- Where do we begin? (3:29-36:29)
- From the ground up: Addressing patient and ECP expectations (36:30-50:17)
- What “amazing” looks like: Defining potential treatment outcomes (50:18-54:40)
- Looking to a trusted partner for educational support (54:41-57:01)
- Q&A (57:02-1:04:55)
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Where do we begin?
Since cataract surgery is a journey, it’s important to have a firm grasp of related statistics. Most eyecare providers (ECPs) are familiar with the prevalence of cataracts and the impact on quality of life for millions of individuals.
Dr. Whitley noted that it’s increasingly common for younger patients with cataracts to seek intervention because they want to improve their daily quality of life.
“Traditionally, we've been told that for cataract surgery to be appropriate, a patient’s visual acuity should be 20/40 minus or worse," he explained. “But it's all about their quality of life. If they have cataracts that are impacting their quality of life, then those are patients who could be candidates for both cataract surgery and presbyopia-correcting IOL procedures.”
Referencing the prevalence of cataracts in older Americans, he said the demand for eyecare services continues to grow.
“We know that by 2030 there's going to be about a 30% increase in demand for medical eyecare services and about a 33% increase in patients who need cataract surgery,” Dr. Whitley said. “That means we have an opportunity to grow our practices and should consider the role of elective and cash-based procedures in doing so.”
In that context, he said there are various factors and trends which impact decision-making behavior when it comes to selecting presbyopia-correcting IOL patients.
Regarding the impacts such dynamics are having on patients’ decision-making behavior, Dr. Fram said advances in technology make this an “exciting time.”
“Now, the technology's actually performing, whereas in the past there were so many caveats we had to talk about when discussing different multifocal lenses or even extended depth of focus lenses,” she explained. “We're getting closer to being able to deliver on the promise of full range of vision, or less dependence on glasses.”
But she added that having so many effective options to choose from can be a double-edged sword.
“If you have all of those choices, it can be difficult to discuss them with a patient in a way they can absorb, especially if they’re already anxious or experiencing other negative emotions,” Dr. Fram explained. “So, what I like to do is really ask them what they do all day, and I can't delegate this process to someone else because I have to understand their habits.”
For example, Dr. Fram said she asks patients what they do when they wake up; whether they put their glasses on all the time; and if they’re using glasses to look at their phones.
“That's a big, big question,” she said. “And then I ask to see the font on their phones, because if the font's really big, I know I can nail that. But if the font is small, I have to be careful, because I don’t want to take away something they can do well now. That's the best way to get someone upset after surgery.”
Dr. Fram said that once she has a better understanding of a patient’s lifestyle, she can “narrow the menu.”
“If somebody is consistently takes their glasses off to read, then you're going down one road with that patient,” she explained. “But if someone doesn't want to wear glasses at all and has mixed astigmatism, then you have to think about an extended depth of focus or a trifocal technology.”
Either way, Dr. Fram said she doesn’t give the patient a menu and make them choose.
“I try to match the IOL to their current lifestyle or what they want it to be,” she explained. “I also discuss the side effects of the different lenses, which is another thing I don’t delegate to a counselor. I do that myself because the last thing we want the patient to say is, ‘You never told me.’ At the end of the conversation, I tell them, ‘This is your choice. You can wear glasses for everything, or you can try this new technology.’"
Dr. Fram said she also uses a preoperative questionnaire with every patient.
“There are two reasons to use it,” she said. “One, you can actually learn a lot from it, particularly from their type of handwriting. Additionally, you can use it as a medical-legal document to demonstrate that you did review and discuss the questionnaire.”
Dr. Tanner said that although a questionnaire can be helpful, he relies more on the patient conversation — especially regarding lifestyle choices, side effects, and range of vision — to match the IOL with the patient.
Dr. Shafer said a phrase he likes to use in this context is to “marry the lens to the patient's eye.”
