Comanagement has had a bad rap, and rightfully so. When premium intraocular lenses (IOLs) hit the market, many optometrists were left with the same minimal Medicare fee, even though these IOLs required far more work and chair time, both before and after surgery. No wonder only 7% of all cataract surgeries today involve premium IOLs. Even new and improved technologies such as extended depth-of-focus and a new trifocal IOL have not moved the dial much. To be fair, some surgical practices offering premium IOLs provide ODs adequate fees for the time, effort and additional testing. So how do we make sure this is true for all comanagement relationships?

Get Educated

Companies rolling out innovative technologies must educate both surgeons and ODs. Approximately 88% of all comprehensive eye exams are conducted by optometry, and patients are far more likely to trust their OD than a surgeon they just met. When the primary care optometrist makes an IOL recommendation in our office, the likelihood of the patient pursuing this is north of 95%. Optometrists would be more comfortable recommending an IOL if they were properly educated on its merits, limitations and safety data. 

Fortunately, premium IOL companies have begun educating optometry—perhaps a little late and a little less than what’s required, but we are getting there. 

Get On Board

Education will be a must when two surgical technologies launch in 2020. 

The success of RxSight’s light adjustable lens (LAL) hinges on optometric inclusion because it requires extremely accurate refractive measurements and other refractive decisions such as the amount of monovision and whether or not to include full distance correction. In addition, the lens allows for further correction after surgery—the optometrist’s domain. The IOL has a photoreactive ultraviolet (UV) absorbing material that allows for the refractive error to be modified after implantation using a UV light source. 

To fine-tune the Rx, ODs will rely on contact lens trials for monovision, trial lenses, precise refractions and discussions on what to correct, at what distance and even whether to address small amounts (0.50D) of astigmatism. This IOL is similar to monofocal lenses on the market and will be similar in cost and reimbursement as current cataract surgery, but patients will pay for the light delivery device enhancements. 

Clinical trials show that patients receiving the RxSight LAL achieved uncorrected vision of 20/20 or better twice as often as those receiving a monofocal lens, and nearly 92% of patients receiving the LAL achieved results within 0.50D of the intended target.1 The company understands optometry’s crucial role, and I expect surgeons, primary eye care providers and patients will benefit equally from the effort, time and commitment this premium IOL will require.

A second surgical technology I hope we’ll see in 2020 is the ReFocus VisAbility implant for presbyopia. Young eyes that can accommodate have zonules that are taut in static position; as the lens grows throughout life and enlarges, the zonules become loose and can’t flex the crystalline lens. These scleral micro-inserts are placed to expand the zonular space. Data from one of the investigational sites shows more than 90% of patients with the implants regain reading capabilities to that of newspaper print or better. There is no surgery in the visual axis—or even the cornea, for that matter—so the risk of visual loss is minimal. This is another procedure for which surgeons will need to work closely with optometry to ensure proper patient selection and education on the surgical procedure, expectations, not to mention the proper peri- and postoperative care required to achieve these results. 

Great presbyopia solutions are ahead, and ODs must educate themselves and prepare their offices to provide the perioperative care required. Your knowledge and skills will solidify your patient’s trust in doing what is best for them when recommending these innovative surgical advances.

Note: Dr. Karpecki consults for companies with products and services relevant to this topic.

1. Chayet A. A single center exploratory study to evaluate the use of the RxSight Light Adjustable Lens (LAL) and the Light Delivery Device (LDD) to improve visual outcomes. (unpublished data).