On-Target Patient Selection
On-Target Patient Selection
Exceed expectations by educating and matching each patient with the appropriate refractive IOL.
BY LARRY E. PATTERSON, MD
The advanced IOLs available today provide surgeons with the ability to use lenticular surgery to improve vision for a wider range of patients. To do this effectively, we must realize we're now dealing with two somewhat separate groups of patients, those who could benefit from refractive cataract surgery (RCS) and those who could benefit from refractive lens exchange (RLE).
These two groups differ in many ways, including age, mindset, awareness of vision-correcting options and expectations for surgery. (See "RCS vs. RLE Patients") But in spite of these differences, the process for determining whether they're good candidates for premium IOLs is the same. They should have no significant pathology, and they should have realistic expectations and an understanding of functional vision. Furthermore, they must be motivated to achieve the best possible results. In general, any personality type is fine, but detail-oriented patients require more education and discussion about neuroadaptation, functional vision and related issues.
At our practice in rural Tennessee, we focus on providing thorough education and matching individuals to the implant and type of procedure that best meets their needs and desires. This has allowed us to exceed expectations, which is our goal in every case. Here, I share some of the approaches that have proven most beneficial to us in pursuit of that goal.
If patients are to have realistic expectations, they must understand the concept of functional vision. To help them, we use a visual aid I heard about years ago at a conductive keratoplasty course. In every lane of our practice, we have a can of Campbell's Tomato soup. Invariably, patients ask "Why the soup?" We take that opportunity to show them what their vision will be like following the various procedures we offer. We use the various print sizes on the can to illustrate what they will and won't be able to see without eyeglasses.
|RCS vs. RLE Patients|
To successfully incorporate premium IOLs into their practices, surgeons must recognize the differences between two groups of patients: those who could benefit from refractive cataract surgery (RCS) and those who could benefit from refractive lens exchange (RLE).
• age 60+
• Great Depression mentality
• accepting by culture
• poor BCVA pre-op
• reasonable expectations
• pay less – expect less
• less litigious
• less computer usage
• often unaware of options
• age 40-60+
• baby boomers
• demanding by culture
• excellent BCVA preop
• high expectations
• pay more – expect more
• more litigious
• more computer usage
• seeking the procedure
Drill Down to Vision Specifics
Part of how we get to know our patients is by using a simplified questionnaire. We've narrowed it down to a few questions. First we ask whether they use a computer — laptop or desktop. Then we ask whether they read much and what kinds of things they read. When we know these basic answers, we pursue more details. We keep samples of different reading materials in the office and ask them to hold them where they're comfortable. Not where they see it best but where, in a perfect world, they'd like to hold it. In addition, my surgical counselor keeps a tape measure in the office and actually documents where the patients like to hold things. All of this has a bearing on which implant we recommend and what refractive outcome we strive to achieve.
Next, still keeping things simple, we ask patients to list three activities or hobbies they'd like to do without eyeglasses, in order of importance. Again, this is important for choosing the right implant. At first, many patients say reading is the top priority. But whatever they say, we really want them to think about what's important to them, so we rephrase the question. "So you'd be OK wearing eyeglasses for driving?" Often, that prompts the patient to identify a different top priority. We continue the interaction along those lines until patients are confident about the priorities they've listed.
|Sample Language for Thorough Informed Consent|
These sections from our informed consent papers for lens and implant surgery illustrate crucial points for patient education and managing expectations.
- I am electing to have Standard Cataract Surgery. I understand that I have a cataract that is affecting my activities of daily living, and surgical removal is medically necessary to improve my vision. I understand I will need eyeglasses for most, if not all, activities after surgery. Eye Centers of Tennessee will file my insurance for the standard surgery. I will be responsible for any deductibles or co-payments for this procedure depending on my insurance policy.
