Ophthalmologists are oftenconcerned about contrastsensitivity among theelderly to ensure thosepatients can perform day-

to-day tasks like walking downsteps in low light conditions.

Contrast sensitivity as meas-ured by modulation transfer func-tion looks at the quality of animage through the lens optics andreally is the first step to achievingbetter contrast sensitivity.

Clearly, modulation transferfunction is better with the aspher-ic AcrySof ReSTOR IOL (Alcon,Fort Worth, Texas) compared withthe standard ReSTOR lens, accord-ing to Jim Schwiegerling, Ph.D.,Depart-ment of Ophthalmology &Vision Sciences, University ofArizona, Tucson.

aspheric design, without giving upanything to obtain it.”

Dr. Schwiegerling’s studyinvolved a benchtop test, with amodel eye that has a simulatedcornea with clinical levels ofspherical aberration and chromat-ic aberration. The different IOLswere then inserted into the eyemodel, and the images were ana-lyzed to objectively measure thedifferent designs’ relative perform-ance. The methodology is verystandard, having been used overthe last 20 years in modulationtransfer function testing, he said.

Dr. Schwiegerling noted thatthe standard ReSTOR lens designignored the impact of sphericalaberration on a patient’s visionwhile the ReSTOR aspheric designtook it into account.

“The aspheric design works inconjunction with the cornea tocancel out these aberrations,” Dr.Schwiegerling said. “That’s wherethe performance enhancementcomes from.”

The Tecnis MF (AdvancedMedical Optics, AMO, Santa Ana,Calif.) lens is a similar design tothe ReSTOR aspheric, as it hasboth aspheric and multifocalproperties.

“The advantage of the ReSTORis that the apodized diffractiveportion turns into a pure refractivelens in the periphery, and thattends to suppress halos and glare,”Dr. Schwiegerling said. “The Tecnisdesign’s diffractive nature goes allthe way out to the periphery sofor large pupils you get halos. TheReSTOR turns into a purely refrac-tive lens in the periphery, so in

comparison it reduces the out-of-focus stray light. Asphericity aloneis not enough to overcome the dif-fractive effects produced by thedesign of the Tecnis lens.”

www.eyeworld.orgAchieving Successwith Cataractand RefractiveTechnology

Supplement to EyeWorld June 2008 • Reprinted from the 2008 ASCRS Chicago Show DailySupported by an unrestrictededucational grant from Alcon, Inc.

Measuring modulation transfer function of the Alcon asphericapodized diffractive multifocal IOL and clinical outcomes

“[With the ReSTORaspheric] patients willhave slightly bettercontrast for distancevision, slightly sharperimages, and fewer sideeffects especially atnight in terms of halosand glare.”

Jim Schwiegerling, Ph.D.

An ETDRS letter chart imaged through an eye model (6-mm aperture) containing four different multifocal IOLs;the AcrySof ReSTOR aspheric IOL produces the highest quality image with the fewest stray light effects

Table of Contents

Measuring modulation transfer function of theAlcon aspheric apodized diffractive multifocalIOL and clinical outcomes ............................1

ReSTOR aspheric, premiumresults for demanding patients ......................2

High energy blue light filtration:An evidence-based assessment ....................3

A new tool to analyze how muchthe cataract incision influencesthe refractive outcome ................................4

Early experience withthe AcrySof Toric IOL ..................................5

Silo Scheduling: Proactive templatesdeliver the practice you desire ......................6

Are lifestyle IOLs worth it?Establishing realistic financialgoals for upgraded lenses ............................7

That means “patients will haveslightly better contrast for distancevision, slightly sharper images, andfewer side effects especially atnight in terms of halos and glare,”Dr. Schwiegerling said. “We see abit of a distance boost with the continued to page 7

The News Magazine of the American Society of Cataract & Refractive Surgery

Bret L. Fisher, M.D., inprivate practice, The EyeCenter of North Florida,Panama City, Fla., beganimplanting patients with

the AcrySof ReSTOR aspheric IOL(Alcon, Fort Worth, Texas) in April2007, and since has found visualacuity, contrast sensitivity, andeven intermediate vision to beexceedingly good.

