The real, premium IOL learning curve

A discussion with Richard L. Lindstrom, MD and Kerry D. Solomon, MD.

Performing premium IOL surgery involves financial commitment and continually learning new procedures, but maybe not as much as some suspect. The bottom line, ultimately, is giving patients quality vision. As for getting expert opinion on these points, we asked Kerry D. Solomon, MD, and Richard L. Lindstrom, MD, to give theirs.

Richard L. Lindstrom, MD: There are about 18,500 ophthalmologists and 9,000 to 10,000 are cataract surgeons, performing at least a few cataract surgery procedures every year. Some of these ophthalmologists are relatively low volume and it is a challenge for them to have all of the high-tech equipment. The median ophthalmologist sees about 5,000 patients a year and does about 400 cataracts. If you do 400 cataracts a year, I think it is possible to support the basic technology and do refractive cataract surgery. But if you’re doing, say, 50 to 100 procedures a year, it may be difficult.

I think if you’re going to do refractive cataract surgery you need access to a few core technologies, including an IOLMaster (Carl Zeiss Meditec) or Lenstar (Haag-Streit USA). I believe you need one or another form of corneal topography, and ideally you have an OCT. But you need OCT to follow your glaucoma and macular degeneration patients as well, so OCT is a reasonable technology for every cataract surgeon. Comprehensive ophthalmologists who see contact lens wearers will need to rule out keratoconus and the like, so they need topography. And, of course, it is critical to have a good IOL power calculation system and biometry.

For toric IOL, you can mark manually and do okay, so I think that it’s probably not required to have advanced technology in the operating room as far as aligning toric lenses and the like. But, of course, if you have it that certainly can reduce the number of enhancements you need.

Finally, the biggest challenge for most comprehensive ophthalmologists is having an enhancement strategy, because only about 2,000 of the [total] cataract surgeons know how to use an excimer laser. I find myself doing about 15% enhancements. I’m pretty aggressive with it to end up with happy patients at a year or more out. So, lack of access to a good enhancements tool is one of the biggest challenges. Mobile lasers are available, but I think you can’t really do a great job if you just treat patients with residual myopia or hyperopia and astigmatism with glasses.

Kerry D. Solomon, MD: I agree with everything you’ve said, Dick. The only area that I might add a little is that I think that we’re used to the statistic that the average ophthalmologist is likely to be somewhere in the 65% to 75% range for hitting his or her patient’s intended target refraction, which is why the issue of enhancements comes up a lot. How are people going to handle it?

So I wouldn’t just say an IOLMaster because the older IOLMasters did a poor job managing keratometry measurements, specifically the magnitude and the axis of orientation. It would be worthwhile to consider upgrading to the IOLMaster 700. The K values will be better, you actually can get swept-source OCT and get total corneal power out of it, and I think you’ll get improved outcomes.

Similarly, for the Lenstar users, I think the IOLMaster 700 and the Lenstar are going to be pretty comparable. The Lenstar is also coming out with swept-source OCT, which people smarter than me seem to feel may improve outcomes.

Lastly, you need to use modern formulas — Graham Barrett’s Universal II Formula, Warren Hill has an RBF formula, Jack Holladay has his Holladay 2. I think when people use more modern formulas, that’s going to improve outcomes.

And even if the surgeons are doing 400 cases a year, if they’re doing modern biometry, they’re screening patients appropriately and making sure that the measurements are good; if they’re using a good, modern formula and optimizing their outcomes by looking at their preoperative and postoperative refractive results and customizing their A constants or surgeon factors, the enhancement rate ought to be less than 25% to 30%. They should be on the order of 10%. Folks like Jack Holladay, Warren Hill, Graham Barrett, they all feel we should be approaching that 85% to 90% within 0.5 D in the next year or two, if surgeons are doing that.

So, my advice to the average comprehensive ophthalmologist is, make sure your biometer is updated. Use modern formulas and track your outcomes and you’ll more likely hit the target refraction.

