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Five pearls for successfully co-managing the premium IOL patient


The aging baby boom generation could create significant new opportunities for optometrists. ODs are the gatekeepers to cataract referrals and to intraocular lens (IOL) technology. Four out of five cataract diagnoses are made by an optometrist, so referring ODs should make a point of discussing all IOL options with patients.

By Richard Hyer



Josh Johnston, OD

Dr. Johnston disclosed a commercial relationship with Allergan.



The aging baby boom generation could create significant new opportunities for optometrists. ODs are the gatekeepers to cataract referrals and to intraocular lens (IOL) technology. Four out of five cataract diagnoses are made by an optometrist, so referring ODs should make a point of discussing all IOL options with patients.


A practice treating just five new cataract patients per month could generate additional revenue of $86,610 per year-not including ancillary revenue sources.

The graying baby boom generation offers optometrists a major opportunity for revenue


“Cataracts are now seen every day in clinic. The number of patients being diagnosed with cataracts by optometrists will continue to increase for years to come,” said Josh Johnston, OD. “For years you’ve been hearing about baby boomers, and now they’re here. In response to this influx of patients, ophthalmologists’ primary focus will shift to providing surgical care. As eye care evolves, ophthalmology will be busy with the surgical demands from the aging population, so optometry is poised to be the primary eyecare provider.”

One baby boomer turns 65 every 8 seconds. In 2011, there were 78 million boomers, of whom a record 2.8 million qualified for Medicare. By 2030 4.2 million a year will cross that threshold,1 said Dr. Johnston.

These demographics suggest that the baby boom population will put stress on the existing healthcare system and could possibly create significant new opportunity for ODs.

Higher expectations

Optometrists are the gatekeepers to cataract referrals and to intraocular lens (IOL) technology, said Dr. Johnston. Many cataract diagnoses are made by an optometrist, so referring ODs should make a point of discussing all IOL options.

“It’s our job to educate patients about cataracts and stay abreast on current treatment options. Patients now have the ability to have laser cataract surgery and choose IOLs that reduce or eliminate the need for glasses after surgery,” he said.

The IOL market is forecast to reach $3.1 billion by 20172 because of increasing demand for premium products such as multifocal, accommodating, and toric IOLs. Although the adoption level of premium IOLs in the U.S. during 2010 was 13%,2 the revenue generated by premium IOLs accounted for 39% of the total IOL segment. 2

 “Cataract surgery today has become refractive surgery,” said Dr. Johnston.

Patients who choose premium lenses are very demanding, he said. Many had LASIK and automatically assume that cataract surgery will essentially be the same, with the same outcome.

“These patients expect distance, intermediate, and near vision, and spectacle independence.”

This underscores the importance of discussing all lens options prior to cataract surgery, so patients know that technology is now available which will allow them to achieve their visual goals.

Optometry is a medical practice, but it’s also a business, said Dr. Johnston, so ODs must be mindful of good business practices. As an example, he broke down the typical charges associated with co-managing cataract surgery while also treating ocular surface disease (OSD), which is prevalent in this patient population. This can generate additional revenue of approximately $1,443 per patient. [See box: Financial impact]

A practice treating just five new cataract patients per month could therefore generate additional revenue of $86,610 per year, and this does not include ancillary revenue sources such as eyeglasses and sunglasses, retail products, optical coherence tomography, endothelial cell counts, and A-scans, said Dr. Johnston.

Five pearls

Dr. Johnston offered five pearls to guide the OD to success when co-managing premium IOL patients: plano outcome; proactive treatment of OSD; pre-operative counseling; proper screening; and picking the right IOL. Dr. Johnston placed particular emphasis on the first two.

Pearl #1: Plano outcome The number-one problem with premium IOLs is residual refractive error (RRE), said Dr. Johnston.

“Not that these lenses cause it, but when people have RRE, that’s where the problem is.”

Premium IOLs will not perform to their full capacity when residual refractive error is left untreated, he said. Plano outcomes should be the goal.

RRE can cause blurry vision, dysphotopsia, and can even increase symptoms of glare and halos increasing night vision complaints. Dr. Johnston suggested planning for RRE, including working with a surgeon who adds the cost of enhancement into the initial fee.

“It helps to work with experienced cataract and LASIK surgeons that can bail you out and treat any RRE.”

The OD should be aware that if the problem occurs, it’s best to fix the refractive error as soon as possible. “The key here is to take care of it early. I find it best to educate patients early on and let them know things may be blurry and that we can easily fix it. Tell the patient, ‘We will need to perform a slight tune up procedure,’” said Dr. Johnston. Correct the problem as soon as possible after the patient’s refraction has stabilized, he said. Validate the patient’s complaint and work together to develop a treatment plan.

