Refractive cataract surgery one of the best values in medicine today
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In an earlier Lindstrom’s Perspective, I described cataract surgery and IOL implantation as a modern-day miracle.
The implantation of an advanced-technology/premium IOL that corrects preexisting regular or irregular astigmatism and/or presbyopia can further enhance the miracle of restored vision that we offer the patient with visually significant cataract. I will share a few personal thoughts that to some may be controversial.
First, there is standard cataract surgery and there is refractive cataract surgery. When we do refractive surgery, the patient is responsible for the cost, much the same as they are responsible for the cost of eyeglasses or contact lenses. With minimal counseling, most patients understand the difference. Refractive cataract surgery includes the management of both regular and irregular astigmatism, higher-order aberrations and presbyopia. Preexisting astigmatism can be managed with preoperative, intraoperative or postoperative incisional or laser corneal relaxing incisions, a toric IOL or Light Adjustable Lens (RxSight), and preoperative or postoperative excimer or femtosecond laser corneal refractive surgery. Regardless of the timing or the preferred procedure, refractive surgery justifies an incremental fee. Just like when dispensing eyeglasses or contact lenses, the individual eye care professional can set their own fee, and those fees vary widely from one surgeon and one practice to another.
Second, today nearly every patient is a candidate for refractive cataract surgery. We now have advanced-technology/premium IOLs that can enhance refractive outcomes while providing equivalent quality of vision and contrast sensitivity to a standard monofocal IOL with no increase in unwanted daytime or nighttime visual dysphotopsia. Even in the patient with coexisting corneal pathology, retinal pathology and/or glaucoma, there is no downside to correcting a patient’s astigmatism with a toric monofocal IOL or Light Adjustable Lens. In some patients with significant irregular astigmatism or higher-order aberrations, we can actually enhance visual outcomes with the now available small-diameter aperture IOL.
In the presence of other ocular disease, degeneration or dystrophy, we all prescribe spectacles or contact lenses that fully correct a patient’s sphere and cylinder using increments of 0.125 D to 0.25 D. Today, for the willing patient, we have an advanced-technology/premium IOL that can do the same. Technology advances and continuing surgeon education have allowed advanced-technology/premium IOLs to grow to 19.1% of cataract surgeries performed today in the U.S., according to Market Scope. Over the next decade, I expect advanced-technology/premium IOLs to reach a 30% to 35% penetration in the U.S., a virtuous outcome for patients, surgeons and industry.
In my opinion, every patient deserves to be informed regarding the refractive cataract surgery options available to correct their astigmatism and, when appropriate, presbyopia. Proper informed consent requires a discussion of the potential benefits, risks and alternatives of refractive cataract surgery in all cataract surgery cases. Together with the patient, the best surgical plan, including economic considerations, can then be customized for each individual patient.
Third, I believe standard cataract surgery and refractive cataract surgery are a bargain regarding value. In medicine, one way to estimate the value of a surgical procedure is the so-called QALY (quality-adjusted life year). The math is complex, and the interested reader can learn more on the internet. QALYs are used by health care economists to estimate the negative burden of a disease on a patient and the potential benefit in quantity and quality of life that treating that disease has on a patient in dollars. While calculations vary from country to country and from one health economist to another, the QALY value for refractive cataract surgery in the U.S., looking at multiple references, is between $20,000 to $30,000 for first eye surgery and $10,000 to $15,000 for second eye surgery. Refractive cataract surgery is not only a modern-day miracle, but also an extraordinary value — perhaps the best value for any surgical procedure in all of medicine. No ophthalmic surgeon needs to be embarrassed by the typical fees we charge for a lifetime of restored and in many cases enhanced vision.
Refractive cataract surgery is a modern-day miracle, an option for nearly every cataract surgery patient and the best value in surgical care today.
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