And that’s not counting IOL procedures other than cataract. “We’re probably going to see more interest in presbyopic lens exchange because surgeons are getting more comfortable with newer technology and its availability,” says R. Bruce Wallace III, of Alexandria, La.
Just as the number of cataract patients has risen, so too have the IOL options you can offer these patients. “One of our primary responsibilities as eye surgeons today is to help guide patients through a dizzying array of new technology,” says Michael Colvard, MD, of Encino, Calif. “Our goal should be to help patients select the specific technology that best meets their needs and expectations, and you can’t do this by simply giving patients a mind-boggling laundry list of options.”
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| Surgeons recommend that you think of the referring OD as part of your team. |
But, how do you accomplish this and still have enough time left over to actually perform the surgery? Here are some suggestions.
In the Mail
You don’t need to wait until the patient is in the exam lane—or even in the office—to begin the education process. You can send the patient and family members introductory letters and brochures that provide information about your practice and introduce cataract surgery and IOLs to the patient ahead of time. Don’t forget to include some information on your practice’s website as well.
“This information gives the patient and his family the chance to begin understanding what will occur during his cataract evaluation and what will be discussed when they come to the office,” says James Loden, MD, of Nashville, Tenn.
Another item to send patients in advance: a lifestyle survey such as the Dell questionnaire (developed by Austin, Texas, surgeon Steven Dell in 2004). The questionnaire should ask about the patient’s preference for achieving distance or near vision without glasses, what activities the patient engages in and for which he would be willing to wear glasses, whether issues such as glare would bother him, and even how the patient sees his or her own personality.
“By the time I see patients, they’ve given some thought as to their desire for spectacle independence,” says Daniel H. Chang, MD, of Bakersfield, Calif. In his questionnaire, Dr. Chang also asks patients if they would be willing to pay extra if they could potentially avoid needing glasses. (Medicare requires that you inform patients prior to surgery that Medicare will not pay for services specific to the insertion, adjustment and other subsequent treatments related to premium IOLs and vision-correcting technology.) This gets the discussion started.
Once the patient arrives at the office, you can continue the education process right in your waiting room or further into the visit as patients dilate. For example, software and videos are available from such companies as Rendia (formerly Eyemaginations) and Patient Education Concepts—some of which let you select only those options suitable for the patient.
In the Office
Once the patient is in the exam lane, if you’ve had him fill out the Dell questionnaire or something similar, you’ll know whether he wants distance or near vision without glasses, whether the patient is willing to tolerate a certain amount of glare, and what the patient’s vocations and avocations are.
“I ask the patient: ‘In a best-case scenario, what are you hoping to achieve with cataract surgery?’ ” Dr. Colvard says. “The answer almost always is, ‘I want to see better.’ So then I ask, ‘How important is it to you to reduce your dependency on glasses?’ This introduces the concept that there are possibilities beyond just better vision with glasses. And it helps me to understand what the patient is thinking or is hoping for as an additional benefit to cataract surgery.”
There are several keys for making the patient evaluation more efficient—starting with clear guidelines and getting your staff on board with those guidelines. “The staff should be aware of all of the lens choices and be able to recognize potential candidates for certain types of lens implants based on those guidelines,” says Cory Pickett, an ophthalmlic consultant in the Midland, Texas, area.
Mr. Pickett’s advice: Start your involvement early on. For example, once pretesting is done, you might review the initial results and perform a preliminary slit lamp exam, explain that the patient has cataracts and instruct the staff which follow-up tests to perform. “It is important the surgeon puts his own spin on that so it doesn’t come off as robotic,” he adds.
For example, Dr. Chang uses an eye model to demonstrate to patients what happens during cataract surgery and what implant he or she might wish to consider. He also uses an IOL model that shows the difference between monofocal and diffractive lenses.
