The IOLMaster and its Role in                 ®                    Modern Cataract Surgery                      8 Shareef ...
Figure 3: Surgeon Ratings of Ease of Use for Different Technologies                     “Earlier versions of the device   ...
Use in Keratometry                               Figure 5: IOLMaster Return-On-Investment                    “Doctors ofte...
this is a win-win,” remarked Dr.                         Figure 6: Surgeon Confidence With            embraced on a widespr...
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The iol master and its role in modern cataract surgery


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The iol master and its role in modern cataract surgery

  1. 1. The IOLMaster and its Role in ® Modern Cataract Surgery 8 Shareef Mahdavi • SM2 Consulting • Pleasanton, CA 7Advances in capsular extraction and lens implant technolo- Figure 1: Preferred Biometry Method of U.S. Sugeonsgies have commanded significant attention in the world ofcataract surgery. New implants allow surgeons to provide Applanationeven higher levels of visual outcome, including spectacle % of U.S. Cataract Surgeons 80% Immersionindependence and a continuous range of vision covering all IOLMasterdistances. One of the enabling technologies that makes this 60%possible is non-contact biometry offered by the IOLMaster. Injust five years since introduction, the IOLMaster has become 40%rapidly adopted as the preferred method for obtaining IOLcalculations among the majority of surgeons in the U.S. and 20%is used in 7,000 locations worldwide. Manufacturer Carl ZeissMeditec engaged SM2 Consulting to survey ten of its original 2001 2002 2003 2004 2005 2006customers to illustrate the impact this technology has made Source: Annual Leaming Survey of ASCRS memberson cataract surgery. These surgeons also provided feed-back on the newly-released Advanced Technology Software Most cataract surgeons understand, however, that their results(referred to as Version 5). are limited to the accuracy of the input variables, including axial length, K readings, and the formula used to determine theIntroduction IOL dioptric power to be implanted. “While one perfect com- In the year 2000, Carl Zeiss Meditec launched a novel tech- ponent won’t yield a perfect result, one poor component cannology to perform biometry for IOL calculation that employed lead to very poor results,” commented Warren Hill, MD. Thepartial coherence interferometry (PCI). Unlike the two tradi- weakest component in the system, according to these surgeons,tional methods of obtaining anterior chamber depth and axial had been the accuracy of the biometry. Now, with multiplelength, applanation and immersion ultrasound, the proposi- years of experience, these surgeons are unanimous (10 of 10,tion afforded by the IOLMaster was that it could gather moreaccurate results without touching the eye. Since that time, the Figure 2: Participating SurgeonsIOLMaster has gradually become the preferred method among David Chang, MD Los Altos, CAcataract surgeons in the U.S. for obtaining these calculations, Robert Cionni, MD Cincinnati, OHas shown in Figure 1. Ten leading cataract surgeons who were Warren Hill, MD Mesa, AZamong the earliest adopters of the technology were surveyed Doug Koch, MD Houston, TXto better understand how the IOLMaster has impacted their Sam Masket, MD Los Angeles, CA Mark Packer, MD Eugene, ORpractice as well as surgical outcomes. These surgeons (see Figure Brad Shingleton, MD Boston, MA2) also are among the first to use the newest release of the Joel Shugar, MD Perry, FLIOLMaster, known as Advanced Technology Software Version 5 Jack Singer, MD Randolph, VTof the IOLMaster. Richard Tipperman, MD Bala Cynwyd, PAAxial Length Measurement: The Weak Link Key Surgeon Demographics: Mean (range) While cataract surgery has undergone tremendous trans- Experience with IOL Master 6 years (4 to 7 years)formation in terms of extraction and implantation technology, # of IOL implants per month 92 eyes (20 to 236 eyes)the field is perhaps now at an even greater rate of innovation.New lens technologies are allowing surgeons to provide spec- % of patients that upgrade to 22% (<5% to 30%) Premium IOLtacle independence for patients and achieve levels of accuracy (accommodating or multifocal)(intended vs. actual correction) typically associated with LASIK. 1
  2. 2. Figure 3: Surgeon Ratings of Ease of Use for Different Technologies “Earlier versions of the device Extremely Extremely required our techs to figure out Easy Difficult 1 2 3 4 5 6 7 8 9 10 how to shine the light around A-scan Biometry Mean = 4.9 opacities using the joystick. Now, that’s not even necessary with Immersion Biometry Mean = 5.1 Version 5. It’s fully automatic.” IOLMaster Mean non Version 5 = 2.4 that they are much more satisfied (9 of 10, 90%) or more satisfied (1 of 10, 10%) with IOLMaster Mean IOLMaster versus previous forms of biom- Version 5 = 1.1 etry for IOL power prediction.100%) in their belief that IOLMaster is the standard of care for Reading Through Dense Cataractsbiometry and strongly agree that they would recommend the One of the early concerns of surgeons when they firstIOLMaster to other surgeons. As seen in Figure 1, this feat has acquired the IOLMaster was its ability to read through densebeen achieved through increasing adoption by surgeons over the cataracts. The surgeons were asked how often they had topast seven years. use an alternative method to perform biometry. The