March 20, 2023
12 min read
Hovanesian reports consulting for AcuFocus, Alcon, Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson and RxSight and having a financial interest in MDbackline. Shamie reports consulting for Alcon, Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson and RxSight. Talley Rostov reports consulting for Alcon, Bausch + Lomb and Johnson & Johnson. Yoo reports consulting for Carl Zeiss Meditec.
A premium cataract surgery experience is much more than just choosing a lens. It is a personalized patient journey in which excellence is infused in every step, from first contact through to surgery and aftercare.
“The premium IOL experience is multifaceted. It has to do with matching the patient’s needs with the best IOL technology available, with how we remove the cataract using straight ultrasound or femtosecond laser, and with the use of any additional intraoperative technology such as aberrometry or IOL-alignment systems,” OSN Refractive Surgery Board Member Sonia H. Yoo, MD, said.
It also involves quality and efficiency of service: keeping wait times as short as possible, streamlining the visit and making time for a comprehensive conversation.
“But, above all, you as a surgeon have to believe that this is the best thing to do for your patient,” OSN Cataract Surgery Board Member Audrey R. Talley Rostov, MD, said. “I think that the reason why I have such a high percentage of premium cataract patients is because I truly believe it is the best value ever, and this engenders trust in the patient. It is essential that everyone in the practice understands and communicates the value proposition of premium cataract surgery because success in a premium practice is surgeon-driven and team-driven.”
In addition, a premium experience involves every aspect of postoperative care, including postoperative enhancements should they be required.
“Every premium practice should be able to address any unresolved refractive error with every available technique and to exchange the lens if necessary,” Talley Rostov said.
Every patient may be a premium IOL patient
“All patients should be considered as premium care patients in that they at least deserve to have a discussion on the different types of lens options,” Yoo said.
Today’s technological advances in cataract surgery make it possible to meet most expectations for spectacle-free vision at all distances, but it is also important “not to trivialize the surgery and to make sure that the patient is well informed,” she said.
Difficult cases that would have been excluded in the past may now be eligible for a premium implant, according to Talley Rostov.
“Previous surgeries like RK or corneal transplantation or conditions such as keratoconus are no longer a contraindication for advanced-technology IOLs,” she said. “There are options suitable for anybody who wants to optimize their vision to the extent that it can be optimized, given any limitations of their eyes. About 70% of my patients get some sort of premium channel IOL.”
A survey carried out by OSN Associate Medical Editor John A. Hovanesian, MD, FACS, through MDbackline revealed that the number of people interested in advanced-technology lens implants has grown exponentially in recent years. As many as 83% of the 3,500 respondents were at least interested to know more about these options regardless of the additional cost.
“It’s time to think that your advanced-technology IOL patients are your IOL patients, and what they want is youth. They want the vision of a 20-year-old again. We must be aware of what they expect when we counsel them because if we don’t deliver on that, and we don’t meet their expectations, then we fail in their eyes,” Hovanesian said.
While in the past there was a lot of discussion on who should or should not receive a premium lens, with many considered unsuitable candidates, nowadays there are advanced options for almost everyone.
“I don’t think it’s up to us surgeons to have preconceived beliefs on which of our patients or demographics of patients would be interested in the premium IOL category. I feel that it is our responsibility to offer the options to every patient as each and every one deserves the opportunity to achieve spectacle independence if so they desire,” Healio/OSN Board Member Neda Shamie, MD, said.
Patients in her Los Angeles practice are highly educated and well informed, and they expect spectacle independence as much as possible with the least amount of tradeoffs.
“More and more patients seek a youthful outlook and don’t want to be tethered down by limitations such as reliance on glasses,” she said.
Range of options
In her conversations with patients, Talley Rostov makes clear from the start that there is still a basic option with cataract surgery and that a high-quality lens will be implanted, but the expectation is glasses for everything. She then explains that if they want to be less dependent on glasses and achieve their best vision possible, there are three “vision correction options” available.
“Vision correction one consists of whatever it takes to get them the best vision in one particular place. And usually, this is distance vision. Most of the time, this includes a toric IOL or sometimes a monofocal non-toric lens and femtosecond corneal relaxing incisions to address astigmatism. In addition to that, they can have a PRK touchup if needed to address any unresolved refractive error,” she said.
Vision correction two includes all that with the additional benefit of an extended depth of focus (EDOF) or a trifocal or multifocal IOL, with or without a toric component, to expand the patient’s range of vision. The choice between these lenses will be based on patient desires and on the diagnostics involved, including the higher-order aberration profile.
Vision correction three is the premium option for eyes that have previously undergone refractive surgery, specifically LASIK, PRK or RK.