- I am electing to have Refractive Cataract Surgery. I understand that I have a cataract that is affecting my activities of daily living and surgical removal is medically necessary to improve my vision. Eye Centers of Tennessee will file my insurance for the standard cataract surgery. I will be responsible for any deductibles or co-payments for this procedure depending on my insurance policy. Eye Centers of Tennessee will not file my insurance for the refractive portion of the surgery to reduce my dependence on eyeglasses as this portion is considered elective.
- I am electing to have Refractive Lens Exchange simply to reduce my dependence on eyeglasses. This procedure is an elective procedure and is not medically necessary, therefore it is not covered by my insurance. Eye Centers of Tennessee will not file my insurance and I will be responsible for the full cost of the procedure.
- I have selected or my doctor has recommended I have a Standard implant. This implant may reduce nearsightedness or farsightedness at only one point of focus and does not correct corneal astigmatism. Eyeglasses will need to be worn for most if not all tasks after surgery.
- I have selected the Crystalens (Bausch & Lomb) implant. This implant has a solid optic which provides good clarity of vision. The primary focal point of this lens is distance, but it is designed to use the eye's natural muscle to "flex" the implant and also provide functional vision at near and intermediate ranges without depending on glasses. This implant does not correct corneal astigmatism. A limbal relaxing incision may be required to reduce any corneal astigmatism you may have. Most patients who have this implant in both eyes see well enough to legally pass a drivers license test, use the computer and read newspaper print or restaurant menu size print at near without eyeglasses. Functional vision without eyeglasses is our goal.
- I have selected to have the ReSTOR (Alcon) implant. This implant has an optic with diffractive rings (like a bullseye) that provide functional vision at distance and near. This implant does not correct corneal astigmatism. A limbal relaxing incision may be required to reduce any corneal astigmatism I may have. Most patients who have this implant in both eyes see well enough to legally pass a driving test and read newspaper print or restaurant menu size print at near without eyeglasses. Functional vision without eyeglasses is our goal. The rings in the implant that help me to see without eyeglasses may also cause reduced contrast sensitivity, waxy vision and increased glare or halos.
Present Solutions for Every Pocketbook
If you're offering anything other than the standard Medicare-paid cataract surgery in your practice, it's important to offer convenient and affordable financing options. Even patients who don't need to take advantage of this sometimes elect to use a special payment plan anyway.
Some patients aren't at all interested in paying $2,000, or whatever the fee may be, to get presbyopia-correcting IOLs. And that's fine. But in our practice, we always let them know that we offer other lenses and procedures that can give them better-than-standard vision, and these options cost less than a procedure with a presbyopia-correcting IOL.
Depending on the patient, an aspheric IOL, toric IOL, monofocal IOL with limbal-relaxing incisions, or some version of blended vision with monofocal IOLs may work best. No matter which option is ultimately chosen, patients know they were informed about all options and were able to choose from the ones that applied to them, based on their personal comfort level.
By the way, if you don't offer premium IOLs, it's still your responsibility to let patients know they're available, even if it means referring them somewhere else. We're hearing more and more stories of patients who, when the topic randomly comes up, are angry at their primary surgeons who didn't mention the option.
Final Check on Expectations: Informed Consent
Finally, complete and thorough informed consent is crucial for managing patient expectations. The forms we use in our practice list and explain all of the options, including standard cataract surgery, RCS and RLE. They include information about how insurance does or doesn't apply. And they include a description of the vision each of the various IOLs is expected to provide. (See "Sample Language for Thorough Informed Consent").
While patients are in the office, we go through the forms with them, and they check off the boxes that apply to their chosen procedure and implant. Then we allow them to take the form home, so they'll have more time to read it. They bring it to the ASC on the day of surgery and sign it there.
Play Educator and Matchmaker
The approaches outlined here should help you exceed expectations and grow your practice. Always remember that the key to success lies in your ability to educate and match patients to the appropriate IOL. ■
Dr. Patterson is medical director of Eye Centers of Tennessee in Crossville. He is also the president of the Outpatient Ophthalmic Surgery Society and chief medical editor for Ophthalmology Management. You can reach him at firstname.lastname@example.org.
Ophthamology Management, Issue: May 2009