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A return to monovision with femtosecond cataract surgery?
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As femtosecond laser cataract surgery becomes increasingly available in the United States, it is becoming apparent that patients are quite self-motivated to choose this technology and do not seem to balk at the added cost.
This comes at an economically interesting time. In every industry, consumer behavior has recently shifted from high-tech orientation toward value orientation. In other words, the consumer now much more critically asks, "What do I pay and what do I get?" Many of us who use a lot of premium IOLs have distinctly noticed this recent trend in consumer behavior. Our conversations with patients increasingly shift from how the technology works to what it's worth to the patient. Despite the added costs, it seems that the value of femtosecond cataract surgery is self-evident to patients, even though surgeons have broadly expressed skepticism about this value proposition.
But at what price will our patients begin to turn down the value-added services of a presbyopia-correcting implant combined with astigmatism correction and femtosecond cataract surgery? At an out-of-pocket cost of $2,500 to $3,000 per eye, presbyopia-correcting cataract surgery without a femtosecond laser may be near that limit. To add another $800 to $1,000 to the cost to perform a limbal relaxing incision and other steps with a femtosecond laser may simply be cost-prohibitive. For this reason I believe that monovision may be increasingly combined with femtosecond cataract surgery to reduce the patient's out-of-pocket cost.
Many practices, including mine, offer "advanced monovision" as a value-added service to cataract surgery. Because monovision requires advanced diagnostic testing, additional refractions and biometry, and often entails postoperative enhancements, patients pay extra charges for these services that are not covered by Medicare. Since advanced monovision does not require a presbyopia-correcting implant, we can save the patient nearly $1,000 in the out-of-pocket cost. For this reason, in my practice advanced monovision offers a middle tier for presbyopia correction that is more affordable to many patients.
Granted, pseudophakic monovision is not the same as phakic monovision, which employs at least some degree of accommodation to fill in the gaps between distance and near. Pseudophakic monovision also does not offer nearly the seamless range of vision that patients get with an accommodating IOL such as Crystalens, which typically gives 1.5 D to 2 D of accommodation. Despite this, combining advanced monovision with femtosecond cataract surgery makes perfect sense, since the monies normally paid for the implant itself can now be used to pay for the laser, keeping the patient's out-of-pocket cost the same.
As new presbyopia-correcting implants emerge that offer even better results, we and our patients will certainly have a growing menu of choices for add-ons to cataract surgery. For now, in an economy in which every patient counts every penny, femto
monovision may be a good way to give spectacle independence while keeping the price of high tech within reach.