Overcoming Barriers to Presbyopic IOL Uptake

Nearly half of cataract and refractive surgeons either don’t implant presbyopia-correcting intraocular lenses or do so in less than 6% of cases. Yet 80% will see their usage increasing, according to the 2023 ESCRS Clinical Trends Survey.

So why the optimism?

Ageing populations that stay active and technology advances that enable it without spectacles are two major drivers, said Yehia Hashad MD. Growing patient awareness from physicians and online resources also helps.

Some countries are adopting or considering at least partial insurance coverage for the procedure—and more may follow as clinical and cost savings evidence pile up, Dr Hashad added. “All of these will contribute to more demand.”

Balancing—and explaining—options

On the technology side, presbyopia-correcting IOL options are constantly expanding, potentially making more patients eligible, Dr Hashad noted.

Yet proliferating options also challenge physicians in understanding and explaining them to increasingly curious patients, said Terry Kim MD. To avoid confusion, he suggested physicians recommend a specific solution meeting each need. “The key factor is the surgeon has to be the driver.”

Arthur Cummings MD agreed. “You’ve got to take away confusion. The paradox of choice is a real thing, so you’ve got to break it down into something really simple where we explain the upside and the cost to make it real for them.” He uses tools including the SimVis Gekko (2EyesVision), which allows patients to see how different lenses might look.

Video is another effective tool, especially when posted on social media. And while social media is definitely raising patient awareness of new technologies, it should be approached with caution, said Basak Bostanci MD. “You must be careful with your words. Always add that you have to go through some measurements in the clinic to see whether they are eligible for this kind of surgery.” She also uses the SimVis to help patients see how lenses might affect their vision.

Doctors also should be aware of new technologies and how to access them, Dr Cummings stressed.

“What happens is patients say they want a particular lens that maybe their friend has. If you’re not offering that specific IOL or know who to send them to who does offer it, you are not providing good service,” he advised, adding the day may come when information on advanced technology lenses must be included in informed consent.

Getting paid

Cost plays a big role, Professor Kim said, citing South Korea, where presbyopia-correcting IOL penetration skyrocketed to second in the world after health insurance covered them. A friend came back with no glasses, saying she had an ‘eye-washing’ procedure, he added.

Public insurance in most European countries does not cover presbyopia-correcting IOLs, and in the United States, patients must pay the difference over standard IOLs, plus any additional tests needed. Germany and France have a similar co-payment approach, and more may follow, said Tanja Cotoaga. As long-term cost and benefit evidence builds, she sees a shift towards hybrid reimbursement by payers already strapped for cash.

“The patient is the most important player for all of us,” Cotoaga said. “Across all ages, people want to engage fully in daily activities. They are also willing to pay more for personalised medical care.”

Gathering evidence

Building the evidence base is key, requiring a mix of controlled, randomised trials that exclude patients with comorbidities to focus on core lens performance, plus real-world studies to see how lenses perform in typical populations, Prof Kim said.

For example, he said the Vivity registry study involving 41 European sites showed the lenses performed consistently. It also yielded valuable information about how the lenses function with monovision, post-refractive surgery, and diseases such as dry eye, glaucoma, and mild retinal pathologies.

Such information, combined with new technology, is critical to improve patient satisfaction, said Tim Clover. And while 95% sounds good, he said it still leaves five dissatisfied patients if surgeons perform 100 procedures. “The technology isn’t quite there yet; people are trading range of vision for dysphotopsias. ... [Rayner’s] new tech takes several steps towards better range of vision,” he said, referring to the recent Galaxy spiral optic IOL.

But informing patients of the trade-offs is critical, Dr Cummings said. “You can tell patients ‘I promise I will get the best range of vision that I can and at the same time protect your quality of vision as much as I can.’” He generally takes a custom match approach of implanting a diffractive trifocal in the non-dominant eye. After one week, if the patient loves it, they get the same in the dominant eye. If not, they get a non-diffractive IOL in the dominant eye.

All comments were made at iNovation Day at the 2024 ESCRS Congress in Barcelona.

Arthur B Cummings MMed(Ophth), FCS(SA), FRCS(Edin), is an ophthalmologist at the Wellington Eye Clinic and Beacon Hospital, Dublin, Ireland. abc@wellingtoneyeclinic.com

Basak Bostanci MD, FEBO is an associate professor of ophthalmology at Bahcesehir University School of Medicine and a cataract and refractive surgeon at Dunya Goz Hospital, Istanbul, Turkey. drbbostanci@gmail.com

Terry Kim MD is professor of ophthalmology at Duke University, Durham, North Carolina, US, and chief medical officer and vice president of global safety for Alcon, Geneva, Switzerland, and Fort Worth, Texas, US. globalmedia.relations@alcon.com

Tanja Cotoaga is global marketing director at VSY Biotechnology, Leinfelden-Echterdingen, Germany. contact@vsybiotechnology.com

Tim Clover is CEO at Rayner, Worthington, UK. feedback@rayner.com

Yehia Hashad MD is an ophthalmologist and executive vice president of research and chief medical officer at Bausch + Lomb, Vaughn, Ontario, Canada.