A Win-Win-Win Situation

Refractive lens exchange has the potential to save the government a lot of money. It also has the capability to give patients excellent vision—in many cases, better than they have ever had in their lives. Moreover, the procedure's elective status allows surgeons to establish a free and open relationship with patients, as in the days before insurance companies and governmental influence. Here, I will explain why refractive lens exchange is a triple win: a win for the patient, a win for the doctor, and a win for the government.

WIDESPREAD BENEFITS

Patients
Patients benefit from refractive lens exchange because it is a relatively safe procedure; it eliminates all of their refractive errors, including sphere and cylinder; and it can address their presbyopia with a multifocal lens. As long as the implant correctly targets the refractive error, refractive lens exchange can relieve a patient of a dependency on glasses and contact lenses for the rest of his or her life. In addition, the procedure's elective status allows patients more freedom of choice: they can select the physician with whom they feel most comfortable, without the hassle of obtaining a referral or having to worry about the government and insurance companies intruding upon their care.

Surgeons
Ophthalmologists favor refractive lens exchange because it reestablishes their natural relationship with patients. As an elective procedure, it avoids intervention by insurance companies and the government on pricing and care issues, which allows the surgeon singular discretion over administering the most appropriate form of care to each patient. Ultimately, market forces will dictate the price of the procedure.

Government
Refractive lens exchange could relieve the government of much of the financial burden of subsidizing cataract surgery. Currently, the US government pays for cataract surgery for patients aged 65 years or older. A large number of baby boomers are reaching the age at which they will require cataract surgery, which could theoretically place a large demand on governmental resources. However, if these individuals undergo refractive lens exchange 10 or 20 years before developing cataracts, then they will essentially reach Medicare age as pseudophakes. If enough patients undergo refractive lens exchange, then the demographic shift will ease the government's financial burden for patients requiring cataract surgery.

NO TRUE DRAWBACKS
There are virtually no drawbacks for surgeons, the government, or insurance companies if refractive lens exchange remains an elective procedure, and any drawbacks for the patient will be perceived. Some patients may initially be deterred by having to pay out-of-pocket for this procedure, but they must realize that, if refractive lens exchange were covered by the government or insurance, the public would pay for it indirectly through higher taxes or increased insurance premiums. Patients over the age of 65 may not pay directly for cataract surgery, but that doesn't mean that the procedure is free.

TALKING TO PATIENTS ABOUT THE PROCEDURE
Our practice does not advertise the refractive lens exchange procedure; we simply market our practice as a refractive surgery center. When we see patients who are better candidates for refractive lens exchange than LASIK because of their age or type of correction, we counsel them on their surgical options. We explain that refractive lens exchange costs more than LASIK, that it is a more technically demanding procedure, and that it carries a slightly higher risk. We also explain its advantages. For example, it allows us to implant a lens that will provide patients with both distance and near vision without using monovision, which 15% of patients cannot tolerate. We describe how refractive lens exchange offers a permanent solution to their visual problems. Performing monovision LASIK usually gives patients near vision in one eye (based on their age). However, 10 or 20 years later, that near power will not be sufficient. A surgeon performing monovision LASIK might leave a 40-year-old at -1.25 D, but when that patient turns 50, this near power will not be strong enough. Refractive lens exchange using a multifocal lens eliminates the need for any retreatments, and the patient does not have to worry about developing cataracts later in life.

The only disadvantage of refractive lens exchange is a minimal risk of serious complications. The rate of endophthalmitis for modern cataract surgery runs approximately 1 out of 5,000.1 Refractive lens exchange also carries a small risk of retinal detachment depending on the length of the patient's eye and the duration of follow-up. A candidate who has a very long eye and is extremely nearsighted has a 7% risk of developing a retinal detachment with this procedure.2 Some studies have shown that watching these patients carefully and treating them for tears reduces their risk of a retinal detachment to that of the population that has the same eye length.3-5 Nevertheless, patients who are extremely nearsighted and have very long eyes are probably poor candidates for refractive lens exchange and may benefit from other technologies such as phakic IOLs. However, for the majority of patients, the risk of serious complications is relatively low.

PRICING ISSUES
Our practice's pricing policy for refractive lens exchange may vary with particular cases, but ordinarily, a Nd:YAG capsulotomy required after the procedure would be included. In the rare case of a retinal detachment, the retinal specialist would treat the patient and then bill the insurance company. For the most part, however, it is rare for patients to develop complications after refractive lens exchange.

SUMMARY
After all the considerations, the elective status of refractive lens exchange is a better option for all parties involved. It represents a better standard of care for patients because they can choose to undergo the procedure and select their care provider. Removing the insurance companies eliminates the limitations of a closed panel. As a noncovered elective procedure, neither the insurance companies nor the government can interfere with a physician's determination of proper care.

Richard S. Hoffman, MD, is Clinical Instructor of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, and is in private practice in Eugene, Oregon. He does not hold a financial interest in any technology discussed herein. Dr. Hoffman may be reached at (541) 687-2110; rhoffman@finemd.com.
1. Eifrig CW, Flynn HW, Scott IU, Newton J. Acute onset postoperative endophthalmitis: review of incidence and visual outcomes. Ophthalmic Surg Lasers. 2002;33:373-378.
2. Colin J, Robinet A, Cochener B. Retinal detachment after clear lens extraction for high myopia: seven-year follow-up. Ophthalmology. 1999;12:2281-2284.
3. Pucci V, Morselli S, Romanelli F, et al. Clear lens phacoemulsification for correction of high myopia. J Cataract Refract Surg. 2001;27:896-900.
4. Jimenez-Alfaro I, Miguelez S, Bueno JL, Puy P. Clear lens extraction and implantation of negative-power posterior chamber intraocular lenses to correct extreme myopia. J Cataract Refract Surg. 1998;24:1310-1316.
5. Lee KH, Lee JH. Long-term results of clear lens extraction for severe myopia. J Cataract Refract Surg. 1996;22:1411-1415