“Patient satisfaction wassubstantially better subjectivelyand objectively,” than with thestandard AcrySof ReSTOR IOL, Dr.Fisher said. “The patients functionmuch better.”

Dr. Fisher performed a study of33 patients implanted with theaspheric IOL and 35 patients withthe standard ReSTOR lens. Averagevisual acuity for distance vision was20/25 with the ReSTOR aspheric.For preferred reading distance (atnear), it was 20/20. Intermediatevision was even a little better than20/20.

“That was in contrast to someof the published data, includingwhat Alcon published themselvesfor Food and Drug Administrationapproval,” Dr. Fisher said. Dr.Fisher explained the difference inresults by saying he measuredpatients in “more of a real-worldway” at preferred near, rather than

using a phoropter.The ReSTOR has been criti-

cized for yielding plenty of read-ing and distance vision, but not asmuch intermediate, Dr. Fishersaid. “That is what was discussed,but it was never really clinicallyexperienced,” Dr. Fisher said.“When I look at my patients,[intermediate] is very good.”

Contrast sensitivity resultsclearly set the ReSTOR asphericIOL ahead of the standard one.

When asked how satisfied theyare with vision after surgery, on ascale from 0 to 10 (10 being mostsatisfied), ReSTOR asphericpatients scored their vision a 9,while standard ReSTOR patientsgave their vision a 7.5.

Further, Dr. Fisher said inphotopic conditions, asphericpatients performed as well as age-matched controls with healthyeyes in another study.

“Even though this is a multifo-cal implant and you can expectsome loss of contrast sensitivity,the results are virtually identicalbetween ReSTOR aspheric patientsand patients with the naturalcrystalline lens,” Dr. Fisher said.

One sizable concern related tomultifocal lenses has been thepotential loss of contrast sensitivi-ty. “When you’re taking light andsplitting it to different focuspoints, that process is not 100%effective,” Dr. Fisher said. “If youlose light transfer in the process,you lose contrast sensitivity. Butwith the ReSTOR aspheric, because

ReSTOR aspheric, premiumresults for demanding patients

2 Achieving Success with Cataract and Refractive Technology

“With the ReSTOR,because of the designand different steps andzones, it gives you themost light for the situ-ation that you’re using,whether reading ordistance.”

Bret L. Fisher, M.D.

Contrast sensitivity in normal subjects; compared to these patients, those implanted with the AcrySof ReSTORaspheric IOL achieved nearly identical contrast sensitivity results

Of AcrySof ReSTOR aspheric IOL patients, 87.5% achieve spectacleindependence

Source: Bret L. Fisher, M.D.

Results

Results

of the design, it gives you the mostlight for the situation that you’reusing, whether reading or dis-tance.”

Now, Dr. Fisher uses theReSTOR aspheric as the lens ofchoice on any cataract patient whowants to be less dependent onglasses. He said he achieved a rateof 87.5% spectacle independencewith the ReSTOR aspheric.

“There’s not another lens onthe market that I’m aware of thatcan show this type of consistency,”Dr. Fisher said.

Dr. Fisher said the AcrySofReSTOR aspheric IOL providessurgeons with added benefits aswell. “The designers of the implantwere able to move to a proprietary

biconvex shape, which makes theeffective lens position moreconstant across the entire dioptricrange of the lens. This can alsoimprove predictability in calculat-ing implant power and achievingthe desired refractive outcome.”

The excellent contrast sensitiv-ity results are a “nice confirmationthat the underlying technology inthe lens really does work,” Dr.Fisher said. “We’re not seeing adegradation of contrast sensitivitycompared to normal individuals.”

Dr. Fisher has no financial interests relat-ed to this supplement. He can be con-tacted at 850-784-3937 or bfish-er@eyecarenow. com.

Innovations in IOLs are seem-ingly endless. Whether youchart the progress frommonofocal to multifocal tech-nology or silicone to acrylic

material, we live in a world inwhich cataract patients are betteroff today than yesterday.

