Measuring modulation transfer function of the Alcon

www.eyeworld.org
Achieving Success
with Cataract
and Refractive
Technology
The News Magazine of the American Society of Cataract & Refractive Surgery
Supplement to EyeWorld June 2008 • Reprinted from the 2008 ASCRS Chicago Show Daily
Supported by an unrestricted
educational grant from Alcon, Inc.
Measuring modulation transfer function of the Alcon aspheric
apodized diffractive multifocal IOL and clinical outcomes
phthalmologists are often
concerned about contrast
sensitivity among the
elderly to ensure those
patients can perform dayto-day tasks like walking down
steps in low light conditions.
Contrast sensitivity as measured by modulation transfer function looks at the quality of an
image through the lens optics and
really is the first step to achieving
better contrast sensitivity.
Clearly, modulation transfer
function is better with the aspheric AcrySof ReSTOR IOL (Alcon,
Fort Worth, Texas) compared with
the standard ReSTOR lens, according to Jim Schwiegerling, Ph.D.,
Depart-ment of Ophthalmology &
Vision Sciences, University of
Arizona, Tucson.
O
An ETDRS letter chart imaged through an eye model (6-mm aperture) containing four different multifocal IOLs;
the AcrySof ReSTOR aspheric IOL produces the highest quality image with the fewest stray light effects
That means “patients will have
slightly better contrast for distance
vision, slightly sharper images, and
fewer side effects especially at
night in terms of halos and glare,”
Dr. Schwiegerling said. “We see a
bit of a distance boost with the
Table of Contents
Measuring modulation transfer function of the
Alcon aspheric apodized diffractive multifocal
IOL and clinical outcomes ............................1
ReSTOR aspheric, premium
results for demanding patients ......................2
High energy blue light filtration:
An evidence-based assessment ....................3
A new tool to analyze how much
the cataract incision influences
the refractive outcome ................................4
Early experience with
the AcrySof Toric IOL ..................................5
Silo Scheduling: Proactive templates
deliver the practice you desire ......................6
Are lifestyle IOLs worth it?
Establishing realistic financial
goals for upgraded lenses ............................7
aspheric design, without giving up
anything to obtain it.”
Dr. Schwiegerling’s study
involved a benchtop test, with a
model eye that has a simulated
cornea with clinical levels of
spherical aberration and chromatic aberration. The different IOLs
were then inserted into the eye
model, and the images were analyzed to objectively measure the
different designs’ relative performance. The methodology is very
standard, having been used over
the last 20 years in modulation
transfer function testing, he said.
Dr. Schwiegerling noted that
the standard ReSTOR lens design
ignored the impact of spherical
aberration on a patient’s vision
while the ReSTOR aspheric design
took it into account.
“The aspheric design works in
conjunction with the cornea to
cancel out these aberrations,” Dr.
Schwiegerling said. “That’s where
the performance enhancement
comes from.”
The Tecnis MF (Advanced
Medical Optics, AMO, Santa Ana,
Calif.) lens is a similar design to
the ReSTOR aspheric, as it has
both aspheric and multifocal
properties.
“The advantage of the ReSTOR
is that the apodized diffractive
portion turns into a pure refractive
lens in the periphery, and that
tends to suppress halos and glare,”
Dr. Schwiegerling said. “The Tecnis
design’s diffractive nature goes all
the way out to the periphery so
for large pupils you get halos. The
ReSTOR turns into a purely refractive lens in the periphery, so in
comparison it reduces the out-offocus stray light. Asphericity alone
is not enough to overcome the diffractive effects produced by the
design of the Tecnis lens.”
continued to page 7
“[With the ReSTOR
aspheric] patients will
have slightly better
contrast for distance
vision, slightly sharper
images, and fewer side
effects especially at
night in terms of halos
and glare.”
Jim Schwiegerling, Ph.D.
