Earlier this year, the Outpatient Ophthalmic Surgery Society (OOSS) performed a survey about the use of standard and premium IOLs in the ASC setting. OOSS heard from 146 respondents — surgeons (42%), managers/administrators (32%), directors of nursing (13%), and others (13%) — about which IOLs are used in their ASCs and how they’re chosen. The answers reveal some current trends and may offer a hint at the future of refractive cataract surgery.

Standard vs. Premium IOLs

According to the survey results, the highest-volume procedures in the respondents’ ASCs are cataract removal/IOL implantation, glaucoma procedures, and YAG laser capsulotomy. Diving deeper into cataract practices, the survey showed that monofocal lenses are by far the most commonly used IOL at roughly 75% of cases, followed by toric, multifocal, extended depth of focus, and accommodating lenses (Figure 1).

In the past 12 months, most respondents say that their ASCs are using more toric and multi-focal lenses, while the use of accommodating lenses has remained the same in most facilities (Figure 2).

Jay Pepose, MD, PhD, medical director of the Pepose Vision Institute in St. Louis, was pleasantly surprised to see the proportion of toric lenses used by ASCs in this survey (11.8%), as well as the indication that the number is increasing. He says the trend for these lenses indicates a broader move toward premium IOLs.

“Most surgeons who are dipping a toe in refractive cataract surgery start with torics, which have fewer potential visual side effects than multifocals. The percentage of toric lenses, which is much higher than I’ve seen in the past, is a positive sign that surgeons are realizing that cataract and refractive surgery are merging and have evolved with the technology,” Dr. Pepose explains. “However, this number still represents only about half the patients who qualify for toric lenses, which may mean patients are underserved, or perhaps they simply choose to continue wearing eyeglasses without added expense.”

“Shocked” to see that respondents used accommodating lenses in less than 2% of cases, Dr. Pepose wondered if the number could be off based on the survey’s sample, or if the number might be an accurate reflection of changes wrought by new multifocal IOLs. “It might be a sign that new advances in multifocal lenses have made them a preferred choice over accommodating lenses. There are new low-add multifocals and multifocal torics that simultaneously correct astigmatism and design enhancements in spherical aberrations. With more predictable outcomes, less haloing, and better quality vision, surgeons can use multifocal lenses more confidently today than they did in the past.”

Dr. Pepose says the percentage of extended depth of focus IOLs (3.46%) is both high and promising, considering the lens is a new player in the market, having been released in 2016.

The IOL Decision

Surgeons consider many different factors when selecting the best IOLs for their patients. To learn more about this decision process, the OOSS survey included questions about how surgeons weigh both tangible and intangible characteristics of various lenses.

Asked what factors were the most important drivers of choosing a monofocal lens, responders pointed to cost first, followed by availability, and familiarity. When choosing a premium IOL, they considered “providing the newest technology” to be most important, followed by familiarity, and availability (Figure 3). Other factors rated lower by respondents included customer service from manufacturer/distributor, ease of loading/insertion, and incision size.

For toric IOLs specifically, the survey showed that rotational stability was most important, followed by availability in a range of parameters, familiarity with the product, providing the newest technology, and cost to ASC/patient.

Naturally, cost is a concern for monofocal lenses, because the cost comes out of the facility fee, whereas patients pay for a premium IOL. William J. Fishkind, MD, FACS, of Fishkind, Bakewell, Maltzman & Hunter Eye Care and Surgery Center in Tucson, AZ, looks at monofocal costs a bit differently.

“I’m an idealist. I’d rather make less money and have more happy patients than increase my margins and deal with unhappy patients. If a lens produces better outcomes and costs a little more, I absorb the cost. However, I take the opportunity to explain to the patient that the lenses cost more, but the outcomes will be worth the cost. Patients accept that. I also pursue negotiations with the IOL manufacturer to lower the purchase price of the IOL, if possible.”

Familiarity — a top-three consideration for monofocals, torics, and all premium IOLs — is an understandable desire for surgeons, says Dr. Fishkind, one that grows through surgeons’ well-worn pattern of technology adoption.

“To become familiar with a lens, somewhere along the line, we have to step outside our comfort zone,” says Dr. Fishkind. “We start by talking with colleagues who are early adopters or have used a lens outside the U.S. They offer insights into the procedure, techniques, outcomes, best candidates, and tips about patient satisfaction. Next, we find likely candidates (generally, people who have a relaxed attitude). We implant the IOL in five or 10 patients and watch the outcomes. If there are any roadblocks, our expert is there for advice. When we feel comfortable with the outcomes, we start implanting the lens on a regular basis.”

Asked to rate the importance of monofocal features, respondents rated small incision size most important, followed by glistening-free optics, and limited susceptibility to posterior capsular opacification. Pre-loading and yellow chromophore platform features were considered less important.

Options for Presbyopia and Astigmatism

With a range of presbyopia-correcting IOLs from which to choose, it seems that surgeons are taking full advantage of their options. Which IOL designs are they likely or very likely to use to correct presbyopia? The answers were multifocals for 85% of respondents, compared with 68.46% for extended depth of focus IOLs, 50% for extended depth of focus monofocal in a mini-monovision setting, and 31.30% for accommodating IOLs.