“That's really what it is,” he explained. “And I think our job is to be the matchmaker. More specifically, the OD co-manager is the true matchmaker, because they know the patient’s vision history best.”
When it comes to making an IOL selection, Dr. Shafer said he decided to simplify the process to bypass the “a la carte menu” that patients have historically been given.
“I just put it into two categories: standard vision correction or customized vision correction,” he explained. “In standard, I just say, ‘No problem, insurance minus copay and deductible. You can expect to be in glasses full-time afterwards.’”
But if the patient is looking for more, Dr. Shafer said he has an in-depth conversation about customized vision to guide the decision about which lens will “best marry” to the patient’s eye to meet their lifestyle expectations.
“For one patient that may mean a toric monofocal lens for near vision,” he explained. “For another it may be an extended depth of focus lens in both eyes. And for another, it may be a small aperture IOL in one eye and a light adjustable lens in the other eye.”
To add to the simplicity of his process, Dr. Shafer said he maintains the same cost across the board so patients don't make the wrong choice based on cost alone. Additionally, he said the cost discussion is a “really important conversation to not fumble over.”
“Because the second you fumble, the second they feel like you're a salesman — and that’s not what we are,” he explained. “This technology actually does cost us money, and therefore our job is to make sure the patient is paying for something of value.”
Dr. Shafer said his cost versus value discussion goes something like this: “If you want to wear glasses full-time afterwards, no problem, save your money. But, if you want to customize your vision a little bit more, there is a cost associated with that. Now, for that cost, you get the lens technology, but most importantly, you get that really in-depth conversation with me where we decide what lens is best for you. Additionally, you buy an insurance package at the same time, because you have an extended global period with me for an extra 90 days. So, you've got six months of covered postoperative care. You've got a laser fine tune if needed. If I missed the refractive target and I promised you that I wouldn't, I owe that to you. And that's all included in the same cost. I promise you that there's not anything hidden within this. My job is to just make you happy afterwards.”
“Frankly, patients appreciate the honesty,” he added. “And many — if not most — of these patients end up converting because they are looking for a little bit more.”
Quality-of-life patient testimonials
Real-world quality of life remarks from patients also demonstrate the positive impact of selecting the right lens.
Dr. Fram said hearing patients say how happy they are after surgery never gets old.
“I always tell them, ‘It's a privilege to take care of you,’" she explained. “And it really always feels like the first time, because it is one of the greatest professions to be involved in. So I try not to take it for granted.”
She said she recently received a text from a patient saying, “I can't believe I waited so long. I never knew I could see as well as I did when I was 15 years old."
“And this was a patient who had a PanOptix that all his friends were trying to talk him out of, but he really wanted to see at all distances,” Dr. Fram said. “He didn't drive a lot at night and was willing to go down the road with me. So, I told him, ‘One to three percent, I might have to remove it, but that's very, very rare, more like one percent. Just know I’m here for you on this journey."
“He thanked me for taking the leap with him to get him out of glasses,” she added. “It doesn't get old. It's a wonderful thing.”
Dr. Ferguson agreed, noting that current options clearly provide a substantial improvement in quality of life for patients.
“This is supported by good data,” he explained. “I think there's a nice quality-adjusted life year study comparing a trifocal versus a monofocal which shows that the quality-of-life improvements of the trifocal are pretty substantial. So, assuming the patient’s an appropriate candidate and considering the quality-of-life impact, I think selecting the best option goes back to understanding the patient's goals and lifestyle — and then, using Brian's phrase — marrying the lens to that patient, whether it be a trifocal, extended depth of focus, or another option.”
Dr. Shafer said his patients are really satisfied, too.
“They're giving hugs and I give them back,” he said.
Dr. Fram added that when patients are unhappy post-operatively, it’s important to listen to their concerns — and that body language is important.