range of responses is shown in Figure 4 both before and after the intro-Ease of Use duction of Version 5. Before Version 5, surgeons needed to use In 2001, applanation biometry was in use by the majority an alternative method 12 percent of the time on average. Withof practices, mainly due to its ease of use relative to immersion Version 5, that need has dropped to 3 percent on average.biometry (which was considered the “gold standard” at thetime). “Now, we have a technology which is both the easiest to Automation of Scan Analysisuse and the best for our patients,” according to Samuel Masket, Given their long tenure with the IOLMaster, these surgeonsMD., who viewed this as an unusual combination of events. literally marveled at the technical expertise and intelligence thatThe relative ease of use of each of the technologies was rated has been progressively added to the device. Today’s IOLMasterby each of the surgeons, as shown with Version 5, they exclaim, hasin Figure 3. While the IOLMaster made the data capture virtuallyhas traditionally been easier to Figure 4: Percent of Time Alternative foolproof, as it gives technicians Device Required (Cataract Too Dense)use than either of the ultrasound feedback using a green-yellow-techniques, surgeons feel the new red (i.e. traffic light) system to letVersion 5 takes ease to a whole (Each color represents a different MD in the survey) them know that accurate read-new level. “Every office had one 30% ings are being taken. By using Mean = 12%tech who was best at applanation; sophisticated signal-to-noise 25%this pressure was relieved with the analysis, the device software isIOLMaster,” noted Mark Packer, 20% able to automatically excludeMD. “Earlier versions of the device bad readings and create a com-required our techs to figure out 15% posite best measurement for eachhow to shine the light around eye. “We used to be left with aopacities using the joystick. Now, 10% packet of A-scan images, tryingthat’s not even necessary with Mean = 3% to decide which one is best,” 5%Version 5. It’s fully automatic.” remarked Dr. Packer. “That bur- As a result of this technology 0% den has now been taken away.”and its ease of use by technicians, Prior to Version 5 Version 5this group of surgeons responded 2
  3. 3. Use in Keratometry Figure 5: IOLMaster Return-On-Investment “Doctors often failReadings Another early concern Time Via IOLMaster Via A-scan and Manual Keratometry to recognize the costswas the accuracy of K read- they incur with poorings obtained from the device. to perform results” Biometry and 5 minutes 30 minutesAccording to surgeons, KeratometryIOLMasters automatedkeratometry has continuously Intangibles “Peace of mind” Return-On-Investmentimproved with each release. “Much less frustration” Calculating return-on-Dr. Jack Singer MD believes K “Confidence” investment (ROI) is anreadings from the IOLMaster “WinWin” important decision whenhave always tended to be evaluating capital equipmentmore accurate because of the skill and calibration issues associ- expenditures. All ten surgeons in this survey were unanimous inated with manual keratometers. “Ks are foolproof and faster their statement that the IOLMaster has provided a meaningfulusing IOLMaster.” Dr. Hill, whose practice has a Javal Schiotz ROI for the practice. Using current reimbursement in the U.S.,Ophthalmometer for performing keratometry, has stopped using the payback period for these surgeons ranged from under sixit and relies solely on the IOLMaster Version 5. Their sentiment months to two and one half years. In addition, the time savingsis shared by 60% of these surgeons who rated the IOLMaster using IOLMaster (5 minutes) versus A-scan and manual K read-as either more accurate than (4 of 10) or equivalent to (2 of 10) ings (up to 30 minutes) serves as an important component inmanual keratometry. The remaining 4 surgeons felt manual Ks the ROI equation.are more accurate. Two additional questions were asked to help assess return on investment: When asked how this device compared in terms“Dr. Hill, whose practice has a Javal Schiotz of relative value to other diagnostic devices in the practice, such as topography and visual fields, 90% (9 of 10) said IOLMasterOphthalmometer for performing keratometry, was more useful than these other devices and the remaininghas stopped using it and relies solely on the surgeon viewed it as equally useful. To assist surgeons whoIOLMaster Version 5” already own an IOLMaster, these surgeons were also asked to use their experience with the new Version 5 and comment on itsThroughput and Quality value relative to its cost. All 10 surgeons indicated it was worth Surgeons were adamant about how the device has improved the cost, with 4 of these 10 rating its value as higher and “defi-overall quality of the cataract surgery process as well as out- nitely” worth the cost.comes. All surgeons either agreed strongly (8 of 10) or some- Surgeon’s comments in the survey revealed an intangiblewhat (2 of 10) that the IOLMaster has significantly improved ROI that can’t be measured using standard accounting or timepatient flow in their practice due to its accuracy, speed and and motion methods. “Priceless” is how one surgeon describedconvenience for surgeons, technicians and patients. Beyond this, the peace-of-mind the device has given, citing less frustrationhowever, many of the surgeons interviewed brought forth how and greater confidence in determining the right measurementsIOLMaster has helped solve a deficiency in the overall process: prior to selecting the IOL power.