Match your patient with the optimal IOL

It can be argued that the most challenging aspect of offering premium intraocular lenses (IOLs) at your practice occurs long before a surgeon enters the operating room. That challenge is patient selection.

The optimal premium IOL patient is someone with both the wherewithal and motivation to part with up to $5,000 to avoid reading glasses but also with the sort of laid-back, Type B personality that can accept a lifetime of compromised vision-traits not always present in the same person.

But such patients do exist, and if your practice depends on them, support staff can play an important role throughout the selection process. However, doing so means knowing how to discuss the basics of multifocal and accommodative IOLs.

Lens choices

There are three multifocal IOLs approved for use in the U.S., and one accommodative IOL. Taken together, these lenses are often referred to as premium IOLs because they correct for the lack of accommodation that occurs after cataract surgery. Patients pay an out-of-pocket fee for this extra advantage, usually around $2,500 per eye.

• AcrySof IQ ReSTOR (Alcon)-The original version of the AcrySof, approved in 2005, offered a near power of +4.00 D. A newer version, approved in 2008, has a lower near power of +3.00, which offers patients a slight improvement in intermediate vision. This IOL uses diffractive optics to produce its multifocal effect.

• ReZoom (Abbott Medical Optics [AMO])-This is basically an enhanced version of AMO’s Array multifocal IOL. The design applies refractive optics-different zones within concentric rings focus light differently at varying distances but at the same location on the retina.

• Tecnis (AMO)-Approved in 2009, this lens employs diffractive optics to produce the multifocal effect. It is the first and only FDA-approved wavefront designed optic that corrects for small spherical aberrations, according to the company.

A big design difference among these lenses is whether diffractive or refractive optics are used to produce the multifocal effect. Diffractive optics was the first-generation technology. It involves splitting incoming light into two different focal points, one for near objects and one for distance. This essentially creates a bifocal IOL. Generally, diffractive optics are known for producing excellent near vision but unremarkable intermediate vision.

Refractive optics is the newer technology. All incoming light through these lenses reaches the retina at one focal point. Generally, refractive optics are known for producing excellent intermediate vision but unremarkable near vision. Both types of lenses produce the same level of distance vision.

In the past, avoiding reading glasses meant improving near vision. However, in today’s world “reading” frequently involves sitting in front of a screen, such as tablet, phone, or laptop, and that requires intermediate vision. So surgeons will often choose lens types based on the patient’s lifestyle or job. Also, some surgeons mix and match lenses, implanting a diffractive lens in one eye and a refractive in the fellow eye.

It’s worth noting that visual outcomes rely on many other factors besides refractive vs. diffractive optics. These factors include the chosen near addition, the quality of the biometry, the surgical centration of the lens, and the patient’s uncorrected refraction.

The other FDA-approved premium lens, Crystalens (Bausch + Lomb), is not a multifocal lens but a monofocal one that works by shifting its position in the eye in response to the patient’s muscle movements. The theory is that so-called accommodative lenses like this one produce better contrast sensitivity and fewer side effects, such as glare and halos. However, they may also provide less range of focus than multifocals, therefore increasing the need for reading glasses.

Patient selection

The fact of the matter is all current options for IOL presbyopia correction involve some level of compromised vision. It is hoped that in the future accommodative IOLs with dual or flexible optic design may provide vision with minimal side effects, but that day has yet to arrive. Patients must understand that they will be sacrificing a little bit of distance vision and may encounter nighttime halos and glare in exchange for reduced spectacle dependence.

It is generally agreed that the best patients for premium IOLs are those with hyperopia. The next best are those with high myopia, –6.00 D or greater. Emmetropic patients may be poor candidates for premium lenses because they have so little experience with compromised vision.

Patients must be made to understand that they still may need to wear spectacles on certain occasions. Additionally, some post-operative correction, in the form of LASIK, limbal relaxing incisions, or piggyback IOLs, may be also necessary. Even the best surgeons have an enhancement rate of about 15%, studies show. Potential candidates should also know that even without postoperative correction, adapting to IOL vision may take as long as several months.

The patient should be highly motivated but also must be willing to accept some unmet expectations. Surgeons often look for Type B personalities rather than demanding Type As. Anyone who does a lot of driving at night-truck drivers, for example-is likely a poor candidate for premium IOLs.

Paying for lenses

As a final note, support staff should be aware that paying extra for a medical service already covered by Medicare is a special exception that the CMS made for premium IOLs only. This was a regulatory decision made several years ago that does not apply to any other medical service. Charging extra for other government-funded procedures, known as balance billing, is expressly forbidden by the 1965 legislation creating Medicare. If patients ask to pay extra for other covered services, be sure to dissuade them in no uncertain terms, or else risk seeing your practice on the local evening news.ODT

Premium IOLOptions

Multifocal IOLs

• AcrySof IQ ReSTOR (Alcon)

• ReZoom (Abbott Medical Optics [AMO])

• Tecnis (AMO)

Accommodative IOL

• Crystalens (Bausch + Lomb)

In order to best meet the needs of your IOL patient, you not only need to know the types of lenses available, you also need to know the occupation, lifestyle, and temperament of your patient.