Cataract Surgery Report

Are premium IOLs set to break out?

The market forces that have held them back may be about to change.

By Jeffrey S. Eisenberg

Ask any real estate professional the cardinal rule of success, and the answer is “location, location, location.” Ask the same question of a cataract surgeon, and the answer is likely to be “education, education, education.”

Jamie M. Monroe, MD, of the Cataract & LASIK Center of Utah, in Orem, reports about 20% of cataract patients in her practice convert to premium IOLs. “Just like other practices, we try to introduce the options early – prior to the patient coming in to our office,” she says.

That share of premium IOLs in Dr. Monroe’s practice exceeds the overall market penetration. About 14% of the 3.5 million cataract surgeries performed each year in the United States involve a premium IOL, according to Market Scope, a company that tracks ophthalmic trends and data.

PREMIUM IOLS TRENDING

Upside potential

Increasing life expectancy, the need for people to work longer and the evolution of technology from laptops to tablets to cell phones all bode well for premium IOL conversions. While a number of ophthalmic market studies and watchers confirm that premium IOLs are poised to grow, their performance in the US market has lagged behind expectations.

The outlook for premium IOLs was a focus of panels at the Ophthalmology Innovation Summit during the AAO meeting last year and at ASCRS in April. They analyzed the market from several angles, from the increased revenue premium IOLs generate to challenges preventing the modality from gaining market share faster. This article explores those trends and how they can impact ophthalmology practices.

Outsized revenues

The impact the small market share of premium IOLs has on surgical fees is much greater. “When you do some calculation of the premium fees, the surgical fees that are deserved when premium lenses are used, it has increased the surgical fees in the US market by 40%,” says William J. Link, PhD, managing director of Versant Ventures, a venture capital firm in the ophthalmic space.

However, that 14% market share is far below the market penetration of 25% to 30% the panelists were expecting by now, some eight years after the premium channel launched with a favorable CMS ruling in 2005.

In fact, the market for presbyopia-correcting IOLs, in particular, has remained flat, barely above 7%, according to Market Scope. Indeed, the market only grew 1% between 2005 and 2012, Market Scope reports. “That’s an astonishingly flat curve for something that seems to offer advantages for patients – and that doctors get paid a lot to do,” says Douglas Koch, MD, of Cullen Eye Institute, Baylor College of Medicine in Houston.

Why the market lags

Andy Corley, cofounder of eyeonics Inc. and a senior consultant for Bausch + Lomb Surgical, cites four possible reasons why the premium IOL market has not met expectations in eight years: inadequate technology, poor outcomes, economics or lack of patient awareness.

Says John Barr, executive vice president and global president, Bausch + Lomb Surgical: “I think it may be inadequate technology in terms of maybe selecting the wrong lens for the specific patient’s needs.”

Dr. Koch provides the physician’s perspective on multifocal IOLs. “There are many surgeons who don’t have a lot of confidence in the outcome of multifocals,” he says. “There are some concerns about the quality of vision, and they’re not prepared to deal with the patient complaints, including issues such as the occasional IOL exchange.”

PARSING THE TRENDS

Understanding the challenges

In the quest to reduce spectacle dependence, multifocal IOL designs present several challenges with respect to quality of vision. “First, they are much less forgiving of residual astigmatism or slight spherical refractive error than monofocal IOLs,” says David F. Chang MD, clinical professor at the University of California, San Francisco. “With a diffractive multifocal optic, 0.75 D of cylinder can reduce both image quality and depth of focus to a surprising degree, and excimer laser keratorefractive enhancement may be needed more often than we might have expected.”

The second challenge is the inherent reduction in contrast sensitivity. “This might be a very acceptable trade-off in a perfectly healthy eye,” Dr. Chang explains. “However, there is little margin for error and minor degrees of maculopathy or any higher order corneal aberrations, such as coma or spherical aberration can reduce the image quality or uncorrected near function in eyes implanted with these IOLs.”

Selecting the right eyes

Nonetheless, presbyopic IOLs can be a positive option. “Some of the happiest patients I’ve had in my practice are patients with a multifocal IOL,” said Ed Holland, MD, director of cornea services at Cincinnati Eye Institute and professor at the University of Cincinnati. “It’s our job as surgeons to try to select out those patients we think are going to be happy. And if you do a good job of that, and can select that patient out, they’re thrilled.”