Without a doubt, that progresscontinues with adding a protectivechromophore to the lens toachieve wonderful health benefits,according to Miguel N. BurnierJr., M.D., professor of ophthalmol-ogy, pathology, medicine, andoncology, McGill University,Montreal, Canada.

“Yellow is the gold standard,”Dr. Burnier said. Yellow is thecolor that prevents blue light toxi-city and concomitant problems,he said. If cataract patients don’tget a yellow lens, such as theAcrySof IQ IOL (Alcon, FortWorth, Texas) or the AcrySofNatural IOL (Alcon), their eyehealth – and much more – is injeopardy, Dr. Burnier said.

“Over the lifetime of eachpatient, the retinal pigmentepithelium [RPE] accumulates thefluorescent material called lipofus-cin,” Dr. Burnier explained. “Bluelight absorption by the lipofuscin

generates substances which aretoxic to the RPE. As a result, RPEcells die and no longer nourishthe retina, affecting vision.”

Age-related macular degenera-tion clearly could result undersuch circumstances, he said.Putting excellent vision aside forthe moment, consider life-threat-ening consequences of blue lighttoxicity, like uveal melanoma.

“Laboratory rats exposed tolong-term blue light developintraocular masses, pathologicallydiagnosed as ocular melanoma,”Dr. Burnier said.

Further, Dr. Burnier cited astudy linking high energy lightemitted from commercial weldingto uveal melanoma. “There wasevidence implicating welding as arisk factor for uveal melanoma,”Dr. Burnier said. But he added thatthere is a high emission of bluelight in arc welding.

In a letter to the journalOphthalmology, Dr. Burnier wrote,“There is evidence suggesting thatthe major culprit is not ultravioletlight but blue light exposure.Okuno et al evaluated variouslight sources for blue light hazard.Among these sources, arc weldingwas found to have extremely higheffective radiance, with correspon-ding permissible exposure times ofonly 0.6 to 40 seconds, suggestingthat viewing this light source isvery hazardous to the retina.”

Dr. Burnier added that usingUV and blue light filtering IOLsshould be preferred for all adultpatients undergoing cataractsurgery, as it could be a preventa-tive measure against possible bluelight-induced malignant transfor-mation.

Critics of the AcrySof NaturalIOLs have incorrectly suggestedthat the AcrySof Natural “blocks”blue light. They have suggestedthat blocking blue light couldinterfere with natural circadianrhythms regulated by melatoninand negatively impact sleep pat-terns and mood levels.

The AcrySof Natural IOLs filteronly a specific range of very high-energy blue light. A patient satis-faction questionnaire used atMcGill, under the oversight of Dr.Burnier’s research team, foundsome enlightening results that allophthalmologists need to know.Of 360 AcrySof Natural patientsanswering questions related to

quality of vision after cataract sur-gery, none said they experiencedinsomnia or depression aftercataract surgery.

There is no definitive evidenceto justify statements that theAcrySof Natural chromophorecauses alleged problems with visu-al acuity, color perception, con-trast sensitivity, circadianrhythms, or sleep pattern. Theseand other criticisms are shallow,Dr. Burnier said, such as thoserelated to glistenings.

The bottom line is that theAcrySof blue light filtering tech-nology is not only beneficial tovision, but can prevent seriouslife-threatening conditions, Dr.Burnier said. There are strong indi-cations that blue light filteringIOLs may play an important partin preserving vision for the longterm.

“For all these reasons, sur-geons must use the gold standardin cataract surgery: Alcon bluelight filtering IOLs,” Dr. Burniersaid.

Dr. Burnier has no financial interestsrelated to this supplement. He can becontacted at 514-843-1544 ormiguel.burnier@mcgill.ca.

High energy blue light filtration:An evidence-based assessment

Achieving Success with Cataract and Refractive Technology 3

“Yellow is the goldstandard. Yellow is thecolor that preventsblue light toxicity andconcomitant prob-lems.”

Miguel N. Burnier Jr., M.D.