2 Achieving Success with Cataract and Refractive Technology
ReSTOR aspheric, premium
results for demanding patients
ret L. Fisher, M.D., in
private practice, The Eye
Center of North Florida,
Panama City, Fla., began
implanting patients with
the AcrySof ReSTOR aspheric IOL
(Alcon, Fort Worth, Texas) in April
2007, and since has found visual
acuity, contrast sensitivity, and
even intermediate vision to be
exceedingly good.
“Patient satisfaction was
substantially better subjectively
and objectively,” than with the
standard AcrySof ReSTOR IOL, Dr.
Fisher said. “The patients function
much better.”
Dr. Fisher performed a study of
33 patients implanted with the
aspheric IOL and 35 patients with
the standard ReSTOR lens. Average
visual acuity for distance vision was
20/25 with the ReSTOR aspheric.
For preferred reading distance (at
near), it was 20/20. Intermediate
vision was even a little better than
20/20.
“That was in contrast to some
of the published data, including
what Alcon published themselves
for Food and Drug Administration
approval,” Dr. Fisher said. Dr.
Fisher explained the difference in
results by saying he measured
patients in “more of a real-world
way” at preferred near, rather than
B
“With the ReSTOR,
because of the design
and different steps and
zones, it gives you the
most light for the situation that you’re using,
whether reading or
distance.”
Bret L. Fisher, M.D.
Results
Contrast sensitivity in normal subjects; compared to these patients, those implanted with the AcrySof ReSTOR
aspheric IOL achieved nearly identical contrast sensitivity results
using a phoropter.
The ReSTOR has been criticized for yielding plenty of reading and distance vision, but not as
much intermediate, Dr. Fisher
said. “That is what was discussed,
but it was never really clinically
experienced,” Dr. Fisher said.
“When I look at my patients,
[intermediate] is very good.”
Contrast sensitivity results
clearly set the ReSTOR aspheric
IOL ahead of the standard one.
When asked how satisfied they
are with vision after surgery, on a
scale from 0 to 10 (10 being most
satisfied), ReSTOR aspheric
patients scored their vision a 9,
while standard ReSTOR patients
gave their vision a 7.5.
Further, Dr. Fisher said in
photopic conditions, aspheric
patients performed as well as agematched controls with healthy
eyes in another study.
“Even though this is a multifocal implant and you can expect
some loss of contrast sensitivity,
the results are virtually identical
between ReSTOR aspheric patients
and patients with the natural
crystalline lens,” Dr. Fisher said.
One sizable concern related to
multifocal lenses has been the
potential loss of contrast sensitivity. “When you’re taking light and
splitting it to different focus
points, that process is not 100%
effective,” Dr. Fisher said. “If you
lose light transfer in the process,
you lose contrast sensitivity. But
with the ReSTOR aspheric, because
of the design, it gives you the most
light for the situation that you’re
using, whether reading or distance.”
Now, Dr. Fisher uses the
ReSTOR aspheric as the lens of
choice on any cataract patient who
wants to be less dependent on
glasses. He said he achieved a rate
of 87.5% spectacle independence
with the ReSTOR aspheric.
“There’s not another lens on
the market that I’m aware of that
can show this type of consistency,”
Dr. Fisher said.
Dr. Fisher said the AcrySof
ReSTOR aspheric IOL provides
surgeons with added benefits as
well. “The designers of the implant
were able to move to a proprietary
biconvex shape, which makes the
effective lens position more
constant across the entire dioptric
range of the lens. This can also
improve predictability in calculating implant power and achieving
the desired refractive outcome.”
The excellent contrast sensitivity results are a “nice confirmation
that the underlying technology in
the lens really does work,” Dr.
Fisher said. “We’re not seeing a
degradation of contrast sensitivity
compared to normal individuals.”
Dr. Fisher has no financial interests related to this supplement. He can be contacted at 850-784-3937 or bfisher@eyecarenow. com.
Results
Of AcrySof ReSTOR aspheric IOL patients, 87.5% achieve spectacle
independence
Source: Bret L. Fisher, M.D.
Achieving Success with Cataract and Refractive Technology 3
High energy blue light filtration:
An evidence-based assessment
nnovations in IOLs are seemingly endless. Whether you
chart the progress from
monofocal to multifocal technology or silicone to acrylic
material, we live in a world in
which cataract patients are better
off today than yesterday.
