Why Screen Multifocal IOL Patients With OCT?

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To optimize visual outcomes with multifocal IOLs, it is wise to rule out macular pathologies before cataract surgery. However, previous research has shown that the standard preoperative dilated fundus exam can miss retinal disease in many cases.¹

A new analysis suggests that ophthalmologists could fill this information gap by imaging the retinas of multi­focal IOL candidates with optical coherence tomogra­phy (OCT) preoperatively—and that it could be cost-effective to do so.¹

“OCTs are able to detect subtle macular pathologies in 9% to 30% of normal-appearing retinas. Preoperative detection of macular pathologies can help guide IOL selection and improve patient outcomes,” said coauthor Ella H. Leung, MD, at Baylor College of Medicine in Houston.

Study specifics. For this analysis, the researchers used a theoretical case of a 67-year-old man who was screened with OCT before undergoing cataract surgery and receiving a multifocal lens. His vision improved from 20/60 preoperatively to 20/20 postoperatively. His out-of-pocket cost for the IOL was $2,500.

Although the OCT increased the costs of the pre-op evaluation, it theoretically detected 11% more of macular pathologies before surgery than did a dilated fundus exam alone, the authors said. This resulted in “decreased overall costs, slightly improved visual gains, and slightly improved” quality-adjusted life years (QA­LYs) over time.¹

Putting it into practice. Coauthor Allister Gibbons, MD, at Bascom Palmer Eye Institute in Miami, said he orders OCTs for all his patients who are considering paying the extra cost of a premium IOL implant. “Per­sonally, I have been requesting a macular OCT for all my presbyopia-correcting IOL candidates, as I have a low threshold to exclude patients from this category of lenses.”

Dr. Gibbons added, “I recall hearing from Dr. David Brown that a premium IOL requires a premium macu­la. For those surgeons who currently do not perform screening OCTs in their multifocal IOL candidates, this study may add to their decision-making process.”

Dr. Leung noted that Medicare currently does not routinely pay for screening OCTs performed before cataract surgery without a qualifying diagnosis. “If the screening OCT is not reimbursed, then the physi­cian’s practice covers the expense. However, the actual cost of an OCT depends on several factors, including whether the practice already owns the OCT machine,” she said.  

Coauthor Douglas D. Koch, MD, at Baylor, said the study confirmed the value of OCTs, even without reim­bursement for the imaging. “This has not changed but rather reinforced my practice of preoperatively screen­ing multifocal IOL candidates with a macular OCT,” Dr. Koch said. “I feel that it is in the patient’s best interest to do so, and I willingly absorb this cost.”

—Linda Roach

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1 Leung EH et al. Ophthalmology. Published online Jan. 31, 2020.

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Relevant financial disclosures—Drs. Gibbons and Leung: None. Dr. Koch: Alcon: C; Carl Zeiss Meditec: C; Johnson & Johnson Surgical Vision: C.

For full disclosures and the disclosure key, see below.

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