Cataract surgery is covered by health insurance companies provided you satisfy your deductibles, agree to the copays, stay within your network, and accept the basic package.  The basic package includes 90 days of post-operative care with no additional office visit fees related to cataract surgery.  The patient should expect to pay for medically necessary eye drops and a pair of bifocals.  Only a portion of these additional costs are covered by insurance and they almost always involve a highly restricted selection of generic medications and a modest assortment of frames.

A decade ago patients desiring a more customized experience were given license to pay for upgrades without relinquishing the basic covered insurance benefits.  Premium Cataract Surgery became an option for millions of patients with the resources and motivation to control their surgical experience and optimize their final visual results.

Manufacturers responded to this landmark ruling by releasing Premium IOLs (intraocular lenses) aimed at capturing this burgeoning market.  Their attempt to exclusively link Premium Cataract Surgery with their proprietary Premium IOLs failed and the result is a richer and more sophisticated ecosystem.

Surgeons understand that each patient’s visual needs and expectations require a unique approach.  This includes extensive counseling, expanded pre-operative testing, judicious intraocular lens selection,  intraocular management of myopic and hyperopic astigmatism, and corneal refractive enhancement (re-sculpting) postoperatively when clinically indicated.  Premium Cataract Surgery is a process and consequently a commitment of time and resources for both the patient and the surgeon.  Successful candidates achieve a highly optimized final visual result expected to last decades.

Costs

Premium Cataract Surgery can cost an additional $500 to $5000 per eye.  Qualified patients should expect a customized visual result that reduces their dependence on glasses when compared to the basic cataract package.  Results are limited by the present state of available intraocular lens technology and the biology of each patient.  Patients expecting to achieve unaided perfect focus for near, far and intermediate after cataract surgery have been born to the wrong century and possibly the wrong planet.

Premium Cataract Surgery patients can also expect to pay the standard fees associated with the basic cataract package including deductibles, copays, out of network charges, and eye drops.  The only way to determine these costs exactly is by contacting one’s insurance carrier.  The Affordable Care Act has not made basic cataract surgery more affordable by any metric.

The Basic Package

Before you can appreciate the benefits of Premium Cataract Surgery it is important to understand what is included in the standard or so-called “covered services”.  Cataract surgery is the removal of the dysfunctional natural lens and its replacement by an implant known as an intraocular lens.  The entire process, performed in an outpatient setting, employs an anesthesia specialist, numerous nurses, scrub technicians, and, of course, your eye surgeon and when appropriate your co-managing eye care physician.  It takes approximately five minutes, is painless, and allows for a swift recovery of vision with minimal limitations or restrictions.  Although Health insurance companies bemoan the popularity of cataract surgery, it is the single most successful, life-enhancing procedure and the most rewarding intervention of modern medicine.  Basic cataract surgery will almost certainly improve your quality of life, extend your functional abilities and enhance your overall well-being.  It is common for skilled surgeons to perform fifteen to fifty of these in a a single surgical setting with nearly flawless precision.  Success rates exceed 99% for most experienced surgeons.

Basic cataract surgery, however, does not result in freedom from glasses and/or contact lenses.  In fact, even patients who rarely needed anything beyond reading glasses should expect to use bifocals or trifocals after cataract surgery.  Patients who could read without glasses prior to cataract surgery cannot anticipate retaining this ability.  Finally, those with mono vision contact lenses will have to return to contacts to enjoy this visual state.  While this may seam counter-intuitive, it is the reality of the basic package.

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This is not the result of an inaccurate intraocular lens choice or a disinterested surgeon but rather a lack of complete predictability of the human visual system.  The concept that the cornea can be described by two scalers (numbers), thrown into an equation with a few other variables and yield the exact implant power for perfect focus is wishful or more precisely, magical thinking.  Surgeons can achieve great statistical outcomes but they can not reliable guarantee individual results. That is, top surgeons have 95% of patients seeing 20/40 or better without glasses but that same surgeon can not promise you a 95% chance of perfect distance vision without spectacles.

Control of their final visual state is requires Premium Cataract Surgery.

Premium Cataract Surgery

Some surgeons employ tiered pricing to help patients choose an affordable and effective package best suited to their needs.

Astigmatism  ($500 to $1500 per eye)

Astigmatism management, the Astigmatism or Toric tier is considered the first rung of Premium Cataract Surgery.

  Basic cataract surgery is astigmatically neutral thanks to small incisions and modern wound construction.  Nevertheless, basic cataract surgery can leave a patient with degraded vision secondary to residual astigmatism.  Even patients without pre-existing astigmatism can leave the operating suite with astigmatism.  This is not the result of substandard technique but rather the complex nature of the human optical system and the vagaries of wound healing.