Without a doubt, that progress
continues with adding a protective
chromophore to the lens to
achieve wonderful health benefits,
according to Miguel N. Burnier
Jr., M.D., professor of ophthalmology, pathology, medicine, and
oncology, McGill University,
Montreal, Canada.
I
“Yellow is the gold standard,”
Dr. Burnier said. Yellow is the
color that prevents blue light toxicity and concomitant problems,
he said. If cataract patients don’t
get a yellow lens, such as the
AcrySof IQ IOL (Alcon, Fort
Worth, Texas) or the AcrySof
Natural IOL (Alcon), their eye
health – and much more – is in
jeopardy, Dr. Burnier said.
“Over the lifetime of each
patient, the retinal pigment
epithelium [RPE] accumulates the
fluorescent material called lipofuscin,” Dr. Burnier explained. “Blue
light absorption by the lipofuscin
IOL Monofocal Technology Advances
1949
PMMA
1983
SILICONE
2005 +
1994
HYDROPHOBIC
ACRYLIC
Aspheric Optic
UV only
UV and Blue
Light Filtering
Sir Harold Ridley
UV and blue light filtering IOLs (pictured above), like the AcrySof Natural
and AcrySof IQ, may prevent visual diseases like macular degeneration,
but could also prevent life-threatening diseases like uveal melanoma
High emission of blue-light
in arc welding
There is growing evidence implicating welding as a possible risk factor
for uveal melanoma. The major culprit is high-energy blue light exposure
(only UV-light is filtered by protective eyewear)
Source: Miguel N. Burnier Jr., M.D.
generates substances which are
toxic to the RPE. As a result, RPE
cells die and no longer nourish
the retina, affecting vision.”
Age-related macular degeneration clearly could result under
such circumstances, he said.
Putting excellent vision aside for
the moment, consider life-threatening consequences of blue light
toxicity, like uveal melanoma.
“Laboratory rats exposed to
long-term blue light develop
intraocular masses, pathologically
diagnosed as ocular melanoma,”
Dr. Burnier said.
Further, Dr. Burnier cited a
study linking high energy light
emitted from commercial welding
to uveal melanoma. “There was
evidence implicating welding as a
risk factor for uveal melanoma,”
Dr. Burnier said. But he added that
there is a high emission of blue
light in arc welding.
In a letter to the journal
Ophthalmology, Dr. Burnier wrote,
“There is evidence suggesting that
the major culprit is not ultraviolet
light but blue light exposure.
Okuno et al evaluated various
light sources for blue light hazard.
Among these sources, arc welding
was found to have extremely high
effective radiance, with corresponding permissible exposure times of
only 0.6 to 40 seconds, suggesting
that viewing this light source is
very hazardous to the retina.”
Dr. Burnier added that using
UV and blue light filtering IOLs
should be preferred for all adult
patients undergoing cataract
surgery, as it could be a preventative measure against possible blue
light-induced malignant transformation.
Critics of the AcrySof Natural
IOLs have incorrectly suggested
that the AcrySof Natural “blocks”
blue light. They have suggested
that blocking blue light could
interfere with natural circadian
rhythms regulated by melatonin
and negatively impact sleep patterns and mood levels.
The AcrySof Natural IOLs filter
only a specific range of very highenergy blue light. A patient satisfaction questionnaire used at
McGill, under the oversight of Dr.
Burnier’s research team, found
some enlightening results that all
ophthalmologists need to know.
Of 360 AcrySof Natural patients
answering questions related to
quality of vision after cataract surgery, none said they experienced
insomnia or depression after
cataract surgery.
There is no definitive evidence
to justify statements that the
AcrySof Natural chromophore
causes alleged problems with visual acuity, color perception, contrast sensitivity, circadian
rhythms, or sleep pattern. These
and other criticisms are shallow,
Dr. Burnier said, such as those
related to glistenings.
The bottom line is that the
AcrySof blue light filtering technology is not only beneficial to
vision, but can prevent serious
life-threatening conditions, Dr.
