Corneal inlays: Picking the right patient is everything

Shamik Bafna, MD, Jeffrey Whitman, MD and Guest Editor William F. Wiley, MD discuss those who an inlay can help best.*

William F. Wiley, MD: Dr. Whitman, Dr. Bafna, thank you for joining me for this discussion. Could either of you speak on patient selection for corneal inlays early on?

Jeffrey Whitman, MD: Everything from marketing to how you talk to the patient, is picking the right patients. I’ve seen some mishaps out there. If they’re not a really good candidate for LASIK, meaning everything from tear film down to topography, thickness and so on, then they’re not a good candidate for an inlay. Whether it’s going to go in a pocket, or under a flap, if there are irregularities, or there’s significant map dystrophy, significant dry eye, all these things can affect results. Either they’re not going to be a candidate or you can get their eye in good enough condition that you could do LASIK on them and only then would you insert an inlay. That’s all part of good patient selection.

The other part of this: Don’t pick patients who can read without eyeglasses. I know that sounds silly, but if you pick patients who are 40 and can read J2 of J3 still, it’s difficult to make those patients happy because they don’t see the miracle. They got better, but it wasn’t that much better. It’s important to pick those patients who are truly dependent on reading glasses. Those are the people we can help the best.

Shamik Bafna, MD: First, I think a lot of times patients will come in to us in their low to mid-40s and they’re a little bit presbyopic but not that bad, and going straight in with an inlay may not be the right thing. You could go ahead and do a mild amount of monovision to get them by short-term with the understanding that long-term when their presbyopia, a dynamic condition, continues to worsen, then you’ve planted the seed where an inlay can correct things. Second, like Jeff said, the ocular surface is extremely critical, even more so than with LASIK. With LASIK, you can have a little bit of dry eye and the patient is fine. But irrespective of the type of inlay, if you don’t have a pristine ocular surface, you’re not going to end up with a good result. We will actually proactively put in a temporary punctal plug at the time of surgery for inlay patients, whereas we don’t necessarily do that for our LASIK patients. But the ocular surface is so critical with inlays that you have to do whatever you can to rehabilitate them.

Finally, the other part that is very important is that both of these approved inlays work best at a certain preoperative refractive starting point. With Kamra, you want to be -0.75 to -1.0 D. With Raindrop,* you want to be a little on the hyperopic side. I feel that a lot of our colleagues may take a patient who is close — maybe they’re only plano or something similar and they put in an inlay. Ultimately, in order to get happy patients, you have to optimize the patients from a refractive perspective to whatever that correct optimization level is for each respective inlay. Then I think you can expect to get happy patients. But if you don’t go through that optimization process, patients are not going to be as happy. (This conversation took place before ReVision closed its business.*)

Dr. Whitman: It is not just the knowledge of how to do a refractive procedure vs. just a simple cataract procedure. All these things have to do with looking at map dystrophy, looking at dry eye. We know that dry eye kills the multifocal and the extended-depth-of-focus patient’s level of vision, and it can be even worse for the inlay patient. As we get into presbyopia correction, whether it be by lens implant or by inlays or monovision for that matter, gone is the day where we can simply slip something in and assume that we’re done with it. Again, thorough preoperative evaluation — and make sure they’re a good candidate by cornea, certainly by lens and retina too.

One thing I’m very proud of saying is that my marketing for inlays has equaled probably a 20%+ increase in my presbyopic lens implantation and LASIK market, because a lot of these patients come in wanting a procedure, but we find out that they are not really presbyopic (good LASIK patient) and that they already have cataract changes (lens replacement candidate). I like to use the HD Analyzer [Visiometrics], not the one for centering but the HD Analyzer that looks at the media and it really picks up early cataract. We can show the patient this is where you are with your early cataract and you’re not a good candidate for an inlay; you’re better for a presbyopic lens. Or, you’re still reading up close well but LASIK may be a good idea for you.

Something that a lot of inlay surgeons have seen — because you’re doing something to the nondominant eye, you need to make sure that you’ve optimized vision in the dominant eye. A lot of times we forget that. From the Raindrop standpoint, patients have dropped a little bit in their distance vision, but I think that’s pretty true of all inlays. That’s what they’re sacrificing for that nice reading vision. But, if they’re not 20/20++, perfectly emmetropic in their dominant eye, you have a big problem because these patients are going to bitterly complain about driving issues. So, you need to think about the eye that is not getting the inlay.

Is the price right?

Dr. Wiley: Could you discuss pricing the inlay? Do you look at it as sort of looking at both eyes and saying, “To achieve the goal, we’re going to have a fixed price for whether we operate on one eye or both eyes, and whether you need LASIK or not LASIK in both eyes,” or do you go à la carte?