In Dr. Wallace’s practice, two technicians who serve as IOL counselors meet with patients after he finishes his examination. These counselors refer prospective candidates to the staff optometrist or perform further testing themselves to determine if any factors might make the patients unsuitable for premium IOLs. They also review the brochures the patient was sent to answer any questions the patient or family members may have, then show them their options and discuss pricing.
This brings up two additional points. First, think of the referring optometrist as part of your team. “One of the values of having referring optometrists is that they know the personality traits of the patient better than we do,” Dr. Wallace says.
They also know based on their own findings who may be a good candidate for a premium IOL and any history that might make the patient unsuitable, such as a history of RK or PRK. And the referring optometrist can let the patients know which options you’ll likely discuss when the patient is in your chair. “It helps to use a group effort to find out which patients are good candidates,” Dr. Wallace says.
Second, consider delegating discussions of cost to your staff. “Most of the time I try not to talk about cost,” Dr. Chang says.
Instead, he has his surgical coordinator discuss cost and financing options with the patient—another way of reminding him or her that premium IOLs aren’t covered by Medicare. Given that some patients will not consider options that aren’t covered, this is a time-saver for the doctor.
The Technology Advantage
In addition to your staff’s help, continue to take advantage of diagnostic technology to guide your exam. Just as IOL technology has evolved—and continues to evolve—so, too, has diagnostic technology. “Another way to expedite the evaluation is by using this technology to find out information quickly,” Mr. Picket says.
For example, Mr. Pickett recommends the OPD-Scan III Wavefront Aberrometer (Marco), which essentially serves as autorefractor, keratometer, pupillometer (up to 9.5 mm), corneal topographer and integrated wavefront aberrometer. “You get this information quickly and have a basic idea of what the patient may be a candidate for very early in the evaluation,” he says. “This can be used to help guide the rest of the exam,” he says.
To narrow down in advance which lenses might be appropriate for the patient, look at the information you have in hand, including:
• Ocular surface health. Blurred vision postop and ocular surface issues, often the result of pre-existing dry eye, are among the major causes of patient dissatisfaction after an implant with a multifocal IOL. “If they have keratitis present, with dry eyes, and/or meibomian gland dysfunction, this must be treated before considering a multifocal IOL,” says Dr. Colvard. “If the findings persist despite treatment, I try to lead patients away from multifocal IOLs.”
• Macular health. “The first thing I consider when I begin to review options with the patient is the presence or absence of macular pathology,” Dr. Colvard says. “If macular issues exist, I show the patient the OCT, explain the implications, and guide the patient away from IOLs with multifocality. Macular degeneration, epiretinal membranes—any kind of macular pathology—will reduce the patient’s contrast sensitivity.”
• Corneal topography. Research has shown that toric IOLs provide better uncorrected vision, greater spectacle independence, and lower residual astigmatism than non-toric IOLs, even with relaxing incisions.1
“If the corneal map shows -2 D of astigmatism, I’ll only talk toric lenses,” Dr. Loden says. “So it narrows my choices down before I even come in. If the eye looks healthy and patient says, ‘I’m interested in these options,’ then we go into the lenses.”
Dr. Colvard discusses toric IOLs if the patient has more than -1 D of astigmatism. “If the patient has an astigmatic error greater than -1 D, I explain the significance of this and explain that we have two options with new technology to correct astigmatism and improve vision without glasses,” adds Dr. Colvard.
Invest the time
Obviously, the IOL selection process involves a lot of information for the patient to assimiliate. “It’s sometimes a lot for doctors to assimilate, too,” Dr. Loden says.
Accept that you’ll need to spend more time than you did 10 years ago, when there were fewer options. But, in those extra minutes, you’ll be able to satisfy the patient’s visual needs and grow your practice—more than you might have been able to do with standard monocular IOLs several years ago. “You’d have to do five cataracts minimum to make up that difference,” Dr. Loden says. REVIEW
1. Kessel L, Andresen J, Tendal B. Toric intraocular lenses in the correction of astigmatism during cataract surgery: A systematic review and meta-analysis. Ophthalmology 2016;123:2:275-86.