Burnier said. There are strong indications that blue light filtering
IOLs may play an important part
in preserving vision for the long
term.
“For all these reasons, surgeons must use the gold standard
in cataract surgery: Alcon blue
light filtering IOLs,” Dr. Burnier
said.
Dr. Burnier has no financial interests
related to this supplement. He can be
contacted at 514-843-1544 or
[email protected].
“Yellow is the gold
standard. Yellow is the
color that prevents
blue light toxicity and
concomitant problems.”
Miguel N. Burnier Jr., M.D.
4 Achieving Success with Cataract and Refractive Technology
A new tool to analyze how much the cataract
incision influences the refractive outcome
imbal relaxing incisions
(LRIs) and other methods
to address astigmatism
have been around the ophthalmology block for a
while, but as cataract surgery
becomes more like refractive surgery, surgeons are looking for new
ways to optimize outcomes.
In this era of premium IOLs,
surgeons have shifted their attention to surgically induced astigmatism (SIA), said Robert P.
Lehmann, M.D., clinical associate
professor of ophthalmology, Baylor
College of Medicine, Houston,
Texas. Surgeons now understand
that whether they are implanting
multifocal lenses, accommodating
lenses or doing an LRI, to get more
precise refractive results they must
take SIA into account.
Enter the Surgically Induced
Astigmatism Calculator, designed
by Warren E. Hill, M.D., available
from his website, www.DoctorHill.com. “It’s an excellent fit with
both the [AcrySof] Toric lens
(Alcon, Fort Worth, Texas) and
LRIs,” Dr. Lehmann said. “That’s
the obvious place where you
would first think of using it, as
surgically induced astigmatism is a
key element in the AcrySof Toric
Calculator.”
The AcrySof Toric Calculator
(Alcon,www.AcrySofToricCalculator. com) takes into
L
“The Toric really
allowed me to achieve a
level of precision and
success I never came
close to with LRIs. It’s a
precise and easy way
for surgeons to transition into premium IOLs.”
Robert Lehmann, M.D.
account how much astigmatism
you induce during surgery so that
it can be compensated for in lens
calculations. “It’s very applicable
to toric lenses,” Dr. Lehmann said.
“The calculator provides a default
value but your results will be
improved if your own SIA is
used.”
While there are a number of
astigmatism calculators available,
Dr. Lehmann said the SIA
Calculator is the only one he
would use because of Dr. Hill’s
reputation and contributions to
ophthalmology. “Warren Hill’s
work has been second to none,”
Dr. Lehmann said.
Dr. Lehmann noted that smaller incisions cause less induced
astigmatism. The range of possible
induced astigmatism, for example,
is greater with 3.0-mm incisions.
“In that light, this [SIA
Calculator] is going to be incredibly valuable, too,” he said, especially for surgeons who have had trouble optimizing results with some of
the latest IOL technology. A tool
like this [SIA Calculator] is going to
enable a surgeon who has had an
up and down love affair with premium implants to hone in and do
a better job to get more precise
refractive results, which is what it
takes to make patients happy.”
Dr. Lehmann added that surgeons cannot have more than half
a diopter of uncorrected residual
astigmatism in patients and expect
to be successful with premium
lenses. “These people want to function if at all possible with reduced
dependence on glasses,” he said.
Dr. Lehmann added that his
surgically induced astigmatism
with vector analysis is between 0.3
and 0.4 D, and he has excellent
results with Toric IOLs.
“The AcrySof Toric IOL really
allowed me to achieve a level of
precision and success I never came
close to with LRIs. It’s a precise
and easy way for all surgeons to
transition into premium IOLs,” Dr.
Lehmann said. “In my hands, I
thought I was doing a good job
[with LRIs]. With LRIs, patients
might see really well on day one,
but after the eye heals, residual
astigmatism comes back. I don’t
think I came close in 20 years to
achieving the kind of results I
have in two years with the Alcon
Toric lens. On day one, 20/20 is
not unusual now. LRIs now are a
very poor second to Toric.”