Dr. Lindstrom: So, we agree on those core issues as far as the preoperative exam. You do have to invest in some office technology to be involved here, and probably the investment is about $100,000. But if you’re going to do even 30 or 40 premium IOLs a year, it doesn’t take long to amortize that so, yes, you do have to invest something and yes, you do have to learn how to use the technology.

But I think we may agree to disagree here. I have a lot of patients who I do a premium IOL on and they’re pretty happy, although as I look at their refractive outcome, it’s not as good as it could be. Maybe they have 0.75 D of residual astigmatism and they’re 20/25 or so, and they’re happy. Some surgeons would say if they’re happy, leave them alone. But I encourage people to have enhancements. I want as many of my patients as possible to be plano sphere. In my opinion, they paid a premium for a premium outcome; if a year later a patient is playing cards with his friends and wearing glasses and my patient is saying, “Yes, I paid the extra money for a special implant, but I’m still wearing glasses,” that is not a word-of-mouth practice builder. I want him playing cards, spectacle independent!

So, there are two ways to think on enhancements. One is to only do them when the patient is really complaining. The other is if you think you can make patients better, encourage them to have one. And that’s what I do. Kerry, how are you on that?

Dr. Solomon: I do the same thing, but my rationale is a little bit different. If you’re prescribing glasses or contacts for someone, you’re not going to leave them with 0.75 D of residual astigmatism. Nobody would. And while patients may not complain to you because they’re 20/25 or 20/30, that’s very different from someone who’s ecstatic with their outcome. More likely, what happens is they leave the office and tell their friends, “I paid a lot of money and it’s better, but really not that great.”

So, we always offer people the option. I tell the patient, “You’re doing very well and you’re really finding you’re not needing glasses. But if I did this enhancement, a LASIK or PRK touch-up, or an LRI, I could make the vision better. If you’re happy with your vision, we don’t have to do anything, but if you want to see a little clearer, know that there’s something more we can do.”

That way, if the patient is happy, they’re not going to ask for an enhancement. But in that instance, if they go back and talk to their friends around the poker table six months later, they’re going to say, “Well, there’s something that can be done,” so they’re less likely to be as disappointed in the result. And if they’re truly bothered by it, they’ll get the enhancement, and my experience with modern LASIK technology is that they do very well.

For the surgeons who aren’t doing LASIK or PRK, I think most people can be trained to do PRK for sure. Dick, do you feel similarly?

Dr. Lindstrom: Yes, it’s quite easy to access a mobile excimer laser and learn how to do PRK. It really is easy.

Dr. Solomon: Yeah, work it out with someone in your group or in town or learn how to do PRK with a mobile laser. I think it should be in everyone’s armamentarium to do a PRK for sure, and perhaps eventually LASIK.

OM: What I’m hearing is that you are constantly learning, constantly keeping yourself abreast of what is going on. How do you do that? How do you constantly stay current, even if you don’t have the money to invest?

Dr. Solomon: First of all, what Dr. Lindstrom and I are talking about should be achievable by the core comprehensive ophthalmologist that’s doing cataract surgery. In my opinion, all comprehensive opthalmologists who perform cataract surgery should join ASCRS. As part of your membership, you can participate in the chat line where people discuss cases, common dilemmas and issues every day, and ASCRS members talk peer to peer about how to improve their outcomes, what formulas to use and what technology. You also have access to the ASCRS journals, as well as online CME and the ASCRS Center for Learning, so there are lots of opportunities for people to be updated.

And then, there’s regional and satellite and national meetings for people to go to. So, without even leaving your own office, I think there’s ample resources to access via the Internet, online CME and learning resources.

In terms of the investment, if people are looking to get involved with premium IOLs or advanced technology, there is some investment required, but the return on investment will be more than covered.

OM: But, you said the enhancement rate is much higher than it should be. So, obviously, a lot of people aren’t very interested in hitting the goal.

Dr. Lindstrom: I think we would agree with you in that regard and, to be honest, it’s somewhat confusing to me why premium IOLs are less popular than expected. The consensus of many experts engaged in the field is we should be doing 30% to 35% “premium” channel IOLs in America where we are correcting patients’ astigmatism, presbyopia or both. I think a rate of at least one in three patients, if we’re doing a good job of informing people and have the skills to generate a good outcome, is certainly achievable and appropriate.