Premium cataract surgeons use specialized near-perforating perpendicular corneal incisions (limbal relaxing incisions or LRI) and/or astigmatic keratotomy (more centrally placed corneal incisions) to address astigmatism in appropriate patients.  Incisional control of astigmatism utilizes selective weakening of the patient’s corneal structure, modulation of wound healing, and calculated anterior corneal curvature change to achieve the desired refractive endpoint.

Micrometer controlled ultra-thin diamonds (Mastel) have been been the gold standard for decades.  Recently, new algorithms based on pre-operative pachymetric vector fields (corneal thickness) have further refined the diamond blade technique. These incisions are magnificent but they are entirely dependent upon surgeon skill, experience and instrumentation.

Femtosecond lasers (LenSx, LensAr, Catalys, Victus) have gained popularity for this same application. Guided by real-time corneal imaging, femtosecond based corneal incisions are exact in location, depth and range and minimally dependent on surgeon skill.  Unfortunately, these lasers do not make a diamond-like cut.  Femtosecond lasers create a perforated space which must be completed by the surgeon using blunt dissection.  This induces trauma, microscopic irregularities, and yields inflammation, scaring and variations in wound healing.

While effective, both technologies are plagued by individual corneal structural differences and variable healing characteristic resulting in limited precision and accuracy.

Another option available to patients and surgeons for the management of astigmatism is the use of an astigmatism correcting implant also known as a Toric IOL.

All intraocular lenses are manufactured in a range of powers.  Most as fine as half and quarter dioptric steps in the most common range.  A specific power is selected to match the characteristics of the patient’s original lens and yield a planned final visual focal point.  Toric implants have a second parameter designed to neutralize the patient’s astigmatism.  Unfortunately, Toric lenses are available in far less precise increments.  Additionally, the surgeon must orient the Toric implant precisely to achieve appropriate functionality.  Post-operative rotation of the implant while rare may require a return to the operating room.

Astigmatism control is only half the story because many post-operative cataract patients still require nearsighted-ness and far-sightedness (spherical) correction for most vision tasks.  Even patients with complete elimination of their astigmatism have only a portion of their refractive needs satisfied.

Accommodation   ($1250 to $5000 per eye)

The next tier of Premium Cataract Surgery assumes successful astigmatism correction. 

In this Accommodative tier the spherical error is addressed.

Only one manufacturer, Eyeonics, now Bausch and Lomb, produced an implant satisfying the CMS (Centers for Medicare and Medicaid Services) definition of accommodation.  This implant, Crystalens 4.5, had a stormy course.  The original design employed a small 4.5 mm optic and resulted in considerable problems with decentration, edge glare and night driving complaints.  Next, Crystalens HD, a poorly conceived and heavily marketed upgraded version of the lens resulted in an unprecedented number of lens exchanges.  This experience caused Crystalens and Bausch and Lomb to fall out of favor with many Premiums Surgeons.  Subsequent improvements in lens design and refined surgical techniques has allowed the latest generation Crystalens AO to regain much of the ground it lost.  Unfortunately, post-operative complications including capsular contraction syndrome, induced astigmatism and the infamous Z-Syndrome still loom as a potential complication.

Staar’s nanoFLEX, although not presented to CMS for accommodative labelling demonstrates equivalent or even superior performance in testing with none of the above-mentioned post-operative complications.  While a purest might claim only Crystalens has been approved as accommodating, Bausch and Lomb’s own Crystalens Trulign built on the exact Crystalens platform failed to satisfy CMS criteria for accommodative labelling.  No other manufacturer has submitted an implant for this designation by CMS in the last decade.

Selection of the ideal focal point for each patient requires effective patient counseling.  Surgeons must then select an implant power to achieve that goal.  Practices collect information about anterior and posterior corneal curvature (k-readings, topography, wavefront aberrometry, dynamic skiascopy, RGP lens over refraction), historical refractive data (previous RK or LASIK surgery), anterior chamber depth, lens thickness, axial length (non-contact ultrasound, laser biometry), and other variables like horizontal white to white distance in an effort to determine ELP or effective lens position.  These values are submitted to a growing collection of predictive formulae (Holladay, Hoffer, Shammas, Haigis, etc) with the hope of determining the ideal lens power.  Frustrating these efforts is the FDA abject refusal to allow manufacturers to label their products with the exact optical lens power. (A lens labelled 19.50 may actually measure 19.26 creating approximately a quarter diopter error in surgical results.)

Compounding these inaccuracies is the reality that patients don’t always know what they want.  Frequently a patient seeking perfect distance vision will report remorse post-operatively.  They wish they could traded some of the distance clarity for improved vision in the intermediate range.