Dr. Lehmann is a consultant for Alcon,
but states that he holds no financial
interest in the products mentioned herein. He can be contacted at 936-569-8278
or [email protected].
A surgeon readies to implant an AcrySof Toric IOL
Final alignment of the AcrySof Toric IOL
Please visit www.Doctor-Hill.com and
www.AcrySofToricCalculator.com for
more information.
Achieving Success with Cataract and Refractive Technology 5
Early experience with the AcrySof Toric IOL
n ocular surgery, there are
plenty of ways to manage
astigmatism. One method is
emerging as supremely advantageous: the AcrySof Toric IOL
(Alcon, Fort Worth, Texas), according to Johnny Gayton, M.D.,
Eyesight Associates, Warner
Robins, Ga.
Incisions to correct astigmatism lack precision. They also lead
to unpredictable outcomes and
potential regression, not to mention their limited treatment range,
I
Dr. Gayton said. Lasers, meanwhile, can weaken the cornea.
The ideal astigmatism treatment is precise and accurate with
predictable outcomes; it is permanent, safe, and convenient. The
AcrySof Toric IOL has proven to be
an option that can meet these criteria.
So who are the candidates for
surgery?
Patients who are “able to have
lens surgery and also have significant regular corneal astigmatism,
More than 60% of Toric patients achieved less than or equal to
0.5 D of absolute residual refractive cylinder at six months compared to about 20% of controls
Of patients with bilateral implantation, 97% were spectacle-free
Source: Johnny Gayton, M.D.
whether or not it is asymmetric”
are ideal, Dr. Gayton said. What’s
more, he said, none of the multifocal contraindications apply, such
as diabetic retinopathy, macular
disease, or even “personality difficulties.”
The Toric can also be combined with other more traditional
astigmatism correcting procedures.
A Toric and LRI at the time of
surgery is one possible solution, as
is a Toric and LRI post-op, and a
Toric and laser vision correction.
Conceivably, a surgeon could even
employ all three methods.
Dr. Gayton recommends that
between 1.0 and 2.75 D of againstthe-rule astigmatism, a Toric IOL
should be used. With 2.75 or
greater against-the-rule astigmatism, a Toric and LRI could be
used, correcting residual astigmatism with a laser. Between 0.5 and
2.25 D with-the-rule astigmatism is
also suitable ground to employ the
Toric only. For 2.25 or greater
with-the-rule astigmatism, he suggested a Toric and LRI once again,
correcting residual astigmatism
with a laser.
Don’t take Dr. Gayton’s word
about the clinical benefits of Toric
IOLs. The results speak for themselves in one multicenter clinical
investigation in which 211 AcrySof
Toric IOL eyes were compared to
210 control eyes.
In the study, patients were
three times more likely to achieve
less than or equal to 0.5 D of
residual refractive cylinder with
the AcrySof Toric IOL than with
the control group.
More than 60% of Toric
patients achieved less than or
equal to 0.5 D of absolute residual
refractive cylinder at six months
compared to about 20% of controls.
Further, the mean absolute
residual refractive cylinder was
0.55 D for all AcrySof Toric IOL
patients compared to 1.22 D for
controls.
Importantly, 97% of the 37
patients who were implanted bilaterally were spectacle-free for
distance viewing.
“The AcrySof Toric IOL
demonstrates excellent rotational
stability within the capsular bag,”
Dr. Gayton said. The unique properties of the AcrySof material make
it the optimal IOL to address astigmatism.
Implantation of the Toric lens
requires only minor variations
from a standard cataract procedure.
Surgeons determine the
required spherical power using
their preferred method. They then
use the AcrySof Toric IOL
Calculator (Alcon,
www.acrysoftoriccalculator.com)
to determine the correct IOL
model and optimal axis location
of the IOL in the capsular bag.
The eye is marked on the limbus pre-op in three locations 90
degrees apart (3, 6, and 9 o’clock).
Later, during the procedure, axis
marks are placed on the eye using
the pre-op reference marks.
“Axis marks identify the
optimal axis of IOL placement as
determined by the AcrySof Toric
IOL Calculator,” Dr. Gayton said.