But we’re way below that in volume. It may be inertia or apathy or lack of confidence, and many surgeons who have just decided not to bother and only tell their patients about the option of glasses after surgery ­— personally, I think that’s inappropriate. In the modern era every patient deserves the opportunity to have their astigmatism and presbyopia corrected and to have a “close to perfect” outcome, because we can generate that outcome today. We have the technology. The challenge is more the surgeon than the technology and I don’t know how to overcome that inertia. Kerry and I have spent a lot of time trying to educate our colleagues, but there seems to be an inability for some people to “cross the chasm” and learn how to do this.

Dr. Solomon: I actually think people ARE interested in hitting the goal or target refraction. But to improve outcomes requires some education, updating technology and tracking outcomes. There’s also inertia in many offices from a practice management standpoint. It’s not just the doctor deciding I want this to happen. They’ve got to do a lot of reorganization and perhaps change their process within the office from the way people handle phone calls, how patients are worked up and educated, to offering financial counseling and financial options. It’s more than just the surgeon saying, “I’m going to start this tomorrow.”

In an EMR world, it’s very hard and somewhat confusing and, perhaps, intimidating to try to get everything from an EMR, document and assimilate it all and come up with a plan for how to correct astigmatism or astigmatism and presbyopia. There are some new things coming out, digital-type interfaces that will allow surgeons to more readily assimilate information and come up with a more confident plan.

Part of the issue is, some don’t quite know how to approach astigmatism and what to do, so more simplification may reduce some obstacles as well. I am involved with a new digital device called Veracity Innovations (which was recently acquired by Carl Zeiss). I think more of these sorts of technologies that make it easier for people to adopt will help. But there certainly has to be work on the practice management end, as well for offices to be adept at presenting these options.

Dr. Lindstrom: I think the Veracity system will be useful. But the doctor still does lead the practice, and many still think that it’s okay to not offer advanced technology intraocular lenses, toric and presbyopia-correcting and toric presbyopia-correcting. I think that’s inappropriate today. Every cataract surgeon should be offering refractive cataract surgery as an option. And offering it can mean, if you’ve a very low-volume surgeon, maybe you do 50 to 75 cataracts per year; offering it can mean referring the patient to someone else to have it done. Many patients are quite upset they’re not told about the opportunity.

Dr. Solomon: You’re exactly right, Dick. But the other thing practices may not consider is that patients may just go elsewhere. If you’re not offering these options you may not even be aware of them, but you may be losing some of your patient base; patients are pretty savvy these days, and someone who wants to be less dependent on glasses is more likely to seek a second or third opinion, and then you may lose that patient for life.

Dr. Lindstrom: One place we might disagree, is when we move into the operating room. Femtosecond lasers can be utilized, including custom capsulorhexis and corneal-relaxing incisions; there’s WaveTec, now Alcon ORA, there’s the Callisto (Carl Zeiss Meditec) and Verion (Alcon) systems for toric IOL alignment. I had one of the first femtosecond lasers. None of my associates engaged in any meaningful fashion, and after two years we weren’t convinced FLACS added any value and was necessary.

I thought it was interesting. I liked the corneal-relaxing incisions and we also had ORA. Again, I was the only one who used it routinely. I think it did reduce my enhancement rate. But we have excimer lasers in all my offices, and our practice approach was to do the enhancements when needed.

I had the same experience with the Callisto: I thought it was interesting, but so far my partners are not impressed enough to acquire it. So, we do a little more than 8,000 cataracts a year with 10 cataract surgeons and in the operating room we’re pretty rudimentary in regards to special technology for refractive surgery.

I use a Mastel intraoperative keratoscope to mark the steeper and the flatter meridian in the operating room. But most of my partners simply mark it at the slit lamp or just have the patient sit up and mark with a pen; they’re pretty sophisticated surgeons but they think they are getting good results without sophisticated technology in the operating room.

