Q: What are the implications of Medicares new balanced billing policy for my patients who are considering multifocal IOLs?

A: In May, the Centers for Medicare & Medicaid Services (CMS) allowed Medicare beneficiaries to opt for a presbyopia-correcting intraocular lens (IOLs) if they pay the portion of the facility fee and surgeons fee that exceed the charges for the implantation of a conventional IOL.

Before this change in CMS policy, Doctors werent allowed to balance bill the patient for one of these lenses. We werent even allowed to offer one of these lenses to the patient, says Christopher J. Quinn, O.D., of Iselin, N.J. Now, this [change in policy] opens up the population who can potentially benefit from this option. It really gives the patient more choices.

These choices include the accommodating Crystalens (Eyeonics inc.) and the multifocal IOLs, ReStor (Alcon) and ReZoom (Advanced Medical Optics).

Alcon AcrySof ReStor IOL.

Q: Is the pre- and post-op care with these IOLs different than the care with a standard IOL?

A: There are several very important differences:

Manage patient expectations. The biggest aspect to this is educating patients about expectations, says Robert B. Pinkert, O.D., of Phoenix. If the patient thinks hes going to get vision back like when he was 25, hes going to be disappointed. But if he understands that hes going to achieve better reading vision with one of these lenses compared with a standard implantbut not a panacea in terms of near visionthen I think that hell be satisfied.

Exhaust informed consent. Be ready for a lot more chair time. These patients need a lengthy discussion about the risks, benefits and alternatives, says Dr. Quinn.

Also, have the patient sign a consent form that clearly spells out that there are additional charges, says surgeon Stephen E. Pascucci, M.D., of Bonita Springs, Fla. Its important that the patient recognize that this is indeed a non-covered service, he says.

Choose patients wisely. These implants are unproven in cataract patients who have concomitant eye disease, such as glaucoma, macular degeneration or diabetic retinal disease, Dr. Pascucci says. Also, patients with corneal dystrophies, large pupils, pseudoexfoliation, vision in only one eye or those with limited potential acuity may be better off with a traditional IOL, Dr. Quinn says.

Patients older than age 50, generally speaking, are better candidates than those younger than 50, Dr. Pascucci says. If [patients younger than age 50] come out of the procedure with anything less than fabulous distance vision, theyre going to feel like the procedure was a failure, he says.

Test critically. Preoperatively, these patients require careful corneal examination, including axial length measurement, topography and dry eye testing. Basically, approach these patients as if they are true refractive surgery patients who are considering LASIK, Dr. Pascucci says.

Postoperatively, dont expect a wow factor, he says. Vision generally improves over time, even up to six months to a year post-op.

Indeed, some patients will experience post-op problems, so your choice of whom to send the patient to is critical. Be sure that the surgeon you work with has a good chairside manner and a reputation for spending time with patients, Dr. Pascucci says. This way, when problems do arise, it will take some of the burden off of the comanaging optometrist.

Lastly, be conservative with these implants, Dr. Pascucci says. While these lenses are FDA approved, they are not miracle lenses, and some patients do have difficulties afterwards, he says.

Vol. No: 142:09Issue: 9/15/2005