The lens is then rotated to its
proper alignment. It’s that simple.
This IOL technology has
turned out to be a huge benefit for
patients and surgeons. It’s an easy
way for all surgeons to get
involved in elective IOLs. Patients
understand that they have astigmatism. They know they need it
corrected in their glasses, in their
contact lens, and now in their
IOLs.
Dr. Gayton has no financial interests
related to this supplement. He can be
contacted at 478-922-2994 or jlgayton@
aol.com.
“The ideal astigmatism
treatment is precise
and accurate with
predictable outcomes;
it is permanent, safe,
and convenient. The
AcrySof Toric IOL has
proven to be an option
that can meet these
criteria.”
Johnny Gayton, M.D.
6 Achieving Success with Cataract and Refractive Technology
Silo Scheduling: Proactive templates
deliver the practice you desire
magine a world in which
more patients need to be
cared for by your practice, but
your practice nonetheless suffers more financial pressure as
fees drop. Stop imagining because
without making some changes,
this will likely be the future.
The baby boomer population
is aging, bringing with it a
tremendous amount of patients
who need more “interactive, collaborative care from their medical
provider,” said Kay Coulson, president, Elective Medical Marketing,
Boulder, Colo. Specifically, in the
next 20 years, the number of
patients with cataracts are slated
to increase 60%, and glaucoma
patients will increase by 46%, Ms.
Coulson said. Meanwhile,
reimbursements have been and
will continue to decline.
“We’re at a critical threshold
where efficiency alone cannot
carve any additional time from a
surgeon’s day,” Ms. Coulson said.
Instead, ophthalmologists first
need to revisit the services they
provide. “We are rapidly moving
into a period where further specialization of ophthalmologists
will be required,” Ms. Coulson
said. “The comprehensive practice
that continues to schedule and
treat patients simply as the phone
rings will be overwhelmed within
glaucoma and lens surgery
requests.”
Second, special scheduling
help could ensure a practice’s
I
“Silo Scheduling allows
a practice to create
definition in its
appointment calendar
to deliver the right mix
of patients.”
Kay Coulson
financial well-being. “Now is the
time to revisit your appointment
template and provide the visit
type definition that reflects the
type of practice and mix of
patients you desire,” Ms. Coulson
said.
Silo Scheduling, a technique
developed by Elective Medical
Marketing, “allows a practice to
create definition in its appointment calendar to deliver the right
mix of patients, and more importantly, restrict visit types that
threaten to overwhelm the practice,” Ms. Coulson said. See Figure
A for an example of Silo
Scheduling.
So why can’t a practice simply
analyze how to better optimize its
own scheduling? “Adjusting the
schedule template cannot be
undertaken in isolation, as each
practice must understand how
visit types relate to diagnosis
codes and revenue; there is not a
one-to-one correlation,” Ms.
Coulson said. Elective Medical
Marketing has years of experience
perfecting unique scheduling to
find just the right financial solutions for practices.
The way Ms. Coulson speaks
about it, scheduling sounds like a
science. “What Elective Medical
Marketing has done for several of
our clients is develop an appointment mix summary by silo and
revenue realized per appointment
type, correlating diagnosis codes
to silos,” Ms. Coulson said. “This
determines an event-to-appointment billing ratio.” Using the
example worksheet shown in
Figure B, a practice can perform a
scenario analysis that indicates,
for example, ‘If I reduce the glaucoma and pathology portions of
my practice and concentrate on
growing lens and LASIK surgery,
how will my bottom line be affected?’”
In that example, revenue was
increased by 13% by revising the
appointment mix. “These appointment mix percentages can then be
built into the schedule template
with reassurance that schedule
changes will result in a positive
bottom-line impact,” Ms. Coulson
said.
This way, ophthalmologists no
longer have to feel overwhelmed
caring for more patients as their
practice suffers financially. By
working smarter – with a little
help from Silo Scheduling – they
can put their worries behind
them.
Ms. Coulson is a consultant for Alcon.
She can be contacted at 303-994-0014
or [email protected].