Pearl #2: Proactive treatment of OSD  Next most important is the proactive treatment of OSD. This is important because poor tear film and ocular surface disease change the measured corneal curvature, affecting preoperative biometry. The visual potential can also be limited and can affect the performance of these IOLs.

To evaluate the ocular surface, Dr. Johnston uses diagnostics ranging from fluorescein and lissamine green to a slit lamp exam.

A recent study3 found that 59% of patients undergoing cataract surgery have blepharitis. Dr. Johnston treats meibomian gland dysfunction (MGD) various ways, including use of Azasite (azithromycin, Merck), Restasis (cyclosporine, Allergan), combination topical drops such as Tobradex ST (tobramycin/dexamethasone, Alcon), oral doxycycline, and gland expression. The LipiFlow Thermal Pulsation System (TearScience), which massages and heats the eyelids, also shows compelling data in early clinical trials and seems to be a promising new treatment option, he said.

“You can’t ignore dry eye, meibomian gland dysfunction, and other OSDs. If it’s there, you’ve got to treat it.”

The dry eye workup

Dry eye is also uncomfortably prevalent. The PHACO Study4 found that 62% of patients had a tear break-up time (TBUT) of <5 seconds. The study also found that 76.8% of patients showed positive corneal staining, and 50% showed central corneal staining.

“This study is very significant to optometrists,” Dr. Johnston said.

His dry eye treatments range from artificial tears to autologous serum. “I follow the International Task Force guidelines for evaluating and treating dry eye. I recommend using these guidelines to objectively access and treat each patient.”

Dr. Johnston finds at least 80% of cataract patients are above severity level I. Restasis is indicated for Stage II and above.

“I use Restasis aggressively in treating dry eye, as it’s a chronic inflammatory disease that needs medical treatment.”

He frequently prescribes OTC palliative artificial tears, but almost always in conjunction with Restasis. “Don’t be afraid to prescribe safe efficacious therapeutics available.”

Ironically, he said, patients often cannot even recall the trade name of the eye drop they are using every 2 hours. A study by the Gallup organization5 found that patients use on average six different brands of artificial tears to self-treat dry eye. “The key is for us to make a specific recommendation,” said Dr. Johnston. Recommending a specific brand of artificial tears will help patient compliance and hopefully prevent use of non-desired products such as Visine, he said.

“Do we use steroids?” Dr. Johnston said. “Absolutely.” There is evidence for treating dry eye disease with the “soft” steroid loteprednol in conjunction with cyclosporine to reduce signs and symptoms and maximize therapy.

Pearl #3: Preoperative counseling and setting realistic expectations “Always have a discussion prior to surgery so patients will have an understanding of potential side effects and possible visual limitations,” he said.

Pearl #4: Perform a full evaluation In Dr. Johnston’s words, “from front to back, lids to the retina.” His clinic performs topographies, endothelial cell counts, and retinal OCTs on all of these patients to make sure it has the full picture before recommending a premium IOL.

“We even look at the iris to see if there is any evidence of trauma,” he said. Patients with floppy iris syndrome, previous trauma, pseudoexfoliation syndrome or zonular weakness may not be candidates for some IOLs.

Pearl #5: Pick the right IOL Dr. Johnston suggests developing a refractive treatment plan for each patient based on both visual goals and personality types, and then sharing this plan with the surgeon prior to the pre-op consult.

“Optometrists know their patients better than the surgeon in most cases, and it’s really helpful to have a clear plan spelled out for the surgeon,” he said.

There are many premium IOLs on the market today, Dr. Johnston said, and each has a unique niche. Every premium IOL has pros and cons, so he advised selecting one based on the patient’s personality and visual demands.

The issue of IOL rotation

Dr. Johnston cited a study which found that 73% of Acrysof Toric (Alcon) lenses rotated less than 5 degrees, vs. 37% of Staar Toric (Staar Surgical) lenses.6

“Generally, for every 1 degree of IOL rotation, 3.3% of lens cylinder power is lost,” Dr. Johnston said. “We have had wonderful results with the Acrysof Toric. It’s especially rewarding to use these IOLs in patients after having corneal transplants. We can eliminate large amounts of astigmatism and eliminate the need for glasses at distance.”

The Crystalens AO is the only aspheric accommodating IOL on the market in the U.S., said Dr. Johnston. Because it’s a monofocal, he said, it is less likely to produce visual side effects such as night vision problems and glare and halos.

“The Crystalens performs well at distance and intermediate; however, patients usually will need a near SRX for close work,” he said.

Study compares three lenses

A single center open-label study compared AMO’s Tecnis Multifocal IOL with Alcon’s ReStor +3.00 D and Crystalens IOLs.7 The study compared corrected and uncorrected visual acuity at distance, intermediate, and near for 207 eyes. Patients also received a questionnaire assessing their level of satisfaction with their vision.