Dr. Whitman: We have a package price for LASIK and the inlay in the patient’s nondominant eye, but we don’t throw in or package the other eye. We actually charge full price for the other eye. Here’s the great thing about inlay patients. They’re generally in their mid-40s to mid-to-late 50s and they’ve worked for a long time and can afford it. They never argue with me about the price. But early on, when I wasn’t doing surgery to a +.5 or -.5 in the dominant eye, I would hear them moan about how miserable they were because they didn’t feel like they could drive well. Once I learned to correct the dominant eye and charged them for it, I didn’t find resistance to it. I got more 20/happy patients. I don’t think you have to discount that eye. I think they understand they’re getting a standalone procedure in that eye to make them happier in both eyes.

Dr. Bafna: We’re kind of the same way. We package the LASIK with the inlay with one eye, and if they need something in the second eye that’s sort of an independent procedure. That tends to work very well.

As opposed to younger individuals like millennials who are in their 20s and 30s and much more price sensitive, individuals in their 40s and 50s tend to be much less price sensitive. Difficulty with reading vision is a true disability to them, and they’re willing to pay what’s needed to correct it.

Dr. Whitman: The feedback I’ve gotten from some inlay patients are those I call the “working wounded.” These people are still working. They’re not – 72 and retired. I can’t tell you the number of times I’ve had patients come in and say, “I’m the odd one out in the office or in the board room and I’m the guy taking my readers off and on and I feel old.” It’s kind of like plastic surgery — I’m not making them look younger by doing this, but I think it’s a self-confidence feeling:“I’m like everybody else in the room now. I don’t have to take my readers on and off and I feel better about myself.” You’re doing a procedure that makes somebody in a key earning area feel better about themselves.

Everybody cares about price to some extent, but I think that unless you’re charging some exorbitant fee, it’s easy to explain what the advantages are and they’re willing to spend the money on it.

Reaching the right patients

Dr. Wiley: The patients coming in, are they mostly saying, “Hey, I want this inlay,” or are they saying, “I’m looking at getting refractive surgery. What do you have for me?” They are thinking LASIK, but then you are redirecting them and saying, “Well, we could do LASIK, but you can do LASIK plus this other refractive device and do the inlays.” Discuss how patients are learning about the inlays. Is it internal through a patient base, a captive audience that’s already there, or is it external that you’re actively bringing these patients in for this product?

Dr. Whitman: We do a fair amount of TV in our practice. It’s kind of direct-to-consumer in that they can read about it on our website as well. We’re really trying to hit that age range on TV, so we do have patients more often than not asking for it.

The ones that I’d like to find the secret sauce for, though, is the pseudophake (off-label treatment). These inlays should work just fine for pseudophakes. We’ve gotten really good about getting close to emmetropia with our pseudophakes, so you’d think this would be a great market. What I have found is that the longer they’ve been pseudophakic, the less interested they are in getting out of their reading glasses because they got used to them. They say, “I don’t need anything for driving. I just put my readers on when I need them.” And that seems to be very true for my retired patients. But younger patients and patients who had cataract surgery recently are more easily influenced to consider having an inlay.

Dr. Bafna: We don’t do as much direct marketing for inlays. We’ve got a slew of patients who come in for LASIK surgery who are already presbyopic. Since LASIK has been around for so long, most patients feel like it cures everything. When they come in for LASIK, they may come in with the concept that they want to have both eyes corrected for distance and may need to think about wearing reading glasses, or they may have heard of something called monovision with one eye distance, one eye near. These individuals are in everyone’s practice. They’re presbyopic, and you can discuss the advantages of an inlay as opposed to traditional monovision; you maintain binocularity in terms of not really sacrificing much distance vision in the inlay eye and you have something that gives them a greater range of vision, extended depth of field. Once you explain the differences between traditional monovision vs. an inlay, then most of these patients tend to go ahead with more of a presbyopic solution with the inlay.

Dr. Whitman: That’s part of the reason why we see that inlays help float our refractive boat higher. In the past, I think we were either putting off the 40-, 50-year-old patients and telling them they’re getting closer to cataract surgery age and we’d wait, or we’d suggest to them that clear lens extraction may be a good way to go. Now we have something that’s simpler, easy to explain and keeps those patients in the refractive market, and eventually they’ll need cataract surgery.

Dr. Bafna: It’s not just a function of the uncorrected vision. Many times patients may have 20/20 uncorrected vision in the dominant eye but refractively they may be +0.75. That may not seem like a big deal, but if you put the inlay in and the patient is accommodating that 0.75, the nondominant eye will not have as good near vision. So, even though in this situation they may have great distance vision, but because of having to accommodate in the dominant eye, they will not see as well in their near vision in the inlay eye.