Figure A: An example of Silo Scheduling
Figure B: Scenario analysis can be performed to determine how
changing practice workloads will affect the bottom line
This supplement was produced by EyeWorld under an educational grant from Alcon, Inc.
Copyright 2008 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here
do not necessarily reflect those of the editor, editorial board, or the publisher and in no way imply
endorsement by EyeWorld or ASCRS.
Achieving Success with Cataract and Refractive Technology 7
Are lifestyle IOLs worth it? Establishing
realistic financial goals for upgraded lenses
Before
After
Our hypothetical practice sees 40 cataract
Exams
per week evaluations per week, which include known
cataracts, either from your diagnosis of
patients presenting for a recheck, or referred in
from ODs/non-surgical MDs. The number of
evaluations is based on a weekly average over
the prior 90 days.
This practice performs 12 cataract surgeries
Surgeries per week for a conversion rate of 15%. In our
per week experience, we’ve found practices dramatically
overestimate their surgical conversion, with 15
to 20% being the industry average.
This practice implemented Silo Scheduling, blocking the
same 40 weekly consultations into two mornings per week,
separate from all other appointment types, rather than dispersing them throughout the schedule.
Blocking all cataract evaluations into two days and ensuring
all staff are geared on those mornings toward evaluating
and educating patients about lens surgery options increased
surgical conversions to 25%, resulting in 20 surgical eyes
per week versus 12 from the same 40 exams.
Lens mix
This practice was dabbling in presbyopic IOLs
and had not begun implanting toric IOLs. They
perform LRIs, but did not charge for them as
they considered results too unpredictable.
All cataract evaluation patients were mailed educational
materials one week ahead of their visit. These materials covered all lens options, procedure costs, and patient testimonials. In addition, each patient filled out the Vision Preferences
Checklist, and all were shown a multifocal testimonial DVD
while dilating. Conversion to lifestyle IOLs increased from
5% to 35%.
Fees
This practice charged $3,000 per eye for a
presbyopic IOL, and as part-owner of its ASC,
paid $745 incrementally for multifocal lenses
(above the $150 ASC reimbursement).
Realizing the $3,000 fee was preventing adoption by many
interested patients, this practice lowered its presbyopic IOL
fee to $1,975 per eye, and added an astigmatism management service at $975 per eye.
o-called “lifestyle IOLs” –
that is, multifocal or
pseudoaccommodative
ones – clearly have more
potential for profit as
associated fees are higher than
with standard IOLs. But before
offering them in your practice,
wouldn’t it be good to know the
likely financial outcome of doing
so? Other businesses carefully
study the advantages of new product lines before they offer them.
Why shouldn’t you? The Lifestyle
IOL Financial Calculator, a
method developed by Elective
Medical Marketing (Boulder,
Colo.), allows ophthalmologists to
“evaluate current practice performance and set targets for specific areas of improvement that can
be continually monitored as your
practice expands,” said Kay
Coulson, the company’s president.
S
The chart above shows beforeand-after scenarios of one hypothetical practice, which with the
help of some of the method’s
implementation steps, dramatically increased revenue by more than
75%. The chart was provided by
Elective Medical Marketing.
As a result of the practice
changes made, revenue increased
from $476,000 to $835,000 annually without having to do any
more cataract evaluations.
“This revenue increase of more
than $350,000 is the result of
increased practice focus on the
patient experience through Silo
Scheduling and pre-exam education,” Ms. Coulson said.
Ms. Coulson is a consultant for Alcon.
She can be contacted at 303-994-0014 or
[email protected]
Schwiegerling from page 1
Overall, it is wise for all IOLs
to move to the aspheric platform,
Dr. Schwiegerling said. While
today’s IOL technology is excellent, any small improvement will
still make a difference, he said.
Dr. Schwiegerling did note
that the aspheric design had no
impact on near vision in ReSTOR
patients.
“I think that’s fairly predictable,” Dr. Schwiegerling said.
“Most aspheric effects only
account for large pupil conditions.”