All three groups did well at distance and reported good overall visual satisfaction without correction. Both diffractive multifocal groups reported greater spectacle independence than the accommodating group. The Crystalens group had fewer reports of halos at night than the diffractive multifocal groups. The Tecnis group had the least difficulty reading without spectacles and had a higher percentage of patients report the ability to perform activities at ease without the need of glasses and contact lenses after surgery. The Tecnis IOL also subjectively performed better at night driving, seeing distance, seeing at arms length and reading compared to ReStor.

The Crystalens patients had the highest percentage of patients 20/25 or better at intermediate VA. The Tecnis group had the highest percentage of eyes 20/25 or better at near. Results also showed that Tecnis patients had a superior performance at intermediate and near distances when compared to ReStor, while both had equivalent distance vision outcomes. One hundred percent of patients in the Tecnis IOL group had 20/40 or better distance corrected near visual acuity (DCNVA), with 98% having 20/32 or better DCNVA. In comparison, the ReStor group 90% had 20/40 or better DCNVA, and 77% had 20/32 or better DCNVA. Sixty-four percent of Tecnis patients had 20/40 or better distance corrected intermediate visual acuity compared to 44% of ReStor patients.

Premium IOL technology has improved over the years and optometrists should be comfortable recommending all three of these IOLs to their patients, said Dr. Johnston.

And three final pearls…

Three additional pearls are worth considering, said Dr. Johnston. First, pick the right surgeon. It’s helpful to work with a cataract and refractive surgeon experienced in LASIK/PRK and skilled in explanting IOLs. “The surgeon should be optometry friendly and willing to participate in co-management,” he said.

Second, watch for posterior capsular opacification (PCO). Even trace to very mild PCO can cause problems with diffractive multifocals.

Finally, don’t ignore IOL centration.

“Proper alignment and proper centration with diffractive multifocal IOLs and toric IOLs is critical. The lens should be centered on the macula, and not the pupil,” Dr. Johnston said.ODT




1. Nemani, L. Medicare: An insight, Patient Protection Affordable Care Act (PPACA) provisions, inherent challenges and critical success factors. Voluntary Benefits Magazine; Dec 20, 2012. www.voluntarybenefitsmagazine.com/article/medicare-an-insight-patient-protection-affordable-care-act-ppaca-provisions-inherent-challenges-and-critical-success-factors.html. Accessed March 25, 2013.

2. The global cataract surgery devices market is forecast to exceed $3.8 billion by 2017. ASDReports.com; Feb. 22, 2012. www.asdreports.com/news.asp?pr_id=261. Accessed March 26, 2013.

3. Luchs J, Buznego C, Trattler W. Prevalence of blepharitis in patients scheduled for routine cataract surgery. Poster presented at ASCRS Symposium on Cataract, IOL and Refractive Surgery; April 11, 2010; Boston, MA.

4. Trattler W, Goldberg D, Reilly C. Incidence of concomitant cataract and dry eye: Prospective health assessment of cataract patients. Presented at World Cornea Congress; April 8, 2010; Boston, MA.

5. The Gallup Organization Inc. The 2008 Gallup Study of Dry Eye Sufferers. Princeton, NJ: Multi-Sponsor Surveys Inc.

6. Wei-Han Chua. Matched comparison of rotational stability of 1-piece acrylic and plate-haptic silicone toric intraocular lenses in Asian eyes. Journal of Cataract & Refractive Surgery; 2012;38,4:620-624.

7. Logan D, Ehsan S, Johnston J. Tecnis Multifocal IOL Compared with ReStor +3.0 D and Crystalens IOLs. Atlantis Eye Care. Orange County, CA 



Financial impact of treating OSD and premium IOL co-management

92004                                                $126.50 – initial exam; cataract and OSD diagnosed

92012                                                $85.00 – follow up treating OSD

99213                                                $65.00 – additional follow up for OSD

92285 (ant. Seg. Photo)       $45.00 – done at baseline exam for OSD

68761-E2 & E4 (plugs)       $262.00 – done if indicated

66984-55 (20% of global)  $160.00 – shared post op care

Co-mgmt. fee                            $350.00 X 2 = $700.00 for PC-IOL


Total (1 patient)                  $1,443.50 per patient

** Above based on avg. Medicare reimbursement rates.

** Rates will vary by state and region.


Pearls for success

Five pearls for success with premium intraocular lenses

Plano outcome Proactive treatment of ocular surface disease Pre-op counseling (and setting realistic expectations) Properly screening candidates Picking the right IOL

Plus three…

  • Picking the right surgeon

  • Posterior capsular opacification

  • Poor IOL centration
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