IOL IOL MonofocalMonofocal Technology AdvancesTechnology Advances

PMMA SILICONE HYDROPHOBIC ACRYLIC

1949 1994

Sir Harold Ridley

1983 2005 +

Aspheric Optic

UV only

UV and Blue Light Filtering

High emission of blueHigh emission of blue--light light in arc weldingin arc welding

UV and blue light filtering IOLs (pictured above), like the AcrySof Naturaland AcrySof IQ, may prevent visual diseases like macular degeneration,but could also prevent life-threatening diseases like uveal melanoma

There is growing evidence implicating welding as a possible risk factorfor uveal melanoma. The major culprit is high-energy blue light exposure(only UV-light is filtered by protective eyewear)

Source: Miguel N. Burnier Jr., M.D.

Limbal relaxing incisions(LRIs) and other methodsto address astigmatismhave been around the oph-thalmology block for a

while, but as cataract surgerybecomes more like refractive sur-gery, surgeons are looking for newways to optimize outcomes.

In this era of premium IOLs,surgeons have shifted their atten-tion to surgically induced astigma-tism (SIA), said Robert P.Lehmann, M.D., clinical associateprofessor of ophthalmology, BaylorCollege of Medicine, Houston,Texas. Surgeons now understandthat whether they are implantingmultifocal lenses, accommodatinglenses or doing an LRI, to get moreprecise refractive results they musttake SIA into account.

Enter the Surgically InducedAstigmatism Calculator, designedbyWarren E. Hill, M.D., availablefrom his website, www.Doctor-Hill.com. “It’s an excellent fit withboth the [AcrySof] Toric lens(Alcon, Fort Worth, Texas) andLRIs,” Dr. Lehmann said. “That’sthe obvious place where youwould first think of using it, assurgically induced astigmatism is akey element in the AcrySof ToricCalculator.”

The AcrySof Toric Calculator(Alcon,www.AcrySofToric-Calculator. com) takes into

account how much astigmatismyou induce during surgery so thatit can be compensated for in lenscalculations. “It’s very applicableto toric lenses,” Dr. Lehmann said.“The calculator provides a defaultvalue but your results will beimproved if your own SIA isused.”

While there are a number ofastigmatism calculators available,Dr. Lehmann said the SIACalculator is the only one hewould use because of Dr. Hill’sreputation and contributions toophthalmology. “Warren Hill’swork has been second to none,”Dr. Lehmann said.

Dr. Lehmann noted that small-er incisions cause less inducedastigmatism. The range of possibleinduced astigmatism, for example,is greater with 3.0-mm incisions.

“In that light, this [SIACalculator] is going to be incredi-bly valuable, too,” he said, especial-ly for surgeons who have had trou-ble optimizing results with some ofthe latest IOL technology. A toollike this [SIA Calculator] is going toenable a surgeon who has had anup and down love affair with pre-mium implants to hone in and doa better job to get more preciserefractive results, which is what ittakes to make patients happy.”

Dr. Lehmann added that sur-geons cannot have more than halfa diopter of uncorrected residualastigmatism in patients and expectto be successful with premiumlenses. “These people want to func-tion if at all possible with reduceddependence on glasses,” he said.

Dr. Lehmann added that hissurgically induced astigmatismwith vector analysis is between 0.3and 0.4 D, and he has excellentresults with Toric IOLs.

“The AcrySof Toric IOL reallyallowed me to achieve a level ofprecision and success I never cameclose to with LRIs. It’s a preciseand easy way for all surgeons totransition into premium IOLs,” Dr.Lehmann said. “In my hands, Ithought I was doing a good job[with LRIs]. With LRIs, patientsmight see really well on day one,but after the eye heals, residualastigmatism comes back. I don’tthink I came close in 20 years toachieving the kind of results Ihave in two years with the AlconToric lens. On day one, 20/20 isnot unusual now. LRIs now are avery poor second to Toric.”

Dr. Lehmann is a consultant for Alcon,but states that he holds no financialinterest in the products mentioned here-in. He can be contacted at 936-569-8278or rplehmann@suddenlink.net.

A new tool to analyze how much the cataractincision influences the refractive outcome

4 Achieving Success with Cataract and Refractive Technology

“The Toric reallyallowed me to achieve alevel of precision andsuccess I never cameclose to with LRIs. It’s aprecise and easy wayfor surgeons to transi-tion into premium IOLs.”