Mr. Barr agrees. “I think doing a better job at picking the right lens for the patient based on what they expect and what that lens can deliver will lead to better outcomes, which will lead to more positive patient experiences, more confident surgeons, and higher market penetration,” he says.

FEMTOSECOND AND PREMIUM IOLS

Competition or complement?

The increasing use of femtosecond lasers for cataract surgery may have an effect on premium lenses – but what kind? In its 2013 Laser Cataract Surgery Survey, medical device consulting company SM2 Strategic found that 30% of all cataract procedures involved a femtosecond laser.

“The laser is a key addition to the premium cataract offering,” notes Shareef Mahdavi, president of SM2 Strategic in Pleasanton, Calif. “It helps ‘close the loop’ by working synergistically with lens selection and preoperative diagnostics. Together, these improve patient preference as well as patient outcomes.”

Others also consider femtosecond laser a part of the premium channel. Indeed, Stephen Slade, MD, of Slade & Baker Vision Center in Houston, says presbyopia-correcting IOL conversions in his own practice have increased dramatically, particularly in the 2½ years he has performed femtosecond laser cataract surgery.

Femto boosts premium IOLs

Dr. Slade is not alone. Indeed, the SM2 Strategic survey found that two thirds of laser cataract procedures in the first quarter this year involved premium IOLs. Further, 46% of 205 surgeons SM2 Strategic surveyed said the adoption of the femtosecond laser increased their premium IOL procedures. Forty five percent said femto made no difference, while 9% said premium IOL procedures declined with femto.

Use of premium IOLs may also get a boost by a somewhat favorable Medicare ruling last year. Specifically, the Centers for Medicare and Medicaid Services (CMS) released a guidance document that states the femtosecond laser for performing arcuate corneal incisions for astigmatism – with any IOL – is a non-covered refractive surgery that the surgeon can bill separately to the patient.

Femtosecond may have another positive influence on premium IOL procedures. “Cataract patients’ expectations are on the rise, as more patients around the world seek a visual outcome following cataract surgery that delivers the predictability and efficacy of a refractive procedure,” says Seba Leoni, vice president and global franchise head of cataract for Alcon, Fort Worth, Texas.

“In order to provide such refractive outcomes, we have to approach the procedure from a holistic standpoint. Ensuring that technologies employed during the procedure are working synergistically to reduce the sources of refractive error, thus increasing the overall precision, and, consequently, predictability of the procedure from beginning to end,” Mr. Leoni adds.

Penetrating patient perceptions

The continuum of innovation around refractive cataract offerings is essential to continued growth of the category, Mr. Leoni adds. “As we know, astigmatism or residual astigmatism after cataract surgery is one of the key factors that can negatively impact, for example, patients’ levels of satisfaction with multifocal outcomes. Therefore, the ability to treat both astigmatism and presbyopia at the time of cataract surgery is critical,” he says.

Likewise, effective lens position and IOL centration are key with multifocal and accommodating lenses. “Innovative cataract imaging technologies, such as the ones provided by femtosecond lasers, can ultimately have a big impact relative to patient outcomes and relative to physicians’ confidence in their ability to recommend these solutions to their patients,” Mr. Leoni says.

Another advantage of femto is the potential to heighten patient awareness. “The reason I like the idea of a femtosecond laser is the word ‘laser,’” Dr. Slade says.’ “Patients don’t get ‘accommodating,’ they don’t get ‘multifocal,’ they don’t get ‘presbyopia,’ ‘aspheric,’ any of that, but they will get the word ‘laser.’ Tying the premium IOL with the laser, I think, is the pathway.”

THE GLASS HALF FULL

Nonetheless, Richard Lindstrom, MD, of Minnesota Eye Consultants in the Twin Cities area, remains optimistic. “In the face of ‘the great recession,’ the lowest consumer confidence we’ve had in decades, and a lot of surgeon training to do and still some deficiencies in our ability to deliver the refractive outcomes that patients need, one could argue that 14% over five to seven years is pretty good,” he says.

Mr. Corley predicts that surgeons will achieve the original goal of 25% to 30% market penetration with premium IOLs as long as outcomes are satisfactory. “The promise when you have LASIK surgery is your eyes will get fixed, you walk out, and you can see fantastic,” he says. “If we could deliver the promise [with premium IOLs], what would the number be?” OM