So, we’re known as a pretty advanced practice at Minnesota Eye Consultants, but we don’t have a lot of the special in-the-OR technology. We do a significant number of premium channel IOLs. We do have the advanced IOL power calculation formulas, we personalize our A-constants and we do about 10% to 15% enhancements with either PRK or LASIK. To date, we have not found an intraoperative technology that is convincing enough to purchase.

Kerry, does this advanced technology help you? Do your partners use it?

Dr. Solomon: I am using it. Some of my partners use it all and some don’t use any of it. To be clear, I don’t think any of this advanced technology in the operating room is necessary for folks to get involved with premium IOLs and refractive cataract surgery. I do think it’s necessary to have a modern biometer, modern formulas and to optimize your outcomes. And, to have an enhancement strategy planned.

My partners and I enjoy the image-guided systems. We have access to both Verion and Callisto. Perhaps it gives everyone a higher level of confidence to have an image-guided system that makes it a little easier to orient your toric IOLs or your LRI or arcuate incisions. Is it necessary? No. But everyone in our practice has adopted image guidance.

I use femtosecond lasers. I don’t think it’s necessary that you have them in order to be able to do these sorts of procedures, but I do enjoy using it. For my patients looking to be less dependent on their glasses, I like having the technology that performs perfect arcuate incisions and a perfectly round, well-centered capsulotomy every time. The technology has been welcomed by our doctors, and patients love it!

I began using intraoperative aberrometry when it first came out, and have used every iteration since. Interestingly, over time, I’ve been relying on intraoperative aberrometry less and less. I think that’s because I’ve been able to optimize surgeon factors for my spherical outcomes through my own due diligence. And as IOL formulas have gotten better — especially our toric IOL formulas, which take into account posterior corneal astigmatism — I’m finding that|I’m changing my surgical IOL plan less frequently than I used to; this includes post-refractive cases. I’ve been impressed with the Barrett True K formula.

I’m not saying that intraoperative aberrometry isn’t helpful. I think it is, but in my practice it’s playing less of a role, and my partners really aren’t using it much.

People have been more comfortable using the femtosecond laser and the image-guided systems. But I think an absolute must-have is a modern biometer, modern formulas and optimizing your surgeon factors or A-constants by tracking the outcomes.

Dr. Lindstrom: So, for the typical comprehensive ophthalmologist, that’s good news because they’re in control while in the office. However, many of them might operate in another physician’s ambulatory surgery center, where they might not be in control of the technology.

I think the good news is you don’t need all that fancy equipment in the operating room, so long as you have adequate technology in your office.

And I think, again, there are many other reasons besides just doing well on premium IOLs to have corneal topography and an OCT in your office.

Unfortunately, I think there are some technologies that are must-haves in the office but again, you’re going to get a return on that as you offer your patients a good opportunity to have a premium IOL and get paid for it, but you’re also going to get a return on it as you just take care of your typical daily patient load with glaucoma, corneal problems, etc. And if you don’t have those tools, then I don’t think you should be doing premium IOLs; perhaps you should be referring most patients who want premium IOLs to someone else.

And that’s not uncommon. I get a few referrals from places like rural Minnesota, North Dakota, South Dakota, Iowa and Wisconsin where there are ophthalmologists who have chosen not to do it and if they have a patient who really needs it, then they’ll send the patient to me or someone else who can.

If you’re kind of negative about it, you’re probably only going to have a conversion rate of about 5%.

Another option is to look at the amount of astigmatism in patients who present for surgery; this will depend on how small of an astigmatism you want to look at and address – for me, it’s someone who has between 0.5 D and 0.75 D.

In my case, I want to treat these patients if they’re interested in being less dependent on glasses because patients that you leave 0.75 D of astigmatism aren’t necessarily happy with their uncorrected vision.

So if you look at the amount of patients, that’s roughly one in two who have about 50%, upwards of 70%, walking in with cataracts, who have astigmatism that would benefit from treatment with either a limbal-relaxing incision, arcuate incision or a toric intraocular lens. OM

About the Authors