Refractive Surgery | May 2010

Managing Patient Expectations With More Chair Time

Learn how to control patient flow.

The use of premium lenses has become common in ophthalmic surgery all over the world. With the introduction of the Crystalens (Bausch + Lomb, Rochester, New York), the ReZoom (Abbott Medical Optics Inc., Santa Ana, California), the Restor (Alcon Laboratories, Inc., Fort Worth, Texas), and the toric lenses available today, the use of premium lenses has climbed from 2% to 7.6% in the United States (Marketscope 2010). Europe is starting to experience a similar trend.

Usually social insurance covers cataract surgery only with a standard IOL (a foldable lens with a 6-mm spherical optic with a sharp edge). With standard lenses, patients can focus only at one distance; therefore, these lenses often do not fulfill patients' special needs. Premium lenses, including aspheric, toric, and presbyopia-correcting IOLs, have the potential to improve patients' quality of life when properly selected for the individual. However, introducing these IOLs to the patient requires extra preoperative counseling.

Aspheric lenses such as the Tecnis optimize mesopic vision and contrast sensitivity as long as the patient's pupil does not get too small in mesopic conditions. Therefore, younger cataract patients who drive a lot, even at night, benefit from the aspheric lens design. Some aspheric models have a blueblocking filter to eliminate dangerous blue light and protect the retina from macular degeneration. There are many opinions on blue-light–filtering IOLs, but no clinical proof that they protect the macula. In Europe, Hoya (Tokyo), one of the world's first manufacturers of blue-blocking lenses, is in the process of conducting a 5-year intraindividual comparison of white and yellow lenses; it will take some time until we will know the results.

Toric lenses such as the AcrySof Toric are a good option for patients with astigmatism of at least 1.50 D. Although high astigmatism can be corrected with limbal relaxing incisions (LRIs), quality of vision is better after IOL correction or LASIK due to the remaining higher-order aberrations with LRIs.1 Very often, BCVA after toric lens implantation is better than the patient's preoperative BCVA if the lens is placed in the precise axis.

Multifocal lenses provide good visual acuity at near and at distance, and the goal is to provide patients with spectacle independence. However, surgeons cannot guarantee that this goal will be reached with a single surgery. In some cases, patients accept the costs for a touch-up with LASIK in order to become happy patients. Otherwise, glasses for a specific distance (near or far) are still necessary. The patient must be informed preoperatively that greater visual benefit will be noticeable after surgery of the second eye; they should also understand that it will take time until visual acuity stabilizes due to neural adaption to the two foci of multifocal lenses. Proper patient selection for multifocal IOLs is crucial. Sometimes, patients may not fully understand the mechanism of multifocal lenses, which require more preoperative consultation and chair time than any other type of premium lens.

In the United States, presbyopia-correcting IOLs account for 50% of the premium lenses implanted today.2 Surgeons in the United States seem more partial especially to accommodating IOLs, compared with European surgeons.

The Internet, journals, and other resources detail clinical results as well as personal accounts of success with premium lenses. Patients often enter our practices asking for these lenses, but they may be disappointed when they find out these premium lenses are not covered by social insurance. Fear, confusion, cost, family, and the possible need for spectacles postoperatively are reasons why a patient might not choose a premium lens. The surgeon must remain committed to counseling the patient through these doubts to ensure that the patient receives the best lens for his personal requirements.

In my part of Germany, we are not allowed to charge extra fees for premium lenses. Cataract surgery is paid for by insurance only if the patient's BCVA is 20/40 or worse. If the patient wants a premium lens, he must pay for the entire procedure. Therefore, less than 1% of my socially reimbursed patients opt for a premium lens. However, taking into consideration that the present cataract population is of the post-World War II generation, they have typically saved more money than the young generation of today. The trend among the younger generation is to directly spend what is earned, which is why people in this patient population are good candidates for LASIK.

Because the older population has more money saved, there is still a chance to convert them to a premium IOL. It is important to tell patients about the benefits of premium lenses and explain that it is worthwhile to spend extra money for a lens that will stay in the eye for the rest of their life. It helps if a family member accompanies the patient to the preoperative exam.

The extra cost should not only refer to the difference in price between standard and premium lenses, but it also includes the extra time and additional preoperative exams, including topography for toric and multifocal lenses. During toric IOL implantation, the axis must be marked while the patient is seated. Additionally, patients who receive a multifocal lens need adequate treatment postoperatively, which often includes reading training that demonstrates the distance at which the patient can read best. Patients who are suitable for an aspheric lens should undergo contrast sensitivity testing as well as measurement of pupil size before surgery. Patients who are considered to be good candidates for blue-blocking IOLs or presbyopia-correcting IOLs should undergo optical coherence tomography.

In my opinion, the ophthalmic surgeon should take time to talk to patients during the preoperative exam, providing a general overview of cataract surgery. At the end of the preoperative exam, the surgeon should mention the availability of premium lenses and their benefit over standard lenses. At the end of the conversation, I may say something like the following: “For you, I recommend a toric lens, because you have high astigmatism. My assistant will tell you more about this lens and its extra fees.” In this way, the surgeon does not spend extra time explaining all of the premium lenses but refers to his well-trained assistant to continue the preoperative counseling process.

The optometrist or refractive manager should administer any additional chair time, including explanation of lens types. The surgeon should not act as a sales manager in his practice. Patients usually appreciate the preoperative counselor (I refer to this role as the premium-lens manager), because they do not feel forced to choose the premium lens in front of the surgeon. In these cases where they do feel forced, patients will often end up canceling surgery. Once the patient selects a lens, the premium-lens manager arranges the date for surgery and goes over all instructions for the day of surgery. The entire counseling process can take as little as 30 minutes when done effectively.

We have to invest chair time to teach patients about the benefits of premium lenses. There must be a wellinformed staff member dedicated to preoperative patient counseling who should talk to patients and discuss the advantages and disadvantages of the available lens options. If patients have questions, they should feel comfortable asking the premium-lens manager and have the opportunity to talk to the surgeon during their visit. The patient flow for cataract surgery with premium lenses is shown in Figure 1.

Premium IOLs represent an enormous value to the patient, with minimal risks, high success rates, and maximal benefits. The patient will use every waking moment of his postoperative life considering the value of excellent vision.

Stefanie Schmickler, MD, practices at Augenärzte Gemeinschaftspraxis Ahaus-Gronau- Lingen, Germany, and Augen-Zentrum-Ahaus, Germany. Dr. Schmickler states that she has no financial interest in the products or companies mentioned. She may be reached at tel: +49 2561 93000; fax: +49 2561 9300138; e-mail: