Lifestyle IOLs, composed of toric, multifocal, and accommodating IOLs, represent a significant opportunity for surgeons who wish to offer glasses-free vision to their cataract patients while simultaneously increasing practice profitability. One of the challenges that busy surgical practices face is how to better identify ideal candidates for presbyopic or toric lenses and then optimizing the surgeon's time with this patient. In the examination lane, I suggest rigorous adherence to the program I call the "Four Levels of Either/Or."

EITHER/OR NO. 1: RECOMMENDING CATARACT SURGERY OR NOT?
Your first step when conducting a cataract evaluation should always be the same. Are you recommending that this individual proceed to surgery? If not, the examination is over. Do not talk about lifestyle IOLs. Do not hand this person literature to consider before he returns in 6 months or a year. The technology and options will have changed by then. The patient who presented for a cataract evaluation and left your office without a recommendation for surgery is relieved and will not think or worry about surgery again until the next visit. Handing these individuals a packet as they walk out the door yields virtually no return and will not work as preemptive education. You told them they were fine, and they will go about their business.

If you are recommending cataract surgery, however, and the patient agrees to proceed, then it is time to introduce lifestyle IOLs.

EITHER/OR NO. 2: OPTIMIZE DISTANCE OR FULL-RANGE VISION?
The majority of patients are not aware that they have options in choosing the type of vision they desire. Most have no idea that cataract surgery can restore a range of vision that they have lost due to growing older. Ophthalmologists are in the early stages of educating the 55 population about vision options for aging eyes. We need to inform these individuals about lens-replacement options in a process much more extended than what is required for a LASIK patient.

Start the educational process prior to the preoperative examination. Before their visit, make sure all cataract evaluation patients are mailed educational material that describes common cataract symptoms, provides reassurance regarding the procedure's safety, and informs about new options to restore vision and minimize reliance on eyeglasses. After the technician's workup, play one of the testimonial videos available from lens manufacturers while the patient's eyes are dilating, so that he (as well as family members, if present) is thinking about improved vision before you walk in the room.

Use the Vision Preferences Checklist (Figure 1) as a conversation starter for determining whether the patient desires optimized distance or full-range vision. Does the patient want perfect distance vision day and night and will not mind wearing glasses to achieve it? This person is considered a monofocal candidate. Does he want improved distance vision without glasses, not mind using readers, and have pre-existing astigmatism? This is a toric candidate. Does the individual want to minimize the time needed for wearing glasses, not drive much at night, and he is willing to trade off some distance vision so that crossword puzzles or the computer screen are clear? This person is a presbyopia-IOL candidate. Once you determine the type of vision the patient wants, you can proceed with asking questions to assess which specific lens or mix of lenses would be best.

Now that you have determined the type of vision the patient wants, you can move on to finding out whether his expectations are reasonable given what you and the technology can deliver.

EITHER/OR NO. 3: EXPECTATIONS REASONABLE OR NOT?
Lifestyle IOLs, whether presbyopia- or astigmatism- correcting, are designed to reduce a patient's reliance on glasses. Surgeons will be doing the industry and themselves a disservice, however, to promise that they can eliminate the need for glasses, at any distance. Use the Vision Preferences Checklist to evaluate whether patients' expectations are reasonable. Look at what they wrote and how they respond when you ask, "Do you mind wearing glasses? Are there times in your day when you would absolutely not want to wear glasses? If you had to wear glasses for some tasks, when would it least bother you?" Use the checklist to help assess when the patient will be able to tolerate wearing glasses if the surgery does not yield perfect results. If the patient has paid the upgrade fee, attained 20/20 distance vision without halos, but cannot read a paperback in bed for an hour each night and that's what he really wanted, you have failed. Lifestyle IOL vision is patient-preferred vision. Make sure you understand what that means, uniquely, for each patient.

If you agree that a patient will undergo surgery, if he agrees on an upgraded IOL, and if you believe his expectations are reasonable, then proceed to the final level of "Either/Or."

EITHER/OR NO. 4: UPGRADE FEES AFFORDABLE OR NOT?
It is the surgeon's responsibility to convert a patient to elective vision surgery. You must gain agreement to proceed. A critical component is making sure the patient understands there is a fee beyond what insurance will pay for this lens. My practice's fees are listed in the materials that we mail before the patient's visit, and they are also posted on our Web sites. However, if you have recommended an upgraded IOL, you must personally tell the patient what it costs. For example, the most effective method of communicating this idea seems to be, "Mrs. Smith, based on all we've talked about, I'm recommending the ReSTOR lens (Alcon Laboratories, Inc., Fort Worth, TX) for you. This surgery is $5,000 per eye. The good news is that you have a cataract, so your insurance will cover the majority of the cost. This means your payment will be approximately $2,000 for each eye. Do you have any questions about this fee?"

You do not need to cover the details of financing or payment requirements, but it is important that patients hear the fee from you so they appreciate its validity. I have seen many upgrades that the surgeon considered confirmed but were lost with the surgical scheduler simply because the patient was not aware of the added cost. Mentioning the fee does not make you a salesperson. It should not put you on the defensive, and you should not succumb to any pressure to discount fees in the lane. Your fee is your fee. Do not apologize for it, but also do not think a scheduler can do a better job than you of conveying the value of vision.

Use the "Four Levels of Either/Or" to bring increased focus and productivity to your lens practice. This program will save you from reviewing every lens option for every cataract evaluation patient while hoping that he will choose one option. "Either/Or" streamlines your patient interaction and increases your surgical bookings.

Kay Coulson is the founder of Elective Medical Marketing in Boulder, CO, and assists surgeons in growing their elective vision service lines. She may be reached at (303) 994-0014; kay@electivemed.com.