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Up Front | May 2010

Editor’s Page: Premium IOLs: For A Promising Technology, it Still Has Compromises

ll premium IOLs share one characteristic: There is significantly more cost and time involved compared with monofocal IOLs. In this cover focus, John F. Doane, MD; and James A. Denning address the financial implications associated with premium IOLs in a typical US practice. However, the difference between the United States and Europe is that surgeons charge an additional fee for the extra time associated with premium IOLs, with the medical insurer reimbursing for the higher cost of the IOL. In Europe, the opportunities to charge an additional fee vary between countries. In the Netherlands, an additional fee is tolerated, but with no current reimbursement for the IOL. It is uncertain what the future holds. Bernard Heintz, MD, also defends the extra fee for premium IOLs. He, and other authors in this cover focus, emphasize extensive patient counselling in a refractive cataract practice.

Resi Pauwels describes her function as a refractive coordinator/ counselor at the Medipolis Centre, in Antwerp, Belgium. Her experience is a perfect example of how welltrained and motivated staff contribute to the premium practice. I envy my Co-Chief Medical Editor Erik L. Mertens, MD, FEBOphth, for having such great people at Medipolis. Surgeons must surround themselves with a strong staff before entering the refractive side of cataract surgery. I plan to implement this concept soon. Arthur B. Cummings, MB ChB, FCS(SA), MMed (Ophth), FRCS(Ed); and Pavel Stodulka, MD, PhD, reinforce the focus on patient counselling and mastering the patient conversation; I agree that a good preoperative strategy, even with the increased chair time, will ensure postoperative patient satisfaction. Stefanie Schmickler, MD, discusses her strategy to compensate for increased preoperative counselling in her article.

It is impossible to discuss all premium IOLs at the same level, because there are several types including multifocal, accommodating, toric, and supplementary IOLs. Although all models promise maximal postoperative outcomes, each has unique compromises. (Notice that I emphasized promise in the headline to remind the reader that both promises and compromises exist with premium IOLs.)

Multifocal IOLs provide some or complete spectacle independence, but at the cost of loss of contrast and optical side effects. The Lentis Mplus (manufactured and distributed by Oculentis GmbH, Berlin, and Topcon, Rotterdam, Netherlands) is attracting increased attention.

Toric IOLs are a promising technology, and toric multifocal IOLs are even more promising. Nienke Visser, MD, and colleagues confirm the opinion that these lenses provide excellent results, without any drawbacks. Bartlomiej J. Kaluzny, MD, states that LRIs have diminished importance with the availability of toric multifocal IOLs. LRIs are reasonably predictable for up to 2.00 D of astigmatism.

Many surgeons are not convinced of the suggested mechanism behind single-optic accommodating IOLs. The small central add of the Crystalens HD (Bausch + Lomb, Rochester, New York), combined with mini-monovision, should provide adequate intermediate vision. But, in my opinion, it should not be considered as a pure accommodating IOL.

Tanja M. Rabsilber, MD, and Gerd U. Auffarth, MD, overview existing premium IOLs on the European market. Antonio Toso, MD, and Simonetta Morselli, MD; and Leonardo Akaishi, MD, and colleagues, also provide a list of available premium IOLs in their pearls for considering and incorporating premium IOLs.

Much progress is yet to come for presbyopia-correcting IOLs. I would feel more comfortable with the concept of a good monofocal IOL in the capsular bag if a dedicated sulcus fixated add-on is implanted for residual astigmatism and/or multifocal correction. I advise traditional cataract surgeons who have had disappointing results with multifocal IOLs or have been uncomfortable with premium IOLs to first implement toric IOLs. The consensus is that these lenses offer benefits to patients and few potential pitfalls.