“What you really want to do is lean in and listen,” she explained. “Patients will always feel more cared for and view you as a better doctor when you lean in, rather than say, ‘Oh, it's dry eye. Oh, you just need to adapt. Oh, let's laser that capsule.’ If you’re going to put these types of lenses in, I think it’s important to support patients in that period when they're just dating the lens and haven't yet gotten married.”
ATIOL market penetration
In terms of the market, Dr. Whitley noted that ATIOL penetration increased from 2016 to 2021, but said he’s surprised that the penetration of presbyopia-correcting toric lenses isn’t hirer, since “we know that over 35% of the patients have over a diopter of corneal astigmatism.”
Dr. Shafer agreed.
“I think that number should be higher if we're truly treating all patients who have that level of corneal astigmatism,” he said. “I like to say, "Would you ever give a patient a pair of glasses that doesn't correct for the astigmatism?’ No, you would never do that. So, why wouldn't you take care of that at the time of cataract surgery when you have that opportunity?”
Referencing the chart, he said what’s “truly striking” is that there is less penetration globally than there could be.
“If you look at the orange line representing presbyopia-correcting IOLs, they account for all of that growth in the total premium share,” he explained. “I believe that’s because the technology from 2016 to 2021 improved so dramatically. We got our first trifocal IOL and our first non-diffractive EDOF IOL. We have really good lenses now that are able to deliver on the promise we're trying to give our patients. I'm not surprised to see that it's going up, and I hope that trend continues.”
Dr. Fram said she was also shocked about the low market penetration of presbyopia-correcting toric lenses.
“That means that as educators we may not be teaching how to use it successfully and screen successfully,” she said. “I think it also means that [providers] don't know what to do if they don't have the right preoperative testing or intraoperative technology to help them achieve their targeted goals. I think that has a lot to do with confidence, and we can all work on that.”
Like Dr. Shafer, she said that during the 2019-2021 period, ATIOLs greatly improved.
“We're finally seeing technology that has tolerable nighttime symptoms, that has excellent distance intermediate and near, and not just one or two or the other,” she explained. “I fully agree. And as long as we understand, as Dr. Ferguson said, how to match the technology given their preexisting conditions, then we’re going to have success. Although there’s no one-size-fits-all solution, there are some easy buttons.”
Dr. Ferguson added that he expects the figures on the graph to continue to rise as the options expand.
“We have options now available that have expanded our percentage of patients who are candidates for this technology,” he said. “If this graph included an adjustable lens, which is the LAL — a monofocal IOL — then I would expect this percentage to continue to rise.”
The importance of tracking metrics for business growth
Dr. Whitley noted that since healthcare is a business, it’s important to track metrics in order to grow.
“Are you all tracking your conversions and are you separating them out?” he asked the panelists. “Are you tracking patient satisfaction?
Dr. Fram said she does track her metrics, and software has made that an easier process.
“It's become a lot easier using some of these software databases such as Veracity, and Alcon has a digital database that you'll be able to record on,” she explained. “You can search it to get information about your IOLs and look at your refractive results based on the type of lens.”
She said that recently, she wanted to see how patients were doing with specific IOLs, so she looked at her metrics.
“It's helpful because you don't know if you're doing well until you look in the mirror,” she explained. “It only takes one patient who is having a tough time to make you decide not to use a particular lens. But what if you had 500 who were happy? You don't want one patient to dictate your whole future with the technology. That’s why I find that it’s really important, especially when you're implementing new technology, to look in the mirror and examine your outcomes to help you optimize your lenses.”
The role of the defocus curve in IOL selection
Dr. Shafer said he never heard about the defocus curve in residency training, and didn’t even know it existed. But as new IOL technology becomes available, its importance is growing.
“The defocus curve is so important as new technology becomes available, especially for those of us who are on the leading edge of early adoption and are willing to try out these new technologies,” he explained. “Prior to implanting the lens, we want to understand what to expect in terms of visual acuity for our patients at various distances. The defocus curve is what shows us that.”
