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Presbyopia-Correcting IOLs: Which patients are choosing them?
BY JERRY HELZNER, SENIOR EDITOR

David Pernelli, M.D., practices in blue collar Vineland, New Jersey, which is located in Cumberland County, the poorest county in the state. Yet 20%-30% of his cataract surgery patients are choosing to share the significant cost of having presbyopia-correcting lenses implanted. That compares to the results of a national survey taken by the industry newsletter MarketScope, in which the consensus of surgeons was that about 16% of their cataract patients would opt to pay $2,000 an eye for these premium IOLs in 2006.

"When people want these lenses, it's amazing how many find a way to have them," says Dr. Pernelli.

The fact that Vineland has a predominantly Italian-American population, characterized by large, close-knit families, may contribute to the relatively high percentage of cataract patients who choose to pay the additional cost of these IOLs.

"I think it's a factor," says Dr. Pernelli. "We're seeing adult children chip in and give the lenses as a Christmas present because 'Mom wants them.' I don't know if you see that in every community."

But ethnicity aside, Dr. Pernelli believes that other elements are playing a more important role in his success with presbyopia-correcting IOLs.

"I don't pre-determine who might be able to afford these lenses," he says. "We explain their possible advantages to everyone. I think as a surgeon you have to believe in these lenses and be committed to them." Dr. Pernelli has received training to implant all three of the currently FDA-approved presbyopia-correcting lenses — the ReZoom (Advanced Medical Optics [AMO], Santa Ana, Calif.), the AcrySof ReSTOR (Alcon, Fort Worth, Texas) and the crystalens (eyeonics, Aliso Viejo, Calif.). This enables him to offer options for patients with a variety of lifestyles, ranging from those who mainly want to read to those who do a substantial amount of night driving.

"We also offer financing, which is the way the majority of my patients handle the costs associated with these lenses," he says.

Dr. Pernelli also takes ads in the Vineland daily newspaper and has given two seminars on IOL options at the local hospital.

"But more than any of that, I think I have built up a trust factor with my patients and their families over the years," he says. "I'm heavily involved in the community. I coach football. I'm a Boy Scout leader. When I recommend the presbyopia-correcting lenses to a patient, they don't see it as a sales pitch. They see it as good advice from someone they trust."

Dr. Pernelli's experience with these IOLs is not the exceptional case. Other surgeons concur that income level is not always the chief determinant of which cataract patients opt for presbyopia-correcting lenses. This article will explore why the marketplace for these premium-priced IOLs is more complex than it may appear at first glance.

A Surprising Statistic

Farrell Tyson, M.D., of Cape Coral Eye Center in Cape Coral, Fla., has five offices on the west coast of Florida, serving a patient base that ranges from wealthy to working class.

"It's interesting that we're seeing about 40% of our lower-income cataract patients choose the presbyopia-correcting IOLs while only about 20% of our affluent patients opt to share the cost," says Dr. Tyson. "I can't totally explain that statistic but many patients of modest means simply pull out a credit card and say 'I want the best.' We also offer financing, but only about 5% of our IOL patients who share the cost are choosing to finance."

Dr. Tyson believes that his success with presbyopia-correcting IOLs comes from his willingness to spend time with his cataract patients, listening closely as they tell him about their lifestyles and what they would consider a good outcome.

"I believe in talking about outcomes," he notes. "I discuss my outcomes in our advertising."

As with Drs. Pernelli and Tyson, all the surgeons who are enjoying success with presbyopia-correcting IOLs cite surgeon commitment to the lenses as key in patients choosing to have them implanted.

"Surgeon confidence and commitment are very important factors," says David Chang, M.D., of Los Altos, Calif. "The concept [of presbyopia-correcting IOLs] is complicated and can be confusing. Also, it's not the primary reason that patients have decided to have surgery. It takes a significant investment of time to adequately educate patients and address their many questions and concerns. The surgeon's enthusiasm for these lenses — or his lack of enthusiasm — will strongly influence a patient's decision."

