Setting the Stage

Article By Stephen G. Slade, MD

Medical practitioners, and ophthalmologists in particular, always keep an eye toward the future (pun intended), constantly devising and evaluating innovations that may better serve our patients’ needs. Although corneal refractive surgery received much of the attention in the late 1990s and early 2000s, the focus has been shifting in recent years back to the cataract market with the advent of refractive and presbyopia-correcting IOLs. Cataract surgery is an enormous industry. Each year in the United States, more than 3,000,000 cataract surgeries are performed translating to a billion dollar market for industry alone. Medicare still holds about two-thirds of the patients, although that percentage may shift as the nation adopts new healthcare laws.

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The baby boomer population is entering the cataract age, and these individuals will be candidates for cataract and presbyopic treatments for years to come. In fact, it is likely that ophthalmic residents who are earning their medical licenses now will be treating baby boomers for the rest of their careers. Are we ready for them? Although cataract patients are becoming more like their refractive counterparts in terms of demanding excellent visual quality and spectacle independence, data adapted from the latest FDA trials for the Crystalens AO IOL (Bausch + Lomb, Rochester, NY) and the WaveLight Allegretto Wave excimer laser (Alcon Laboratories, Inc., Fort Worth, TX) show that cataract surgery does not give patients the same quality of uncorrected visual acuity as LASIK (Figure 1 [slide 7]). Yet, many baby boomers have already had LASIK surgery and expect that they will be able to see prefectly without spectacles after cataract surgery as well. Can we meet this expectation? We need to prepare ourselves for the coming boon and set the stage for meeting these patients’ demands, or else we risk disappointing our patients.

Currently, only 20% of the more than 8,000 eye surgeons in the United States consider themselves cataract and refractive surgeons, and approximately 6,000 U.S. surgeons say they only perform cataract surgery. Any ophthalmologists implanting presbyopia-correcting IOLs such as the Crystalens Accommodating IOL should consider themselves a refractive-cataract surgeon and need to organize their practices as such. For those practitioners who have not yet adopted these lenses, it is wise to do so in this changing healthcare climate. For surgeons in both camps, this monograph presents data, surgical techniques, and patient-management strategies regarding the use of the Crystalens AO IOL based on years of clinical experience. Hopefully, the information is valuable no matter what type of practice you have.

LASIK Orange County – Harvard Eye Associates in Orange County, California specializes in LASIK laser vision correction.

Article by Dr. Stephen Slade

This month we are looking at premium IOLs, not so much the technology or surgery but their actual practical implementation. Our articles cover conversion rates, how to incorporate these lenses into your practice, understanding the patient and pearls for success.

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And this is a most important topic. By the year 2020, the number of people in the US over 65 years old will double. These are the Baby Boomers and no other demographic group is larger. Medicare will likely be maxed out and is on track to pay only about 150 dollars for a cataract with a standard IOL. If you are a resident today or just starting practice, this premium IOL market will likely be what supports you and your family. It will be my fourth wave.

When I was a resident the great wave of patients was phacoemulsification. Phaco built practices, both large and small. Then came RK, followed by LASIK. Both became the main, if not the only, procedure many surgeons did. Now premium IOLs are poised to become the main surgery that many of us do.

Yet today, only 6.4% of all IOLs implanted in the US are premium IOLs. (1) In my own practice, we are at 64%. I believe I should be at 85%! I know every practice is unique, mine is smaller than some yet we are extremely focused on refractive surgery. I believe premium IOL surgery is refractive much more than cataract surgery. It is done on “healthy” eyes, patients are paying for it out of pocket and they expect perfect vision right away. Bingo, refractive surgery!

What are the hurdles? The lenses are excellent, and improving all the time.  Today they are far superior to a standard monofocal. The Crystalens, with the latest HD modified central optic, has recently attained 51% share of the US market. The new Restor +3 and the Technis Multifocal have excellent early reviews as well. Money is a factor but most patients realize the price is actually discounted by their insurance and that this is a one time only opportunity to pay for better, more useful vision. I believe the main reason for the low conversion rate is our own comfort and confidence with the surgery. Many pure cataract surgeons do not deal with astigmatism, and which really is better, laser or blade? We are not geared to counsel cataract patients as refractive patients. We don’t tell patients their options. A new survey on patients implanted with monofocals revealed 81% would have chosen a self-pay premium lens if given the choice. Indeed, according to a recent survey, most patients are not even told about premium IOLs! We fear a surgical complication. The best answer to this is better technology such as a femtosecond laser that does the incisions, relaxing incisions, capsulorhexis, nucleus, etc. The idea is to make cataract surgery more like a YAG. We need more to be focused information on all the above, astigmatism, refractive outcomes, patient counseling and technique.

Premium IOLs are my fourth wave, it’s only a question of when. This timing is largely under our control because it remains a question of value. Patients will choose a real benefit, a true value and this fits that description. When or where else can you purchase something that you will help you see every waking moment of every day for the rest of your life?

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