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Positioning Refractive IOLs in your Practice
Begin with candidates for cataract surgery.
BY LESLIE GOLDBERG, ASSISTANT EDITOR

Charles Williamson, M.D., of the Williamson Nelson Eye Center in Baton Rouge, La., began incorporating premium refractive IOLs into his practice by marketing these upgrades to existing cataract patients. The eye center surveyed its own surgical population and found that 30% of the current cataract patients were under the age of 60.

"This represented a considerable number of active patients — not retirees," says Dr. Williamson. "This is the first population you want to look at. It is also the most cost-effective, as there is no need for outside marketing. These patients are already prepared to have cataract surgery and many have already selected your practice.

"If you place the lenses in patients who are already planning to have cataract surgery, anywhere between 40%-60% of their surgery is paid by insurance. It is not uncommon for the total cost including lenses, surgeon's fees and the surgery center to be $4,000 to $4,500 per eye for the overall program."

A Refractive Program

Dr. Williamson makes sure that patients understand that this is a comprehensive refractive program, not just a surgery. The doctor is trying to target a specific refractive result, which may require further enhancements or a longer follow-up. This program includes the use of YAG lasers, LASIK touch ups and LRIs, if necessary. Dr. Williamson explains that the most important thing for these patients is an accurate A-scan and that postoperatively the patients need really low or no astigmatism.

"I do not try to position these lenses as a way to get rid of reading glasses," Dr. Williamson asserts. "Many patients don't mind using reading glasses. We cannot guarantee that they will not need reading glasses, although many patients will become less dependent on them. It is hard to sell something you may not achieve and that has a pretty inexpensive alternative. This is not the best way to position the lens."

A Better Technology

"I believe a better way to position the lens is as a better technology," says Dr. Williamson. "This technology not only involves the surgery, but a promise, basically, to achieve a refractive result. This promise not only includes lens implant surgery but a host of other types of possible refractive procedures to fine tune, if needed. They are buying a refractive program, not just a lens."

These premium lenses allow people to have a wider range of vision. "Some patients may still require light reading glasses," says Dr. Williamson. "but if they do, they are usually getting readers one-third the strength needed prior to surgery. They are able to look at computers, read newspapers, look at watches and car dashboards. We are not promising that they can read the small print of stock quotes, and they accept that."

Dr. Williamson has found it is best to position these premium IOLs as a new technology that has a good track record for the last several years. "You have an older technology that the government agrees to pay for totally and this new technology that the government recognizes, and in a landmark decision, has allowed us to upcharge for. Patients should not be denied a newer technology just because the government is not prepared to pay for it entirely," concludes Dr. Williamson. "We are not talking about a large-scale upcharge. On the scale of many procedures, this is a very inexpensive type of operation. A lot of people readily accept this."

Patient Expectations

"We are asking the patient to accept this new lens technology for a specific refractive result," says Dr. Williamson. "So they do have expectations above and beyond ordinary cataract surgery. They are entering a refractive program that initially starts with the lens you have chosen for them. Each of the lenses has a particular postoperative pattern that is unique to that lens. You need to find out from the patients what their refractive needs are."

Dr. Williamson believes that a three-tiered system is best for advising patients:

►Patient Work-up. A patient will receive a work-up similar to a regular cataract patient. The technician will see if a patient meets the criteria for premium lenses and ask about their activities, job, close vision requirements and nighttime driving.

►Preoperative Exam. The doctor then examines the patient and discusses specialty lenses, counseling whether the patient is a good candidate for the refractive program, which includes surgery and refractive touchups.

"The patients just want to know our recommendation and why. We tell them all the major advantages, disadvantages and potential complications," says Dr. Williamson.

►Surgical Counseling. The patient goes to a surgical counselor immediately after seeing the doctor. Specialty lens patients are given product information, brochures and an informed consent. These materials are not only cataract specific, but lens specific. "We let the counselor talk about price, including financing options," says Dr. Williamson. "They explain the cost benefits of improving lifestyle with the premium lens refractive program. If they are on Medicare, about half of this cost is covered. While cataract surgery is usually covered by insurance, the additional cost of the lens and refractive surgery program is, on average, an additional $2,000 per eye. Since this extra expense is in the range of most LASIK surgery, patients don't see this expense as out of the ordinary."

"Using this multi-disciplinary approach to incorporating premium lenses in your practice lets the physician concentrate on the best surgical and refractive result for the patient, leaving the more retail aspects of the program to the staff," says Dr. Williamson.

