Viewpoint FROM THE CHIEF MEDICAL EDITOR

Who Pays for Monovision?

Paul S. Koch, M.D.

Over the years, I've left lots of implant patients with monovision on purpose. I've also left a whole lot more monovision by accident. "Oh my gosh, Mrs. Smith, isn't this great? You don't have to wear glasses; aren't you really, really happy?" Some monovision patients were really, really happy. The others were really, really upset with me and responded with either passive aggression or very active aggression.

I try to have more of the happy and fewer of the mad by almost exclusively reserving pseudophakic monovision for patients who had already done that with contact lenses. That way I know ahead of time that they will adjust and my only challenge will be to be sure I kept the distance eye distance and the near eye near.

This is why I always considered monovision cataract surgery to be routine cataract surgery and not elective refractive surgery, and that is why I never felt it justified an additional professional fee. Until now, that is.

I spent some time recently with a young ophthalmologist who prefers the combination of aspheric implant and monovision over multifocal lens implants. She feels it gives better quality of vision and a comparable range of focus. However, she's faced with the challenge that most of her patients have not worn contact lenses.

So, for many of her cataract patients, she does a contact lens trial by doing a quick monovision fit with extended-wear contacts. Three days later, she has them come back to the office to see how they're adjusting. If the near lens is too strong or too weak, she changes the lens and gives them a few more days to adjust. Then she checks again.

Her protocol causes her to use up several additional office slots per patient for uncompensated "refractive" visits. She is providing professional services that are only peripherally related to the cataract operation and more directly related to presbyopia correction. Therefore, it is her position that the patient, not his insurance, should pay for these services.

Monovision Is Elective

We are all learning how to handle the business of presbyopia correction. As far as I'm concerned, if my routine cataract operation gives someone a refractive effect just because I added a few diopters to the lens power, it's still my routine cataract operation and I bill his insurance. But I now believe that if additional services are rendered specifically for an elective refractive result, the patient should pick up the tab.