Premium IOLs: The Bottom Line

Are you still on the fence about presbyopia-correcting IOLs? This surgeon offers his take on the benefits.

By Robert J. Cionni, M.D.

We've certainly come a long way from the days of 180° corneal incisions, intracapsular procedures with 2 weeks' bed rest and the promise of aphakic eyeglasses. Cataract surgery has become one of the most successful procedures in all of medicine. Are we better surgeons than surgeons 40 or 50 years ago? Well, our results are better, but much of the credit goes to remarkable technological improvements made over the last four decades.

We've now reached a point where most procedures can be performed through incisions of 3 mm or less, with little to no induced astigmatism. And we're implanting IOLs that can provide a high likelihood of spectacles-free vision. Unfortunately, each step along the way has been met with a resistance to any change in technology.

When IOLs were first introduced by Sir Harold Ridley, he was ridiculed and chastised. Now it almost could be considered negligent to not implant an IOL in most uncomplicated cataract surgeries. A similar story can be told of Charles D. Kelman, M.D. after he introduced the now standard technique of ultrasonic phacoemulsification. With the advent of refractive IOLs, we've already seen some hesitancy among surgeons to adopt this technology. The question is: Why?

THE COMFORT ZONE

Humans, and for some reason physicians in particular, harbor a natural resistance to change. Once we're comfortable with something, we don't feel a need to try something new. This holds true for everything from our favorite pair of jeans to a surgical technique and implant style that's yielded good results. So, until we begin to see a need to change to a new technology, we won't. Why risk something new if we're already getting good results? This was the argument when ophthalmologists were thrilled with their results performing state-of-the-art intracapsular cataract surgery. Imagine where we'd be if we didn't move forward with the changes that have occurred since then.

Later, ophthalmologists performing extracapsular cataract surgery were hesitant to learn the skills needed to perform small-incision phacoemulsification until real benefits to the patient and practice were demonstrated. Eventually, patients began to seek out those surgeons performing small-incision surgery with a single stitch or no-stitch technique, and surgeons who did not incorporate these techniques saw their practices dwindle.

So, what's the impetus for ophthalmologists to incorporate refractive IOLs into their practices? There are basically two: significant benefits to their patients and concomitant benefits to their practices. Let's discuss patient benefits first.

LESS SPECTACLE DEPENDENCE

Patients with significant amounts of astigmatism have depended on eyeglasses most of their lives. Some 97% of these patients who receive toric IOLs bilaterally will be spectacle-free for distance tasks.¹ Although most will need standard reading glasses for near vision, they'll no longer require prescription bifocals or prescription sunglasses. The collective experience at the Cincinnati Eye Institute and the Eye Institute of Utah shows overwhelming patient satisfaction with toric IOLs.

We have found a similar response to presbyopia-correcting IOLs. No longer do our patients of any age need to experience immediate and complete presbyopia following cataract surgery. We can, and are, providing these patients with the opportunity for quality of vision that they may never have known. We've found that some of the happiest patients in our practice are those who no longer require eyeglasses for almost everything they do, including distant, intermediate and near tasks.

It's easy to see the significant benefits these IOLs provide to our patients. What about benefits to the practice?

TANGIBLE AND INTANGIBLE PRACTICE BENEFITS

Your practice can benefit from these new-technology IOLs in several ways. But first, you may need to change your mindset. Unfortunately, ophthalmologists have undervalued the services they provide to their patients for everything from cataract surgery to laser refractive surgery.

A landmark ruling by the Centers for Medicare & Medicaid Services now allows us to charge patients for refractive IOLs and for our services related to their use. Therefore, we can begin to enjoy the financial rewards that should go along with the tremendous value we provide to our patients. Just be careful not to undervalue your refractive IOL services. After all, what value can we place on restoring a patient's vision to a level he hasn't known for many years, perhaps to a level he's never known?

Within the first year of incorporating these IOLs into our practice at the Cincinnati Eye Institute, we realized significant financial benefits — an increase in revenue of more than $3.3 million. This was accomplished with only minor changes to our normal office processes, the same number of cataract procedures and no additional advertising dollars. In addition to increased practice revenue, I've found a change in my day-to-day office lifestyle that I believe is a favorable trend.

All patients need to be educated about the options available with refractive IOLs, so it's necessary to spend more time with each patient. Face time with each patient has doubled in my practice. While some physicians may find this a barrier to seeing the high volume of patients needed to offset declining reimbursements, I've found it's a great opportunity to enjoy my practice more. By spending more time with patients, I can better educate them about the benefits and limitations of the different IOL styles available. Therefore, my patients have a better understanding of their options and more realistic expectations.

I have slightly decreased my clinic volume so I can get to know each patient better, and I'm truly enjoying this new, improved doctor/patient relationship. Yet, even though my clinic volume is intentionally less, my income has not decreased. This is due to the favorable revenue provided by refractive IOLs.

There's no doubt that patients enjoy this type of practice as well. Certainly, physicians who spend more time with their patients will have higher conversion rates to refractive IOLs. Rushing through an exam in 5 minutes does not allow enough time for patients to fully understand the available options and therefore, they'll be less likely to pay out-of-pocket for any noncovered option.

WHAT'S NEXT?

What about the future of refractive IOLs? Although currently available toric and presbyopia-correcting IOLs are a significant improvement over those we used in the past, technological advances will further the benefits and decrease the limitations of these IOLs.

As a case in point, the original AcrySof^® ReSTOR^® IOL performed very well, with the highest level of spectacle freedom of all the presbyopia-correcting IOL styles, but not all patients were thrilled with their results. The new aspheric ReSTOR IOL reduces corneal spherical aberrations, which improves image quality. This translates into better quality vision at all distances.

My experience with the aspheric ReSTOR IOL thus far has been quite good, with about 87% of patients attaining complete spectacle freedom and a very high level of patient satisfaction. Although the ReSTOR lens has been shown to perform better after bilateral implantation,² patients seem to do well with the aspheric ReSTOR lens, even with only the first eye implanted.

SEIZE THE OPPORTUNITY

As the technology continues to improve and patient awareness increases, refractive IOLs will become the new standard of care for all patients. Just as with small-incision cataract surgery, as patients become more aware of the refractive IOLs, they'll begin to demand these options. In time, surgeons who don't offer these IOLs will see their practices dwindle as patients seek those who do.

The opportunities refractive IOLs offer to patients and ophthalmologists are significant. It's imperative that surgeons embrace this technology and learn the pearls that lead to happy patients and successful refractive IOL practices.

Robert J. Cionni, M.D., is medical director of the Cincinnati Eye Institute, and he practices at the Eye Institute of Utah in Salt Lake City. He is adjunct professor of ophthalmology at the University of Cincinnati and The John Moran Eye Center at the University of Utah in Salt Lake City.

References

1. Ernest PH. Evaluation of clinical outcomes with the AcrySof Toric IOL: 1-year results. Presented at 2007 ASCRS, San Diego.
2. AcrySof^® ReSTOR^® IOL Package Insert.