He said the U.S. Food and Drug Administration (FDA) mandates that companies publish the defocus curves of all new IOLs, which helps ECPs know what to expect from the lens and allows them to make comparisons between the options available.
“In general, the defocus curve shows you what you can expect a patient's visual acuity to be at different distances,” Dr. Shafer said. “This chart shows a defocus curve of emerging presbyopic patients. This was a study we did, and it's really illustrative of what is happening to a defocus curve over time.”
“I'm going to force you all to think back to basic optics 101,” Dr. Shafer added. “There's a simple formula: Focal length equals one over diopter.”
He said that when discussing new IOLs, there are only three “really important” focal lengths that are considered.
“One of them is at infinity,” Dr. Shafer explained. “That's distance, and that's a defocus step of zero. This is a patient who has no defocus. Their manifest refraction is put in front of them and they have no defocus.”
“Then we often talk about intermediate being 66 centimeters,” Dr. Shafer said. “Well, how do we get to 66 centimeters at a defocus step? One divided by 1.5 is 0.66 meters, so 66 centimeters.”
“What you're actually doing to the patient here is putting in their manifest refraction to give them their best corrected distance vision, and then you progressively defocus them in half diopter steps,” he explained. “You put minus 0.5 in front of them, minus one, minus 150, and you measure their actual visual acuity at those defocus steps. When you have them set to emmetropia, that's a defocus step of zero. And you look on the Y-axis here and you can see their visual acuity. On the left Y-axis you have their LogMAR vision, and on the right Y-axis you have the Snellen equivalent. At a defocus step of zero, that's emmetropia. At a defocus step of minus 1.5, that is 66 centimeters, or intermediate vision.”
“Similarly, if you get to a defocus step of minus 2.5, one divided by 2.5 is 4.4, .4 meters, 40 centimeters,” Dr. Shafer added. “That's what we all talk about as near vision.”
In terms of the various age groups represented on the chart, he noted that the orange line representing 37-39 year-olds is flat, because those patients can still accommodate.
“If you progressively defocus a myope or an emmetrope who's young and can accommodate, and you put myopic lenses in front of them, they're going to be able to accommodate through that,” he explained. “Think about all of our young patients who over accommodate.”
“If you look at the progressive ages, look at what happens at age 40 to 42,” Dr. Shafer said. “Starting at a defocus step of minus 1.5, they start to fall off the defocus curve. What that means is that their vision is progressively getting worse at these near ranges. Importantly, we consider a LogMAR of 0.2 to be the level of visual acuity that is considered acceptable. If you look at these different ages starting at age 46 to 48, suddenly, even at intermediate ranges they're really starting to fall off. And as you get to a near defocus step of 40 centimeters or minus 2.5, you see a big splitting, because they're really starting to fall off the defocus curve because they're no longer able to accommodate.”
Dr. Shafer then couched his explanations with a real-world example.
“You can see that this is the LogMAR of 0.2,” he said. “I want you to look at these three ovals and that LogMAR of 0.2 as we go through the IOLs that are available on the market right now so you can see what we can expect a patient's vision to be at these different distances.”
Commonly-used presbyopia-correcting IOLs
“We can see the Vivity lens is a non-diffractive extended range of vision IOL,” he said. “What I mean by that is that you don't have circles of diffraction where light is splitting. Instead, you have a central area of the optic of the lens that's a little bit steeper, and it creates this continuous extended focal range by stretching the wavefront rather than splitting it.”
To better understand what to expect in terms of vision with the Vivity lens, Dr. Shafer referenced its defocus curve.
“The black dots here are the Vivity lens,” he explained. “The circles are the monofocal control. The general shape shows us what we can expect. At a defocus step of zero, you can expect a patient's vision to be 20/25, 20/20 — and that's what we see here. A LogMAR of zero is 20/20, and a LogMAR of 0.1 is 20/25. We expect 20/20 here. As we move to a defocus step of minus 1.5, remember that's the intermediate range. We can see that the Vivity lens still hovers above LogMAR of 0.2, versus the monofocal control which drops below LogMAR of 0.2. However, when we get to our near range, minus 2.5, both have fallen off the defocus curve.”