Robert Lehmann, M.D.

Final alignment of the AcrySof Toric IOL

A surgeon readies to implant an AcrySof Toric IOL

Please visit www.Doctor-Hill.com andwww.AcrySofToricCalculator.com formore information.

Achieving Success with Cataract and Refractive Technology 5

whether or not it is asymmetric”are ideal, Dr. Gayton said. What’smore, he said, none of the multi-focal contraindications apply, suchas diabetic retinopathy, maculardisease, or even “personality diffi-culties.”

The Toric can also be com-bined with other more traditionalastigmatism correcting procedures.A Toric and LRI at the time ofsurgery is one possible solution, asis a Toric and LRI post-op, and aToric and laser vision correction.Conceivably, a surgeon could evenemploy all three methods.

Dr. Gayton recommends thatbetween 1.0 and 2.75 D of against-the-rule astigmatism, a Toric IOLshould be used. With 2.75 orgreater against-the-rule astigma-tism, a Toric and LRI could beused, correcting residual astigma-tism with a laser. Between 0.5 and2.25 D with-the-rule astigmatism isalso suitable ground to employ theToric only. For 2.25 or greaterwith-the-rule astigmatism, he sug-gested a Toric and LRI once again,correcting residual astigmatismwith a laser.

Don’t take Dr. Gayton’s wordabout the clinical benefits of ToricIOLs. The results speak for them-selves in one multicenter clinicalinvestigation in which 211 AcrySofToric IOL eyes were compared to210 control eyes.

In the study, patients werethree times more likely to achieveless than or equal to 0.5 D ofresidual refractive cylinder withthe AcrySof Toric IOL than withthe control group.

More than 60% of Toricpatients achieved less than orequal to 0.5 D of absolute residualrefractive cylinder at six monthscompared to about 20% of con-trols.

Further, the mean absoluteresidual refractive cylinder was0.55 D for all AcrySof Toric IOLpatients compared to 1.22 D forcontrols.

Importantly, 97% of the 37patients who were implanted bilat-erally were spectacle-free fordistance viewing.

“The AcrySof Toric IOLdemonstrates excellent rotationalstability within the capsular bag,”Dr. Gayton said. The unique prop-erties of the AcrySof material makeit the optimal IOL to address astig-matism.

Implantation of the Toric lensrequires only minor variationsfrom a standard cataract proce-dure.

Surgeons determine therequired spherical power usingtheir preferred method. They then

use the AcrySof Toric IOLCalculator (Alcon,www.acrysoftoriccalculator.com)to determine the correct IOLmodel and optimal axis locationof the IOL in the capsular bag.

The eye is marked on the lim-bus pre-op in three locations 90degrees apart (3, 6, and 9 o’clock).Later, during the procedure, axismarks are placed on the eye usingthe pre-op reference marks.

“Axis marks identify theoptimal axis of IOL placement asdetermined by the AcrySof ToricIOL Calculator,” Dr. Gayton said.The lens is then rotated to itsproper alignment. It’s that simple.

This IOL technology hasturned out to be a huge benefit forpatients and surgeons. It’s an easyway for all surgeons to getinvolved in elective IOLs. Patientsunderstand that they have astig-matism. They know they need itcorrected in their glasses, in theircontact lens, and now in theirIOLs.

Dr. Gayton has no financial interestsrelated to this supplement. He can becontacted at 478-922-2994 or jlgayton@aol.com.

Early experience with the AcrySof Toric IOL

“The ideal astigmatismtreatment is preciseand accurate withpredictable outcomes;it is permanent, safe,and convenient. TheAcrySof Toric IOL hasproven to be an optionthat can meet thesecriteria.”

Johnny Gayton, M.D.

Of patients with bilateral implantation, 97% were spectacle-freeSource: Johnny Gayton, M.D.

More than 60% of Toric patients achieved less than or equal to0.5 D of absolute residual refractive cylinder at six months com-pared to about 20% of controls

In ocular surgery, there areplenty of ways to manageastigmatism. One method isemerging as supremely advan-tageous: the AcrySof Toric IOL

(Alcon, Fort Worth, Texas), accord-ing to Johnny Gayton, M.D.,Eyesight Associates, WarnerRobins, Ga.

