Jul 06, 2016
by John Doane, MD Discover Vision Centers Kansas City MO & KS.
I wanted to discuss what can be expected with patients regarding refractive “upgrades” in relation to technology offerings. Before I proceed to refractive corneal or lenticular surgery let us look at others areas of vision care. If we look at progressive add spectacle lenses (PAL) in 1994 approximately 20% presbyopic prescriptions were PAL. Today, PAL correction is selected by the majority of the presbyopic population. Granted some individuals cannot tolerate the optical downsides of PAL technology overtime and with earlier introduction of PAL to the burgeoning presbyope population the acceptance has risen. Will traditional bifocals ever go to zero? No, but they will likely decrease.
What about the treatment of presbyopia with contact lenses. Multifocal contacts have improved over the last few decades but monovision with contacts is still preferred by more patients than multifocal technology. This is even more so for the higher add multifocal required by the 50-60 year-old patient. There remains an issue of quality of vision being still more important than the overall range or quantity of vision. Will multifocal contact lens technology improve? Yes, but I think there is a ceiling of patient acceptance due to the downsides.
How about upgrading technology for Laser Vision Correction? Well, depending on where a patient has laser vision correction there can be a menu of options. For example some clinics will have a standard option where lower order aberrations (sphere and cylinder) are corrected for a price, say $ 1,500 per eye. If the patient wants wavefront optimized treatment they may pay $ 2,150 per eye and if the patient opts for wavefront customized or guided treatment they may pay $ 2,450 per eye. Our clinic offers only wavefront corrections for all patients treated. We have decided by design to provide only our best visual option to all comers. We do vary price based upon refractive error as there is distinctly more effort provided for the higher corrections. So, penetration of the market for LVC is not so much based upon an upgrade by our philosophy as it is with patients opting for surgery or staying with their current visual aides.
Lastly, let us discuss upgrades to Toric-correcting and Presbyopia Correcting IOL’s
As a background, it has been 11 years since the “Premium IOL Channel “was legally created in the US. Prior to May 3, 2005, Medicare and virtually all insurance companies would not allow a patient to pay out-of-pocket to upgrade to IOL technology beyond a spherical monofocal IOL. I said prior to this time what a complete shame, embarrassment and irony this was. We have asked America’s finest men and women to go beyond our shores to defend, protect and promote liberty and freedom but their own government would not allow for them to have the best medical devices. In fact it was against the law for a surgeon to provide these technological breakthroughs to consenting patients. On May 3, 2005, FDA Ruling No. 05-01 created what is known today as the “premium IOL channel.” Under this ruling, cataract patients eligible for Medicare can upgrade from a monofocal lens to a premium refractive lens, as long as they are willing to pay the additional cost. It was a watershed moment in the history of ophthalmology because from this day forward, patients could choose the technologies that were best for them. It also created a new market in which breakthrough technologies and treatments could thrive. Reference, EyeWorld: http://eyeworld.org/printarticle.php?id=7407; accessed 2016-5-5 13:58:47
Date published online: September 2014, NEWS & OPINION, Chief medical editor’s corner of the world. It never hurts to have friends in high places; David F. Chang, MD
In this vein, let us look at premium IOL adoption in the US. Like other choices, and especially one where patients must make a value proposition decision, not all patients will opt for an upgrade. We can look at the sheer numbers in the US. In 2015, there were 3,960,000 intraocular lens implants placed. 201, 000 presbyopia correcting IOLs (accommodative and multifocal combined) or 5.1% of all IOL’s implanted were placed. There were 277,000 toric iol’s implanted or 7.0% of all IOL’s implanted in the US. The percentage breakdown is similar in other Western Countries. What could we expect for ultimate goals of penetration for these technologies? For toric IOL’s the basic numbers one must look at would be what % of eyes have 0.75 D or more of corneal astigmatism. That number is roughly 35%. So, 35% of 3.96 million is 1.386 million. With 277,000 toric IOL’s I would call the penetration best case scenario as 20% of those eligible.
What about presbyopia correcting IOL’s? For the sake of argument let us subtract the toric population. So, 201, 000 of 3,683,000 is 5.4 % penetration. Does this means that 94.6% of the non-toric population is accepting of presbyopia postop? Not exactly. Let us break down our clinic. I am very “pro” refractive correction, i.e. laser vision correction, monovison for the presbyopes, toric IOL’s, toric IOL’s with monovision, monovision with monofocal IOLs and presbyopia correcting IOLs. If there was a perfect presbyopia correcting IOL I think monovision would go by the wayside. Much like monovision with contact lenses still having greater penetration than multifocal contact lenses the same can be said for monovision with monfocal and toric monofocal IOLs than multifocal implant penetration. Why is this? First it is tolerated and the quality of vision is excellent with a relatively large near range of vision as compared to a short range of near vision with multifocal technology. Second, it is less expensive. For IOL technology there is no cost difference if one targets a monofocal IOL for plano or -1.5 or -2.25. This is a non-existent financial hurdle for patients.
Will presbyopia correcting IOL penetration increase with time? I believe so. The over age 70 population has as a whole been wearing correction for 30 years and they are less apt to spend any extra funds than younger age demographics. For the under age 40 crowd that gets a cataract and is looking at 3-4 decades of absolute presbyopia they are far more inclined to look at presbyopia correcting technology. Two very important parts of the puzzle are technology improvements to extended depth of focus IOL’s which will have less unwanted imagery than current multifocal technology and accommodative IOL’s that surpass the status quo technology and secondly the next generation of surgeons and eye specialist that are willing to provide these presbyopia correcting technologies. This latter variable should not be underappreciated as there is significant work at present to present and follow patients through this process to achieve optimal success.
NOTE: Dr. Doane is a world famous refractive, cornea and cataract surgeon, has authored many scientific papers, books, served as Editor of a medical journal and lectures extensively. He practices in Kansas CIty MO & KS