As lens technologies advance, ophthalmologists have an even greater opportunity to provide excellent vision for cataract patients, including correcting for presbyopia. However, those advances come with out-of-pocket costs for patients that may make choosing a presbyopia-correcting intraocular lens (PC-IOL) a difficult decision.

Fortunately, you and your staff can help patients adopt premium lenses with techniques that include setting appropriate expectations and having all staff delivering a unified message. First, let’s look at the technical approach necessary to make PC-IOLs an attractive option.

TECHNOLOGY ADVANCES

Precise calculations required

Advances in lens technologies can help achieve higher conversion rates. During the past 25 years, lens technology has made doing these procedures easier “in the sense that our outcomes are better than they were years ago. Outcomes not so much in refractive outcomes as much as keeping and reducing negative visual effects to a minimum,” notes Sydney L. Tyson, MD, MPH, founder of Eye Associates & SurgiCenter of Vineland, N.J.

“The lens designs have just gotten better and better over the years that if done in a manner that tees it up for the surgeon, you shouldn’t have as many of those types of side effects for people,” he says. “Teeing it up” means that the surgeon’s calculations must be as accurate as possible, which entails using the right diagnostic equipment “to make sure that if you aim for a -.25 residual refractive error, that you get it postoperatively so the theoretical formulas match reality.”

It’s important that you are delivering — at least from a refractive standpoint — as perfect an outcome as you can get, Dr. Tyson adds, “because any little bit of refractive change or error can lead to dysphotopsias and negative visual effects,”

New IOLs can be game-changers

Innovations in IOL technology also help convert patients to premium lenses. One such advance, the Light Adjustable Lens (RxSight), is having a big impact on conversions for says David Rex Hamilton, MD, MS, FACS, founder and medical director, Hamilton Eye Institute, Beverly Hills, Calif. The lens is “already changing the game a lot for me,” he says.

For patients where he has concerns about satisfaction with nighttime vision, Dr. Hamilton will opt for the Light Adjustable Lens. “That is my go-to for patients who are very, very concerned about quality of vision and quite honestly those who want the best,” he says, as well as for patients who’ve had LASIK. “I don’t want to deal with a multifocal lens in somebody who’s had previous myopic LASIK.”

J. David Stephens, MD, cataract, glaucoma, cornea surgery, Tyson Eye, Fort Myers, Fla., uses the Light Adjustable Lens for patients who’ve had refractive surgery or those who have another issue that prevents them from getting a diffractive lens. He will also use it for those who want crisp 20/20 vision but want to avoid glare at all costs, such as airline pilots, he says.

UNDER-PROMISE AND OVER-DELIVER

Even with advanced lenses to implant, setting expectations properly is key to success — including at the beginning of the counseling process. “We never promise spectacle-free vision,” says Dr. Tyson. “That is the number one thing I would say to all the doctors who are starting a premium lens business, because we really do live by that code of under-promising and over-delivering.”

This entails careful expectation setting from the start, as well as informing patients of potential limitations of the lens “because there is no IOL design that is perfect yet,” notes Dr. Tyson. Setting the expectation properly, says Dr. Tyson, means that “overall, you should be much less spectacle dependent than you were prior to surgery.” That can improve adoption rates, notes Dr. Tyson, because patients understand the potential need for compromise.

Patients need to have a “clean eye” and “clean mind,” says Dr. Tyson. A “clean eye” means patients have no macular or corneal pathology, dry eyes are optimized, and that other conditions in the eye that could affect the outcome aren’t present. This helps ensure optimal PC-IOL performance.

“By clean mind, I mean patients whose expectations are not ridiculous. I use the term ‘ridiculous’ because some folks actually do have the conception that they’re going to see like they did as a 20-year-old,” says Dr. Tyson.

PATIENT CONCERNS

Dr. Stephens deals with similar challenges. “I would say the two most common things I hear are, ‘My friend paid a lot for that extra lens, but they still need glasses or they’re not happy,’ or, ‘My friend didn’t pay any money at all, and they don’t have to wear glasses for anything.’”

For the first issue, Dr. Stephens notes that “some people see 20/20 and can read the back of a pill bottle, and they still feel like they’re not super happy with their vision. Everyone has different levels of blur that they tolerate. My job is to tell the patient what the majority of people who get different types of lenses experience.” This can assuage patients’ concerns about a friend’s experience with premium IOLs, as well as help prevent patient dissatisfaction later.

For the second concern, “my answer is every eye is different,” Dr. Stephens explains. “A lens that works for somebody’s eyes may not be the same that gives the best outcome for you.”

A main worry that Dr. Hamilton hears involves patients experiencing nighttime dysphotopsias with a multifocal lens. Patients want to know how long those disturbances will last. He’ll quote FDA trials and note that typically one in 20 patients is significantly bothered at 6 months. For most patients, he notes, this helps alleviate their concern.

Using these techniques, they say, can help you achieve optimal outcomes with PC-IOLs — and that will grow your confidence in these lenses. Happy patients will tell friends and family about their positive experience, who may then arrive at your office interested in these premium lenses.

PINPOINT THE SOLUTION

Once a patient schedules a cataract surgery evaluation, Tal Raviv, MD, FACS, associate clinical professor of ophthalmology, New York Eye & Ear Infirmary of Mount Sinai, and founder and medical director, Eye Center of New York, says his office sends the patient educational information both by mail and digitally. Then, when the patient visits the office, the office will give the patient a questionnaire created by the practice. That questionnaire asks whether the patient would be interested in having their need for eyeglasses corrected at the same time as their cataracts. It also inventories their current use of eyeglasses or contact lenses.