“We offer the Light Adjustable Lens (LAL, RxSight) to these patients. I am going to move more toward the new Apthera pinhole optics lens (AcuFocus) for our RK patients, but for the others, I recommend the LAL because it overcomes the power calculation problems we have with other IOLs in post-refractive surgery eyes,” Talley Rostov said. “I always say, ‘Once a refractive surgery patient, always a refractive surgery patient.’ Expectations will always be the highest. The Light Adjustable Lens offers various refractive options and is the most customizable of all lenses.”
Even going back to the first days of advanced-technology lenses, the majority of well-selected patients had positive results, Hovanesian said.
“We have many studies with 5-year outcomes, and in one study, we went out to 10 years with some patients. They continue to be just as pleased after that time as they were at the beginning. With the newer technologies, we expect even better long-term outcomes,” Hovanesian said. “We now have lenses like the Synergy (Johnson & Johnson Vision) and the PanOptix (Alcon), which are the two approved trifocals in the U.S., and lenses like the Symfony (Johnson & Johnson Vision) and Vivity (Alcon), both terrific EDOF, and all of them are available in the toric version.”
He applauded J&J for releasing the OptiBlue modification of its Symfony lens and Alcon for evolving its lens material from AcrySof to Clareon, which will help provide better vision, long-term safety and stability.
“Trifocals have given us full range of correction. No longer do we have to consider compromising on the patient’s desire to have focus at every distance. Whereas before when we only had the option of bifocal IOLs, we had to compromise vision for one focal point or mix and match IOLs to try to cover the full range of vision. This led to confusion for patients and doctors and complicated the discussion. Now with the option of trifocal IOLs, the chair time is lessened and the discussion streamlined,” Shamie said. “Also, the non-diffractive EDOFs have expanded our offering to patients who were previously considered non-candidates for presbyopia-correcting lenses, and the Light Adjustable Lens has further expanded our offering to patients who may have been at risk for refractive surprise, namely post-refractive surgical patients, or ones who seek the most optimized vision at the distance of their choosing.”
The LAL has an important place for eyes with prior refractive surgery in Hovanesian’s practice.
“We can take the hardest-to-please patients and make them among our happiest patients,” he said.
Surgeons who are concerned that the LAL postoperative titration and lock-in treatments might be too burdensome should be reassured.
“Patients who come back for the adjustments invest personally in their final vision. They’ve seen it evolve, and by the time we are locking it in, they are fully settled that this is their vision forever and are pleased that they have invested the time in this. So, it actually adds to rather than detracts from their satisfaction,” Hovanesian said.
“It allows patients to be more involved in their postop care. They can test drive a refractive target and fine-tune it with the light adjustments until they reach the outcome that is most customized to their visual needs. This has caused a paradigm shift in how we manage patient expectations. The discussion has now shifted from guessing the patient’s outcomes based on assumptions made preoperatively to titrating vision to the most optimized it can be based on postoperative measurements,” Shamie said.
Another game changer is the Apthera small-aperture lens, she said, for the opportunity to provide better vision for patients with irregular corneas, as well as presbyopia correction as a monocular implant in the nondominant eye.
A monofocal lens can also be part of the premium lens experience, according to Yoo. New-generation monofocals, such as the Eyhance (Johnson & Johnson Vision) and the enVista (Bausch + Lomb), have an improved modulation transfer function profile and the ability to provide a slightly extended range of vision.
“There are different options also in terms of materials, blue-blocking filters and toric vs. non-toric models. So, if the patient is not a typical premium lens patient, there is still customizability in the monofocal platform to optimize their visual outcomes,” Yoo said.
Last but not least, the toric IOL has been a most welcome addition to the armamentarium of refractive cataract surgery.
“It is maybe the easiest way for cataract surgeons to transition into the space of premium IOLs,” Yoo said.
Screening technologies for IOL selection
Candidate screening for advanced-technology IOLs mandatorily requires optical biometry, corneal topography, tomography and wavefront analysis.
“You can measure high-order aberrations in a number of ways. I use the Pentacam with the Holladay report (Optovue), and equally good are the iTrace (Tracey Technologies) and the Galilei (Ziemer), but you have to look at the higher-order aberrations. Highly aberrated eyes are not candidates for a trifocal lens, but you can still choose an EDOF or the LAL,” Talley Rostov said.
She is currently trying the SimVis Gekko, an adaptive optics headset device that simulates postoperative vision with different implants.
“You can program in the patient’s prescription, and then you can show them what their vision will be through an EDOF or a trifocal lens compared to monofocal or to monovision. It shows also the downsides in terms of any glare and halo effect, and it helps them decide,” Talley Rostov said.
Looking at the ocular surface, tear quality and corneal contour with imaging technologies, such as the LipiView (Johnson & Johnson Vision) or iTrace or tomography/topography, is also essential to detect dry eye or any other corneal source that could potentially affect the outcomes of cataract surgery, Shamie said. She also performs macular OCT in all her premium cataract surgical patients to ensure no macular source of concern, such as an epiretinal membrane.