Dr. Chang estimates that about 10% of his cataract surgery patients are currently opting to pay the additional costs associated with presbyopia-correcting IOLs. He says that the percentage is in line with his expectations and that the number will likely rise with increasing patient awareness about this option.

"Patients value their vision and are willing to spend money on improved visual function and convenience," says Dr. Chang. "However, presbyopia-correcting IOLs all have tradeoffs and patients depend on us to decide whether they are good candidates or not."

Richard Mackool, M.D., of the New York Eye and Ear Infirmary, is so committed to presbyopia-correcting lenses that he counts his wife and many of his employees among his hundreds of premium IOL patients.

"It certainly doesn't hurt when I mention that to patients," says Dr. Mackool, who says he is currently implanting presbyopia-correcting lenses in approximately 25% of his cataract patients.

The Voice of Experience

One surgeon who has long been committed to refractive lens solutions is Kevin L. Waltz, M.D., of Eye Surgeons of Indiana. Dr. Waltz is recognized as one of the pioneers of refractive lens exchange for presbyopes, a procedure he and R. Bruce Wallace III, M.D., dubbed Prelex, or presbyopic lens exchange.

In performing Prelex, Drs. Waltz and Wallace used AMO's groundbreaking Array multifocal IOL, which was phased out last year when the ReZoom was launched.

"I anticipate that the percentage of patients choosing presbyopia-correcting lenses will grow gradually. This will happen through increased patient awareness and as surgeons and staff gain confidence and experience with these premium IOLs," says Dr. Waltz, who is currently seeing about 10% of his cataract patients opting to pay the additional costs associated with presbyopia-correcting lenses. "I think the fact that it has become more acceptable to other ophthalmologists to use these IOLs is a huge factor in their adoption."

Drawing on his extensive experience in refractive lens procedures, Dr. Waltz advises that practices market these premium IOLs to create patient awareness and interest. He also believes that offering patients a financing plan "is very important and under-appreciated."

Dr. Waltz asserts that many patients of modest means "will dig deep" to obtain the best vision possible.

"Having a high-income patient base may increase the number of patients who can more easily afford the surgery but this in itself is not sufficient to see a rise in surgery volume," he says. "The commitment, confidence and experience of the surgeon and staff are the keys to success with these IOLs."

Patient Selection

For surgeons who have witnessed declining reimbursement for traditional cataract surgery, the new presbyopia-correcting IOLs can offer better, spectacle-free vision for patients and a real bottom-line boost for practices. However, patients who choose to spend the money for these lenses will have high expectations and may be difficult to please if they consider their results less than stellar.

It is one thing to offer all patients information about the potential benefits of these IOLs but surgeons who have extensive experience with the lenses emphasize that the lenses are not for everyone.

Surgeons say that more than half of their cataract patients will prove not to be candidates for presbyopia-correcting IOLs for simple reasons such as cost, lifestyle, severe dry eye and having no problem with wearing glasses. Patients with compromised capsular bags also make poor candidates for these IOLs because of the precise centration that is required to provide excellent vision.

In addition, implanting presbyopia-correcting IOLs can test a surgeon's skills.

"To do multifocals right, you need to know how to use an IOLMaster (Carl Zeiss Meditec, Dublin, Calif.), you should know how to do immersion A-scans, you should be comfortable performing limbal relaxing incisions (LRIs) and you might have to do some explants," says Dr. Tyson. "Multifocals may be beyond the realm of some smaller practices."

Several high-volume surgeons told Ophthalmology Management that LASIK touch-ups may be necessary for about 10%-20% of these IOL patients.

"One must have a refractive surgery mindset when seeing the patients pre- and postop and be able to perform refractive surgery enhancements in offering these lenses," says Asim Piracha, M.D., of Louisville, Ky. "If you view it as a 'one-shot' deal, you cannot be successful with these lenses."

But Dr. Tyson takes issue with the fact that up to 20% of these patients may need LASIK enhancements.

"If you do good biometry you shouldn't need to do a LASIK touch-up. The only touch-ups I have had to do are LRIs," he says.

