational stability in long eyes.

Marketing and patient education

According to Corcoran Consulting Group, overall conversion rates increased from about 1% in 2004 to about 11% in 2014. Conversion rates for astigmatism-correcting IOLs are currently higher than those for presbyopia-correcting IOLs.

Increasing conversion rates to premium IOLs depends on marketing, patient selection, testing and optimal outcomes, Holladay said.

“To increase the conversion rate for premium IOLs, which is key, what the surgeon has to do, what the clinic has to do, is improve their results so that they can confidently give that patient the option for a premium IOL with a success rate that’s far in excess of 90%,” he said. “The second aspect of that is not so much data-driven but is related to how you deliver the care to the patient throughout the process. It has to be an upscale type of delivery that at each step, from the time they walk in the door to the time they walk out of the clinic, promotes the premium IOL.”

First, marketing a premium cataract practice involves attracting younger patients who have the economic means to pay out of pocket for premium IOLs. Second, once in the office, the patient has to be informed about various options. Third, preliminary diagnostic testing must be performed to determine which patients are good candidates for premium IOLs, Holladay said.

Rostov said her practice uses a patient education program named CheckedUp to advise patients about their surgical and lens options.

“It really cuts down the amount of time that I need to explain a lot of things for the patient. I look at what their answers were on their CheckedUp questionnaire, so going into the exam room, I already know whether we’re going to be having a presbyopic conversation or they’re fine with standard,” Rostov said.

Jackson said he and his staff discuss lifestyle outcomes with patients, not medical terminology.

“What people want are their lifestyle outcomes. They tell me they want to be able to drive without glasses day or night or be able to read their cell phone, computer or laptop, or read books or whatever their jobs or hobbies are,” he said.

Jackson’s practice offers basic and advanced options. The basic option generally involves a monofocal IOL. The advanced options are “legal to drive” and “forever young,” the latter which involves presbyopia correction.

“It’s back in the surgeon’s hands to do his or her job, meaning deciding if I should do astigmatic incisions, a toric lens, on-axis incision, whatever it takes to correct their astigmatism, with or without the femtosecond, with or without intraoperative aberrometry using ORA, what type of presbyopia-correcting IOL, etc.,” Jackson said.

Patients fill out a lifestyle questionnaire that helps Jackson and his staff devise a treatment plan that is appropriate for the patient’s needs and desires.

“I do the no-chair-time approach, which is the lay approach that patients understand, and they usually pick it based on what they want lifestyle-wise. Then it’s up to me as a surgeon to deliver,” he said.

Devgan said that in his practice, some patients pay a flat fee for refractive cataract surgery, regardless of which premium IOL they choose. Patients pay the list price for premium IOLs.

“I’m actually not in the business of doing any kind of conversion,” Devgan said. “All of my patients get premium surgery, and the lens they get is tailored to their eye and they pay only the exact price of the lens with no markup. I’m not selling that lens any more than the artist is selling you a palette of paint and a canvas. I’m offering you the finished piece of artwork.”

Diagnostics and measurements

Diagnostic devices such as the Pentacam (Oculus) and HD Analyzer (Visiometrics) are important in measuring axial length and posterior astigmatism.

“All of those are essential because it’s clear that if you don’t have patients within 0.5 D of residual astigmatism, [those patients] don’t do well,” Holladay said. “In other words, if you’ve got 0.5 D of spherical equivalent error and 0.5 D of residual astigmatism, that patient doesn’t do well. The total of those two has to be less than 0.5 D.”

Whitsett said the iTrace (Tracey Technologies) helps with lens placement by pinpointing the visual axis.

“We use the iTrace routinely on all surgical consultations,” Whitsett said. “It gives us a very good idea of who’s the best candidate as far as where their visual axis is and whose visual axis might have a high angle kappa. That instrument has helped us be very much engaged as far as where their visual axis lay and who might be the best candidate for a multifocal and who might be a challenge.”

The ORA intraoperative aberrometer (Alcon) maximizes outcomes and saves time, Whitsett said.

“We probably change our lens selection, I’d say, probably a third of the time,” he said. “The time it takes to do an ORA scan in surgery is a whole lot less than it takes to do an enhancement after surgery. If it slows you down 2 minutes and you have a happy patient and you don’t have to wait 3 months to do an enhancement on them, it’s worth the 2 minutes you have to wait.”

