Discussing the Value of Intraoperative Aberrometry

In one of the top episodes of Informed Consent, Kendall Donaldson, MD; William Wiley, MD; P. Dee G. Stephenson, MD; and Russell Fumuso, MD, speak with Marguerite McDonald, MD, about intraoperative wavefront aberrometry. How do they educate patients about the benefits of this technology?

Speaker 1:

Informed Consent, Getting to Yes, is editorially independent content supported with advertising by Johnson & Johnson Vision.

Marguerite M.:

Welcome to the fifth episode of our podcast, Informed Consent, Getting to Yes. I'm Marguerite McDonald of the Ophthalmic Consultants of Long Island in Lynbrook, New York.

Ranna:

I'm Ranna Jaraha of EyeWire TV.

Marguerite M.:

On this podcast, we talk to leading ocular surgeons about the specific words they use to honestly and ethically obtain buy in from patients.

Ranna:

And in doing so we'll also learn a lot about their treatment philosophies and how much they believe in or potentially are skeptical of these advanced technologies.

Marguerite M.:

Today we'll be focusing on the use of ORA intraoperative aberrometry, which Alcon acquired when they bought WaveTec Vision in 2014. With us are four very successful ocular surgeons who are all believers in the value of this technology.

Ranna:

That's right. There are no skeptics today.

Marguerite M.:

First, I'd like to introduce Dr. Kendall Donaldson. She is Associate Professor of Clinical Ophthalmology at the Bascom Palmer Eye Institute, which is part of the University of Miami Health System. She's also the Medical Director of the Bascom Palmer Sight Implantation Florida and Codirector of the Cornea Fellowship. She specializes in cornea external disease, cataract, and refractive surgery and has a national and international reputation, so it's our great pleasure and honor to have her with us today.

Dr. Donaldson:

Thank you.

Marguerite M.:

Next is Dr. Bill Wiley, the medical director of the Cleveland Eye Clinic. Thank you so much for taking the time to give us your perspective.

Dr. Wiley:

Thank you. Thanks for having me.

Marguerite M.:

Our third prominent cataract surgeon is making a return appearance. She's the founder and CEO of Stephenson Eye Associates in Venice, Florida, Dr. Dee Stephenson.

Dr. Stephenson:

Thank you, Marguerite.

Marguerite M.:

Finally, another return guest, my colleague Dr. Russ Fumuso, the director of office design and development at Oakley, has just a few thoughts to add as well.

Dr. Fumuso:

Well, thank you very much, Marguerite.

Ranna:

What a great group.

Marguerite M.:

Absolutely. Let's get started. Let's begin with Dr. Wiley. Bill, you are one of the world's leaders in intraoperative aberrometry reading. Tell us a little about it, and then we'll get to how you would explain that to a patient.

Dr. Wiley:

Sure. So intraoperative aberrometry is a device that connects to the microscope to give you information during cataract surgery. In particular, it can take an aphakic reaction that can help give you information on the spherical power of the lens, both the sphere power and the cylinder power. It can also take pseudophakic images and give you information on astigmatism and positioning of a toric IOL well or placement of a limbal relaxing incision. In general, it's a great tool to help improve the accuracy of hitting that distance target or near target, getting the correct lens, and the correct astigmatism correction and alignment.

Marguerite M.:

Kendall, you've also been using intraoperative aberrometry for a long time. Before we get to what you say to patients, why don't tell us when you use it and why you use it?

Dr. Donaldson:

We've been using ORA intraoperative aberrometry for almost 10 years at Bascom Palmer. We had ORange back in around 2008, and we have sort of watched the evolution of this technology over the last, basically, 9 or 10 years now. It's gotten much better. It's gotten faster, more efficient, and it's really become an essential part of my practice, both for upgraded packages, our presbyopia packages, our astigmatism correction packages, and for our patients that have a history of prior refractive surgery. With every passing year, we have more of those patients reaching cataract age, and so we're using ORA with those patients all the time, actually, every week. I can't remember the last day I went to the operating room without using intraoperative aberrometry actually.

Dr. Wiley:

In our practice we use intraoperative aberrometry for all our premium cases. So anybody that's choosing to pay an additional fee for let's say astigmatism correction or presbyopia correction, we use that as a tool to help better hit that target. There are cases that we use it on traditional cataracts surgery. If I have challenges in getting the biometry, if I don't have confidence in the biometry, if the patient has had previous surgery, or I have questions, or if I'm just not sure about the exact lens choice, I'll use that as well for traditional cases. Typically, we use it in our premium upgraded patients.

