MAY 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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30 EW CATARACT May 2013 The art of advanced technology IOLs Addressing the most common cause of patient dissatisfaction by Richard Tipperman, MD Richard Tipperman, MD T ipperman's dictum #1: The No. 1 cause of patient dissatisfaction with advanced technology IOLs is residual refractive error. Corollary to Tipperman's dictum #1: Correcting this refractive error leads to a happy patient. I am always surprised at the number of patients I see in consultation for a "problem" with their advanced technology IOL who smile and respond, "That's great. That's how I want to see!" when I hold an appropriate trial lens up in front of their operated eye. Ophthalmologists have learned over time that even small residual refractive errors of 0.5 D can have a dramatic effect on patients' visual function. Fortunately, as noted above, in these instances, correcting the residual refractive error resolves the problem. There are multiple ways that surgeons can correct a residual refractive error after cataract surgery, which include optical correction, mini-RK, piggyback IOL, IOL exchange, or laser vision correction. Optical correction is obviously the simplest and least invasive way to correct vision, and I still feel it is important to discuss it as an option with the patient. Nonetheless, nearly 100% of patients with advanced technology IOLs will state, "Oh no, I don't want glasses. I paid all that money so I would not have to wear them again." Piggyback IOL and IOL exchange are both viable methods for correcting residual refractive errors; however, they require performance of an intraocular procedure and may have limited effect on residual cylinder. Mini-RK also can be helpful for small levels of myopia, but it is not a commonly used procedure and has the potential for regression and variable effect. If the patients' spherical equivalent is plano and they have a low astigmatic error, then limbal relaxing incisions or astigmatic keratotomy can be a very effective solution. In most cases of residual refractive error, surgeons will consider laser vision correction (LVC) if there are not any contraindications. LVC offers the safety of an extraocular procedure along with a predictable treatment. For anterior segment surgeons who perform LVC, this is very straightforward; however, many cataract surgeons do not perform LVC, and there is always a question as the best way to arrange for and handle a refractive procedure that will be performed by another surgeon. The voucher option For those cataract surgeons who do not perform LVC, I will describe an approach termed a "LASIK voucher," which addresses many of the logistic issues that can occur if the original operating cataract surgeon does not perform LVC. (Actually, this can even be used by surgeons who perform LVC for their own advanced technology IOL patients.) Obviously all surgeons want to provide the best care possible for The debate continued from page 29 of whether or not to use this type of procedure. The biggest impediments are that if an infection occurs, it could affect both eyes. Possible problems like endophthalmitis or TASS occurring on the same day are bigger concerns than the cost of the procedure, she said. EW Editors' note: Dr. Bakewell has financial interests with Abbott Medical Optics (Santa Ana, Calif.). Dr. BragaMele has no financial interests related to the article. Dr. Thompson has no financial interests related to this article. Contact information Bakewell: eyemanaz@aol.com Braga-Mele: rbragamele@rogers.com Thompson: Vance.Thompson@SanfordHealth.org their patients. If Dr. Jones, a cataract surgeon, does not perform LVC, he can partner with Dr. Smith, a refractive surgeon, in his own or nearby community. When Dr. Jones' patients schedule surgery for an advanced technology IOL, they receive a "voucher" from Dr. Jones good for a reduction (for example, $1,000*) off the cost of a refractive procedure should they need an enhancement following their cataract surgery. For example, if Dr. Jones operates on a patient with an advanced technology IOL and the patient ends up with a residual refractive error, he can refer the patient to Dr. Smith, his refractive colleague, for management and correction. When Dr. Smith sees the patient and concurs that the patient is a good candidate for LVC, she can explain that the cost for LVC is normally $2,000 but because of the "LASIK voucher" the patient has from the operating cataract surgeon, the patient will receive a $1,000 discount. The patient then undergoes LVC by Dr. Smith to correct his or her residual refractive error. This makes both Dr. Jones (the original cataract surgeon) and the patient happy, but does not really offer much benefit to Dr. Smith, the refractive surgeon. In most cases, Dr. Jones' cataract surgery patients will not require a refractive procedure and so are just left with a worthless piece of paper. As such, in this format, the "LASIK voucher" program would not be selfsustaining since it is not beneficial to all parties involved and not utilized in most cases. However, with one simple change, the LASIK voucher becomes both self-sustaining and beneficial to all parties each and every time. At the bottom of the voucher certificate is printed wording such as: "This voucher is transferrable to a friend, family member, or co-worker for a BILATERAL laser vision correction with Dr. Smith." There are many advantages to adding this wording and it makes things "win-win" for everyone involved. As noted above, most patients who receive advanced technology IOLs are not going to need LVC enhancement. In this case, they can give the certificate as a "gift" to a friend or family member who then receives a $1,000 discount from Dr. Smith, the refractive surgeon, for bilateral LVC. The original cataract patients are thrilled because they got back from their advanced technology IOL a full $1,000 of value, which they could gift to another person. The patients who elect to undergo LVC are happy because they receive a true $1,000 discount, and Dr. Smith is happy because she is able to increase the volume of her refractive surgery practice with a $500 per eye discount and no other associated marketing costs. Finally, Dr. Jones, the cataract surgeon, is happy because he knows that this approach treats everyone fairly and allows his rare patients who need a refractive procedure to have a discount with a refractive surgeon (Dr. Smith) who is willing and motivated to provide those services. With this approach, the most common problem associated with advanced technology IOLs—residual refractive error—can be addressed by any anterior segment practice, even if it doesn't provide LVC services "in house." One final note There are some patients where there is a high likelihood of them requiring a refractive enhancement following their advanced technology IOL surgery. A classic example would be a high astigmat who wishes to receive a presbyopia-correcting IOL. In these cases, it is important to discuss the issue of bioptics preoperatively with the patient, including any additional costs. Even more important, however, would be to formally assess the patient's cornea with pachymetry, mapping, and possibly even wavefront measurements to determine prior to the cataract surgery the patient's candidacy for LVC. EW *All pricing described is for example purposes only and does not necessarily reflect or suggest pricing in any community. Editors' note: Dr. Tipperman is affiliated with the Wills Eye Institute, Philadelphia. Contact information Tipperman: rtipperman@mindspring.com

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