December 2019


“Patient Out-of-Pocket Expenses for Premium Cataract Surgery: Today’s Best Practices and Lessons Learned”

George Waring IV, MD


At the 2019 ASCRS ASOA Annual Meeting in San Diego, the Refractive Surgery Clinical Committee hosted a roundtable. The roundtable was chaired by John Vukich, MD, and Vance Thompson, MD. They were joined by Daniel Chang, MD, Eric Donnenfeld, MD, Kerry Solomon, MD, Robert Maloney, MD, George Waring IV, MD, and William Wiley, MD. What follows are highlights from a transcript, edited for length, from the final part of the discussion, with the first two appearing in the September and November issues.

Dr. Vukich: In a recent ASCRS survey, we learned up to 40% of cataract surgeries are done with a mini-mono or a monovision strategy using single-vision lenses. How do you handle that within your practice, knowing that it’s a form of premium expectation, if not a premium lens?

Dr. Donnenfeld: We offer monovision but I don’t do a lot of monovision any longer. I feel the quality of vision and the quality of life is tremendously better with a presbyopia-correcting IOL. There are significant risks with monovision once you get over a half a diopter—patients lose stereopsis. I make it clear to all my patients who want monovision, specifically if they have used it in the past, that I expect them to wear glasses when they drive because it doesn’t make sense to me to give patients suboptimal vision for driving, particularly at night. There is a lot of information about patients with monovision losing stopping speed and distance recognition. Finally, I’ll mention that the monovision patients are accustomed to their vision with the crystalline lens. It’s augmented by the higher order aberrations and the residual accommodation that’s there, so a diopter of monovision with a cataract often needs to be replicated with 2 D of monovision with a pseudophakic IOL.

Dr. Thompson: We do monovision. We do EDOF and multifocality more than all of them, but we still offer monovision, especially for people worried about reduced contrast sensitivity and don’t mind wearing a pair of glasses. I tell them when you want best both eyes distance, you wear reading glasses. and when you want monovision, you may wear glasses some of the time. For instance, with monovision, when you want both eyes great at distance or near you wear glasses; the key is with quality monovision you are not dependent on glasses. If they’re OK with that, then pseudophakic monovision is a great choice. We do need to remember though that we are removing cataracts at younger ages and there is often loss of accommodation. Pseudophakic monovision is different and more of a dramatic change for a 50 year old to adjust to compared to a 70 year old and they need to understand that in the informed consent.

Dr. Vukich: I will follow up with the question: Is it imminent that adjustable lenses will be available in the U.S. market as a premium procedure? It will be positioned as a refractive fine-tuning of the end result. Do we see that as a solution for monovision patients, knowing that you can achieve a predictable end result for their distance and can fine tune the near?

Dr. Waring: There is a lot of excitement around postoperative lens adjustability, not only in the monovision circumstance, which is a massive portion of our population. We’ve got FDA approval for adjustability and we’ve got upstream technologies that may allow us to do multiple treatments to truly customize and try, and then fine tune and adapt all the way through. The future is bright, if this ends up working like we hope it does.

Dr. Solomon: I do a lot of monovision. I think for those practitioners who are optimizing their outcomes and getting good results with monofocal lenses, I think they can get a very good result with monovision, whether they’re treating astigmatism or not. For those folks who are struggling, or don’t optimize, or are just interested in some of the new things like Light Adjustable Lenses (RxSight), I think that’s great, but I don’t think we need to wait for Light Adjustable Lenses to add monovison to our practices.

Dr. Vukich: How do you enhance your patients’ vision when they have a refractive error that is close but not exactly what they need for optimal vision? What methods do you use and how do you approach them?

Dr. Chang: The first thing I do is to make sure that the enhancement will help. If it’s not obvious that correcting the small refractive error will make the patient happy, I’ll first have them try out the prescription in glasses or contact lenses to see if they like the improvement. If I’m pretty sure that the correction of their residual refractive error will make them happy, then I offer them laser vision correction with PRK. I like to take my time and wait for stability—ideally at least 3 months unless there is a significant refractive error. If the patient is very unhappy I offer it to them earlier. Either way, I make it clear that I am happy to continue working with them until they are happy. In general, none of us enjoy doing enhancements, but I make it a point to the patient that I am on their side and am willing to do whatever it (reasonably) takes to get them the great outcome they deserve.