Incisions to correct astigma-tism lack precision. They also leadto unpredictable outcomes andpotential regression, not to men-tion their limited treatment range,

Dr. Gayton said. Lasers, mean-while, can weaken the cornea.

The ideal astigmatism treat-ment is precise and accurate withpredictable outcomes; it is perma-nent, safe, and convenient. TheAcrySof Toric IOL has proven to bean option that can meet these cri-teria.

So who are the candidates forsurgery?

Patients who are “able to havelens surgery and also have signifi-cant regular corneal astigmatism,

6 Achieving Success with Cataract and Refractive Technology

Imagine a world in whichmore patients need to becared for by your practice, butyour practice nonetheless suf-fers more financial pressure as

fees drop. Stop imagining becausewithout making some changes,this will likely be the future.

The baby boomer populationis aging, bringing with it atremendous amount of patientswho need more “interactive, col-laborative care from their medicalprovider,” said Kay Coulson, presi-dent, Elective Medical Marketing,Boulder, Colo. Specifically, in thenext 20 years, the number ofpatients with cataracts are slatedto increase 60%, and glaucomapatients will increase by 46%, Ms.Coulson said. Meanwhile,reimbursements have been andwill continue to decline.

“We’re at a critical thresholdwhere efficiency alone cannotcarve any additional time from asurgeon’s day,” Ms. Coulson said.

Instead, ophthalmologists firstneed to revisit the services theyprovide. “We are rapidly movinginto a period where further spe-cialization of ophthalmologistswill be required,” Ms. Coulsonsaid. “The comprehensive practicethat continues to schedule andtreat patients simply as the phonerings will be overwhelmed withinglaucoma and lens surgeryrequests.”

Second, special schedulinghelp could ensure a practice’s

financial well-being. “Now is thetime to revisit your appointmenttemplate and provide the visittype definition that reflects thetype of practice and mix ofpatients you desire,” Ms. Coulsonsaid.

Silo Scheduling, a techniquedeveloped by Elective MedicalMarketing, “allows a practice tocreate definition in its appoint-ment calendar to deliver the rightmix of patients, and more impor-tantly, restrict visit types thatthreaten to overwhelm the prac-tice,” Ms. Coulson said. See FigureA for an example of SiloScheduling.

So why can’t a practice simplyanalyze how to better optimize itsown scheduling? “Adjusting theschedule template cannot beundertaken in isolation, as eachpractice must understand howvisit types relate to diagnosiscodes and revenue; there is not aone-to-one correlation,” Ms.Coulson said. Elective MedicalMarketing has years of experienceperfecting unique scheduling tofind just the right financial solu-tions for practices.

The way Ms. Coulson speaksabout it, scheduling sounds like ascience. “What Elective MedicalMarketing has done for several ofour clients is develop an appoint-ment mix summary by silo andrevenue realized per appointmenttype, correlating diagnosis codesto silos,” Ms. Coulson said. “Thisdetermines an event-to-appoint-ment billing ratio.” Using theexample worksheet shown inFigure B, a practice can perform ascenario analysis that indicates,for example, ‘If I reduce the glau-coma and pathology portions ofmy practice and concentrate ongrowing lens and LASIK surgery,how will my bottom line be affect-ed?’”

In that example, revenue wasincreased by 13% by revising theappointment mix. “These appoint-ment mix percentages can then bebuilt into the schedule templatewith reassurance that schedulechanges will result in a positivebottom-line impact,” Ms. Coulsonsaid.

This way, ophthalmologists nolonger have to feel overwhelmedcaring for more patients as theirpractice suffers financially. Byworking smarter – with a littlehelp from Silo Scheduling – theycan put their worries behindthem.

Ms. Coulson is a consultant for Alcon.She can be contacted at 303-994-0014or kay@electivemed.com.

Silo Scheduling: Proactive templatesdeliver the practice you desire

“Silo Scheduling allowsa practice to createdefinition in itsappointment calendarto deliver the right mixof patients.”