Dr. Shafer said that since that’s the case, it’s critical to not promise patients excellent near vision when implanting Vivity lenses.
“We can promise them that they're going to have acceptable intermediate vision, because it's above LogMAR 0.2 in greater than 50% of patients,” he explained. “But as you get to a LogMAR of 2.5, you're at LogMAR 0.5. That's 20/60 vision. That's not phenomenal near vision. It's phenomenal intermediate vision, but not phenomenal near vision. Looking at this defocus curve, we can expect that. And as long as we expect that, we can expect to see that result in our patients. So, when they're not seeing at near, it doesn't mean something went wrong, it means the lens lived up to its defocus curve.”
Dr. Fram added that with the Vivity lens, some of her patients can read without the aid of spectacles, which was confusing for providers when it first came out.
“I think that's what tripped everyone up in the beginning,” she explained. “I think we've talked about this before, but it is pupil size that probably determines the depth of focus. The smaller the pupil size with the Vivity lens, the more depth of focus you could get.”
“It's an extended depth of focus IOL and a diffractive lens, so this is splitting light,” she explained. “But it has an echelette design, which is this high resolution lathing. Because of that, the technology has been developed to change the height of these actual rings to elongate the focus. As a result, there aren’t the abrupt edges which cause a high focal point, then a dip, then a halo, then a high focal point, then a dip, then a halo. This lens does create some glare and halos, but the elongated depth of focus is really what’s most impressive.”
Dr. Fram said the Symfony’s defocus curve demonstrates the broadening that occurs.
“In this lens, you can see that when you're at 66 centimeters, or at minus 1.5 on the defocus curve, you're still within that 0.1 LogMAR 20/25,” she explained. “And really, you want to think about J3, which is about 20/30, 20/40 on your near card. That's where patients are expected to be. But if you're a plus 50 or a minus 50 on your refractive target, you can still have excellent vision.”
As a result, Dr. Fram said ECPs don’t have to be “exactly on target” with this lens to be successful.
“Of course, you’d like to be exactly on target, but the lens has this broad defocus curve that allows you to achieve excellent distance vision and also intermediate vision,” she said. “However, with this lens you do have to be careful, because if you aim too myopic, then the nighttime symptoms become a bit more obvious. But, this is an excellent lens for someone who values distance, wants to see dashboard, intermediate, and computer.”
Dr. Fram said once those goals are achieved in the patient’s dominant eye, if the patient wants more near vision, the ECP can consider other IOLs that may offer more near vision, such as the TECNIS Synergy™ IOL.
“The Synergy lens is really an incredible lens that has a very, very steep, steep defocus curve, so you must hit your target,” she explained. “This lens will give you distance, intermediate, and near, and it's probably the best near-vision lens on the market because, as you can see, at minus 2.5, you're able to achieve excellent near vision. So, this is a good choice for the patient who has that goal.”
Reinforcing the need to “hit your target” with the Synergy lens, Dr. Fram noted that “when you're too myopic with this lens,” a “waxy vision” occurs.
“You want to pick your lenses on the plus 50 to plano side, so really your first plus to plano,” she explained. “As you can see, as you're going to infinity on this defocus curve, if you're off by more than that, they're really not going to be able to achieve that 20/20 to 20/25 vision. This is really the same concept of varying the height and width of the echelettes to achieve distance, near, and intermediate vision.”
Dr. Fram said what she finds most impressive about the technology in general is the presence of a violet filter.
“The violet filter that’s on both the Synergy and the Symfony allows for filtering of the blue wavelength, or the shorter wavelengths, that are more associated with dysphotopsia,” she said. “Although some level of dysphotopsia is common with any type of diffractive technology, there’s about 33% less by implementing this OptiLight technology and violet filter.”
