A Chinese philosopher once said, "When there is a lot of wind, one should not seek a hiding place but build windmills." In other words, this adage urges us to exploit all possibilities and act accordingly.
What if we translate this logic into advice for cataract and refractive surgeons? The message would be threefold: (1) in his armamentarium, the surgeon should include all innovative techniques that may benefit his patients (2) he should let the community know that these techniques are available in his office, and (3) he should have adequate experience and training to properly select patients and flawlessly perform these treatments.
INNOVATIVE TECHNIQUES, NEW IOLs
For several years now, all major IOL manufacturers have offered some type of premium option, including aspheric, multifocal, and accommodating IOLs. I will not discuss the differences or pros and cons of each of these lenses because this is not the scope of this review; however, I will discuss a general approach to incorporating refractive IOLs into your practice.
Aspheric IOLs. If a surgeon has no experience with refractive IOLs, the simplest approach is to begin with the aspheric IOL. These lenses either balance or counteract the positive spherical aberration in the cornea and therefore induce significantly less spherical aberration into the eye. Clinical studies1-8 emphasize the ability of new-generation aspheric IOLs to improve contrast sensitivity.
When deciding which aspheric IOL is best for each individual, the surgeon must employ his modern methods to determine wavefront aberrations. According to a patient's wavefront measurement, the surgeon will decide if this particular patient needs (and will benefit from) an aspheric IOL. If the patient will not benefit from an aspheric IOL, the surgeon should reassure him that the IOL most suitable for his condition will be used.
Presbyopia-correcting IOLs. A modern practice should offer presbyopia-correcting solutions, such as multifocal and accommodating IOLs. These technologies are valid for the cataract and the refractive surgeon. The refractive surgeon will be able to treat more patients, including those with moderate to high hyperopia and presbyopia, when he includes presbyopia-correcting IOLs in his practice.
HOW DO YOU DISCUSS THE ADDITIONAL COST?
It is important to identify which patients will pay the extra cost associated with a premium IOL. Clinical experience should guide the surgeon: He must first recognize if the patient is a good candidate and then discuss the options and price afterward. An honest and open discussion of all treatment options is a prerequisite, especially for hyperopes.
My current approach for presbyopia correction is to mix and match, specifically with a zonal refractive ReZoom (Advanced Medical Optics, Inc., Santa Ana, California) and a diffractive Tecnis IOL (Advanced Medical Optics, Inc.). This combination allows excellent distance, intermediate, and near vision, provided that the IOL power calculation was correct. Patient selection is also crucial when mixing and matching IOLs.
HOW DO YOU REACH YOUR PATIENTS?
How do you give maximum information to the maximum number of patients? The best publicity is word of mouth; however, start by first attracting patients in your own office. Here are some tips:
- Make sure that enough brochures or informational pieces are readily available for your interested patients to pick up and read in the waiting room or take home;
- Create a Web site and update it regularly;
- Use other available audiovisual media, including DVDs and the IOL Counselor (Patient Education Concepts, Inc., Houston; and Eyeland Design Network, Germany; See Converting Patients to Premium IOLs With the IOL Counselor) because patients absorb more information by seeing it;
- Have a direct camera connection between the waiting area and your surgical microscope or surgical theater, therefore providing a live feed of the surgery to clientele, family members, and other patients. You can choose to show a view of the entire surgery room or the surgery itself;
- Mix the patients who already underwent surgery with patients in the presurgical area so that that they can exchange experiences; and
- Provide the patient with a recording of his surgery.
More than 20 years ago, I started giving my patients a video recording of their own surgery. Now, I provide them with a DVD of the procedure. Most are interested in watching it afterward and show it to their friends and relatives. Have your name, address, and Web site on the casing. It is a powerful advertising tool.
HOW DO YOU SELECT AND EDUCATE PATIENTS?
Understanding patient selection is primordial and probably more important than the surgery itself. In most cases, an experienced refractive surgeon will immediately sense if a patient is a good candidate for a premium aspheric or multifocal IOL by discussing the patient's lifestyle, needs, and expectations. A surgeon's intuition can be improved by attending educational forums, such as conferences, courses, and wet lab sessions; however, the most important part of the selection process is to advise and counsel patients.
The approach a European surgeon takes to counsel patients is different from the approach of a US surgeon. Generally, European surgeons spend more time with the patient before surgery; however, we do not use the available audiovisual media as well as US surgeons do. We are also not used to delegating part of the counseling process to our technicians, advisers, or nurses. I speculate the cause of our behavior is threefold: (1) fees for technicians and nurses are much higher in Europe, (2) work regulations are tougher in Europe than in the United States, and (3) the traditional European patient is more demanding and wants to speak directly to the doctor.
I am convinced that we could do a better job educating our patients. Automated programs, such as the IOL Counselor, can aide us in educating the patients we currently have and attracting new patients to our practice. It may even convince some patients to choose a premium IOL.
WHAT DO WE PROMISE?
The cataract patient is typically less demanding than the refractive patient. If you do not currently offer premium IOLs, the ideal candidate with whom to start has moderate hyperopia (2.00 to 5.00 D) and is between 50 and 60 years of age. Patients with presbyopia who do not experience distance refractive problems are extremely demanding and are better avoided until you have more experience with premium IOL technology.
Patients always remember the first sentences of any surgeon-patient discussion. Some general sayings, such as underpromise and overdeliver and more chair time before surgery is less chair time after surgery, reflect our surgical goal. The patient should feel that we are confident enough to manage his needs without overselling the product or service. If a patient is a good candidate for presbyopia-correcting IOLs, we should explain the whole story—the good and bad news.
In my practice, I tell patients that the majority (more than 95%) of them will be spectacle independent for far, intermediate, and near vision. I provide patients with actual data so that they can clearly understand the risks and benefits. I tell patients that some will need as long as 1 to 3 months to adjust to the IOL, some will be spectacle independent for near vision, and only a minority will need glasses for intermediate vision.
Our latest customized approach is to mix and match the Tecnis Multifocal and ReZoom IOLs. Our latest study followed 45 patients for 3 months, at which point not one patient used glasses. In a 10-center, prospective study, 160 patients were followed for 120 to 180 days. A total of 96% of patients were spectacle independent at follow-up. Halos and glare were reported as mild in most cases; only a few patients described their symptoms as moderate. All patients said they would select the same procedure again.
The key to building a successful refractive IOL practice is to include innovative techniques that appeal to patients' needs. A surgeon should never stop learning how to incorporate new innovations into his practice; he should have adequate experience and know how to select appropriate candidates.
The first battle is making sure patients come through the door so that we may educate them about our procedures and continue to build our refractive IOL practice.
Frank J. Goes, MD, is the Medical Director of the Goes Eye Centre, Antwerp, Belgium. Dr. Goes states that he receives travel support from Advanced Medical Optics, Inc., and Carl Zeiss Meditec AG. Dr. Goes may be reached at tel: +32 3 2193925; fax: + 32 3 2196667; or frank@goes.be.