Another Response to IOL Marketing

Kevin L. Waltz, M.D., of Eye Surgeons of Indiana, has been implanting specialty IOLs since 1999, starting with the Array IOL. He believes that this has made for a smoother transition in the introduction of premium IOLs into his practice. Dr. Waltz markets refractive IOLs primarily through patient education.

The practice begins with educating patients in the office and then sending them home with additional information. They also have videos available that Dr. Waltz has created, describing the good and the bad of the process. In addition, they have started running TV ads for education and to inform people that there are options available if they are interested. Dr. Waltz explains that this is not a hard sell.

"We ask all patients who are having cataract surgery if being less dependent on glasses is something that is interesting to them," says Dr. Waltz. "The majority say no — glasses are not a big issue for them. Less dependence on glasses is important, but independence from glasses is not. Most patients come in to the office and make a decision about IOLs right then."

At this point, Dr. Waltz discusses what the patients' specific needs are. He says, "I'll tell patients that we have a lens that will give them great distance vision and  intermediate vision — but the near vision may not be as good. They may need to wear glasses at times but it will not give them halos or other glare."

Dr. Waltz also provides other refractive IOL choices. "I'll tell them we have lenses that are going to give strong distance and near vision, but intermediate won't be as good and may cause halos. It depends on the individual what the reaction is," he says.

"Some people will hear this and say 'I don't want any of this, let's talk about monofocals.' Others may say 'I don't care about wearing low-powered reading glasses it's no big deal to me' or they may say 'it's really important for me to see up close. I don't really mind halos, I'd be happy with that,'" says Dr. Waltz.

Dr. Waltz says that his patients who choose not to have a premium IOL implanted do so for three main reasons: lack of desire to be spectacle-free, cost and fear of having to undergo a second refractive surgery.

"If we do cataract surgery with a monofocal, the likelihood that they will need a second surgery is really low — less than 1%," says Dr. Waltz. "With a premium IOL this risk raises to 15-20%."

Telling it Like it is

"Multifocal and presbyopic IOLs are a very helpful addition to the armamentarium of the refractive and cataract surgeon," says David Wallace, M.D., of LA Sight in Los Angeles Calif., "It is a small segment of the overall market but it is not one that should be ignored."

He explains that the market is largely convenience- and freedom-from-spectacle-dependence driven. "Some people see that there is tremendous value in having adjustability of focus across a range of different functional zones. Some patients are quite comfortable having intermediate and distance vision optimized and are willing to wear reading glasses for close work. So, to some extent, it is a cost/convenience or cost/benefit tradeoff. And to some extent, it's an optical function tradeoff because none of the presbyopic lenses that currently exist are optically perfect," says Dr. Wallace. "The challenge for someone like myself, who is engineering and optics-oriented, is to not oversell the technology, but not undersell it either."

Dr. Wallace's practice uses a variation of the "Functional Zones" questionnaire developed by Steven Dell, M.D., of Austin, Texas. He finds the Dell questionnaire helpful when broaching a discussion of premium IOL products with appropriate prospective clients. "It requires the individual to think about how they use their eyes and what's important to them. It also gives us some guidance as to how to address their needs and interests," says Dr. Wallace. "Like LASIK, for some it's an impulse buy and for others it's a process that takes several years. We do not expect people to make a decision when they are in the exam room. We offer them options; we supplement that with brochures and information on our Web site; and when they are ready to make a decision we move forward. It is not a hard-sell pitch."

"The presbyopic refractive and multifocal IOL market is important now and will become increasingly important in the future, particularly as lens' designs evolve and results get better, but I think that there are several issues here," states Dr. Wallace. "One is that the industry has tried to float the suggestion that these lenses are absolutely better in all circumstances than monofocals, which I think is a stretch. Another is that no one has provided any graphic representation or visual image of what the world looks like viewed through these lens products."

As a serious amateur photographer and inventor, Dr. Wallace says that it would be possible to design a macular point-of–view camera that could view and image the world through any of a number of commercial IOLs, which could be changed in an imaging system much like changing the lens in a single-lens reflex camera.

"If you could take photographs of what the world looked like through the multifocal IOL, you could at least provide some visual representation both to patients and to providers of what night vision, a sunny day at the beach or halos actually look like," he says.

Dr. Wallace says that while he is optimistic and enthusiastic about technology, he takes a little longer to explain the risks and benefits associated with premium IOLs to his patients. "We close a smaller percentage of patients in the process," he admits. "However, I think that this somewhat measured approach helps us select the proper candidates and weed out those that would not be happy with the results."