Fortunately, the accommodative tier of Premium Cataract Surgery addresses all of these issues.  Included LASIK (or advanced surface ablation) surgery, when clinically appropriate, allows refinement of the patient’s refractive results.  Patients who do not achieve their ideal visual endpoint either because of the flawed nature of their lens selection or because they don’t really appreciate what they achieved have a solution.  The exception accuracy of excimer based lamellar corneal refractive surgery (i.e. LASIK) allows the surgeon to dial in the exact refractive endpoint.  Patients can reach their ultimate visual goal.

Even more exciting is the use of LASIK with the latest approved platforms (NIDEK, Alcon).  These devices can reduce mild topographic abnormalities considered untreatable prior to 2014.  Topographically guided LASIK in conjunction with Premium Cataract Surgery is expected to produce a higher level of patients with supervision (beyond 20/20) and reduced night vision complaints.

The accommodative tier of Premium Cataract Surgery is best defined as meticulous control of astigmatism and spherical refractive error so that the patient maximizes spectacle independent function in a specific range of distances.  In most cases patients choose to be spectacle independent for distance and intermediate tasks.  They tolerate reading glasses for prolonged sessions of near visual tasks.  In some cases patients choose to mimic the spectacle independence they enjoyed with monovision and wear spectacles for prolonged reading or driving tasks.  Finally some choose a customized mix of mild over or under correction to match their lifestyle.

Multifocality  ($1250 to $5000 per eye)

The third level of Premium Cataract Surgery is the multifocal tier.  The goal is spectacle independence for all distances.

  Multifocality requires management of both spherical and cylindric (astigmatic) refractive errors as well as the use of light-sharing intraocular lens.  Light sharing creates focal points spread between distance and near endpoints.  Interestingly, the first multifocal implant was developed by 3M more than two decades ago.  Multifocals became popular when a foldable, silicone model known as the Array was released in the late 1990’s.  AMO made the implant available to patients at no additional cost for almost a decade.  The ReZOOM lens, a minor modification of the Array (which was promptly withdrawn from the market) was sold as a premium implant and carried a thousand dollar surcharge.  The multifocal market is now dominated by the ReSTOR (Alcon) and the Tecnis Multifocal (AMO).

Multifocality is extremely appealing but one must recognize there are limitations.  Patients with multifocal lenses can complain of glare and halos and decreased quality of night driving vision.  Patients who do not drive at night and can tolerate glare and halos do well in the multifocal tier.

When retinal pathology develops years after implantation of a light-sharing implant the consequences are problematic for both patient and surgeon.  A number of Premium Cataract Surgeons avoid the multifocal tier of cataract surgery eagerly anticipating technology improvement.

Included LASIK enhancement assures success in the multifocal tier.  As with the accommodative tier, excimer laser corneal sculpting allows for exquisite management of residual spherical and cylindric refractive errors.  These multifocal patients with a healthy retina enjoy a lifetime of enhanced visual performance.

Patients best suited to this tier of Premium Cataract Surgery are willing to trade their increased visual functionality for a modest degree of glare and halos. They must also appreciate the potential issues that will arise if they develop macular degeneration, diabetic maculopathy, or other foveal conditions.  Undoubtedly, the future will bring improvements in the design of multifocal intraocular lenses and these compromises will no longer be necessary.

Post-Operative Experience

Visual recovery for both Basic Cataract Surgery and Premium Cataract Surgery is remarkably swift.  Most patients drive legally without glasses the day after surgery.  With the exception of some common sense precautions like avoiding swimming, ski-diving and eye-rubbing for the first week there are no real limitations.

Dropless® cataract surgery is becoming more popular.  Surgeon, employing the Dropless technique instill antibiotics and steroid into the vitreous cavity at the conclusion of the case.  Ninety percent of patients who have Dropless surgery do not need drops during their post-operative period.  Without Dropless, patients require three different medications, each one to four times a day for the first week.  Only two of these drops are required for the next three to six weeks.  Some surgeons actually initiate these drops a week before surgery.  Costs for these medications can vary between $50 and $300 per eye despite excellent insurance coverage.  CMS is contemplating plans to cover Dropless cataract surgery because of its inherent advantages.  (A final  decision will be made before January 2015).

Basic Cataract Surgery patients often qualify for final spectacle correction by the second or third week.  Some of these costs are covered and patients can upgrade their lens and frame selection.  Premium Cataract Surgery patients who have acceptable uncorrected vision can skip this step and await final LASIK enhancement if indicated. By definition, premium patients do not require permanent full-time spectacle wear.

Eventually the posterior capsule, which encased the cataract and was intentionally preserved during surgery, becomes cloudy.  After a few months, it is safe to remove this membrane in a painless outpatient procedure employing a YAG (Yttrium-Aluminum-Garnett) laser.  This is a 30 second procedure with no recovery period.  Surgeons will perform a YAG when the patient describes degraded vision or the surgeon sees obstruction of the visual axis.  Because the vision and lens position can change modestly after YAG, most Premium Surgeons prefer to YAG the capsule prior to scheduling a LASIK enhancement.   The cost of YAG capsulotomy, like basic cataract surgery, is covered by health insurance.

