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Today's Practice | Oct 2013

Six Steps to Success With Premium ioLs

A conversion rate of 35% or higher is achievable for surgeons who are confident in their ability to deliver great results.

It is hard to identify one key to success with premium IOLs. What these lenses demand is careful attention to every step of the process. I have been implanting premium lenses since the introduction of the Array lens. Over the years, multifocal lens technology has improved, but no premium IOL can overcome imprecise surgery or residual refractive error. Ophthalmologists must deliver excellent results—or make it right if they do not.

With this approach, I have a conversion rate of about 35% in my practice, and that is growing, as patients become ambassadors for my practice and tell their friends about their IOL experience.

Here are six steps to get your practice to a similar conversion rate.


From the time that patients first call our office, we begin educating them about contemporary options for cataract surgery. The welcome packet they receive in the mail before their first appointment includes information about IOL choices. My technicians are trained to handle questions and to begin discussing likely options during the workup. Ideally, when I walk into the examination room, the patient already has an IOL brochure in his or her hand.

After examining the patient and reviewing the diagnostic testing results to be sure there is no pathology that would prevent a good refractive outcome, I recommend either a multifocal (<1.00 D of astigmatism) or a toric (>1.00 D of astigmatism) lens, with a standard IOL as the fallback option in either case.

Contrary to the conventional wisdom that premium IOL patients tend to be young and affluent, I have observed no consistent demographic profile. The biggest determinant of conversion is the patient's personal experience with vision correction: those who have always hated wearing glasses will choose a premium IOL to reduce or eliminate their dependence on glasses.

It is extremely important that you make a clear recommendation: “Mrs. Smith, based on your excellent ocular health and low level of astigmatism, I recommend a multifocal IOL.” I explain exactly what that means (reduced dependence on spectacles) and note that there is an additional charge for the premium lens.


The ocular surface is a hugely underappreciated factor in success with premium IOLs. Dry eye disease is very common in the cataract population, with many asymptomatic patients. Dry eye disease can render preoperative biometry and topography inaccurate, limiting the surgeon's ability to hit the refractive target and negatively affecting the patient's comfort and vision. Even when surgery is technically perfect, problems with the ocular surface can make the patient unhappy.

I feel so strongly about this subject that I typically do not rely on the topography or biometry from the initial visit for surgical planning. First, my staff and I optimize the patient's ocular surface by prescribing cyclosporine 0.05% (Restasis; Allergan, Inc.), a mild steroid, oral nutrition, and/or other therapies as needed. We then repeat testing at a second preoperative visit. This approach helps me to achieve consistent keratometry (K) readings from the autorefractor, topographic measurements, manual K readings, and data from the IOLMaster (Carl Zeiss Meditec, Inc.). If there is a difference of more than 0.25 D between these measurements (especially between the autorefractor K readings and the IOLMaster), I repeat them until I have tight agreement.


I strive to perform “clean” surgery, with few complications. Fortunately, with online videos and so many other resources available today, there are always opportunities for improvement. Premium IOLs require stable, well-sealed incisions, a perfect capsulorhexis, excellent cortical cleanup, centration of the lens, and (in the case of a toric IOL) onaxis alignment.

One technical change I have made in recent years is to pay close attention to the construction of my incision. I will make the incision on the steep axis if I can, but it is much more important to me to operate in a comfortable position (usually temporally) so that my wound and surgically induced astigmatism are consistent. I have also started making smaller capsulotomies; I have shifted from a 6- or 6.5-mm capsulorhexis to a 5-mm opening that overlaps the IOL's optic.


Even after flawless surgery, a small percentage of cases do not achieve the desired result. Before offering premium IOL technology, cataract surgeons who do not perform corneal refractive surgery themselves should develop a relationship with a refractive surgeon who can provide enhancements.

I recommend that laser or other enhancements be free of charge and, more importantly, discussed before surgery so that the need for a little “touch-up” does not shock the patient.


I believe in the technology and in my ability to deliver the desired results, and that confidence comes across to patients.

I favor the Tecnis Multifocal IOL (Abbott Medical Optics Inc.), because in my experience, it provides my patients with the best quality of vision possible with current multifocal IOL technology. Their distance and near vision is very crisp, their problems with glare and halo are minimal, and they are generally happy with the IOL's performance at various levels of illumination. A surgeon must also realize when a patient is not an ideal candidate for a multifocal lens implant. Certain personality types are less willing to adjust to rings around lights at night or mild loss of contrast that can occur with this technology. Also, patients with pathology like macular degeneration, corneal disease, advanced glaucoma, and others should not receive multifocal lenses.


To grow a premium IOL practice, you have to encourage referrals. After performing excellent surgery, take the next step of converting that satisfied patient into an ambassador for your practice.

In my practice, a highly successful strategy has been asking patients if we may add them to a call list for future patients who are considering a premium lens. This question alerts each patient that his or her experience is valuable. For surgical candidates, the opportunity to talk to someone who went through the same decision process and received the same lens is tremendously reassuring.


Success with premium IOLs begins with a commitment to excellence. If you are able to deliver the results that patients want through a combination of great technology and great surgery, you will project confidence, and patients will naturally choose the premium IOLs that you recommend. Happy patients will serve as your ambassadors and help you to build a stronger premium practice.

Jeffrey L. Martin, MD, is an assistant clinical professor of ophthalmology at the State University of New York-Stony Brook and managing partner at North Shore Eye Care, with six locations in Long Island, New York. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Martin may be reached at (631) 265-8780; doc7465@aol.com.

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