Refractive Surgery | May 2010

The Surgeon’s Incentives for Adopting Premium IOLs

Offering these lenses may encourage more word-of-mouth referrals.

In the past decade, we have seen an explosion of IOL technology. When combined with improved surgical techniques and more precise biometry, this array of technologies provides surgeons with new and exciting perspectives to offer patients. Parallel with the increased possibilities of lens-based surgery, we note a steady evolution of patient expectations. The baby boomers are getting older, but they maintain an active lifestyle and expect to continue doing so through the coming decades of life. Facing an active older population that expects excellent quality of vision, we are pushed to go further and offer products that produce optimal postoperative outcomes. Meeting patients' expectations with a high standard of care like that provided by premium IOLs may be an ideal solution.

Cataract surgery has undergone some refinements in the shift toward premium IOLs, including changes in the definition of cataract surgery, the technologies surgeons consider, patients' definition of quality of service, procedural costs, and the amount of educational material available to patients on the Internet.

Definition of cataract surgery.
In the past, patients who complained of blurred vision due to cataract followed a common treatment pathway. The solution for every patient was monofocal IOL implantation; however, soon after surgery, patients routinely needed a new bifocal prescription. Now, the possibility to choose an IOL design based on the patient's individual needs creates a major challenge for the surgeon, we must insure that every patient makes the right choice. This choice may be purely basic, as before, or it may be partly refractive, merging our cataract and refractive surgery patient populations. Several good options are possible, making the decision more difficult.

IOL technology and patient expectations.
Obviously, these are the main triggers for the current evolution to premium IOLs. Before deciding on what lens to implant, two questions should be resolved: (1) Does the patient want a premium lens, and (2) Is the patient a good candidate for a premium IOL?

We do not want to get caught in the trap of selling surgical solutions. It is rather our responsibility to present the best possible option that meets the patient's individual demands. For example, the patient who mentions that he plans to continue wearing glasses postoperatively will be dissatisfied with a diffractive multifocal IOL that leaves him with halos at night.

The next step in this equation is to ensure that the patient is a good candidate for a premium lens. It is crucial to take time to discuss everything in detail before surgery. All side effects, even minor, are more likely tolerated if the patient knows about them before implantation. Failure to mention such information preoperatively may result in a dissatisfied patient, fixated on an often minor side effect and unable to adapt. Do not forget that a lack of chair time preoperatively must be compensated for with much longer and more stressful chair time postoperatively.

Do not assume your patients are not interested in premium lenses because of the higher cost. I too often see patients who were not given the opportunity of getting a premium lens. Take your time to explain the pros and cons of the premium IOL; as the more expensive option for the patient, it deserves more of your time.

Selection of the appropriate premium IOL requires a delicate balance between the patient benefits and the lens' side effects, with favor given to patient benefits. There are always minor drawbacks, including the increased cost for the patient and unwanted visual symptoms such as halos, suboptimal intermediate vision with diffractive multifocal IOLs, and slightly compromised near UCVA with accommodating IOLs. Patients should be warned of these and other potential side effects preoperatively, so that they are prepared to tolerate them to achieve the advantages of the premium technology.

The decision to implant toric lenses does not require the same balance of side effects, as the only disadvantage is its cost. This makes the decision more straightforward.

Patient definition of quality of service. Every patient receiving a premium IOL should be considered a refractive surgery patient, which requires attention to several points:

  • Include an extensive preoperative consultation, with time to evaluate the patient's condition and possible treatment options. After evaluating the patient's demands and needs, a motivated recommendation should be made. The patient should never be sent home with a multitude of open options;
  • The patient should be involved in the decision-making process. Use a questionnaire to evaluate the needs of the patient;
  • All possible side effects should be disclosed, and it is imperative that the potential need for a secondary touch-up procedure should be discussed before surgery;
  • Quality surgery is mandatory, and biometry should be accurately measured using the IOL Master (Carl Zeiss Meditec, Jena, Germany) or immersion A-scan. A-constants should be optimized;
  • The patient deserves immediate and unlimited access to the surgeon in case of postoperative problems;
  • Pay attention to each complaint. The patient must be convinced that he is getting the best possible care;
  • Always provide the means for secondary touch-ups, such as LASIK or astigmatic keratotomy, in case of even minor residual refractive errors. Show the patient you are willing to optimize his spectacle independence; and
  • Stress the fact that you are providing a state-of-theart solution but that even the best procedure is not a guarantee for perfection. The patient should be aware that he is getting the best possible solution and that he should be proud of it.

Procedure costs. Implantation of a premium lens always generates an extra cost for the patient. People appreciate expensive goods more than cheap ones. It gives an extra connotation of quality, of extra care. Moreover, extra chair time must be included in the additional cost to the patient. It seems reasonable to charge an extra fee for this extra commitment.

Internet. The amount of knowledge patients have about new technologies has increased tremendously because of the Internet. Often, patients enter the clinic with precise questions and a good understanding of the choices available to them. This phenomenon will only increase as today's population becomes more comfortable with the use of the computer and the Internet.

A successful shift to premium IOLs will transform a cataract-based practice to a refractive surgery practice. There are two major advantages to this scenario: increased patient satisfaction and distinction as a quality institution.

Increased patient satisfaction. This will not happen by itself; you must change the way you approach the cataract patient. Lengthening preoperative chair time and having a staff member dedicated to patient counseling are subtle ways to ensure that the patient is happy. The extra time and effort spent on the patient are more than rewarded. Your patient has the notion he got something more: the best possible care.

Distinction as a quality practice. Adding the option of premium IOLs gives your practice a quality label. Patients acknowledge that the practice is going one step further to serve patients. This increases patients' confidence in you as well as the practice. This is only true if the complete path of quality is at a uniform level throughout the patient's experience. You need a wellorganized office, kind and competent assistants, a professional organization, and clear and correct preoperative information.

If well conceived, the incorporation of premium lenses into your practice will give you a quality boost over your competition. Patients will be proud to have the best solution, and this will make you the best doctor in their eyes. Patients who are proud of their lenses and of their surgeon will tell their fiends and relatives about their experience.

Even if 70% to 80% of patients continue to choose a standard monofocal IOL, they know that, by offering premium IOLs, their doctor is dedicated to the latest technologies. This strategy works only if your premium lens patients are happy postoperatively. Therefore, counseling and correct patient selection are of utmost importance.

Incorporating premium IOLs is not a free lunch ticket; it is a quality label for your practice, and it demands a consistently high-quality environment. If successful, your cataract profile will shift from quantity- to quality-driven. It is a choice for you to make, and I am convinced it is an excellent choice.

Bernard Heintz, MD, practices at Oogcentrum Brugge, Belgium. Dr. Heintz states that he has no financial interest in the products or companies mentioned. He may be reached at tel +32 50 332607; fax +32 50 341140; e-mail: