I HAVE LONG BEEN AN ADVOCATE of utilizing intraocular lenses (IOLs) that provide a range of vision to address presbyopia after cataract surgery, both for improved quality of life and for the safety of patients.1 To maximize patient satisfaction with these range of vision IOLs, it is important to have a good understanding of the expected low-light dysphotopsias. With that in mind, we can counsel and set appropriate expectations regarding these symptoms.
Even with improved technology, the impact of dysphotopsias on success with range of vision IOLs cannot be dismissed. The patient experience with these IOLs—both positive and negative—can have a direct impact on practice economics and an indirect impact on physician reimbursement.
I recently moved from implanting the diffractive Tecnis Symfony extended depth of focus (EDOF) IOL to the Tecnis Symfony OptiBlue (both Johnson & Johnson), which includes a violet light filter (VLF) and is manufactured with a high-resolution lathing process. We compared a series of eyes implanted with each of these IOLs to evaluate both the clinical outcomes and the impact of the VLF and the manufacturing changes on clinic and operating room time utilization and practice economics.
The original study was a single-center, retrospective, consecutive case series comparing eyes implanted with the Tecnis Symfony (ZXR00/ZXT150) IOL (control) in the second half of 2020 to eyes implanted with the newly available Tecnis Symfony OptiBlue (ZXR00V/ZXW150) IOL (VLF) in the first half of 2021. I have previously reported on the clinical outcomes portion of the study, in which we found that both lenses provided similarly excellent visual acuity, with mean monocular uncorrected distance acuity of 0.03 ± 0.08 and 0.05 ± 0.10 logMAR (20/22 and 20/22), respectively, and uncorrected near of 0.27 ± 0.14 and 0.27 ± 0.13 logMAR (20/37 and 20/38), respectively. However, there were significant differences in the rate of dysphotopsias and the need for postoperative counseling.2
In a follow-up retrospective evaluation of the same series of eyes, we also compared the time utility and costs of dysphotopsia complaints, the need for postoperative counseling, and secondary interventions (refractive enhancement or IOL exchange) through 9 months of follow-up.3 There were no differences in age or percentage of toric EDOF IOLs between the 2 groups. However, the VLF group had significantly more eyes with prior laser vision correction (LVC) than the control group (14/73 or 19.2% vs 8/55 or 12.7%, P=0.029).
With regard to the time needed for additional counseling, we estimated that a single case of dysphotopsia complaints requiring additional counseling at the 1-month postoperative visit could take between 30 and 45 minutes of the staff’s time, between 15 and 60 minutes of the optometrist’s time, and between 15 and 45 minutes of the surgeon’s time. Counseling at 3 months was less common but took more time than counseling at 1 month. This finding is not surprising; by 3 months postoperatively, patients who were still symptomatic were likely more frustrated and moving toward secondary interventions. Therefore, we performed more tests and spent more time discussing the tradeoffs of various management strategies at the 3-month postoperative visit compared to the 1-month visit.
At 1 month, the VLF group had a 56% reduction in the number of eyes with dysphotopsia symptoms requiring additional postoperative counseling compared to the control group (P=0.003); at 3 months, the VLF group had a 72% reduction in dysphotopsia complaints requiring postoperative counseling (P<0.001). Impressively, the VLF group had significantly lower rates of postoperative counseling despite this group having a relatively high rate of post-LASIK eyes.
To monetize the extra time spent, we established resource costs based on published and estimated hourly rates, as shown in Table 1.
|MD||$175-$200 per hour|
|OD||$70-$120 per hour|
|Staff||$40-$64 per hour||Front office, clinic and scrub tech, refractive coordinator|
|Operating Room||$44 per minute||Facility, staff, and equipment|
|Refractive Suite||$850-$1,000 per use||Click fee and supplies|
Next, we multiplied the rate of complaints for 100 eyes by the time spent in postoperative counseling and the estimated costs per hour to arrive at a range for the total cost of managing postoperative complaints per 100 IOLs implanted with either the VLF or the control lens, as shown in Table 2.
|1 MONTH||3 MONTHS|
|Symfony OptiBlue (VLF)
|Symfony OptiBlue (VLF)
|Number of Eyes by IOL Model||8 of 63 (12.7%)||17 of 59 (28.8%)||3 of 37 (8.1%)||8 of 28 (28.6%)|
For a single patient with dysphotopsia complaints who requires postoperative counseling, the incremental time-related costs of managing that patient can be as much as $428 more than managing a patient without such complaints—and that is assuming the complaint can be resolved with counseling alone.
