Building a presbyopic intraocular lens practice

October 15, 2009

The introduction of premium IOLs has brought new challenges for catarct surgeons.

Key Points

The most important thing to understand is that being a technically good surgeon is not enough. Having a successful, well-run cataract practice is also no guarantee of success with premium IOLs. Many excellent surgeons with thriving practices have already learned this lesson the hard way.

You will only succeed with premium IOLs in the new cataract surgery environment if you can develop critical new skills that have nothing to do with traditional cataract surgery, namely, communications skills and the ability to perform refractive surgery enhancements. In addition, one must fully understand the refractive strengths and weaknesses of each of the available IOLs in order to tailor the IOL best to the patient.

The first step in re-tooling your practice for refractive IOLs is to reverse the flow of information. In a typical, successful, high-volume cataract surgery practice everything is geared toward moving information from the practice to the patient. In the past, this pathology-based patient education model has alleviated patient anxiety, fulfilled informed consent requirements, and reduced chair time resulting in more efficient flow and high patient satisfaction.

Premium IOLs bring with them an elective surgery component that we have not dealt with before in cataract surgery. In this setting, the pathology-based model that has served us so well in the past will actually increase chair time and keep premium IOL conversion rates low. Instead, we need to increase the flow of information from the patient to the doctor, so the surgeon can better understand the patients' needs and expectations in order to be an advocate for the right procedure and IOL choice for that patient.

Who's in your chair?

In all cases, it's a person, not just a pair of eyes. It is critical to understand what that person's goals are in coming to see you.

The typical cataract patient in the late 60s to 80s is from what Tom Brokaw called the "Greatest Generation." Many people in this age group are more accepting, less litigious, and less computer-dependent than their younger counterparts. Their preop vision is reduced by their cataractous changes. They come in seeking a diagnosis and a cure for the problem (cataracts) and may have little to no understanding of refractive, out-of-pocket options. Their postop vision will usually be dramatically better than their pre-surgery vision.

By contrast, the "baby boomer" generation (late 40s through early 60s) is more demanding, more litigious, and more likely to be still working, perhaps at the peak of their careers. These patients are expecting spectacle independence. They are much savvier about elective surgery and may have already had LASIK, cosmetic surgery, or elective dental work. Their lenses are relatively clear and their distance vision still good, so they will be comparing their postop visual results with their excellent preop corrected vision.

So which generation produces good premium IOL candidates? The answer is both, but the doctor needs to perceive the differences and incorporate their personality styles, needs, and visual realities into the treatment decision. You can meet the younger patient's desire for spectacle independence if you counsel appropriately and are careful not to take away something he or she needs (like intermediate vision). The older patients are going to get a big boost from the cataract removal alone, but you can exceed their expectations with premium IOLs.