By Kirk L. Smick, OD, FAAO
Sept. 6, 2017
At Clayton Eye Center, our surgeons perform more than 3,000 cataract procedures annually, with about 60 percent of those referred by, and co-managed, with local optometrists. The other 40 percent see our in-house optometrists for their pre- and postoperative care, so we are very much in tune with post-operative success rates and the most common causes of patient complaints.
In a large practice, we can’t afford to have a lot of unhappy patients. Even a 5 percent dissatisfaction rate is bad for business—and bad for our co-management relationships. That’s why I have not previously been an advocate of presbyopia-correcting IOLs (PC-IOLs). However, better outcomes with a new category of PC-IOLs have given me a different perspective.
What Has Changed
Extended-depth-of-focus (EDOF) IOLs were introduced in the U.S. about a year ago. These IOLs provide a range of good vision, rather than splitting light into two distinct focal points. Thus far, we have one IOL in this category, the Tecnis Symfony (Johnson & Johnson Vision), but there will likely be other EDOF lenses in the future.
After hearing reports of good outcomes with Symfony in Canada, we began implanting this lens in the practice in a small number of patients, and that number is growing as we continue to see excellent results and receive positive feedback from referring doctors.
A review of the last 50 cases shows that at one month, all had 20/25 or better uncorrected distance vision and 47 had 20/20 (see chart on this page). Only five patients reported occasionally wearing reading glasses, primarily to read stock market reports or medicine bottles. All 50 said they would do it again and thought it was a good investment.
EDOF lenses solve the biggest complaint we had with PC-IOLs in the past—blurry or poor quality distance vision. Think about it—the patient comes in because the cataract has made their vision blurry. They choose to pay a lot of extra money to have multifocal vision, but then some of them still have…blurry vision. With EDOF IOLs, the distance vision is much more crisp and the patient can see well for most near tasks. Because of the way the EDOF technology elongates the focal range, it also seems to have significantly reduced two other frequent sources of complaints: night vision symptoms and unsatisfactory computer-distance vision.
I am very honest with patients: I explain that nothing beats the quality of vision they will get with a monofocal IOL, spectacles for the computer, and another pair of spectacles for reading. But if they want the convenience of all three distances, an EDOF IOL gets them pretty close. I also tell them they may need to wear reading glasses in dim light or for very small print.
What the New Environment for PC-IOLs Means to Practice Owners:
HIGHER CO-MANAGEMENT FEES. Higher fees on PC-IOLs can somewhat offset the overall reduction in surgical and co-management fees. I certainly didn’t consider the higher fees worthwhile when I lacked confidence in the technology. But when the technology delivers what patients want, optometrists might as well participate in the revenue stream.
MORE REFERRALS, LESS CHAIR TIME. Really, really happy patients are much more likely than just “satisfied” ones to talk about the experience to their friends at Sunday school or on the golf course.
NEED TO TREAT OCULAR SURFACE DISEASE FIRST. Patients need to be ready to achieve their best visual outcomes. That means taking the time to treat dry eye problems before referring for cataract surgery.
INCREASED PATIENT AWARENESS. Increased awareness means you can’t opt out. Patients are increasingly aware of EDOF and PC-IOLs, either from their own research or via word-of-mouth. If the optometrist doesn’t have a wide-open discussion about IOL options (or worse yet, doesn’t even mention the developing cataract), and the patient only learns of it at the surgery center, it erodes the patient’s trust in and willingness to return to their optometrist.
I think we have reached a tipping point in the evolution of PC-IOL technology. The shift from only 90-95 percent patient satisfaction to closer to 99 percent has changed the business case for recommending PC-IOLs from “not worth it” to “can’t afford not to” if you want to build a financially strong practice.
Do you educate cataract patients about the opportunity of presbyopia-correcting IOLs? What do you tell patients about the advantages, as well as the drawbacks, of this new technology?