We further estimated that a single case requiring postoperative intervention (laser enhancement or an IOL exchange) requires up to 300 additional minutes of staff and doctor time. When the costs for the refractive suite or operating room use are added in, the total intraoperative and postoperative cost of a refractive enhancement falls somewhere between $1,033 and $1,430, and the total cost of an IOL exchange is in the range of $1,483 to $3,156.
Table 3 shows the actual rate and estimated burden of time and costs to manage that rate of postoperative interventions per 100 IOLs implanted.
|REFRACTIVE ENHANCEMENT||IOL EXCHANGE|
|Symfony OptiBlue (VLF)
|Symfony OptiBlue (VLF)
|Number of Eyes by IOL Model||3 of 73 (4.1%)||3 of 60 (5.0%)||0 of 73 (0.0%)||1 of 60 (1.7%)|
In our relatively small series, there was not a significant difference in the rate of refractive enhancement between the 2 groups despite a greater percentage of eyes in the VLF group having previous LVC. Notably, 2 of 3 eyes in the VLF group requiring enhancement were post-LASIK, compared to 0 of the 3 eyes in the control group. However, there was a significant difference between the 2 groups (P=0.038) in the need for IOL exchange, which is the costliest intervention—and carries the additional risks of a second intraocular surgery.
When all these costs are combined, postoperative counseling for dysphotopsia complaints, in combination with a needed secondary intervention, significantly increases the time utilization and economic impact on the practice. We estimated that a case in which refractive enhancement is needed adds up to an additional 10 hours and total cost impact of $2,176. A case in which an IOL exchange is required adds up to an additional 10.75 hours and total cost impact of $3,902.
These costs are likely underestimated because it is difficult to quantify the potential negative impact of a dissatisfied patient on referrals; patient caregiver considerations, such as the burden of making additional or longer office visits; staff morale and retention; and ultimately the stress and frustration of the doctor and surgeon. In dealing with dissatisfied patients, we also incur opportunity costs of lost time and revenue from other patients who could have been evaluated or treated during the time spent managing complaints and performing secondary interventions.
There is significant patient-to-patient variability in the time involved in postoperative counseling, even within a given practice. Regional differences might affect the time spent at other practices. There are also variations in technician questioning and style that can influence practice time utility. Each practice would be expected to have slightly different cost estimates, based on local wage variability, the style of the practice, and the staff composition. In our practice, for example, a highly qualified optometrist sees most of the patients postoperatively and does much of the counseling to evaluate dissatisfied patients. If more of that work were performed by the surgeon, the costs would be even higher.
Clearly, our data show that the new Tecnis Symfony OptiBlue IOL with VLF and high-resolution lathing improves practice efficiency and reduces practice costs. As cataract surgery patient volumes increase with aging demographics, clinic efficiency becomes an increasingly important consideration. More broadly than just comparing clinical outcomes of one lens against another, the kind of economic evaluation described here can help to guide clinical decision making and improve quality of care while enhancing practice efficiency with any new technology. ■
- Chang DH. Multifocal spectacle and monovision treatment of presbyopia and falls in the elderly. J Refract Surg. 2021;37(6 Suppl):S12-S6.
- Chang DH, Kao AA, Huggins LK. The effect of violet light filtration and manufacturing improvements on the clinical performance of an extended depth of focus IOL. Paper presented at: Annual meeting of the American Society of Cataract and Refractive Surgery; April 22-26, 2022; Washington, DC.
- Chang DH, Kao AA, Huggins LK, Pastuck TJ. Practice economic impact of a diffractive extended depth of focus IOL with violet light filtration and high-resolution lathing. Poster presented at: Annual meeting of the American Society of Cataract and Refractive Surgery; May 5-8, 2023; San Diego, CA.