Dr. Fram said she would choose the Synergy IOL for the patient who really values near vision, but wants it all.
“We know these lenses have performed well with achromatic correction and chromatic aberration correction,” she said. “And with this high resolution lathing, plus providing a wider range of vision that's pupil independent — all of those factors have all been a real boost for this technology.”
When it comes to traditional diffractive multifocal options, Dr. Ferguson said the previous generation of multifocal IOLs have evolved to include the trifocal options that now exist.
“By definition, diffractive optics split incoming light,” he explained. “The trifocal options do this to provide functional vision at distance, intermediate and near. But the drawback is the dysphotopsias that come with that. However, compared to the previous ‘bifocal’ options, the incorporation of the intermediate focal point into the new trifocal IOLs actually strengthens the near point. Plus, the trifocal IOLs actually have reduced incident light loss compared to older IOL options.”
“When comparing the PanOptix trifocal IOL to a monofocal control and looking at the intermediate and near, you can see a pretty demonstrable difference in the vision with close to 0.1 at intermediate and .05 at near,” he explained. “So, for a patient who has no concomitant ocular pathology and really desires spectral independence, the PanOptix is my go-to option.”
Mixing and matching IOLs to achieve desired results
Both Dr. Shafer and Dr. Fram said they sometimes use a combination of IOLs to achieve the desired results. In the instance of EDOFs, Dr. Fram said she attends to the dominant eye first and then adjusts the non-dominant eye if the patient needs more near vision.
“I think it's an excellent strategy,” she said. “If you implant the IOL that is better for distance and you make sure you nail that, you can then titrate what they need for near. Many surgeons are using the Symfony lens in the dominant eye and the Synergy lens in the non-dominant eye. That's because it's harder to hit the distance target with Synergy because of that steep defocus curve.”
From the ground up: Addressing patient and ECP expectations
Dr. Whitley said that addressing patient and ECP expectations starts with education.
“This is a cataract journey,” he said. “The earlier we start the education, the more educated the patient will be regarding this once-in-a-lifetime decision, which will lead to higher patient satisfaction.”
He also pointed out the importance of a strong recommendation to ensure that patients who are willing to pay more for an ATIOL receive one.
“The graphic on the left depicts the results of a survey of cataract surgeons who were asked about their preferred type of IOL if they were personally undergoing cataract surgery,” Dr. Whitley said. “Multifocals led the pack at 69%.”
However, those personal preferences may not be translating to recommendations to patients, as noted on the right side of the graphic.
“The research indicates that 45% of patients are willing to trade up to an advanced technology IOL and pay more,” Dr. Whitley said. “However, only 18% of patients are getting the advanced technology lens, which is why that strong recommendation is so important.”
Dr. Shafer added that he believes the ECP’s mood on any given day can also influence conversion rates.
“The way you come across on an individual day will change the percent of patients who will choose to upgrade their IOL,” he explained. “It’s all about the language and demeanor we use. As I learned during my fellowship at Vance Thompson, people don't care what you know until they know that you care. Once they know that, they’ll be willing to follow your recommendation.”
Potential pain points and contributing factors
ECPs face many potential pain points, and there are various contributing factors that may influence them.
Dr. Fram said one potential pain point she finds very challenging is staff turnover.
“Turnover is really tough,” she said. “We have wonderful people in our practice. A lot of them are pre-med students and they come for a couple of years and then they move on. That's amazing and rough all at the same time.”
“It doesn't really teach them how we speak to patients, so whenever someone starts in our practice they also have to hang out with me for a week or so,” Dr. Fram said. “That gives them a chance to hear how we speak to and care for our patients.”
In addition to using the online training platform, she said that once a month, they close the office on Friday afternoons for staff education.
“If you do not educate your staff, you will be in a world of hurt,” she explained. “There are so many new technologies coming out every year, and ongoing staff education is the best way to be early adopters and implement new technology with confidence.”