Rostov said maximizing the ocular surface is critical.

“If you really take a look, you can see that their tear osmolarity is high or they have a high tear breakup time, or you can take a look at their meibomian glands and such. So, you really want to pay attention to optimize the ocular surface as well as address any corneal issues before even considering cataract surgery,” Rostov said.

IOL power calculations play a critical role in meeting postoperative targets, Holladay said.

“You’ve got to be using the Holladay 2, a Barrett or an Olsen 2 variable calculator so that your spherical equivalent results have 90% of your people within ±0.5 D,” he said.

Devgan said that using a combination of IOL calculation formulas ensures more accurate power calculation.

“There have been a lot of publications with lens calcs, some of them including my own where we now realize that one formula does not fit all. We have to use an amalgamated method of using the best of many different formulas to come up with a more accurate result,” Devgan said.

Some surgeons are using www.iolcalc.com, a free website that collects pooled data that is crowd-sourced from hundreds of surgeons with data on thousands of patients, he said.

“Anyone can use it. We have a very proprietary method of doing lens calcs. On that same site we can link to all of our published papers and explain the details,” Devgan said.

In JAMA Ophthalmology, Ladas and colleagues described a “super formula” that includes key features of each of the existing formulas and selects the optimal formula for an individual eye. – by Matt Hasson

• References:
• Ferreira TB, et al. J Refract Surg. 2016;doi:10.3928/1081597X-20160428-07.
• Garzon N, et al. J Refract Surg. 2015;doi:10.3928/1081597X-20150122-03.
• Gatinel D, et al. J Refract Surg. 2016;doi:10.3928/1081597X-20160121-07.
• Ladas JG, et al. JAMA Ophthalmol. 2015;doi:10.1001/jamaophthalmol.2015.3832.
• Lum F, et al. Ophthalmology. 2015;doi:10.1016/j.ophtha.2015.02.038.
• Matossian C. Clinical outcomes for low-diopter accommodating IOL. Presented at: American Society of Cataract and Refractive Surgery meeting; May 6-10, 2016; New Orleans.
• Rosen E, et al. J Cataract Refract Surg. 2016;doi:10.1016/j.jcrs.2016.01.014.
• Visser N, et al. J Cataract Refract Surg. 2013;doi:10.1016/j.jcrs.2013.02.020.
• Weeber HA, et al. J Cataract Refract Surg. 2015;doi:10.1016/j.jcrs.2015.07.034.

• For more information:
• Mark H. Blecher, MD, can be reached at Philadelphia Eye Associates, 1703 S. Broad St., Philadelphia, PA 19148; email: mblecher@phillyeye.com.
• Uday Devgan, MD, can be reached at Devgan Eye, 11600 Wilshire Blvd., Suite 200, Los Angeles, CA 90025; email: devgan@gmail.com.
• Jack T. Holladay, MD, MSEE, FACS, can be reached at Holladay Consulting Inc., 6802 Mapleridge St., Suite 200, Bellaire, TX 77401; email: holladay@docholladay.com.
• Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.
• Audrey R. Talley Rostov, MD, can be reached at Northwest Eye Surgeons, 10330 Meridian Ave. N., Suite 370, Seattle, WA 98133; email: atalleyrostov@nweyes.com.
• Jeffrey C. Whitsett, MD, can be reached at Whitsett Vision Group, 1237 Campbell Road, Houston, TX 77055; email: jwhitsett@whitsettvision.com.

Disclosures: Blecher reports he is a consultant for Abbott Medical Optics and is editor in chief of Review of Ophthalmology. Devgan reports that he owns stock in LensGen and IOLcalc.com, is a consultant for Alcon and is a former consultant for Bausch + Lomb, Abbott Medical Optics and STAAR. Holladay reports he is a consultant for Alcon, Carl Zeiss Meditec, Haag-Streit, Oculus and Visiometrics. Jackson reports he is a consultant for Bausch + Lomb, i-Optics and Lensar. Rostov reports she is a consultant for Allergan, Bausch + Lomb and Shire. Whitsett reports he is a consultant for Abbott Medical Optics.

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