Premium IOLs: Strategies for Preoperative Counseling

John Hovanesian, MD; and Lisa Nijm, MD, JD, join Marguerite McDonald, MD, FACS, to discuss premium IOLs. How do they educate patients about the options and the importance of ocular surface health?

Speaker 1: Informed Consent: Getting To Yes is editorially independent content supported with advertising by Johnson & Johnson Vision.

MARGUERITE: Welcome to the Informed Consent: Getting to Yes podcast. I’m Marguerite McDonald of Ophthalmic Consultants of Long Island, in Lynbrook, New York, and on this podcast, I discuss with leading ophthalmologists and eye surgeons the fair and balanced language they use with patients to get them to say “Yes” to the recommended treatment, particularly when premium service options may serve the patient best. This episode is about premium IOLs.

JOHN: More than anything, my goal is to help patients understand what's available, what it does to you, what it doesn't do. My goal is not to necessarily get them to yes. It's to get them to say, "Yes, I understand, and this is what I want."

MARGUERITE: That’s Dr. John Hovanesian. He is a partner at Harvard Eye Associates in Laguna Hills, California. He is also a clinical professor of ophthalmology at UCLA's Jules Stein Eye Institute. He also helped develop MDBackline, a software platform for ophthalmology practices.

LISA: We work with three pillars basically. So, we want to educate our patients. We want to communicate with them effectively, and we want to make recommendations that we think are in their best interest.

MARGUERITE: And that’s Dr. Lisa Nijim, the founder and medical director of Warrenville EyeCare and LASIK in Warrenville, Illinois, a suburb in Western Chicago. She is also an assistant clinical professor of ophthalmology at the University of Illinois Eye and Ear Infirmary.

LISA: I do comprehensive ophthalmology, and I'm a corneal specialist. So, I do complex cataracts, I do refractive surgery, I do corneal transplants, and as such I get a wide variety of patients, and I get a lot of patients who are interested in having premium IOLs. So, I'm fortunate that I get to take care of a lot of patients who are looking for having the latest-technology lenses implanted to get them to be able to see as best they can.

MARGUERITE: Do you find that a lot of people show up having Googled this subject and they know a lot, or do most of the patients show up knowing pretty much nothing about cataract surgery?

LISA: Doctor Google is prevalent in practice nowadays. Yes, a lot of patients come in having either looked up about cataract surgery and about some of the different lens options online, or they've heard it from their colleagues through social media or even neighbors.

JOHN: It really varies. Patients do have a variety of levels of understanding. Those who have friends who went through recent surgery, they understand more. Some come in not knowing the first thing about cataract surgery. In fact, most of our patients don't know a lot about what to expect.

One thing we know from studies of this is that 80% of patients, and this is everywhere in the country, when they understand what the premium options are, they are interested in paying extra to have better vision. And so, to me it's just a matter of helping them understand. A friend of mine said, the people don't want to be sold to, but they do want to buy. And so, we don't need to do any selling at all.

LISA: What is the old marketing slogan that you need to hear something three times before it really sinks in? So, part of what we try to do to get them to yes, but to really get them to yes when they're the best candidate for it, is to educate them early in the process about their options for cataract surgery.

JOHN: To me the process is just like it is for explaining the risk of retinal detachment when I'm talking about cataract surgery. It is no less part of the physician-patient relationship than that. And the conversation sounds the same way. Just as I described to the patients, "There's risk with every surgery, and here's what you need to know," I tell them that "We have options for correcting your vision at the same time as surgery, and whatever lens we use for you is going to set your vision for the rest of your life. And you're going to be looking through it. There's no product you'll ever buy that you're going to use more. You literally take your lens implant to your grave. So, here's some of the things to think about, and you decide what's important, and I'm happy to do your surgery any way you like." When people understand that it's an important conversation, they are better equipped to make a decision that's more well thought out.

LISA: When I first discuss cataracts with patients and it's something that they may be thinking about in the next even 6 to 12 months, I will have a brief discussion that there are a lot of different options for lenses at this point, and my staff gives them educational material on it. We have a really nice educational brochure that has the different lens options in it, explained in layman's terms for them to be able to review, because I think it's really important for patients to have the education to be able to understand it, ask informed questions of their doctor to be able to really make an informed decision that this is best for them. And the earlier in the process that you can start that, with help from your staff and your referring providers, can really make the difference.

MARGUERITE: So, they come back. They've gotten your brochure 6 or 12 months ago, and now they're back, and they're actually a pretty good candidate. So, do you use videos to sort of review what they can expect? Do you use ... do you have your own materials, or do you use a combination of what industry has and what you have devised on your own?

LISA: I use a combination of what industry has provided as well as materials that we have developed on our own. And I like explaining to patients myself just what the different options are, and then if they ... and that provides them a good understanding. I like to make the recommendation to them once I've had an understanding of what their expectations are and what they're looking for, of which ones that I think will match what they're looking for closest. I also think it's a good opportunity to explain the risks and benefits of that option that they're choosing. And really set the preoperative expectations appropriately for what to expect postoperatively, which, as we all know, is the best way to achieve, hopefully, a good patient experience all the way around.

JOHN: We use a system that we actually created that is now available to practices everywhere, and it's called MDbackline. So, the way MDbackline works is that, before the patient comes in, they receive this information, and then, when they're in the office, we have their responses in front of us as to what visual needs they have and desires they have. And then our staff and we surgeons can educate them in a much more streamlined way about what to expect.