Dr. Ferguson also said education is a priority for the practice he works in.
“I agree that educating your staff is so important,” he said. “I think every new hire in our practice goes through a formalized educational process. We also have education every Monday morning. It’s similar to a morning huddle that's distributed to everybody across all roles and departments within the organization. I think that's really helpful for getting people on the same page.”
He said they also use a lot of shadowing to build consistency, which he thinks is important.
“When you're educating patients, especially when it comes to presbyopia-correcting IOLs, you want to have very consistent messaging,” Dr. Ferguson said. “I think that helps build trust with the patient.”
Similar to Dr. Fram, Dr. Shafer said he also counsels patients himself, instead of delegating it to someone else.
“If you entrust somebody else to do that for you, it's not coming from you,” he explained. “Then, if that staff member leaves, the message changes with them. But you are consistent and the message stays the same. Plus, you’re the one staying up-to-date on everything, and your patients are trusting you. I attribute my conversion rate to the fact that I do the counseling myself and am the point of contact for the patient without relying on my team for that. Then you can utilize your team to do all sorts of other wonderful things to support the patient experience.”
Dr. Whitley also underscored the importance of “celebrating our wins.”
“The staff needs to hear about the high levels of patient satisfaction we're seeing with these presbyopia-correcting IOLs so they can better support patient conversations,” he explained. “Otherwise, they may sabotage the process with negative messaging.”
What patients want and need
Dr. Whitley also noted that patients would like to have a better grasp of their lens options and rely on the surgeon for guidance.
He said one approach he uses with patients who have early cataracts and aren’t yet ready for surgery is to let the patient know there are exciting options available when the time is right.
“I’ll give them information ahead of time,” he said. “The more engaged the patient is throughout, the higher the patient satisfaction is going to be.”
Noting the discrepancy in the graph between the high percentage of patients who rely on their surgeons for guidance and the low percentage who receive recommendations, Dr. Whitley asked how that could be impacted.
In this context, Dr. Ferguson again underscored the importance of education.
“I think these numbers overall speak to the importance of education with your staff, but they also speak to the need for education outside your building, especially if you're in a collaborative-care environment,” he explained “Because when you connect with the providers outside of your office and they can start to initiate that conversation, patients become more comfortable with the decision process.”
An opportunity to expand with patient selection
Gaining more confidence in both the ability to identify appropriate candidates for presbyopia-correcting IOLs and the best option(s) to fit their needs can support practice growth.
Dr. Fram agreed that this aspect of the pre-operative assessment is critical.
“I think looking at the lids first and the tear film is really important,” Dr. Fram said. “I love this graphic, because all of these presbyopic lenses either stretch light or split light, and I explain to patients that the first thing the light rays hit is their tear film. If that is dysfunctional, they will hate any lens I put in.”
She said she thinks there are times when both surgeons and patients are too eager to get to surgery.
“It’s not only about optimizing the ocular surface before you get to surgery and your biometry measurements, but keeping the ocular surface healthy after surgery,” she explained. “I don't think we talk about that enough. There are so many patients who, once a drop is put in, may experience a sudden improvement in vision. Then you know that that lens is going to function, there's hope.”
“However, if you look at the ocular surface and it's pristine, and they're only seeing 20/30, and things aren't going well, then you know you must start the conversation,” she added. “It's better to discover all these things beforehand. When you diagnose it beforehand, then it's their problem. When you diagnose it after, it's your problem. It’s so important to just slow down.”
What “amazing” looks like: Defining potential treatment outcomes
To set a practice up for success that lasts for presbyopia-correct IOLs, it can be helpful to consider a few questions.
To determine best fit for patient selection, Dr. Fram said the signals she looks for revolve around the patient's habits and lifestyle.
“I want to know how they lived their life before, how they wear their glasses, what they do all day,” she explained. “Then I want to know what their dream is, and I want to see if my expectations of different technologies match with what their expectations are.”
