To begin, I should state that the title is a slight misnomer. I do believe that multifocal, accommodating, and toric lens technologies are all wonderful additions to what we can offer our patients. Furthermore, I do in fact implant these lenses in my patients. That said, there are several trends that have occurred that have lost long-time patients from established practices to my relatively new practice – most notably aggressive marketing tactics and overpromising technology.
One of the most common complaints I receive from new patients is "I have been seeing Dr. X for over ten years, but when I was told I needed cataract surgery he told me I had to have this very expensive lens. I don't care about wearing glasses after surgery." While these newer IOL technologies deliver even greater range of spectacle dependence, we must remember that not all patients care about spectacle independence. To that end, many ophthalmologists do not care about spectacle independence. This can be noted at any academy meeting, but even more interesting is the amount of Lasik surgeons who do not undergo the procedure themselves. Obviously, the value of freedom from glasses is variable, and it should not be assumed that patients desire it at any cost.
Other comments I've heard include, "I told the doctor that the lenses were a lot of money - that I would need to think about it. He told me 'just don't go away for vacation for a year and this will last you a lifetime'". While we should try to guide patients towards what we think will benefit them the most, we should not place any pressure on the patients to make a decision, particularly when it is regarding an elective option that may be a financial burden. The doctor-patient bond has long been felt to be a trusting relationship. With new worlds of co-pays, approvals, etc., this relationship has become strained. Physicians are typically have poor business sense, and have never been salesmen. When discussing premium lenses I always delegate pricing discussions to assistants in my office so that it does not interfere with my exam and discussion of the results with the patient.
"I was told I would never need glasses again." While underpromise and overdeliver would be the key notes of any "clinical pearls" presentation on these lenses, often the opposite occurs. This is not necessarily the fault of the surgeon either – a brief look at television ads or industry-sponsored handouts indeed have the patient believing they will have 18 year old vision again. It's also important to note in any of these clinical studies the manufacturers quote that study patients received the lenses for free. They were also performed on patients with significant cataracts who were ideal candidates (i.e. no astigmatism that may or may not be corrected well with LRI or LVC). Had those study patients been asked 'would you recommend this technology if it cost $5,000+, that number may very well be less than 96%.
"I had the surgery and the haloes are miserable. My doctor told me to just get used to it." Patients are living long vibrant lives, and the concept of living with any type of disability can be scary. While the majority of patients adapt to the glare/haloes that may accompany multifocal lenses, some do not. When told they must "neuroadapt", oftentimes they just "neuroresign" to have these bothersome side effects. Ophthalmologists should be quick not to perform YAG capsulotomies in these patients if they think the patient may require a lens exchange, but even if a YAG has been performed should not tell the patient the exchange is impossible. Every month I see several patients who come to me begging for lens exchange. After a thorough informed consent, I am happy to offer them a lens exchange, and in all of these patients they have been overwhelmingly satisfied. They have said things such as 'I have my life back'. They have gone on to recommend me to all of their friends and family, and I have enjoyed the tremendous word of mouth these cheerleading patients provide.
Ultimately, we are heading into times where reimbursements are decreasing and yet costs to run a medical practice are increasing. In order to survive we must find alternate sources of income. Premium lenses are certainly a good option, but in summary I recommend several pearls:
- Make sure the patient truly desires the technology before recommending it
- Have a staff member instead of you discuss lens pricing and options
- Underpromise and overdeliver
- Avoid YAG capsulotomy if the patient is miserable with minimal PCO and consider IOL exchange.