Dry Eye

Over the last decade eye care professionals have recognized the prevalence of mild to moderate dry eye in the population.  It is responsible for considerable morbidity and visual degradation.  Cataract patients universally benefit from meticulous management of dry eye before and after surgery.

Meibomian gland dysfunction is responsible for 85% of dry eye in the population and it presents with poor tear retention between blinks.  Cataract patients who are careful not to rub their eyes after surgery often develop this form of dry eye.  Meibomian glands, the source of the surfactant holding our tearfilm in place, can become clogged or obstructed without normal lid hygiene.  Other patients have sclerosed glands and non-functional thickened lipids prior to cataract development or surgical intervention.

LipiFlow (TearScience) is an ingenious FDA approved device for rejuvenating the meibomian glands.  It could benefit a large portion of the population were it not for the high cost of actuators which can add another $1000 per eye to the Premium Surgical experience.  MiBo ThermoFlo (MIBO) has no consumables and uses an ingenious technique to transfer 108ºF to the lids in a comfortable 14 minute procedure.  Surgeons can offer this technology to premium patients at very low cost.  These methodologies along with self-administered warm compresses can significant reduce foreign body sensation and fluctuating vision following cataract surgery.

Aqueous deficiency in the cataract population often responds well to Restasis (Abbott) and Lotemax (Bausch and Lomb).  Control of low grade inflammation can significantly improve visual comfort and function.  Most insurance plans will cover some of these costs although a single month’s treatment can still require as much as $180 in copays.

Other therapies including temporary or permanent punctual occlusion, eye lid exfoliation, topical antibiotics, specialized lid hygiene, Omega-3 supplements, and artificial tears can also help control dry eye.

Premium Cataract Surgeons, who are essentially Refractive Surgeons must employ a variety of these modalities to maximizes visual outcomes.  Comfortable and clear vision requires a healthy tearful and an effective lid hygiene program.

LASIK or Advanced Surface Ablation

While many Premium Cataract Surgery patients will not need any fine tuning, enhancement with excimer laser corneal sculpting will ensure optimal visual results.

Patients who have had LASIK or other refractive procedures should expect to need corneal re-scultping after Premium Cataract Surgery.  Despite advances in IOL power formulae most techniques still find post-refractive cataract patients challenging.  Advances in intraoperative aberrometry  (ORA: WaveTec) promise to improve lens power selection in these difficult cases but this is a work in progress.  At this time, post-operative corneal healing and final ELP (effective lens position) can not predicted definitively ensuring LASIK’s role in Premium Cataract Surgery.

Advances in FemtoSecond corneal flap construction (VisuMax, IntraLase, Zeimer) and the latest generation mechanical microkeratomes (Moria) make post-Premium Cataract Surgery highly successful.  The concomitant use of therapeutic agents to eliminate corneal haze (Mitomycin) and supportive amniotic membranes (ProKera, AmbioDisk) ensure excellent results when ASA (Advanced Surface Ablation) is the preferred intervention.

LASIK is no longer limited to the young.

Choosing your Premium Cataract Surgeon

Health insurance companies provide for basic removal of the cataract and empower the patient to select the appropriate upgrades.  Patients with limited resources can be assured that Standard Cataract Surgery remains one of modern medicine’s true miracles returning enhanced visual clarity and renewed color sense after a painless five minute procedure with virtually no downtime.

Those interested in reducing their dependence on full-time glasses should consider Premium Cataract Surgery.  Many believe the accommodative tier remains the best balance of safety, effectiveness, and functionality.  Those both motivated and committed to the process of visual recovery will find not only enhanced vision but considerable freedom from visual appliances for most tasks.  The multifocal tier is ideal for those patients more tolerant of glare and halos and strongly motivated by freedom from glasses for all distances.

Patients should choose a surgeon willing to help explore their options.  There is no substitute for the insights gained during a direct surgical consultation.

Surgeons touting this implant or that laser who are also affiliated with the big hospital system should be summarily dismissed.  Doctors who ask you to Like them on this or that are suspect.  Physicians claiming they charge more because they are worth more are legends only in their own mind.  Don’t believe that the most recent ophthalmic surgeons are privy to the latest techniques.  Similarly, thirty years of experience in cataracts does not prepare a surgeon for the rigors of Premium Cataract Surgery.

Premium Cataract Surgery is about skill, experience, compassion and insight.  Patients have the intuition to choose the correct provider and the best procedure.  Call for an evaluation by a local, well-regarded, specialist in cataract and refractive surgery.  Years of enhanced visual function await.

by
James S. Lewis, MD
SENIOR SECTIONAL EDITOR