“As I said in the beginning, really ask the patient, ‘Do you mind wearing reading glasses?’” she added. “If they say they don’t mind, I may move that patient more into an extended depth of focus or a mini monovision strategy. Those are the signs. Next, I ask the patient if they read the phone without glasses. If the answer is yes, I know at that point that I need to do either an extended depth of focus or mini monovision, or this patient will not be happy. So, that helps me when I go down that road.”
In terms of collaborating with ODs to form meaningful co-management relationships, Dr. Ferguson said they do a lot of co-management and collaborative care in all of their practices.
“We do an annual educational event at each location,” he explained. “But I think more important than that in building meaningful and trusting relationships is to check in on a routine basis to make sure they're happy with how things are going and see if they’re doing okay personally. I think those small interactions show appreciation for what they do for the patients, but I think they also build trust and help ensure that their patients are having a positive experience in your office.”
In terms of what he’s done differently in the past 12 months to improve his confidence in patient outcomes, Dr. Shafer said the biggest change was to switch from an a la carte-type of menu to a bundled single price.
“That’s taken the cost factor out of the decision-making for the patient,” he said. “Instead, it's a single price that allows me to take a fiduciary responsibility to ensure that I put that patient in the best optical setup without them having to worry about the individual split-level costs of the technologies.”
Referencing the point spread function of simulation and related focal points for the various IOLs, Dr. Whitley asked how the panelists address post-surgical dysphotopsias, or the unwanted visual phenomena that can occur in the form of glare, light streaks, starbursts, haloes, etc. This can often frustrate patients who don’t understand that this can be a normal but temporary side effect after surgery.
First, Dr. Ferguson underscored the need for a comprehensive exam to assess tear film and lids, and other signs of instability and dryness, which could potentially contribute to dysphotopsias.
Next, he recommended conversations with post-surgical patients to reassure them that these can be normal but temporary phenomena that occur as the eyes adjust to surgery.
“Studies have shown there's a six month adaptation period, particularly with diffracted IOLs, said Dr. Ferguson “So, I think it’s important to partner with the patient, let them know you’re on their team, and promote confidence that they will improve over time.”
Impact of staff turnover
Since staff turnover can negatively impact both patient care and a practice’s business goals, it is important to adopt an effective strategy to enhance employee retention.
Looking to a trusted partner for educational support
In light of all the challenges ECPs face, it’s important to find a trusted partner to rely on for high-quality and ongoing educational support.
Of course, the patient cataract experience is enhanced when an ophthalmic team consisting of ODs, MDs, and staff collaborate effectively.
And when best practices are applied, they can help ECPs “LEAP” ahead to optimize both patient and practice outcomes.
Final best-practice pearls
When asked to provide final pearls related to best practices, Dr. Fram again underscored the importance of effective listening.
“The best pearl is to listen,” she said. “Take the time. I literally go in the room with an iPad with Rendia
and draw everything for the patient so they understand what they're choosing. In our office, the only time we run into trouble is when we don't listen to the patient.”
Dr. Ferguson said he thinks patient education is key.
“I'd like to emphasize the importance of patient education and continuing to educate the patients,” he said. “When patients come in for a cataract evaluation, we give them a lot of information and they may not remember everything when needed. That’s why ongoing education is key. Giving patients the right piece of information at the right moment in the postoperative period will help promote success with these lenses.”
Along the same lines, Dr. Shafer said it’s important not to subject patients to information overload.
“I think the key is to not inundate them with all of the information we need to know, and focus only on the things they truly need to know to set appropriate expectations,” he said.
Dr. Whitley concurred with all three.
“My best-practice pearl is effective communication,” he said. “Clear communication is key to making sure we're all on the same page and setting proper patient expectations.”
And in support of great education, the Eyes on Eyecare team has created a downloadable cheat sheet for ECPs covering common IOL types, their use cases, and when to avoid them — along with key ways to describe them using patient scripts.