Marguerite M.:

So even if someone is getting a monofocal IOL, but they have chosen femto for instance, they would get intraoperative aberrometry.

Dr. Wiley:

That's right. That's right. So anytime, I guess, when the patients are coming in with that heightened expectation, and typically that's going along with the premium or femto, sometimes you have that patient that's choosing basic surgery, but they still have that heightened expectation, so often I will make a small note in the chart, critical observer, declined premium surgery, but I still want to make sure I give the best possible outcome with the tools I have, so we'll use ORA or intraoperative aberrometry for those patients as well.

Marguerite M.:

Dr. Stephenson, what about you?

Dr. Stephenson:

I'm almost at 100% of doing aberrometry on patients. I do charge for it. The charge is incorporated into my three packages, but you can also get a manual with a monofocal lens, and I highly recommend the intraoperative aberrometry with VerifEye+. I was the first commercial user of ORange in the day, and it has progressed into a pretty darned good aberrometer. It's like GPS on your car. You don't get in your car nowadays without using your GPS, and the ORA for me is my GPS. I've gotten really good preoperatively in the office by using Cassini, which is incorporated into my Lensar so it does cyclotorsion and iris registration. And Cassini measures total corneal astigmatism, anterior and posterior, so we don't have that posterior surprise. So going into surgery, I'm much more prepared than I was in the past, and ORA was the only thing that I depended on. Usually, if push comes to shove, I always go with ORA.

Dr. Donaldson:

Surprises always make me nervous, and I really like to have everything in line. I go through all sorts of calculations preoperatively. I always go to the ASCRS website. You know, I have a range of lenses, and sometimes I may bring, you know, five, six, eight lenses into the operating room. I get nervous if I fall outside of that range. If I bring eight lenses into the room based on my preoperative calculations, and I'm outside of that range, that would make me very nervous.

Still, if I have three or four, then, you know, I almost always kind of fall within that range, but sometimes we have these patients that have high-level ablations. Maybe they were extremely myopic in the past. We don't have any old history or any records on these patients. For those patients, I might have more lenses that I bring into the room, and there's more variability. But yes, it makes me real nervous if I fall outside the range and of those eight or ten lenses I brought into the room, ORA is telling me something outside of that range. In that case, I'll repeat the measurements multiple times with ORA, and I'll look at the patient and try to figure out, well, maybe there is something unusual about this patient. For example, the lid speculum may be pressing on the globe, or I may have had a bit of corneal edema at the wound, something that could throw off my intraoperative aberrometry. Maybe, they have severe ocular surface disease or anything like that that can also throw off your intraoperative aberrometry.

So a lot of times you can reason through it why you have a surprise and kind of make sense of it. I’d like to see everything be consistent and kind of fall into place, but you're right every once in a while you have a surprise. But, usually, if you really think through it, you can think why this patient might be an outlier.

Marguerite M.:

Dr. Fumuso, do you have anything to add?

Dr. Fumuso:

Well, as we're seeing, the baby boomers who had LASIK are now coming into the age where they're getting cataracts. We have people coming who've had previous LASIK surgery, 10-15 years ago; there's no records of what their exams were previous to LASIK surgery, so now how do we determine what would be the right implant for them at the right power? Previous to WaveTec, there was always that crap shoot, we had all the different formulas we used, but there was always that high percentage of people, relatively high, who would have to go back and have the lens swapped out. I tell people that with WaveTec that percentage drops significantly compared to the past.

Dr. Wiley:

PKs are tough and also prior RK. The RK patients that have really had a lot of cuts so those patients with 16 RK incisions and a couple AK incisions thrown in there. Some of those incisions can become hydrated during your case, and that type of thing can really throw you off. I would say that's still the weak area with intraoperative aberrometry. Over the last 5 to 8 years or so, those measurements have gotten better and better, but still with those patients with more cuts, I'm targeting for a little more myopia, so I might target -1.00 expecting a hyperopic shift over the month or so following surgery. That being said, it's gotten so much better, and those patients with four cuts or eight cuts are pretty reliable now. So I find that intraoperative aberrometry has really gotten stronger and stronger even in those patients, but you have to be careful.

Dr. Fumuso:

I just did the second eye of a post-RK patient this past week, and it was almost on the money for the first eye compared to what I calculated. I ended up putting in the lens that WaveTec recommended, and she was spot on, almost 20/20- uncorrected when she healed. Her left eye was done this past week, and again, the lens itself was about half a diopter different from what I had calculated using the ASCRS tool, and 1 day postop she was about 20/30- in that eye. I think she might get better, but I was very happy that I had WaveTec on that particular patient. It was more difficult though, I will say. Unlike people with LASIK, doing WaveTec on people with RK sometimes it does take multiple, multiple reading before you can have a confident reading.

