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Hadi Kjærbo MD
As intraocular lens (IOL) technology and surgical techniques continue to evolve, patients have come to expect good uncorrected visual acuity and quality of vision after their cataract surgery.
In order to meet these expectations, surgeons need to be able to correct more than just the spherical equivalent of a patient’s refractive error. The prevalence of corneal astigmatism before cataract surgery is higher than 80%, with around 40% of eyes having corneal astigmatism equal to or higher than 1.00 dioptres and more than 20% with astigmatism of 1.50 dioptres or higher.1 Uncorrected corneal astigmatism can result in a poor visual outcome, so surgeons need to adopt a strategy for managing astigmatism that is well-tolerated, precise, convenient and yields predictable outcomes.
Until relatively recently, patients with pre-existing astigmatism were either left uncorrected or required corneal curvature-altering procedures to correct this condition.
The introduction of toric IOLs into clinical practice, however, has given surgeons and their patients a tool to treat astigmatism effectively and give patients the opportunity to improve postoperative vision compared to monofocal IOLs.2,3
Advantages of toric IOLs
Toric IOLs offer several advantages: they allow surgeons to perform a standard cataract procedure with only a slight variation needed in surgical technique. Furthermore, the performance of toric lenses are CE marked, validated by FDA and other clinical trials as a well-tolerated and effective means to enable cataract patients obtain excellent uncorrected distance visual acuity and greatly reduce dependence on spectacles.4–6
Yet despite these manifold advantages, many national and regional health systems have been slow to offer anything more than standard monofocal lenses to patients with preoperative astigmatism. There is a perception that advanced technology lenses such as toric IOLs will place a greater financial burden on health systems when in fact the opposite is the case, with a number of studies now showing that toric IOLs are actually more cost effective in the long term.7,8
In this respect, it is encouraging to see one of Denmark’s regions leading the way in making toric lenses available for its cataract patients with preoperative astigmatism. With a population of just over 1.2 million, Central Jutland recently became the first region in Denmark to allow patients undergoing cataract surgery to correct their astigmatism at the same time by selecting a toric lens.
It is hoped that other regions may soon follow their initiative, but we still have a long way to go in educating and informing surgeons, patients and health authorities of the health and economic benefits of toric lenses. In September 2013, the Danish Health and Medicines Authority recommended that everyone with cataracts and astigmatism over 2.00 dioptres should have astigmatism corrected at the same time as the cataract surgery.9
The same body also recommends that patients with cataracts are more closely involved in their treatment, but this takes place all too infrequently. A recent survey of 305 cataract patients carried out by the market research company Userneeds on behalf of Alcon, the eye care company, shows that more than half (54.2%) of all Danes who undergo cataract surgery each year have little or no involvement in their treatment decisions.10
One out of three respondents (32.6%) did not know, for example, that it is possible to correct other vision problems such as astigmatism and near-sightedness or far-sightedness during cataract surgery. More than half of patients were not aware of the different lens types on the market: monofocal lens (65.2%), toric lens (69.2%), multifocal lens (65.6%) and multifocal toric lens (68.9%).10
It is hardly surprising that patients would like to be more involved in something as fundamentally important to them as their vision. Over half (54.6%) of the respondents who had already undergone surgery said they would have liked to have been more involved in planning their treatment and discussing options preoperatively. The level of involvement actually solicited is patently clear when one considers that eight out of ten (82%) patients did not know what type of lens was implanted after their cataract surgery.10
Once cataracts have been detected, there are several important decisions to be made by the patient together with the doctor, including which type of treatment is the right one. The patient’s expectations of quality of vision after surgery also need to be addressed. Therefore, it is important for the patient to be informed of the treatment options and the results they can expect. The recent survey shows that this does not happen enough at the moment.
In Denmark, as in many other European countries, the process of informed consent entails explaining all the risks and benefits of cataract surgery and should also include all the available lens choices for the patient. In the Danish survey, nine out of ten (89.9%) patients considered it is the responsibility of the clinician to inform the patients about all available treatment options and the treatment process before undergoing cataract surgery.10
At present, hospitals are geared mainly towards treating the average patient and providing a standard solution. The problem with this is that we do not always fully meet the patients’ expectations or hopes for their vision. We should discuss with the patient, listen to their expectations, inform them about the IOL technologies available and offer them solutions that are tailored to meet their needs.