The question of astigmatism correction is more complex, as surgical options extend well beyond IOLs. Surveyors covered all corrective surgical options to obtain a complete picture.

Survey respondents were asked to share their treatment choices at their ASCs based on the amount of preoperative corneal astigmatism. With astigmatism greater than 1.5D, the overwhelming choice was toric IOL. Between 1.25D and 1.5D, 77 respondents said toric IOLs, while 31 said femtosecond limbal relaxing incisions (LRIs). Between 0.75D and 1.25D, femtosecond LRIs ranked highest, followed by manual LRIs and toric IOLs (Figure 4). If patients met the criteria for IOL with astigmatic correction, respondents slightly favored manual over femtosecond LRIs.

Dr. Fishkind isn’t surprised to see such enthusiasm for toric IOLs, because he shares it.

“What has happened with premium IOLs is that astigmatism correction has steadily improved in both quality and indications over the past 5 years,” he says. “We can correct higher levels of astigmatism. Surgeons have become more confident in implanting toric IOLs and getting them in the target axis. As a result, we are finding that the reliability of toric IOLs is very high. We enjoy using them and feel more open and optimistic about the lenses than we did in the past. Patients pick up on our attitude and select torics as an option.”

Dr. Pepose says the respondents’ use of LRIs makes equal sense, given some inherent limitations of toric IOLs. “Right now, our only options for toric lenses in the U.S. are effective in treating astigmatism above 1.25D, and we have a great deal of confidence in their efficacy for this purpose. If the astigmatism is 1.0D or lower, the patient won’t show significant improvement with a toric IOL, but LRIs can titrate it lower.”

Patient Education and Costs

A discussion of standard and premium IOLs always involves technological advances, clinical outcomes, and the business side of using a device with a significant out-of-pocket cost. OOSS didn’t neglect that third pillar in its survey, which asked how practices introduce patients to premium IOLs and arrange for payment.

Of 146 respondents, 95 said that their ASC routinely introduces patients to all applicable premium IOLs, while 44 said they introduce patients to premium products selectively. Employees at just three ASCs said they introduce only reimbursable products to their patients.

Dr. Pepose strongly aligns with the majority in this matter.

“If we don’t offer a premium lens and a patient finds out that a neighbor no longer has to wear glasses after cataract surgery, that patient will not be happy. Patients may come back and ask why they weren’t fully informed of their options, which is certainly an uncomfortable conversation. They will definitely complain to friends. When we talk to patients about surgery, part of informed consent is explaining the options. I recommend a lens and give the reasons, and patients make the decision. Most often, they choose the lens I recommend.”

Asked about tiered pricing, only 12 respondents said that their ASC does not use this approach. Some 60 respondents use three IOL packages, 24 use four, and 30 use two.

Dr. Fishkind says packages help him and his staff explain premium IOL costs to patients; keeping the number of packages low is part of their strategy.

“We have three IOL packages: monofocal, toric, and multifocal (including multifocal, extended depth of focus, and accommodating lenses). We also have a separate astigmatism package, because we can surgically correct lower amounts of astigmatism less expensively. We’ve tried to minimize the number of different packages based on the cost and the changes in surgical demands created by each category.”

Adds Dr. Pepose, “The patient discussions about premium IOLs and costs are part of a mindset that the whole practice needs to adopt. The entire staff needs to understand the value of what we’re presenting. Rather than feel uncomfortable asking a patient for $2,000, the staff needs to feel proud to give patients improved care. We’re not only removing the cataract, but also giving people freedom from eyeglasses for near and distant vision.”

Dr. Pepose’s Clinical Cataract Coordinator Sarah L. Fritz says it all boils down to patient education. “Patient education is the most important part. If they have expectations, we have to explain how the procedure will accomplish their goals. We answer all of our patients’ questions and make sure that they understand their options completely. About 90% of Dr. Pepose’s patients choose premium IOLs. They have to decide the financial side, but I can tell you, we don’t have any buyer’s remorse.”

Clues for the Future

Granted, a survey of 146 ASC physicians and staff can’t tell us what broad changes are moving the world of standard and premium IOLs. But according to Drs. Pepose and Fishkind, it does offer some clues.

Dr. Pepose says that a change is afoot, and patients will be the ultimate beneficiaries. “The entry of extended depth of focus lenses seems to have shaken up the equation. Maybe for that reason, more surgeons have been driven into performing refractive cataract surgery. We see in the survey that surgeons are using more toric lenses, a first step that may lead them to other premium IOLs.”

Dr. Fishkind agrees that the rate of premium IOL use appears to be increasing, and extended depth of focus lenses will help raise it even higher.

“I think we’ll see multifocal IOLs used in 10% to 15% of cases in the next year, possibly growing to 20% the following year because of the introduction of the Tecnis Symfony IOL (Johnson & Johnson Vision). It makes extended depth of focus more acceptable and increases indications so more patients can get them,” notes Dr. Fishkind, who says the lenses are changing his practice. “Patients are happy with the quality of vision, the extended depth of focus, and the freedom from spectacle correction. Surgeons are happier recommending them because they work better. When doctors are sold on a technology, that confidence comes through, patients get a more positive impression, and are more likely to choose it.” ■