Ranna:

It's interesting that everyone agrees how helpful ORA is for patients that have had previous refractive surgery, particularly RK.

Marguerite M.:

That's definitely the consensus. So now let's focus in on what you say to patients about ORA, Dee?

Dr. Stephenson:

What I tell them, is I tell them that it is an apparatus on my microscope that allows me to get one more reading on the table in real time, once your cataract is removed, to be able to make the selection of the IOL more precise. I go in with great knowledge, but I can change the power of that lens right there on the table before. I don't have to do it after I put the lens in. I can do it before. So it's one more safety measure and one more precision measure that I use after your cataract is removed. And again, too, with astigmatism, I say that it's such a help with the astigmatism because, in a study I did on Trulign, I changed the power of the toric 73% of the time out of over 116 patients.

It's very, very important to me and my success, and it's what I've hung my hat on the last 8 or so years, 9 years.

So the conversations you have with patients you have to really customize them with the patients.

Mostly, what I've tried to get away from is telling the patient that this is the lens that I'm going to use. I try to get away from that. I say we have several options, and once I get you to the operating room and do ORA, then I will refine what I do. I give them kind of an idea, so it's in my package, and I will give them details about the technology, but not all patients need to know all of that or want to know all of that.

Marguerite M.:

Did you find that you were in general going up on the toric power or down or was it a scatter?

Dr. Stephenson:

It's a scatter. Against-the-rule we increase, and with-the-rule we decrease. So it's really allowed me to fine-tune it. There's more people with against-the-rule out there, I think, than there are with-the-rule.

Dr. Wiley:

In my practice we use intraoperative aberrometry as part of a package, and we typically don't market it or push it or sell it. The patients are coming in, and I discuss, you know, "What is your visual goal? Are you looking to see better distance, or are you looking to see better distance and near." Then the patients will tell me what they're looking for, and I'll use what tools I have to achieve that goal.

Maybe it's a toric lens or maybe it's a presbyopic lens or maybe its femto or maybe its ORA. So, in general, kind of goal-oriented or refractive target-oriented, and we'll use the device that I think is going to hit that target.

So, in general I'm not having a lot of discussion about ORA or intraoperative aberrometry, but it does come up. Patients will ask, "Dr. Wiley, how do you know you've picked the correct lens?"

Marguerite M:

So how do you know you are going to pick the correct lens for me, Dr. Wiley?

Dr. Wiley:

Sure, well, Mrs. Smith, I know that's a common fear. Some patients are worried, or they may have known a relative that they've feared had had the wrong lens placed. In reality, it's extremely uncommon. We do a lot of testing before surgery to ensure that we have the correct measurements for your lens.

But, in addition to that we have an insurance policy that we call intraoperative aberrometry that can help, number one, pick the lens on the table and confirm the preoperative choice, but also after we place that lens inside the eye, I can take a reading and confirm that we've picked the correct lens. So we have sort of three shots at picking that lens for you, number one with preoperative information, that gets us close, number two with intraoperative information after the cataract’s removed. Now we have a clear sight of the eye and can get better measurements, so we can pick the correct lens with that aphakic measurement once that cataract’s removed. And finally, after we put that new lens in, we can repeat the measurements to double-check that it's the right lens for your eye. Rarely after that final measurement, there may be a reading that looks abnormal, and sometimes we will take that lens out and place the new lens in. It's pretty uncommon, but at least we can do it at the time of surgery.

With all that’s being said, even though we go through a lot of work to ensure that you're getting the correct lens, there are some things that are outside of our control. After we put the lens in, on the table, it will be correct, but what's outside of my control is how does your eye heal? During the healing process, the lens can heal a little bit more forward or a little more back, or if it's a toric lens, the lens could adjust, that changes the prescription. So there's a chance it could be right on the table, but you might have a small prescription in the future.

Typically, that's less than 5% of the time, but if that were to occur, we can do a secondary surgery, maybe adjusting that lens or doing LASIK afterwards to fine-tune things. So, in summary we'll assure we get the right lens, but for some reason if your eye heals in a way that leaves you with a prescription, we can always fine-tune it later.

Speaker 1:

Informed Consent: Getting to Yes is editorial independent content supported with advertising by Johnson & Johnson Vision.

Marguerite M:

Kendall, how do you explain ORA to those patients who you feel strongly would benefit from its use?

Ranna:

I'd also like to know if you do most of the explaining or if you have a surgical coordinator who discusses their options, either before or after you meet the patient.

