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Cover Stories | Feb 2009

Getting Started With Refractive IOLs

A primer on how to convert a cataract surgery practice to a refractive cataract surgery facility.

Getting started with refractive IOLs can often seem like a daunting task. Since the advent of premium lenses in 2005, many refractive surgeons have eagerly and successfully begun performing refractive cataract surgery, whereas numerous cataract surgeons have been more reluctant to embrace the changes in IOL technology. This hesitation can primarily be attributed to the different mindsets of these two types of practitioners.

If a practice is to become successful with upgrade, or premium cataract surgery, the practice needs to change. It is imperative that this transformation start at the top with the surgeons and include all members of the team—front desk personnel, technicians, and the surgical coordinator or patient counselor. All of the doctors in the organization need to get involved and demonstrate an enthusiasm for the new technology.

A change in mindset is probably the most important initial step in a practice's conversion to refractive cataract surgery. Physicians should attend meetings such as refractive IOL symposia to gain a basic understanding of the types of lenses available in addition to their benefits. They should seek out pearls on patient selection and education as well as on troubleshooting. Because many refractive IOL symposia are also useful for technicians and coordinators, surgeons should strongly consider having their support staff accompany them. I attended Cataract & Refractive Surgery Today's Refractive IOL Symposium in Las Vegas in September 2008 with my staff, and our participation led to a 200% increase in my premium IOL volume within 3 months.

For ophthalmologists getting started with refractive IOLs, patient selection is crucial to early success. Surgically, all of the lens technologies are easy to manipulate. Medically, younger presbyopic hyperopes with low amounts of astigmatism are ideal. These patients are generally happier than any other subgroup such as myopes or prepresbyopes.

Ophthalmologists getting started with premium lenses will need to spend more chair time with the patient. In general, increased contact improves the quality of the relationship of the surgeon and his practice's staff with the patient. Training one or two of staff members, such as surgical coordinators or patient counselor, how to interact with patients can tremendously increase the productivity of the team. It can also significantly reduce the amount of time the surgeon has to spend counseling patients on potential IOL upgrades. Preoperative counseling regarding expectations—under promising and over delivering—is paramount to success. The more thorough an explanation prior to surgery, the fewer unexpected problems postoperatively.

Physicians should recommend a particular lens technology for the cataract patient prior to the conclusion of the consultation. Patients rarely walk through the door with a request for a specific IOL. Rather, they usually trust the physician to guide them correctly. Handing patients three brochures and telling them to do some research and pick one is a recipe for low surgical volume and poor outcomes.

Surgeons need to recognize that not every lens technology is suitable for every person. Each has its pros and cons. The selection of IOL should be tailored to the individual. Coordinators and counselors in a practice need to learn about each of the available IOLs. These staff members can become invaluable parts of a refractive cataract surgery team.

Managing postoperative side effects and outcomes can help create happier patients. Optimizing the tear film, treating small residual refractive errors aggressively, and performing YAG laser capsulotomies for minimal fibrosis can have a more profound effect on this group of patients than on those undergoing standard cataract surgery. Surgeons getting started with premium IOLs need to know how to perform limbal relaxing incisions and PRK or LASIK, or they need someone in the office who can perform these procedures. Physicians also need to scrutinize an IOL's centration and position. Each of the currently approved technologies can function poorly if not oriented correctly. These considerations are all very important to the creation of a happy physician/patient relationship, and successful early outcomes will fuel the conversion of patients to premium IOLs.

Premium lenses can be a wonderful addition to any cataract surgery practice. The way to succeed in a premium IOL practice is to communicate with patients and evaluate their lifestyle needs. Their satisfaction depends upon their proper evaluation and the careful selection of the appropriate technology. Aggressive intervention for normal postoperative conditions such as secondary membranes, tear-film abnormalities, and small refractive errors can lead to improved outcomes in the refractive IOL subgroup. It is important to stress to these patients that they will likely still need spectacles for some aspects of their daily living and to be realistic about their possible outcomes. Finally, under promising and over delivering will lead to much happier patients than will over promising and under delivering.

Jonathan Stein, MD, is Clinical Assistant Professor in the NYU Department of Ophthalmology in New York City, and he is in private practice at Ophthalmic Consultants of Connecticut, in Fairfield. Dr. Stein may be reached at (203) 366-8000; steinjonathan@hotmail.com.

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