Dr. Tyson advises that the basic fee for the presbyopia-correcting IOLs should cover any additional enhancements.

"People don't like being nickel and dimed," he cautions.

Dr. Tyson, whose patient base on the west coast of Florida is heavily skewed toward retirees, is well aware that just one dissatisfied patient can hurt a surgeon's practice in a close-knit community where word-of-mouth is a key factor in attracting patients.

"Spend the time upfront and learn about their daily activities," he advises. "There's a loss of contrast sensitivity with these lenses. If they do a lot of night driving, I don't give them multifocals."

Jack Holladay, M.D., of Houston, Texas, says that having cataract surgery patients fill out a written questionnaire provides him with a useful profile of a patient's visual needs and expectations. The questionnaire he uses, developed by Steven Dell, M.D., of Austin, Texas, asks questions that help determine a patient's vision priorities and basic personality type.

"Using the profile allows the surgeon to know in advance whether a multifocal, accommodating, aspheric IOL or standard spherical IOL is the correct choice for the patient," says Dr. Holladay.

Building Volume Growth

A few surgeons surveyed for this article say they are disappointed in the low number of their cataract patients opting for presbyopia-correcting lenses. One highly respected surgeon said he had "zero" response to these lenses, especially after his cataract patients learned how much of the cost would come out of their own pocket. However, his answers to the survey questions indicate that he isn't doing anything to make it easier for patients to choose these lenses.

Surgeons seeking to build volume in this area of their practice might first evaluate whether they have made enough of a commitment to presbyopia-correcting lenses in terms of fine-tuning their surgical skills, offering convenient financing, developing a marketing approach and simply spending time with good candidates explaining the advantages of these lenses. In addition, surgeons can obtain advice from non-competing practices that are having success with these lenses.

Recently, the lens manufacturers themselves, who initially focused on training surgeons to implant their presbyopia-correcting lenses correctly, and in the appropriate patients, are now getting more involved in the practice-building aspects of lens-based vision solutions.

For example, Advanced Medical Optics is now providing a comprehensive approach to help practices incorporate presbyopia-correcting and other high-tech IOL technologies through a program called LifeStyle Vision.

This program is designed to educate surgeons and staff on the key processes necessary to be successful with today's new lens options. The LifeStyle Vision program includes training on patient selection, how to discuss lens options with patients, patient-shared billing, educating staff and other relevant topics.

The educational guide that comes with the program includes DVDs and implementation tools that provide the orientation required to shift the focus of a cataract practice to meeting patients' demands with today's lens technology.

Alcon provides a "Surgeon Tool Kit" for the ReSTOR with brochures that can be given to patients, sample ads, advice for Web-based advertising, an outline for seminar presentations and an educational video.

Eyeonics says that its strong emphasis on comprehensive training, clinical support for surgeons and assessment of outcomes are the ways it has chosen to build patient volume for the crystalens.

"We believe surgeon proficiency and good outcomes are the keys to long-term success," says Kathy Kelly, director of marketing for eyeonics.

Happy Patients Drive Growth

Surgeons having the most success with presbyopia-correcting IOLs say that happy patients who have excellent outcomes are the best advertising in terms of creating good word-of-mouth that leads to volume growth.

"Our percentage of patients choosing presbyopia-correcting lenses is somewhere around 15%, but we are training our staff and doctors to offer these lenses more aggressively. We are now providing more educational information and questionnaires to our patients to both gain their interest and weed out poor candidates," says Dr. Piracha. "I think we could increase our volume with time. Probably the best marketing will still be word-of-mouth."

"Pick the correct candidates and you'll have great results and get word-of-mouth referrals," says Daniel Jewelewicz, M.D., who practices in Florida. "Bad patient selection will cause nothing but headaches." Dr. Jewelewicz is currently implanting presbyopia-correcting IOLs in about 15%-20% of his cataract patients.

"You never know who will opt for these lenses, so offer them to everyone who is a good candidate," Dr. Jewelewicz concludes.