Dr. Donaldson:

Actually, I talk to them first, and I have a whole spiel about traditional cataract surgery and upgraded cataract surgery, and ORA is integrated into all of that. So I like to introduce these concepts to them myself first, and then my surgical coordinator goes over it with them again. Then, my, basically, photographer, imager, she goes over it with them yet a third time. So, they hear it from me first, and I make a recommendation, and I think we have so many options in cataract surgery, now patients can really get overwhelmed and very confused. I'll say, all of these options are available, but for you, this is what I recommend after speaking with you, and you're telling me that this is important to you, this is my recommendation. So I try to leave everyone with a recommendation, but I give them all the same spiel, so even if they have macular degeneration and they're not a candidate for a multifocal technology, and they're not a great candidate for ORA I still tell them, "You know, there are all these things you're going to hear about, but this is what I recommend in your situation. And you'll hear more about this in a few minutes from my surgical coordinator."

And so then I write that in the chart, what I've chosen for this patient, and then the conversation goes from there.

ORA is included in all of our upgraded packages like I was saying before, so I don't really have much of a discussion with the patient. We basically have two upgraded packages at Bascom Palmer, and so we're selling patients an outcome, not a technology. We're selling them their astigmatism correction, or we're selling them presbyopia correction, and ORA is included in those packages. They like to hear technology-type words, you know, just like they like to hear the word "laser," or they like to hear that you're using extra computers to make things more accurate. They like those words, but anything that gives them that level of security about their outcome I think is helpful for patients. They appreciate that. I tell them, "You know we'll be making these extra measurements. I'll have you assist with these measurements during your case, and that's called intraoperative aberrometry. But that's something we use to align your toric lens during surgery to get you better astigmatism correction or to adjust your incisions that we're using to correct your astigmatism." So I'll say that's part of that package.

I also tell my patients who have had any kind of corneal refractive procedure in the past that I don't feel comfortable doing their case without intraoperative aberrometry. That gives me the extra security to give them the best possible outcome. I tell them, this is how I've been doing my cases for many years and I feel that this is an essential tool to get them to where we want them to be. So I strongly, strongly recommend it for those patients with a history of refractive surgery. So I do speak that strongly to them.

Marguerite M.:

Most of the time do they agree with you? And they plan for it? And they pay the extra upgrade cost?

Dr. Donaldson:

They do. They don't always pay, but honestly since I'm in an academic institution, if they can't afford it, we have some wiggle room to be able to be able to do that for patient and give them that technology. So I do have the ability to do that in an academic center.

Marguerite M.:

Bill, let me ask you about a situation I run into occasionally. I'll have someone who has an old four-cut RK, and they say they don't want anything extra. They want basic phaco, no femto. They're a bad candidate for a multifocal, even and extended depth of focus IOL, but they want nothing special. On the other hand, I know I will do a much better job of IOL selection using intraoperative aberrometry. So you've got someone with their arms folded. Do you spend extra time explaining how the RK makes it a challenge, or do you just absorb the cost and stop the conversation and just somehow eat it so to speak?

Dr. Wiley:

Sure, those are challenging conversations. And in some regard, an easy answer is the patient chooses not to do the upgrade. I'll make a small note, and then I'll actually use ORA to assure that I've picked the correct lens, so I'm hoping that that patient is going to have a lower expectation. I'll use a tool that at the time is not costing me any more because we have a monthly fee that allows us to use unlimited ORA, so it takes me time, but at least when I do that measurement, it's not costing me for that case. So I'm using the best tools I have and hopefully can exceed that patient's expectations.

So, often in those cases, I'll recommend the patient do the upgrade, and I’ll tell them the upgrade includes other surgeries if we do miss. I say, even with intraoperative aberrometry, there's a chance of missing target, but your upgrade would include lens adjustment or LASIK or PRK or whatever it takes to get you within that range. So, it's a valuable package. If they opt not to have it, I'll do my best to hit it with the first shot, and if for some reason if we do miss target, and the patient does want to do LASIK or something else later, it would then be an additional cost to them.

I try to lay that out and say, "You know what, if I were you, I would choose the package that'll give you the best chance to get the best vision. If we need to do anything, it's all covered." And if they do that great. If they don't, I'm hoping I'll exceed their expectations and use what I can that's within our affordability.

Marguerite M.:

The ASC that I'm currently using has a little different relationship. Every time we use the ORA, we pay for it. So on occasion, if we find someone who just refuses it, they just won't pay, they can't pay, whatever, we'll go ahead and use it anyway and pay for it ourselves. It's very rare because you can dig yourself into a hole that way, but once in a while we just say, "You know, this is going to stack the deck so much in our favor, even though the patient has refused it, we'll just use it anyway."

