Soon after toric intraocular lenses came on the market, Lisa K. Feulner, MD, PhD, jumped at the opportunity to use them. “They give me the option to provide my patients spectacle-free outcomes after cataract surgery,” says Dr. Feulner, of Advanced Eye Care & Aesthetics in Bel Air, Md.

Dr. Feulner implants these lenses so regularly that when she presented at a regional Shire-sponsored event earlier this year on ocular surface disease, she was baffled to discover that no one in her audience used them. “I was completely shocked. I actually took a poll [of the small group] and asked, ‘How many people here are using advanced technology lenses?’ Not a single surgeon raised a hand.”

By talking to the physicians — largely younger ophthalmologists from small practices in northern Virginia — she discovered some felt that their community didn’t support the lenses from either an interest or financial perspective. “Their attitude was that people couldn’t afford it, that nobody really wanted it in their community,” Dr. Feulner recalls. “I think because none of them did it, there was no pressure or competition. They also had a fear of the outcomes, hearing that toric lenses can rotate, so they weren’t necessarily comfortable managing patients after surgery.”

ON THE CASE

Toric lenses represented just 7% of all IOL procedures performed nationwide in the first quarter of 2017, and just 9% of IOL procedures in the second quarter, according to Market Scope data, a figure that has actually risen by a percentage point since 2010. Cynthia Matossian, MD, FACS, founder and director of Matossian Eye Associates in suburban Philadelphia, has for sometime offered these IOLs to her patients. She was curious to find out why the percentage of use remained so low. In talking informally to knowledgeable colleagues and industry representatives, this is what she found:

• Some physicians feel that by discussing toric implants, which have an associated out-of-pocket price, they’re trying to sell something, which makes them uncomfortable. “My view is completely different,” Dr. Matossian notes. “It’s not selling at all. It’s making this wonderful option available to patients. You’re just discussing the options.” Some physicians who do offer the implants have hired surgical coordinators or other professionals to discuss charges and payment plans with potential patients, relieving the doctor of possible discomfort.
• Some ophthalmologists are uncomfortable making a specific recommendation for a toric IOL, so they tell patients about every possible option — including multifocal torics, extended depth of focus torics, monofocal torics, accommodative torics, limbal relaxing incisions and femtosecond astigmatism correction — and let the patients choose for themselves. Patients then get confused, Dr. Matossian says, because too many options are presented. When they get overwhelmed, they tend to pick the safest option: buy a monofocal lens with no astigmatism correction. An industry executive told her some patients become angry with surgeons for placing the decision-making burden on them. “They feel they’re paying the surgeon for his or her expertise, and part of that is a clear, strong recommendation.”
• Some surgeons were uncomfortable with the prospect of managing these patients after surgery. The fact that they had paid out-of-pocket for a premium lens might result in their being more demanding — a daunting and time-consuming scenario for the surgeon.
• Some doctors may not take the time to get to know their patients’ concerns and lifestyles, or they assume that because a patient has worn glasses since elementary school that staying with glasses is a good option for them. As a result, she says, they may not even offer these implants to their patients. “They are almost condemning patients to living the rest of their lives in glasses, when there was an excellent opportunity for them to become less dependent on corrective eyewear,” Dr. Matossian says. “It’s not tailoring the IOL to the patient’s lifestyle. Maybe the patient skis and doesn’t want to have foggy glasses under their ski goggles.”

THE FEE FACTOR

Another potential barrier to toric IOL adoption may come down to investing in technology, adds Kendall E. Donaldson, MD, MS, an associate professor of ophthalmology at the Bascom Palmer Eye Institute in Miami and chair of the refractive subcommittee at the ASCRS. In annual ASCRS surveys, she says, the top two barriers to using femtosecond technology and premium lenses consistently are cost and a demand for proof that a new technology is better than existing options.

“You really have to have all the right technology to put these lenses in accurately,” says Dr. Donaldson, which is “essential for these patients. We’re charging them extra money so that’s raising their expectations, and in order to meet those expectations we must have the technology to make us successful.” This can include a topographer, keratometer and advanced biometer as well as intraoperative equipment like an aberrometry system and/or guidance system to help align the lenses during implantation.

In addition, she says, ophthalmologists and their staffs must be committed to making the technology work: “It takes longer to work with premium patients, so they have the potential to reduce the clinic’s efficiency. Everyone in the office needs to be on board to be able to represent and promote this technology effectively to patients.” Her preoperative evaluations can involve 20 to 30 minutes of chair time for discussion of the various lens options and final recommendations. Procedures themselves can last an additional seven minutes or so, allowing time for the femtosecond laser portion and intraoperative aberrometry to properly align the lenses. Postoperatively, more time may be needed if patients require an enhancement with PRK or LASIK. “The more they pay, the tougher it is to please the patient,” says Dr. Donaldson. “You have to work harder all the way through — from the preoperative evaluation through the surgery and postoperative course.”

A PREFERENCE FOR KEEPING IT SIMPLE

Still other practitioners may not be set up to handle mixed billing, says Salman Ali, MD, who began offering toric IOLs several months ago at his Linthicum Heights, Md., practice. But before starting his practice a couple of years ago, he was at an academic center whose billing department was not accustomed to premium patients. The way most hospitals are set up, he says, all billing goes through insurance. Patients who pay cash typically are uninsured. “Part of the surgery is covered and part isn’t. There’s that aspect of trying to figure out how that will work with billing that’s very different from your traditional cataract surgery.” Most hospitals and institutions also have a cumbersome process to bring in new technology or devices, he adds. The academic center where Dr. Ali had worked has since added toric IOLs to its offerings for cataract patients.

Ophthalmologists looking to add premium lenses have a lot of available support, say Drs. Donaldson, Feulner and Matossian, between trainings by company representatives and key opinion leaders, networking with colleagues and available videos. Some ophthalmologists “May not understand that you get a return on investment once you purchase equipment, but it’s a risk to take that first step,” Dr. Feulner says. By buying equipment one piece at a time with a planned integration blueprint, adds Dr. Matossian, “surgeons will be able to get all the tools they need to pretreat the ocular surface and measure for accurate toric implantation.” OM

Dr. Donaldson is a consultant/speaker for Alcon, Johnson & Johnson Vision, Bausch + Lomb, Omeros, Sun Pharma and Shire. Dr. Matossian is a consultant/speaker for J&J Vision, Bausch + Lomb and Alcon. No other relevant financial conflicts of interest were reported.