The Value of Laser Cataract Surgery and Toric IOLs

Kendall Donaldson, MD, MS; Preeya Gupta, MD; and Marguerite McDonald, MD, FACS, tackle how to explain the value of laser cataract surgery and toric IOLs to patients who have astigmatism.

MARGUERITE: Welcome to Informed Consent: Getting to Yes. I’m Marguerite McDonald of Ophthalmic Consultants of Long Island in Oceanside, New York. On this podcast I interview KOLs—key opinion leaders—about how they get patients to say yes to a recommended regimen, whether it’s a new drug regimen or a type of premium cataract surgery or an in-office procedure. What exactly do they say that makes the difference?

On this episode of the podcast, we’ll be discussing how to explain the value of femtosecond surgery and toric lenses to patients who have astigmatism.

My first guest is Dr. Kendall E. Donaldson, Professor of Clinical Ophthalmology and cornea specialist at the Bascom Palmer Eye Institute in Miami and Medical Director of the Bascom Palmer Eye Institute in Plantation, Florida.

KENDALL: Thanks so much, Marguerite. It's a privilege and honor to be with you today to talk about this.

MARGUERITE: Also joining the discussion is Dr. Preeya Gupta. She is an associate professor of ophthalmology at Duke University and an expert in cornea and refractive surgery.

PREEYA: Thanks so much, Marguerite.

MARGUERITE: But before we get into the main topic, I’d like Preeya to tell us about her practice at Duke, and then we’ll hear from Kendall about her practice at Bascom Palmer.

PREEYA: Sure. So, my subspecialty's in cornea and refractive surgery, but of course I do a lot of cataract surgery, and so I kind of have a diverse practice really centered around both traditional corneal refractive surgery but really refractive cataract surgery.

KENDALL: I am a cornea specialist. I certainly do a lot of cataract surgery, about, I'd say, about 60% to 70% of my practice deals with cataracts. I also do complex cataracts, corneal surgery is another, LASIK, and a lot of dry eye/ocular surface disease. So, a combination.

MARGUERITE: Okay, so the cataracts, I know, do a great deal of premium surgery—toric, femto, etc.

Do you ever do a toric without femto?

KENDALL: All of my toric cases are done with femtos. So, all of our upgraded lenses, the multifocals as well as the astigmatism corrections, done with femtosecond laser, and we've been doing it that way since 2012 when we started doing femto at Bascom Palmer.

PREEYA: I mean, toric lenses I've been using probably since I, you know, first graduated from training a decade ago and probably femtosecond laser maybe really over the last 5 or 6 years. It's been kind of a mainstay of what I incorporate into my offerings for cataract surgery.

I think that, you know, the first thing that ... if you are using a lot of femto and/or toric, I mean, managing astigmatism is really kind of a critical aspect to achieving the end goal of patients being happy with their vision when it comes to cataract and refractive surgery. Over the years I've just found myself favoring incorporating femto, you know, even when I am using a toric lens.

MARGUERITE: The division between when to exactly start using torics ... You know, how much astigmatism do you handle with femto AKs, and when do you start talking about torics? Do you have a scheme?

PREEYA: In general, I would say it really depends on the axis of the astigmatism. So, for patients that have with-the-rule astigmatism, somewhere in that 1.40–1.50 D range is when I start switching over to toric lenses generally. Then for patients with against-the-rule astigmatism, anything kind of in that 0.85–0.90, somewhere in there, for against-the-rule or greater is when I incorporate toric lenses.

KENDALL: If I can correct it with a toric lens, I always prefer to make my correction with the toric lens. So, in those cases where I'm using a toric lens, I'm not doing limbal relaxing incisions. So, I'm doing astigmatic correction with the lens itself. And I think there've been some great studies that have compared astigmatism correction with LRIs versus toric IOLs, and over the long term, it appears that the toric IOL is more stable because you can get some regression of limbal relaxing incision over the first 6-month period following cataract surgery.

So, in patients, clearly with patients over 1.25 D diopter, I would say I'm going with the toric IOL. If it's less than a diopter, I'm using a limbal relaxing incision. And then again you have to take into account if it's with-the-rule or against-the-rule because we're aiming to leave just a little bit of with-the-rule astigmatism, so we'd under-correct with-the-rule astigmatism. So, in those cases I might be going more with an LRI as opposed to against-the-rule astigmatism, where we're trying to really get rid of all of that. So, I'm more likely to use the toric a bit more aggressively with an against-the-rule patient.

PREEYA: I would say in my current practice I really am not offering, you know, one of this and one of that. I try to simplify things for the patient and recommend to them what I think is going to give them the best outcome. And, in my hands, using both the femto and toric in combination seems to work well.

MARGUERITE: So, one of the things our listeners really like is when I pretend I'm a patient and we get our expert to talk to me so that they can hear exactly the words that you use with the approach that you use. So, let's pretend I'm Mrs. Smith, in my late 60s, trouble driving at night, 2+ to 3+ NS, and 3.00 D of astigmatism. How would you talk to me?