The gulf between the visual outcomes that are theoretically possible to obtain and what we are actually delivering is all too apparent. The Userneeds survey shows that nine out of ten (89.1%) patients still wear glasses after cataract surgery, even though it is currently possible to choose different lenses for cataract surgery which correct astigmatism as well. Although patients still need reading glasses after toric IOL implantation, there will be a greater spectacle independence for distance vision.
The survey also found that almost one in five (18%) prefer to undergo cataract surgery in a private institution, as they consider they will be seen more quickly and will receive better service. It is not surprising that many patients prefer to go to a private institution. The common perception is that they will be more involved in the treatment, with shorter waiting times and with more focus on individualised treatment plans rather than standard “one size fits all” solutions.10
For European healthcare systems, the introduction of toric intraocular lenses has led, in many cases, to have patients (co)-paying for the advanced technology. In some countries such as Italy for instance, a patient requesting a toric or multifocal IOL must pay for the entire cost of the cataract procedure themselves or through private insurance. Other countries have introduced a type of co-payment system where patients can choose advanced technology intraocular lenses and pay the incremental costs for implanting them without losing their underlying right to reimbursement for the basic cataract surgical procedure.
Interestingly the Userneeds survey showed that every second patient is highly willing to co-pay for a toric lens (53.8%) if the region is not prepared to do so and almost half of the patients (48.5%) said they would be prepared to buy a lens in order to correct their vision problems after cataract surgery.10
If properly implemented, the co-payment system enables physicians and patients to choose the best IOL for their cataract patients with no additional cost to the national or regional health system.
However, as a recent study showed, there is a marked discrepancy between patients’ acceptance of advanced technology lenses and surgeons’ willingness to suggest them. Although patients’ acceptance is high, it decreases with increasing out-of-pocket expenditure.11
It is also important to stress that several studies have shown that far from increasing the financial burden of over-stretched national health systems, toric IOLs actually reduce lifetime economic costs by reducing the need for glasses or contact lenses following cataract removal.7,8
One study, for instance, found that fewer patients with toric IOLs needed spectacles for distance vision than patients with monofocal IOLs. With monofocal IOLs, more than 66% of patients needed complex spectacles compared to less than 25% implanted with toric IOLs. In France and Italy, toric IOLs reduced overall costs relative to otherwise high spectacle costs after cataract surgery. The estimated lifetime savings were €897 (France), €822.5 (Germany), €895.8 (Italy) and €391.6 (Spain), without discounting. On applying a 3% discount rate the costs became €691.7, €646.4, €693.9 and €308.2, respectively.8
A win-win-win situation for patients, physicians and payers
All of this makes a compelling case to have toric IOLs included as an option for every patient that could benefit from an astigmatism-correcting lens at the time of their cataract surgery. The development of advanced toric IOLs allied to advances in surgical technique, biometry and lens power calculation have allowed us to move one step closer to the ideal of achieving emmetropia in all cataract patients.
As surgeons, it is our duty to inform our patients about the full range of options that are available to give them the best possible postoperative visual outcome. Toric IOLs are a compelling option for a sizeable percentage of our cataract patients, providing them with good uncorrected distance visual acuity, better quality of vision and higher patient satisfaction after surgery than monofocal IOLs.
For surgeons, the introduction of toric IOLs is straight forward and does not require expensive equipment. The technique differs only slightly from a standard cataract procedure, and surgeons can easily adapt to the minor changes needed in preoperative measuring and final IOL alignment. By offering toric IOLs, surgeons can better serve their patients and give them yet another option in achieving optimal visual outcomes.
Cataract patients who receive toric IOLs are more likely to see better and spend less for their ophthalmic needs over time than astigmatic cataract patients who receive a conventional monofocal lens. They have fewer postoperative consultations and also need fewer visits for spectacle prescription. With this in mind, toric IOLs are cost effective and deliver real added value over the long term for national and regional healthcare systems.
Dr. Hadi Kjærbo is the Head of Cataract Services, Consultant Ophthalmic Surgeon, Department of Ophthalmology, at the University Hospital of Copenhagen, Denmark.