Kay Coulson

Figure B: Scenario analysis can be performed to determine howchanging practice workloads will affect the bottom line

Figure A: An example of Silo Scheduling

This supplement was produced by EyeWorld under an educational grant from Alcon, Inc.

Copyright 2008 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed heredo not necessarily reflect those of the editor, editorial board, or the publisher and in no way implyendorsement by EyeWorld or ASCRS.

Achieving Success with Cataract and Refractive Technology 7

Are lifestyle IOLs worth it? Establishingrealistic financial goals for upgraded lenses

Our hypothetical practice sees 40 cataractevaluations per week, which include knowncataracts, either from your diagnosis ofpatients presenting for a recheck, or referred infrom ODs/non-surgical MDs. The number ofevaluations is based on a weekly average overthe prior 90 days.

This practice performs 12 cataract surgeriesper week for a conversion rate of 15%. In ourexperience, we’ve found practices dramaticallyoverestimate their surgical conversion, with 15to 20% being the industry average.

This practice was dabbling in presbyopic IOLsand had not begun implanting toric IOLs. Theyperform LRIs, but did not charge for them asthey considered results too unpredictable.

This practice charged $3,000 per eye for apresbyopic IOL, and as part-owner of its ASC,paid $745 incrementally for multifocal lenses(above the $150 ASC reimbursement).

This practice implemented Silo Scheduling, blocking thesame 40 weekly consultations into two mornings per week,separate from all other appointment types, rather than dis-persing them throughout the schedule.

Blocking all cataract evaluations into two days and ensuringall staff are geared on those mornings toward evaluatingand educating patients about lens surgery options increasedsurgical conversions to 25%, resulting in 20 surgical eyesper week versus 12 from the same 40 exams.

All cataract evaluation patients were mailed educationalmaterials one week ahead of their visit. These materials cov-ered all lens options, procedure costs, and patient testimoni-als. In addition, each patient filled out the Vision PreferencesChecklist, and all were shown a multifocal testimonial DVDwhile dilating. Conversion to lifestyle IOLs increased from5% to 35%.

Realizing the $3,000 fee was preventing adoption by manyinterested patients, this practice lowered its presbyopic IOLfee to $1,975 per eye, and added an astigmatism manage-ment service at $975 per eye.

Before After

Examsper week

Surgeriesper week

Lens mix

Fees

So-called “lifestyle IOLs” –that is, multifocal orpseudoaccommodativeones – clearly have morepotential for profit as

associated fees are higher thanwith standard IOLs. But beforeoffering them in your practice,wouldn’t it be good to know thelikely financial outcome of doingso? Other businesses carefullystudy the advantages of new prod-uct lines before they offer them.Why shouldn’t you? The LifestyleIOL Financial Calculator, amethod developed by ElectiveMedical Marketing (Boulder,Colo.), allows ophthalmologists to“evaluate current practice per-formance and set targets for specif-ic areas of improvement that canbe continually monitored as yourpractice expands,” said KayCoulson, the company’s president.

Overall, it is wise for all IOLsto move to the aspheric platform,Dr. Schwiegerling said. Whiletoday’s IOL technology is excel-lent, any small improvement willstill make a difference, he said.

Dr. Schwiegerling did notethat the aspheric design had noimpact on near vision in ReSTORpatients.

“I think that’s fairly pre-dictable,” Dr. Schwiegerling said.“Most aspheric effects onlyaccount for large pupil condi-tions.”

In the ReSTOR lens, theperipheral part of the IOL –through which light would pass inlarge pupil conditions – is strictlyfor distance vision.

So the fact that Dr.Schwiegerling said most asphericeffects are noted in large pupilconditions means they are notablefor distance vision, and not partic-ularly for near vision. Near visionin the ReSTOR, Dr. Schwiegerlingsaid, is achieved with the central

Schwiegerling from page 1

3.6 mm of the lens.Meanwhile, Dr. Schwiegerling

said, intermediate vision is proba-bly the same in both the asphericand standard ReSTOR IOLs.

“It was difficult from our find-ings to see any differences oneway or another,” Dr.Schwiegerling said.