PREEYA: So, with all patients, I start out by describing what cataracts are and a general brief description of risks and benefits. Once that's out of the way, I like to then kind of focus on the refractive aspects of cataract surgery. So, I'll say, "Mrs. Smith, so now we just have to decide what implant you'd like in your eye. There's a variety of implants that are available. Some help you to be less dependent on glasses, and some don't. There's no wrong decision. You just need to decide how you want to see." And so generally, at this point, you can elicit whether the patient actually wants to be free of glasses.

So assuming Mrs. Smith says, “Yes, I really don't want to wear glasses to drive,” then I would say to the patient, “Well, looking at all your measurements, you have a lot of astigmatism. You may or may not have been told this in the past.” And in our practice, we actually have a 1-page sheet that has kind of a broad category of implants, and so I just circle that section of the sheet that homes in on toric correction.

KENDALL: This discussion takes a bit of time, but it's really important, and I try to say pretty much the same thing to all of my patients independent of the astigmatism level. I have to start by educating the patient. You know, we have to really let them know what astigmatism is, and I usually explain that by explaining the difference between a tennis ball that’s a perfect sphere versus a football that has a lot of astigmatism. And this is a once-in-a-lifetime opportunity to be able to correct that.

So, I start by educating the patient and then let them know that they do have options because some patients don't know. They're thinking of our old cataract surgery, which just involved removal of the cataract, and now, you know, we're fortunate that cataract surgery can also give them more freedom from spectacles. So, I do explain to them that cataract surgery can do both of these things.

And then I try to determine what the patient's goals are. Do they care about glasses or not? You know, if they don't care about glasses, it might not be worth the extra money to them. However, you know, with a lot of astigmatism, I really encourage them, you know, just explaining to them that this is your opportunity.

We can get several lines of improved vision over what you would have with a standard lens.

So, I would really recommend it.

PREEYA: I just spend maybe a minute or 2 just helping the patient to understand not so much what the technology does but what their end result is, and I think that's really what patients want to know: “How am I going to see afterwards?”

Really, to me, it's about that end goal. So, I would say, ‘Mrs. Smith, if you want to be able to drive and not wear glasses, then I would recommend a toric lens to correct your astigmatism. Insurance does not typically cover the toric implant. The extra cost is X. Our schedulers can give you more information and logistics related to the cost.”

I think that that conversation does not have to be very complicated, but patients need to understand how they're going to see after surgery, and I always tell them that "My job is to tell you what you need from this long list of things to achieve your goal. So before we go through the list of anything, I need to know what your goal is," and I think that that really streamlines the conversation and helps the patient sort of feel like you're on their side and that you are helping them not only with a medical need but also helping them with an important decision in their lifetime.

MARGUERITE: I like that you mention that it's not covered by insurance. I do, too. And we've talked to experts about the discussion of money, and it ranges all the way from not mentioning it at all and letting the surgical coordinator talk about it to mentioning it a little bit like you did. That's what I do, too, and the details can be provided by the surgical coordinator. I think, if you let them walk into the coordinators office and then find out, oh, this very important fact, then they feel a little bit betrayed by the doctor.

PREEYA: Absolutely. I couldn't agree with you more.

I'm not really selling technology. I'm helping them.

We're doctors. We don't want to sell things to our patients. But there are so many patients that wish their physician had actually spoken to them about their options because, you know, it is a once-in-a-lifetime so-to-speak decision where, you know, being free of glasses can be such … have such a huge impact on a patient that I think that, at the very least, we're obligated to tell them what options are out there.

KENDALL: And yet remember the same amount of money is not the same to every person. So, you know, when you're talking about a particular amount of money, you know, that could be nothing to one patient. All they want is the best technology. And another patient, you know, they're living on a fixed income. So, you know, just having that discussion and determining their goals because I don't want to be sitting there explaining, you know, in such great detail and then the patient is not on the same page as I am. So, I really have to understand what their goals are.

MARGUERITE: I’ve found that, if you mention CareCredit, Alphaeon, and all the financing options, that really helps. As a matter of fact, I say most patients use CareCredit or Alphaeon so they don't feel self-conscious, like, "Oh, I'm the only one who can't write a check for this right off the bat." You know what I mean?

KENDALL: Right, yeah, absolutely.

MARGUERITE: I really do prefer to have the surgical coordinator talk about money, but you do have to mention that these are expenses not covered by an insurance.

KENDALL: So, I, I agree, Marguerite. I don't like to talk about the money, either.

I'll kind of just mention it and say my surgical coordinator's going to talk to you in more detail about that. So, I try to limit that conversation about money.

MARGUERITE: Do you ever mention the ever-shrinking chance that the toric might rotate and that you might have to go back to the OR with them?

PREEYA: Generally speaking, I don't.

I find that, if you talk about things that happen less than 1% of the time in greater proportion to things that happen 95% of the time, patients get the impression that "Oh, this is going to happen to me," and so I like to reassure them that, if anything happens or if they're unhappy with their vision, that there are things that I can do, and we'll cross that bridge if we need to, but, based on percentages, it's more likely that we won't need to.

MARGUERITE: I couldn’t agree more.

So, Preeya and Kendall, thank you so much for sharing. I know our audience appreciates your insights.

PREEYA: Of course. Thanks for having me.

KENDALL: Thank you so much, Marguerite. Take care.

MARGUERITE: Yes, it’s important for all of us to take care. I appreciate all of you out there for listening to this edition of Informed Consent: Getting to Yes. Stay well.