“My starting point is, what are they doing right now, and what were they doing 5 years ago?” says Dr. Raviv. “Once you know that, it’s easier to match the technologies we have and to offer what would best suit them. I’m always very cognizant of not taking away unaided vision that they have without being fully aware that they understand they’re going to lose that. Ideally, I present them an option where they don’t have to give it up, such as the multifocal lens. I try to always leave what they have that they could do without glasses and try to add to it if we can.”

Similarly, patients referred to the practice by another doctor receive a cataract packet that goes through the basics of cataract surgery. After a workup, and understanding the patient’s history, Dr. Stephens will have in mind the lenses that might suit the patient.

In talking to the patient, Dr. Stephens says he likes to keep the discussion perhaps not simple, but straightforward. He will recommend the specific IOL he feels will achieve the patient’s best visual outcomes. “I try to stress the positives of what lenses they’re going to get. We do discuss the downsides or drawbacks, but I want to make sure that they hear about what they could get out of a lens,” Dr. Stephens explains.

In talking to patients, Dr. Hamilton relies on an online tool called Rendia (Rendia Inc.). The platform, he says, provides animations and simulations of IOLs that can help patients understand their options (Figure).

THE MONEY TALK

When it comes time to discuss financing a PC-IOL, physicians may struggle with talking about fees. “One of the bigger barriers even in beginning the use of these premium lenses for doctors is [feeling] guilt about asking for money,” says Dr. Tyson. “It’s hard for some physicians to wrap their minds around charging an out-of-pocket service for medical care,” agrees Dr. Stephens.

However, Dr. Tyson says you need not recoil at that idea. To help patients put the cost of a PC-IOL in context, he uses the example of a cruise.

“The analogy that I use is suppose this is an $8,000 procedure bilaterally. You can go on a 10-day cruise for $8,000, but when you get back it’s done. This $8,000 is for the rest of your life. The concept of amortization, of that cost over your lifetime, resonates with people.”

Dr. Tyson says that plastic surgeons and dentists discuss paying for services. “We’re just not used to it. Once you understand that you are offering a premium service, your labor, your effort, you have to value yourself properly.”

As to actually talking about the specific costs, Dr. Hamilton’s staff will have those discussions 90% of the time, he notes. He relies on his surgical coordinator for those conversations.

At Dr. Raviv’s practice, the information packet that patients receive includes a price list. He and his staff will get involved in explaining costs, he notes, informing the patient that modern cataract surgery can involve two costs: medical insurance and an elective option for the patient to pay to correct conditions such as astigmatism and presbyopia.

When patients ask about cost, Dr. Stephens will explain that some lenses are covered by insurance and some aren’t, but he will avoid getting into the specifics because he may not know what deductible a patient may have, for instance. He prefers to leave the exact numbers to the surgery counselor.

“I want to be going through a busy clinic and saying, ‘Are you willing to pay this amount of money for a premium lens?’” Dr. Stephens says. While cost won’t be an issue for some patients and other patients simply can’t afford it, “the majority of people are in that zone in the middle where they have to think about it. It gives them more time to consider so that we’re not rushing the decision,” he says.

Financing services may help patients afford lenses and increase adoptions. Dr. Stephens’s practice uses Alphaeon and CareCredit. These services help increase the practice’s adoption rate, he says, as patients often don’t have the funds up front for surgery but can afford payments over 1 or 2 years. Dr. Tyson uses CareCredit, which he finds enhances adoptions, with roughly 25% of his patients choosing a 2-year 0% interest option. Dr. Hamilton uses Alphaeon, and estimates that 10%-15% of his patients finance their payments. Dr. Raviv uses Alphaeon and CareCloud for patient financing. He also uses CoFi to allow one patient financing event to transparently pay the surgeon, the ASC and any co-managing doctor.

‘UNIFIED FRONT’

Increasing your PC-IOL adoption also means that all staff need to speak with one voice. “If you do enter this space, and you’re looking for better uptake from patients, everybody’s got to be on the same page,” says Dr. Tyson. To that end, he holds seminars for his entire staff, not just his schedulers. In those sessions, he emphasizes that when discussing lens options with patients, staff should refrain from hyping the technology and its ability to deliver spectacle-free vision.

“It’s helpful to have a unified front with the entire staff knowing what my preferences are and having seen outcomes with patients,” says Dr. Hamilton.

Dr. Stephens stresses the need for a good handoff of the patient to his surgery counselor. He’ll walk the patient himself to the counselor, explaining the patient’s history and saying what lens he recommends. “That kind of personal handoff is helpful for us so that the patient knows that person is on the same page.”

Opticians, Dr. Stephens notes, are some of their most effective counselors. “They know what people can expect with different types of lenses after cataract surgery,” he says. Additionally, opticians are accustomed to discussing costs with patients — and paying for products or services that deliver superior results. “What we run into sometimes are surgery counselors who have a hard time understanding the value of getting something better. Opticians are really good at explaining that to patients.”

A LARGER IMPACT

Dr. Hamilton estimates that 90%-95% of his patients opt for a premium lens. “I feel I do a patient a disservice when I put a monofocal lens in. I feel like I’ve relegated them for the rest of their life to dependence on glasses. And I don’t feel good about it. I think that mindset contributes to my success in converting.”

He also sees a larger impact for his patients. “It’s the gratification you get when you see this patient come in a year after surgery, and they look younger, they’re wearing hipper clothes. You’ve changed their life. It’s not just about the vision, it’s about psychologically what it’s doing for them.” OM