Dr. Donnenfeld Performing enhancements is vital. I do many more limbal relaxing incisions than I do laser vision correction because as long as the spherical equivalent is close to plano, a limbal relaxing incision is very simple procedure to perform and well-tolerated by patients. Once I get up to over a diopter of cylinder, I’ll go to laser vision correction for astigmatism. For spherical equivalent problems, then you do an IOL exchange, piggyback lens, or you can do an excimer laser photoablation. I feel I’m best with a laser vision correction. I do LASIK on these patients very commonly unless I see loose epithelium. In general, I aim to do laser vision correction for residual myopic spherical equivalent, but when I have a hyperopic residual refractive error, I will go to an IOL exchange or a piggyback lens, because I feel that a hyperopic correction requires a larger flap and is not as forgiving as a myopic treatment.

Dr. Thompson: We have been investigators in the Light Adjustable Lens clinical trial and have been doing it commercially for 6 months. It is amazing how precision monovision through adjusting the optic at 3 weeks postop is so powerful…and the patients love it. I do believe we will see growth in monovision because of light adjustable implant technology. In general I have found it more appealing to patients to have their optic adusted postoperatively versus their cornea, though both have a place in premium cataract surgery.

Dr. Vukich: One thing that we’ve incorporated into our practice is emphasizing that the first refractive surface—the tear film—isn’t the culprit. You can have a small refractive error, but often it’s the quality of vision that is affected by the ocular health and the tear film.

Dr. Waring: This wonderful conversation is around a premium procedure, but you have to have a premium eye to have success in the premium procedure. Whether that’s biometric—there is great peer-reviewed data to support the biometry accuracy if you do not have a dry eye. It’s not a stretch to think that patients are going to have a better healing process if they are optimized and they’re going to see better. We’ve actually objectively demonstrated in our center that you have less fluctuation and better retinal image quality; it’s worse if you’re dry. But we got fancy fixing their cataract but we’re leaving them with poor retinal image quality with dry eyes, so that just doesn’t make sense.

Dr. Thompson: I agree 100%. We need to remember the most powerful focusing element of the eye is the air/tear interface. And if the tear is breaking up there is light scatter and thus reduced image quality. Whether they are having a premium procedure or not we need to make sure the optical properties of the tear film are pristine. The companies have blessed us with amazing EDOF, multifocal, and light adjusting optics but those optics degrade quickly if there is light scatter occurring at the air/tear interface.

About the doctors

Daniel Chang, MD
Empire Eye and Laser Center
Bakersfield, California

Eric Donnenfeld, MD
Ophthalmic Consultants of Long Island
Garden City, New York

Robert Maloney, MD
Maloney-Shamie Vision Institute
Los Angeles

Kerry Solomon, MD
Carolina EyeCare Physicians
Mount Pleasant, South Carolina

Vance Thompson, MD
Vance Thompson Vision
Sioux Falls, South Dakota

John Vukich, MD
SSM Dean Clinic
Madison, Wisconsin

George Waring IV, MD
Waring Vision Institute
Charleston, South Carolina

William Wiley, MD
Cleveland Eye Clinic
Brecksville, Ohio

Relevant financial interests

Chang: None
Donnenfeld: Alcon, Johnson & Johnson Vision
Maloney: Johnson & Johnson Vision
Solomon: Alcon, Allergan, Bausch + Lomb, Johnson & Johnson Vision, Carl Zeiss Meditec
Thompson: Alcon, Bausch + Lomb, Johnson & Johnson, RxSight
Vukich: Johnson & Johnson Vision, Carl Zeiss Meditec
Waring: None
Wiley: None

Contact information


“Patient Out-of-Pocket Expenses for Premium Cataract Surgery: Today’s Best Practices and Lessons Learned” “Patient Out-of-Pocket Expenses for Premium Cataract Surgery: Today’s Best Practices and Lessons
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