CATARACT / IOL

Presbyopia-correcting IOLs will pique patients’ interest

Technical refinement, patient education key to best serve these patients.

Crystalens (eyeonics, Aliso
Viejo, Calif.)


ReZoom (Advanced Medical
Optics, Santa Ana, Calif.)
Source: Jason Stahl, M.D


AcrySof ReSTOR (Alcon,
Fort Worth, Texas)
Source: Jason Stahl, M.D

Physicians should allot more time for patient education and technical procedures in light of a new ruling by the Centers for Medicare and Medicaid Services (CMS), which now allows Medicare patients access to presbyopia-correcting high technology IOLs following cataract surgery.
Practices that center primarily on cataract surgery will have the greatest learning curves under the ruling, physicians said.
Instead of routine procedures that many high-volume cataract practices experience, staff members will need to carefully explain surgical options, align patient expectations, and perform enhancements when necessary, said Jack L. Weiss, M.D., Gordon Binder Weiss Vision Institute, San Diego.
That may be a positive in light of the increasing connections between cataract and refractive surgery through procedures such as refractive lens exchange, said Dr. Weiss.
“More and more, cataract and refractive surgery is like a marriage,” said Dr. Weiss. “There’s not a huge difference between them.”

Who will want these IOLs?

Expect patients with demographics that closely resemble your refractive patients to express the most interest in presbyopia-correcting IOLs.
“They’ll be highly educated, more affluent, and active,” said Richard L. Lindstrom, M.D., Minnesota Eye Consultants, Minneapolis. “It won’t be the 93-year-old patient with macular degeneration. It’ll be the 68-year-old who plays golf and tennis, and goes to the country club and out to dinner.”
“These patients want to control how they age,” said Y. Ralph Chu, M.D., Chu Vision Institute, Edina, Minn.
About 20% of Medicare cataract patients will opt for presbyopia-correcting IOLs, Dr. Lindstrom predicted. In addition, non-Medicare patients will increasingly opt for these lenses, he said.
Practices that work mainly with HMOs may not see as much interest as those that work mainly with Medicare and private insurance, said Dr. Weiss.
Mark Packer, M.D., Drs. Fine, Hoffman & Packer, Eugene, Ore., predicted that 10% to 15% of Medicare patients will choose these specialized IOLs.
“Some will balk at the price,” said Dr. Packer, which is an $895 charge from some companies versus $150 for a standard IOL, not to mention other related charges.
Other patients will not be interested because of possible side effects, such as halos or glare. Still, these IOLs have already piqued some interest.

Technique

Although inserting presbyopia-correcting IOLs isn’t all that different from standard IOL insertion, some refractive surgeons may need to fine tune their skills.
“If a refractive surgeon isn’t doing intraocular surgery, he or she may have to relearn the technique,” said Dr. Chu.
Biometry measurement and astigmatism management are two areas that will help surgeons better use these IOLs, said Dr. Lindstrom.
Surgeons and technicians can become well versed in biometry measurements techniques with immersion ultrasound and use of partial coherence interferometry with the IOLMaster (Carl Zeiss Meditec, Dublin, Calif.), said Dr. Packer.
As for refractive lens exchange itself, incision construction, fluid management, and safety are important, said Dr. Packer. For instance, some of these IOLs can only be inserted in an intact capsular bag.
“The last thing you want in refractive lens exchange is a broken capsule. You then have a situation in which the product cannot be implanted,” said Dr. Packer. “Then you have not only a complication but also a dissatisfied patient.”
As part of informed consent, members of Dr. Packer’s practice discuss the possibility of a broken capsule pre-operatively. In case a broken capsule were to occur during surgery, they ask patients pre-operatively to select a multifocal or standard IOL for insertion as an alternative to an accomodative IOL.

More time

Surgeons that mainly perform cataract surgery, should prepare to spend more time — perhaps 20 minutes or more per patient — on educating patients that qualify for presbyopia-correcting IOLs.
“It’s incumbent upon us to advise all patients of this opportunity,” said Dr. Lindstrom. Even if you don’t personally like the lenses, patients should still know their options, he said.
That doesn’t mean physicians will have to carve out several hours more a day. More involvement from your technicians and surgery counselors and the use of educational aids will help whittle surgeons’ time.
So, for example, the surgeon may introduce surgical options and describe the basics, while a surgery counselor or video provides surgery details and pricing information.
“For a refractive surgeon, it’s not that hard of a transition,” said Dr. Weiss. Refractive practices are already accustomed to extensive patient education, he said.
The companies that make these IOLs will have training tools for patients and staff, said Dr. Lindstrom.
Prepare patients with realistic expectations, said Drs. Lindstrom and Weiss.
Patients should also know pre-operatively about the tradeoff with presbyopia-correcting IOL insertion, Dr. Weiss said.
For example, if patients were told beforehand that they may experience glare or halos, it won’t shock them when it occurs. Patients should also know that one in four or five cases may still need to use glasses, said Dr. Packer.
“Ninety-nine percent are happy if their expectations [are in line]. It’s hard to find time pre-operatively but if you don’t, you’ll be buried on the other end,” said Dr. Weiss.
In a similar vein, technicians must come up to speed on what the new technology offers. Training seminars and videos of surgery will help prepare them, said Dr. Chu.

Editors’ note: Dr. Chu has a financial interest in Advanced Medical Optics (Santa Ana, Calif.). Dr. Lindstrom is a consultant for Bausch & Lomb, AMO, and TLC Vision (Chicago). Drs. Packer and Weiss have no financial interests related to their commnents. Dr. Packer is a consultant for AMO, Bausch & Lomb, and Carl Zeiss Meditec.

Contact Information
Chu: 952-835-0965, yrchu@chuvision.com
Lindstrom: 612-813-3633, rllindstrom@mneye.com
Packer: 541-687-2110, mpacker@finemd.com
Weiss: 658-455-9972, garrett23@aol.com