In the ReSTOR lens, the
peripheral part of the IOL –
through which light would pass in
large pupil conditions – is strictly
for distance vision.
So the fact that Dr.
Schwiegerling said most aspheric
effects are noted in large pupil
conditions means they are notable
for distance vision, and not particularly for near vision. Near vision
in the ReSTOR, Dr. Schwiegerling
said, is achieved with the central
3.6 mm of the lens.
Meanwhile, Dr. Schwiegerling
said, intermediate vision is probably the same in both the aspheric
and standard ReSTOR IOLs.
“It was difficult from our findings to see any differences one
way or another,” Dr.
Schwiegerling said.
Of course, modulation transfer
function testing does not gauge
any neuroadaptivity that occurs
related to quality of vision. After
some time, symptomatic patients
may not notice halos and glare
even with the standard ReSTOR
IOL in larger pupil conditions
because their brains have adapted
to screen them out. Nonetheless, a
better optical system, like the
aspheric design, can only help to
lessen these effects further.
Dr. Schwiegerling receives travel,
honoraria, and research grants from
Alcon. He can be contacted at 520-3223800 x210 or [email protected].
Unlike IOLs that do not closely match the light-transmission spectrum of the human
crystalline lens*, the patented chromophore in the AcrySof® Natural IOL is designed
to filter UV wavelength and blue light in the 400 –475nm range.
“Objective, peer-reviewed studies have shown that
“Having participated in the clinical investigation of the
blue-light filtering IOLs have no significant effect on color
Natural chromophore and seeing for myself real-life patient
perception. There are strong indications that blue-light
benefits, I am gratified by the increasing worldwide
acceptance of the AcrySof® Natural platform. This lens is
filtering IOLs may play an important role for patients
quickly becoming the standard of care as more companies
in the long-term. In my experience, the potential benefits
are attempting to copy this technology and following suit.
outweigh unsubstantiated claims of altered circadian
”
rhythms and other marketing hype.
James McCulley, MD
Founder and Director of Lehmann Eye Center
Professor and Chairman, Department of Ophthalmology
UT Southwestern Medical Center at Dallas (USA)
“I have implanted the AcrySof
®
”
Robert Lehmann, MD
Clinical Associate Professor,
Baylor College of Medicine (USA)
“Over the last five years I have implanted more than
Natural IOL for ten years,
and it possesses a long-term track record of excellent
10,000 blue-light filtering lenses, I also implanted this lens in
clinical performance. The AcrySof® design, material and
my wife and both my parents. There is no definitive evidence
Natural chromophore combine to provide great benefits to
to justify statements that the AcrySof® Natural chromophore
causes alleged problems with visual acuity, color perception,
my patients. This is the IOL I would want if I were a
patient. As a surgeon concerned with my patient’s best
interests, using it allows me to sleep soundly each night.
Stephen Lane, MD
”
Adjunct Clinical Professor,
”
contrast sensitivity, circadian rhythms or sleep pattern.
Richard Mackool, MD
Founder and Director of The Mackool Eye Institute
Assistant Clinical Professor,
University of Minnesota, St. Paul (USA)
“Although it may take years to determine every benefit
associated with the Natural lens, there have certainly
been many clinical studies done that strongly support its
safe use. Excellent clinical performance provided me the
confidence to implant AcrySof Natural IOLs in my wife
®
”
and my sister.
Samuel Masket, MD
Clinical Professor,
UCLA, Jules Stein Eye Institute, Los Angeles (USA)
New York Medical College, New York (USA)
“I believe very strongly that the AcrySof
®
blue-light filtering
IOLs should be the standard of care for all patients. In my
peer-reviewed studies, we have presented laboratory
evidence that clear and/or violet IOLs do not have the
”
qualities of the Natural chromophore.
Miguel Burnier, Jr., MD
Thomas Hecht Family Chair of Ophthalmology and
Director of the Henry C. Witelson Eye Pathology Laboratory,
McGill University, Montreal (Canada)
References; (*) Alcon, Inc. Data on File and Human lens data from Boettner and Wolter, 1962
© 2008, Alcon, Inc.
ACR586