The Primary Care Optometrist’s Role in the World of Premium IOLs
Kevin R. Jackson, O.D.
1. Introduction to how the world of cataract surgery has changed over the last several
decades.
a. Briefly mention the advent of phacoemulsfication for “in the bag” cataract
extraction.
b. Briefly mention foldable IOLs that allow for micro, self-sealing, clear cornea
incisions during cataract surgery.
c. Start the discussion of premium IOLs by discussing their advent and some of the
different make and models.
i. Refractive multifocal
ii. Diffractive multifocal
iii. Anterior/Posterior translating lens (“Accommodating” lens)
iv. Toric
2. Having the Premium IOL conversation with the cataract patient
a. Having this conversation as the primary care O.D. is important because:
i. It lets the patient know that their primary care eye doctor is up to date on
the latest technology. This will give them more confidence in their
primary care eye doctor for the pre and postoperative periods of the
cataract surgery
ii. It prepares the patient beforehand so they won’t be overwhelmed by new
information when they meet with the ophthalmologist.
a. This includes both cost concerns and understanding of the
actual surgical procedure itself.
b. This will allow the patient to make an informed decision
about their having premium surgery more quickly,
therefore, not delaying their care.
iii. It will really build the primary care O.D.’s relationship with the premium
surgeon. The surgeon will then be more available for consultation on all
matters eye care whenever the O.D. might need him/her.
3. How to select a premium IOL surgeon for your patients.
a. Firstly, why is it important for your patients to have cataract surgery by a
premium surgeon?
i. Even if the patient doesn’t end up with a premium IOL, the patient will
probably be more thoroughly screened preoperatively than by a nonpremium surgeon. Premium surgeons are more careful about screening
the cornea and macula before surgery. These surgeons also try to disrupt
the eye as little as possible while doing cataract surgery because premium
IOLs demand a stable eye post operatively for ideal results.
b. The primary care O.D. needs to reach out to different surgeons in the community
and ask a few questions of the surgeon:
i. What is your philosophy on premium IOLs?
1. The O.D. should ask some variation of this question just to see
where the surgeon lands generally on the concept of premium
IOLs.
ii. What is your conversion rate to premium IOLs? Or, what percentage of
your cataract surgeries use a premium implant?
1. This is probably the best question to gauge the surgeon’s use of
premium IOLs. If the surgeon tells the O.D., “5-10%”, then this
should serve as a red flag to the O.D. not to use this surgeon as a
premium surgeon. “Practice makes perfect” mentality.
2. Most good premium IOL surgeons are above 40-45%.
iii. What is your multifocal IOL of choice?
1. Asking this question or another specific question will really show
the O.D. what the surgeon knows about premiums.
c. Take a tour of the surgeon’s office
i. If the office looks very outdated, then the surgeon’s skill has a high chance
of being outdated.
1. Being a premium surgeon means having equipment to screen the
eye preoperatively that will increase the chances of a “premium
outcome.”
a. Premium surgeons will use diagnostic equipment such as:
i. Automated/optical biometry
ii. Corneal topography/tomography
iii. Endothelial cell analysis
iv. OCT (for macular screening)
b. Premium IOL demands the post operative power to be
within 0.5D of target in order for it to function its best.
d. Notice what the surgeon does to be involved in the community and in academia
i. If the surgeon never gives a talk to a local society or academic conference,
then he/she doesn’t have much interest in pursuing a premium practice.
1. Giving lectures is a good way for the surgeon to educate people,
but it is also important for building his/her practice. A premium
surgeon is very motivated to build his/her practice, and if you don’t
see the surgeon being involved in his/her community at all, then
he/she isn’t interested in being a premium surgeon.
e. It is essential to have a premium surgeon who is also proficient in LASIK/PRK
i. This will give the patient and the primary care O.D. confidence that the
visual result will be obtained even if a refractive enhancement is needed
ii. A good LASIK/PRK surgeon will be able to make adjustments to the
cornea taking into consideration the increased demand of the optics of the
premium IOL
4. Premium IOL cataract surgery should be done when the patient is younger
a. No longer should we wait to refer patients for cataract surgery when the cataract
is “ripe.”
i. Surgery is medically necessary when there is a complaint associated with
an activity of daily living and they are 20/50 best corrected, glare to 20/50,
or glare to 2 lines worse than BCVA
b. Cataracts are “ripe” typically when the patient is in his/her 80s and is less active.
1. Having surgery earlier will restore visual function to those who can
more fully utilize their improved vision.
5. Lost glasses revenue and the premium IOL patient
a. It is true that if premium IOL cataract surgery is successful, then the patient will
no longer need a pair of glasses.
i. Some of this loss of revenue will be offset by the comanagment fee that
the O.D. should collect. Although this fee will not make up for all of the
lost glasses revenue, if the patient is happy, then the O.D.’s practice will
grow because of word-of-mouth referral.
ii. Don’t worry primarily about the bottom line, but worry more about what
is best for the patient.
b. Some premium lenses like toric lenses or accommodating lenses will leave the
patient with occasional glasses use anyway. The O.D. can profit from this.
6. Postoperative visits with premium IOL patients/Tips for making the premium patient
happy
a. It is important to be very excited for the patient who has had a premium IOL
i. They have invested some of their money in something that has promised
to perform at a high level, so being excited for them at each post operative
visit is important.
b. If the patient is a multifocal or accommodating IOL patient, show them what their
vision would have been like at near without the premium IOL
i. Give them -2.50D trial lenses in a trial frame and have them try to read a
near card
c. If the patient is extremely satisfied with their vision, and they have reasonable
visual acuity, DO NOT REFRACT!!!
i. By refracting them, this will put doubt in their heads that their surgical
result wasn’t good enough.
d. If you do refract and find 0.75D astigmatism in a toric IOL patient, DO NOT GO
ON AND ON ABOUT THERE STILL BEING ASTIGMATISM LEFT OVER!!
i. These patients will see fine, and trying to do a LASIK/PRK enhancement
of 0.75DC is risky because the error bar of the laser is about 0.5D
e. In my experience in dealing with premium IOLs during residency, we only had
one multifocal IOL exchange during that year (and this surgeon was 90%
premium, doing 25-40 eyes per week!!)
i. This was because of a careful preoperative screening of the eye from
cornea to retina and quick/efficient postoperative management of
complications like corneal edema.
ii. Emotional management of the patient was as big of a contributing factor
as was the clinical management
1. It is important to stay calm and collected with these patients and
gently guide them through the post operative process
7. Keep an open mind when it comes to premium IOLs
a. Just because an O.D. may have experienced one or two bad results, don’t give up
on the technology
i. Evaluate which surgeon did the surgery, and why was there a bad outcome
1. The O.D. can always try a different surgeon, one that he/she has
more confidence in.