Of course, modulation transferfunction testing does not gaugeany neuroadaptivity that occursrelated to quality of vision. Aftersome time, symptomatic patientsmay not notice halos and glareeven with the standard ReSTORIOL in larger pupil conditionsbecause their brains have adaptedto screen them out. Nonetheless, abetter optical system, like theaspheric design, can only help tolessen these effects further.

Dr. Schwiegerling receives travel,honoraria, and research grants fromAlcon. He can be contacted at 520-322-3800 x210 or jschwieg@u.arizona.edu.

The chart above shows before-and-after scenarios of one hypo-thetical practice, which with thehelp of some of the method’simplementation steps, dramatical-ly increased revenue by more than75%. The chart was provided byElective Medical Marketing.

As a result of the practicechanges made, revenue increasedfrom $476,000 to $835,000 annu-ally without having to do anymore cataract evaluations.

“This revenue increase of morethan $350,000 is the result ofincreased practice focus on thepatient experience through SiloScheduling and pre-exam educa-tion,” Ms. Coulson said.

Ms. Coulson is a consultant for Alcon.She can be contacted at 303-994-0014 orkay@electivemed.com

Unlike IOLs that do not closely match the light-transmission spectrum of the human

crystalline lens*, the patented chromophore in the AcrySof® Natural IOL is designed

to filter UV wavelength and blue light in the 400–475nm range.

© 2008, Alcon, Inc.

“Objective, peer-reviewed studies have shown that

blue-light filtering IOLs have no significant effect on color

perception. There are strong indications that blue-light

filtering IOLs may play an important role for patients

in the long-term. In my experience, the potential benefits

outweigh unsubstantiated claims of altered circadian

rhythms and other marketing hype.”James McCulley, MD�Professor and Chairman, Department of Ophthalmology

UT Southwestern Medical Center at Dallas (USA)

“I have implanted the AcrySof® Natural IOL for ten years,

and it possesses a long-term track record of excellent

clinical performance. The AcrySof® design, material and

Natural chromophore combine to provide great benefits to

my patients. This is the IOL I would want if I were a

patient. As a surgeon concerned with my patient’s best

interests, using it allows me to sleep soundly each night.”Stephen Lane, MDAdjunct Clinical Professor,

University of Minnesota, St. Paul (USA)

“Although it may take years to determine every benefit

associated with the Natural lens, there have certainly

been many clinical studies done that strongly support its

safe use. Excellent clinical performance provided me the

confidence to implant AcrySof® Natural IOLs in my wife

and my sister.”Samuel Masket, MDClinical Professor,

UCLA, Jules Stein Eye Institute, Los Angeles (USA)

“Having participated in the clinical investigation of the

Natural chromophore and seeing for myself real-life patient

benefits, I am gratified by the increasing worldwide

acceptance of the AcrySof® Natural platform. This lens is

quickly becoming the standard of care as more companies

are attempting to copy this technology and following suit.”Robert Lehmann, MD

Founder and Director of Lehmann Eye Center

Clinical Associate Professor,

Baylor College of Medicine (USA)

“Over the last five years I have implanted more than

10,000 blue-light filtering lenses, I also implanted this lens in

my wife and both my parents. There is no definitive evidence

to justify statements that the AcrySof® Natural chromophore

causes alleged problems with visual acuity, color perception,

contrast sensitivity, circadian rhythms or sleep pattern.”Richard Mackool, MD

Founder and Director of The Mackool Eye Institute

Assistant Clinical Professor,

New York Medical College, New York (USA)

“I believe very strongly that the AcrySof® blue-light filtering

IOLs should be the standard of care for all patients. In my

peer-reviewed studies, we have presented laboratory

evidence that clear and/or violet IOLs do not have the

qualities of the Natural chromophore.”Miguel Burnier, Jr., MD

Thomas Hecht Family Chair of Ophthalmology and

Director of the Henry C. Witelson Eye Pathology�Laboratory,

McGill University, Montreal (Canada)

References; (*) Alcon, Inc. Data on File and Human lens data from Boettner and Wolter, 1962

© Alcon, Inc. © 2008,

ACR586