Gleaning the Bottom-line Benefits of Premium IOLs

Learn how far premium IOLs have come and how valuable they can be in an ophthalmology practice.

By John F. Doane, MD, FACS

Premium IOLs provide many benefits to patients, surgeons and ophthalmology practices. I couldn't imagine not having the capability of implanting presbyopiacorrecting IOLs. In 1995, as a fellowship-trained refractive surgeon, I believed the fundamental surgical technique would be LASIK. At that time, the median age of the baby boomer population was 40 years old, which coincidentally was the average age of patients seeking laser vision correction. From 1995 to 2004, we saw tremendous growth and then a decline in the number of laser vision correction candidates. I believe demand will pick up again, but probably not for a few years.

In this article, I'll discuss the limitations we once had as cataract and refractive surgeons more than 10 years ago and explain what we can do now with accommodative IOLs to ensure the best outcomes in our patients.

Earlier Unmet Expectations

Around 1997, I realized that corneal refractive surgery couldn't provide everything patients wanted. Essentially, they desired binocular distance, intermediate and near vision without correction. One difficult group of patients were those needing hyperopic corneal procedures greater than 3D. Hyperopes generally don't inquire about laser vision correction until age 50. Usually, the need for correction in this population isn't just for distance but primarily for better near vision. To that end, these patients would need an additional 1.5D to 2D of hyperopic correction. But this is simply too much surgery for the cornea to effectively create an optic for longterm patient satisfaction. The ultimate kicker is that these patients tend to have drier eyes. And the way physicians perform the ablation in the mid-periphery tends to exacerbate dry eye symptoms.

We also have a slight dilemma with the typical emmetropic presbyope and myopic presbyope. For laser vision correction to work, the patient must be willing to have a physician create monovision. Approximately 40% of these patients can't tolerate monovision; 30% enjoy it, and the remainder tolerate it. Those who simply tolerate it may have to wear eyeglasses for night driving and some reading tasks because of the rivalry between the two eyes. In 1997 and 1998, the only way you could combat presbyopia surgically was to induce some aspect of monovision with corneal-based procedures or IOLs. So, in 2000 researchers initiated the first FDA study for accommodative IOLs with the Crystalens (Cumming JS, et al. J Cataract Refract Surg. 2006;32:812-825).

Debut of Accommodative Lenses

The study demonstrated that accommodative IOLs could be the solution to resolving presbyopia. We can't promise 99% of patients spectacle independence, minimal-to-no unwanted scotopic symptoms and equal binocular vision at distance, intermediate and near. However, with bilateral implantation of accommodative IOLs, we can promise excellent quality of vision, minimal-to-no binocular imbalance and no induced scotopic symptoms.

What are the shortcomings? In my practice, I've learned you must reduce refractive astigmatism to 0.50D or less, 20% of eyes will undergo laser vision correction, and a certain amount of surgeon-patient hand-holding is required. You must be available, compassionate, cognizant of patients' time and understanding, because you're serving a group whose expectations are above the traditional monofocal cataract patient who already expects to wear eyeglasses for the rest of his life.

Premium IOLs Are a Must

Fundamentally, offering premium IOLs makes all the sense in the world. Patients want exceptional vision. Performing the surgery and providing the highest quality of vision enables the entire practice to be involved in something that only a few years ago was just a dream for a few innovators in the ophthalmic field.

Because of this, it's important for surgeons and staff to communicate to patients what they can and can't provide. If the surgeon can over-deliver on what the patient is expecting, he can obtain a visual outcome with the glass more than half full. OM