Dr. Wiley:

Right and that brings up, a great kind of question. If you do use it and give it away free in that instance and it does cost you money, it can work against you. Your staff can start to see that you're giving it away free, and they might say, "You know what? You might not really have to pay for that upgrade. The doctor is going to do it for free anyways." And then all of a sudden you might see a decreased conversion rate. It's a fine line. You want to do the right thing, but over time you don't want to erode the value of the packages you're charging for. So it is a conflicting issue.

Marguerite M.:

Kendall, you said earlier that you give all your patients the same spiel. Let's say I'm a patient who has had a four-cut RK, and I'm a good candidate for a toric lens. How would you inform me of my options, including ORA, of course?

Dr. Donaldson:

With my RK patients, I don't like to make any incisions with a femtosecond laser, but I'll tell them, you know, traditional cataract surgery is done with ultrasound. Ultrasound is done through a tiny incision on the side of the eye. The ultrasound breaks up the solid cataract, which is the lens inside the eye that has grown cloudy and denser with time. It turns it from a solid into a liquid that can then be sucked out of the eye through that small tube, and then a new lens is injected through that small incision.

We also have several upgrades with cataract surgery. Most of our upgrades are done with laser cataract surgery, which was approved about 5 years ago. This gives us extra degrees of precision, allows us to put less energy into the eye, and allows us to correct astigmatism more accurately. So, in your case since you have regular astigmatism, patients can have either irregular astigmatism or regular astigmatism, and luckily in your case, you have regular astigmatism, which is much easier to correct. We actually have customized lenses. We can put that prescription with your astigmatism inside the eye, which can make your distance vision or your near vision much, much more precise, and the corrections much more precise. And give you crisper vision so you can get more freedom from glasses. Nowadays we also have presbyopia-correcting lenses that correct distance and near and even astigmatism. That may or may not be good for you. Because you've had RK, I tend to do a monofocal toric lens as opposed to a multifocal toric lens. So that's my preference in RK patients. Then I would just basically talk to them about monofocal toric lenses. Some of these patients have had monovision before. If they've had monovision before, I tell them that's a very comfortable thing since they're already used to it. They could easily adapt to having that done permanently with the toric intraocular lenses. So, we also use ORA in these cases. ORA allows us to correct the astigmatism much more precisely and align that custom lens perfectly, as perfectly as possible, with a steep axis. I show them their topography, and most of them can understand .... You know any type of picture we have in ophthalmology, whether it be related to cataract surgery or other pictures, patients just love images, and it helps them understand what is going on with their eye. I think, if we can create a partnership with the patient and help them understand why we're doing what we're doing, it makes them all that more involved in the process and much more invested in the process and getting that best outcome.

I also told them this is an investment for lifetime. These lenses are made to last a lifetime. Your vision, you want to make an investment in your vision, because this is one opportunity in life that you have to completely change and correct your vision. This is the last great opportunity you have, too. So I think it is a good investment to purchase the best lens possible if you're interested in getting more freedom from glasses. This is a great opportunity.

Marguerite M.:

I love the fact that you touch on the technology, which does impress them, but that you're really talking about outcomes.

Ranna:

That's great information, Dr. Donaldson.

Marguerite M.:

Absolutely. This has been great. Does anyone have any closing thoughts about ORA?

Dr. Wiley:

Sure, I think, with ORA, it's a great way to discuss outcomes and really kind of discuss with the patient what their goals are. Then use ORA as a tool to achieve those outcomes and have confidence that you're using the greatest technology at your availability to achieve those. So I think patients can sense that confidence. When you're getting better results and better outcomes, you'll have more confidence in discussing it with them, and your staff will have more confidence, so it sort of helps increase that conversion rate when you have that tool at your disposal.

Dr. Fumuso

WaveTec is not as hard as people think. It is basically, once you've been with someone who can do it efficiently, it's pretty straightforward. It really is. It's just a matter of learning about head position, where the eye is. The equipment is very straightforward. I think once you do a few of them you kind of get the knack that, okay, this is exactly what I need to do to get the best readings.

Dr. Donaldson:

I think eventually everyone will have the opportunity to have custom cataract surgery in the future. Someday it will become the standard of care. Of course, all these things are upgrades now not covered by insurance, but who knows? At some point if it does become the standard of care, everyone is just going to have this customized package for cataract surgery.

Marguerite M.:

This was wonderful. I've learned so much from our participants today. We're so grateful for your expertise. Ranna and I would also like to thank you for listening, and we hope you'll join us for the next episode of "Informed Consent: Getting to Yes."