When you think about it, a patient coming into your office, it's a very intimidating process to think about, "Oh my gosh, my vision's not good. I know I need to do something. But I'm going to have a big surgery that's going to put me through a risk. And now I've got to make a high-dollar decision on these implants." It's just overwhelming for a patient population who is average age 70, many of them much older than that. So, if we can break it into steps for them, we make it easier.

The other thing that this does is, it follows up with patients after they've had surgery. Marguerite, I'm sure you've found in your practice that happy patients tell three friends, but unhappy people will tell 10 people. So, we want to know who those potentially unhappy patients are. And so, we contact them all about a month after surgery and ask whether they're satisfied, ask if they're seeing the way they expect. It turns out the majority are very happy. And when they say they're happy, we do a couple things. One, we invite them to go to the online review sites and fill in information that shares with the public how they feel. We also share that with our staff.

So, every week our staff gets an email that has all of that week's positive comments that came in from patients. So, it's very motivating to the staff who ... you know, our tendency is to focus on the unhappy patients, but the truth is, the majority have great things to say about us and about our care. And so, reminding our staff of that is really valuable.

LISA: We're a little bit old-school as far as that goes, but we will distribute patient satisfaction surveys in office on a semiannual basis. Take it back, and when we get good quotes from patients that can really describe their experience, we include that in our marketing materials.

We also ask patients to leave their honest feedback when they have had a great experience, be able to share with other patients, so that they know if they're looking to have premium IOL cataract surgery that they can look towards us to provide that care.

MARGUERITE: Do you find that it ever helps to say, "You know, Mrs. Smith, you told us your intermediate computer vision was absolutely number one. That's what you told us before surgery." Does it ever help to gently remind people of what they asked for?

JOHN: Oh, absolutely. Through the whole process, right? To talk about what they want. Because this is all about, and I tell the patients that, "The most important thing to me is that you're happy with the result you got." Knowing what is important to the patient, and what they're sensitive to, I think is enormously helpful. Preparing them by giving learning material to them in multiple formats is really helpful. Because some people are not auditory learners, many are visual. And so, we can share information that's very specific to what we recommended, that they can review in their own terms and in their own way. And we get them to verify that they've viewed the material and that they understood it, so we have a written documentation of that as well, that's through the electronic system, through MDbackline.

MARGUERITE: Suppose somebody's sort of thinking about cataract surgery, but it's not imminent and you give them a brochure. But when they finally make up their mind a year later, you find they have too much ocular surface disease for say an EDOF or whatever. Do you ever find that they say, "Oh, my heart is broken. I thought I could have it 'cause it's in your brochure,” or do you find that they accept the guidance from you. Like, "You know what? It is an option out there for most people, not so much for you."

LISA: What I normally tell them when we hand the brochure early on is that these are your options. What I will do is, when you return for the cataract evaluation, I will evaluate you to see what your best option is at that time. And sometimes if it's something that they can ... it'll take time, we can do something to enhance the ocular surface or repair the ocular surface and make them a candidate for premium cataract surgery. Then I'll explain to them it's not always an easy conversation.

JOHN: You bring up a hugely important topic because, the biggest barrier to success with premium lenses, I'm convinced, is ocular surface disease. It's the most common issue. It affects about 85% of our cataract patients. So, we're failing from the start if in 85% of our patients, if we don't at least evaluate their ocular surface. So, for us it depends upon how severe it is.

We're actually doing a study right now with Xiidra, where we showed that just 4 weeks of treatment with Xiidra alters the accuracy of the presurgical biometry. So, we did biometry before and after treating for 4 weeks with Xiidra, and then we did surgery and measured the refractive outcome and went back into the biometry and said, "Okay, which one was more predictive, the one before we treated their dry eye or the one after?"

And we found there was a clear statistically significant benefit, refractive accuracy benefit, from using Xiidra. It also reduces significantly higher aberrations in the cornea. And I was really surprised at how dramatic the effect was, but it makes sense. You have a good treatment for dry eye. If you employ it—and of course other treatments should work, too—you make the surgery more accurate.

LISA: I think usually when people understand that you're trying to do this to get them the best outcome from their cataract surgery, they are amenable to being patient to improve the surface. If they're not a candidate, then I explain to them that I'm making this recommendation that they're not a candidate because I'm looking out for the best interests and I want them to feel comfortable with this procedure and, if they're not a candidate, they're not going to have a great outcome.

MARGUERITE: I couldn’t agree more. Thank you both so much—Dr. John Hovanesian and Dr. Lisa Nijim—for sharing your insights and experience. Any final thoughts?

JOHN: I would argue that, if you want to call yourself a premium lens center of excellence, then you’d better also be a dry eye center of excellence, meaning you take it seriously. You run toward the dry eye and not away from it.

LISA: I do think part of the education process involves really educating your referring providers on what lens options you can offer to patients. I have done talks for optometrists, explaining to them about the different premium IOLs, so that they're able to, because oftentimes they're the first ones having that discussion with the patient. And so, the more they understand about what type of lens options that patients have that I am able to give the patients at the time of surgery. But better off the patient can receive that education from multiple sources and hopefully ask appropriate questions to help them get to that decision that will lead to a great experience.

MARGUERITE: Thanks again, Lisa and John, and thank you out there for listening to Informed Consent: Getting to Yes.

Speaker 1: Informed Consent: Getting To Yes is editorially independent content supported with advertising by Johnson & Johnson Vision.