“Finally, the more recent, advanced biometers are critical in optimizing the measurements for lens power,” she said.
Now that IOL technology offers such a wide range of choices that almost every patient can be served in a customized fashion, the patient-doctor relationship has become more critical than ever before.
“We are back to the basics of spending time with the patient to capture their history and understand their needs. Because the options are so varied, it’s critical for us to know our patients well to be able to matchmake them to the right lens,” Shamie said.
A trusting relationship begins with the information and education provided to prospective patients and referring doctors through the practice website and printed pamphlets before their visit.
“Coming to us empowered with information and well prepared to ask questions gives them a sense of confidence that they’re having their concerns answered,” Shamie said.
A successful advanced cataract surgery practice also requires expanding the team to optimize patient flow and provide a concierge-style customer service.
“We have invested in hiring more optometrists for our practice, so that the patients can have access to higher-level counseling and testing as well as examination,” Shamie said.
Most importantly, she has invested in having every lens technology available to her patients.
“I felt strongly that we wouldn’t be serving our patients well if we didn’t have lenses in every category available to our patients because no two lenses will accomplish the same for everyone,” she said. “Patients who come to our practice can count on the fact that every advanced-technology lens is considered when we evaluate them. We pride ourselves on customizing the premium cataract surgery experience to each patient individually because we feel strongly that every patient deserves to have their own journey in gaining the visual outcomes they desire and can achieve.”
Quality over quantity
“I think more than anything, culture drives outcomes in business. We have taken the philosophy that we are here to deliver the best technology to patients who know the difference, and they know the difference because we help educate them. They make informed choices, and we are happy to take care of them, whatever choices they make,” Hovanesian said.
Motivation is key to learning and achieving goals, he said. Physicians who are motivated to raise their game to the level of a full-service premium clinic will learn whatever is useful to meet the challenges.
“It’s a virtuous cycle. If you understand that addressing dry eye is important to have a good outcome, then you learn how to do it and adopt whatever testing and new exam process is necessary to refine that. In our practice, we have taken on a number of optometrists who enjoy managing dry eye, and it has been a wonderful enhancement to their career and a fantastic resource for us and our patients,” he said.
For a premium practice, it is also important to stay current with emerging technologies and embrace innovation. The initial investment may be considerable, but it will pay off.
“Thankfully, advanced-technology lenses give us separate reimbursement from what we get paid to do the basic cataract surgery. That means that if you have high adoption of these lenses, you have a revenue stream that can support a higher level of service to the patient,” Hovanesian said.
Stepping into the premium practice mindset means giving priority to quality over quantity, seeing fewer patients and giving them a deeper level of service rather than offering basic services to a large number of patients.
“To me, it is much more gratifying to have a smaller practice with more advanced-technology adoption than to try to do high volume and low touch,” Hovanesian said.
Premium care is best practice
Dealing with a high demand for advanced-technology IOLs is unusual for an academic practice, and yet premium cataract surgery is almost routine at Bascom Palmer Eye Institute.
“We are one of the highest-volume premium lens practices in our region, which is surprising considering we are an academic institution. We may not be as financially motivated as our private practitioner colleagues, but the volume of premium lenses that we put in speaks what we feel: Being able to offer this to our patients is medically the right thing to do and is best practice,” Yoo said.
The exponential growth of lens surgery has created the need for restructuring this part of the practice and siloing the cataract surgery service line.
“We used to see cataract patients along with our other cornea and external disease patients, but given the increasing volume and increasing counseling that is involved, we decided to make the cataract surgery service line more similar to our refractive surgery service line, where we see patients separately and have a prescribed preoperative test workflow. We have trained staff to counsel the patients on the different options and a surgical coordinator who takes care of scheduling surgery and visits, providing financial information, and helping with transportation to and from the hospital,” Yoo said. “That’s a big change that we’re currently undertaking, and I think it’s going to make a big difference in terms of the whole patient experience.”
In essence, what a premium cataract surgery practice should offer is patient-centered, personalized care, covering the whole range of potential patient needs, from straightforward to complex cases, with the whole range of available technologies.
“In our practice, we pride ourselves on being able to deal with anything and anyone, from the straightforward cases of very mild cataracts to the challenging cases of very dense cataract with zonular issues that we still encounter in some patients from lower-middle income countries, and offer whatever is best for all of them to optimize their vision,” Talley Rostov said.
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- For more information:
- John A. Hovanesian, MD, FACS, of Harvard Eye Associates in California, can be reached at email@example.com.
- Neda Shamie, MD, of Maloney-Shamie Vision Institute in Los Angeles, can be reached at firstname.lastname@example.org.
- Audrey R. Talley Rostov, MD, of Northwest Eye Surgeons in Washington, can be reached at email@example.com.
- Sonia H. Yoo, MD, of Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, can be reached at firstname.lastname@example.org.
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