Dr. Whitman: I think that’s the magic that even the companies don’t talk about. Always make sure you optimize the dominant eye, and you’ll have a happy patient.

Dr. Wiley: Do you see that overall your LASIK volume has grown? Let’s say you legitimize even the offerings to these younger patients, the 38-year-old who was sitting on the fence saying, why get LASIK when I’m going to need readers in a couple years anyway? Does it help legitimize the whole idea of refractive surgery now they have a more of a life-long solution?

Dr. Whitman: We have a continuum now, and I think that makes it easier for the patient. If I have a patient who’s 30, late 30s, early 40s, who is just going to have LASIK done, and this was just a Raindrop nonpocket thing, I’d cut the depth flap that I needed for Raindrop. I told them before, during and right after the surgery that at no extra cost to them I had thrown in this thicker flap so if they decided in the coming years that they wanted an inlay done, it would have been ready for that. And they’d profusely thank me because they knew that it was a possibility but they didn’t want or could not afford it with the initial LASIK surgery.

Dr. Bafna: I have sort of the same strategy when we incorporate Kamra. A lot of patients may be in their 40s. You discuss presbyopia, and they’re not really ready for an inlay. When we do their procedure with LASIK, instead of doing a true monovision, we may just do maybe -0.75 D and give them a little bit to help them short term. We let them know that in about five or seven years when their presbyopia gets worse, you have that option where you can create a pocket and put the inlay in. I like the concept of going ahead and basically setting patients up on the front end so that you have them optimized to go ahead with a procedure down the road.

Dr. Whitman: Bill, do you think we should say something about the dreaded subject of fibrosis? With the advent of mitomycin for all these inlay procedures, we’ve minimized that now. I think it’s good for people to know that’s not the issue that they may have heard or thought about in the past.

Dr. Wiley: That’s a great point. The two biggest things that help change inlays for us was doing it with LASIK, and then also the mitomycin C or ways to get around fibrosis. Those are probably the two biggest hurdles. What is the real risk or potential for removal? What do you see now with your newest techniques and what have you done to kind of eliminate that potential?

Dr. Bafna: With Raindrop, this works great from an inflammatory standpoint with mitomycin. With Kamra, mitomycin may not be as critical, but I think depth has been found to be a bigger issue. If one goes deeper with that inlay, the amount of inflammation created tends to be minimalized, because the deeper keratocytes have less likelihood of creating inflammation.

Dr. Whitman: Since even FDA approval, we’ve minimized the fibrosis issues by the use of mitomycin, thicker flaps, deeper pockets. If there are surgeons who have heard, “there’s fibrosis,” that’s a rare thing. It’s so rare for me to see that and to be a reason to remove an inlay. I’ve removed an inlay because the patient wasn’t thrilled with the vision, and I’d rather do that because that’s no harm. The patient will still have good vision.

Or I can consider a little hyperopic correction, which again is off-label and an annular treatment anyway. I can do it around a Raindrop inlay without removing the inlay and boost the reading vision a bit.

Dr. Wiley: How about other ways to spark the growth of inlays within a practice? We talked about the marketing aspect, the upgrade to LASIK aspect. How about staff members or VIP patients or creating these walking billboards within your practice?

Dr. Whitman: We’ve actually done staff members in the practice. That has been very helpful, because it gives people somebody that they can talk to right away. Celebrity endorsements I think can be useful, whether it be somebody in your practice, somebody willing to be vocal whom you’ve performed the procedure on.

Dr. Bafna: I think the biggest competition to inlays is monovision and making people understand what the differences are. I think a lot of our colleagues feel like, “Why get into the inlay segment because I could just do monovision?” They need to understand that this is not monovision. They may think it’s monovision because you’re basically just working on the nondominant eye, but there are a few things that inlays provide as opposed to monovision that brings such value overall.

Dr. Whitman: I think that’s important, because there’s not a substantial loss in distance vision in the treated eye, which makes it not monovision. For a LASIK patient or a cataract patient, I won’t do monovision unless they’ve worn contact lenses monovision sometime in their life and were successful with it because the failure rate is rather high. To explain to somebody about loss of some stereopsis or depth perception is difficult to do, but you’re pretty much going to extinguish their distance vision in that eye. You don’t want to do that with a surgical foray without them having been successful in it in contact lenses.

To me, that means that there’s a minority of patients who are good for monovision. It’s not a bad therapy, but again, surgical treatment shouldn’t be your first the patient’s first experience with monovision. It’s just not a good idea.

So, when I have a patient ask, “Is monovision something I could do?” If they say they have never tried it before, we ask him to try wearing a contact lens simulation. Generally they don’t like it, by the way, because it takes them a while to get used to it. So it’s easy to prove to them it’s not a great thing in their case. OM

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