“Doctors often fail to recognize the costs they incur with poorresults,” commented Richard Tipperman, MD. “This affects us Patient Expectationsboth in having to spend additional time hand-holding unhappy Surgeons in this survey commented that patient expectationspatients and the negative word-of-mouth it creates. To measure for outcomes have changed dramatically in recent years. LASIKthis impact, surgeons were asked to estimate the direct impact outcomes and the availability of advanced IOL technology haveon their time of an unhappy patient whose end result is one clearly impacted the typical patient consultation for cataractdiopter away from intended. The surgeons in this survey indi- surgery, with patients increasingly seeking to be spectacle freecated that such a patient would require nearly one additional for distance vision and, when choosing to have a premium IOL,hour of surgeon management time. (average of responses: 3.7 at near and intermediate as well. “Patients judge the quality ofvisits averaging 14.3 minutes per visit). surgery by the refractive outcome, and anything that improves 3
  4. 4. this is a win-win,” remarked Dr. Figure 6: Surgeon Confidence With embraced on a widespread basis.Tipperman. This sentiment seems to and Without IOLMaster While not perfect, the IOLMasterapply to all types of cataract surgery, Version 5 can be summed up as 1-10 Rating Scale (1= Lowest, 10= Highest)as noted by Dr. Masket: “They may “pretty darn close” by this group ofnot be willing to pay more (for a pre- 10 surgeons. The one caveat with the fullmium IOL), but they definitely expect 9 Mean automation offered by Version 5 is = 9.0more.” that surgeons may view it literally as a 8 When it comes to the premium plug-and-play device. Dr. Hill believesIOL category (defined in this survey as 7 it is important for surgeons to ini-accommodating or multifocal technol- 6 tially supervise measurements so theyogy), surgeons attribute even greater Mean understand the entire process. And 5 = 5.3 Dr. Packer recommends that surgeons 4 who have invested in an IOLMaster“The IOLMaster has also invest in one of the new state-of- 3allowed me to optimize the the-art formulas rather than rely on 2Haigis formula as part of one of the free ones available, whichmy calculations” 1 he likens to “driving a brand new car Rate your overall Assume your IOLMaster on old tires.” confidence today in was taken away from offering premium you. Now, rate your The IOLMaster is making a sig- IOL implants to overall confidence invalue to the IOLMaster, where the your patients. offering premium IOLs nificant difference in both the surgi- without the use of theneed to reach the target refraction is IOLMaster. cal process as well as outcomes formore critical given the additional fees With Without cataract patients. It is a tool that haspaid by patients. Dr. Singer, whose arrived at the right time, allowing sur-practice is focused exclusively on intraocular refractive surgery, geons to extract greater value out of the lenses that are and willbelieves the IOLMaster has been an integral part of his surgical be available in the future.system: “The IOLMaster has allowed me to optimize the Haigis Those who would argue that the IOLMaster is a “nice toformula as part of my calculations,” he said. This in turn has have” rather than a “have to have” need to keep in mind thatallowed him to consistently deliver superior outcomes, which the cataract market of today and tomorrow is vastly differ-Dr. Singer believes has led to significant growth in his refractive ent than that of just a few years ago. In addition to innovativelens exchange procedure volume. technology, patient expectations have similarly risen to the point The impact on each surgeon’s premium IOL offering was where cataract surgery is truly another form of refractive surgery.assessed by asking them to rate their confidence in offering This report was designed to help cataract surgeons evalu-IOLs both using and without using the IOLMaster. As shown ate whether they should acquire the IOLMaster or upgradein Figure 6, surgeon confidence is significantly higher (mean to Version 5. Hopefully, the passion and commitment amongof 9.0 out of 10) when using the IOLMaster than without it the surgeons participating in this project are self evident. They(mean of 5.3). want to see cataract surgery become increasingly effective in step with improvements in safety. They view the IOLMaster asDiscussion a “surgical imperative” that helps increase patient satisfaction The role of technology in improving surgical outcomes can- and decrease risk of litigation (given that cataract surgery is thenot be underestimated in the ophthalmic profession. Cataract top reason for lawsuits filed against ophthalmic surgeons). In asurgery in particular has benefited from numerous innovations world where consumers have greater choice, it seems reasonableover the past 50 years. What’s remarkable about the IOLMaster to conclude that any patient who understands the differenceis that it has become a standard in such a short period of time, between ultrasound and IOLMaster would insist on the latter. Itunlike both phaco-emulsification and the intraocular lens, each appears that most surgeons agree, and we expect the IOLMasterof which was available for several decades before becoming to continue its penetration in the surgical marketplace.© Copyright 2007, SM2 Consulting. All rights reserved. 4