Eye Specialists Flag Concerns About Pricey Lenses in Cataract Surgery

Patients undergoing cataract surgery are often given the choice of a standard lens that’s covered by insurance, or “upgrading” to a multifocal lens that uses newer technology — at a much steeper out-of-pocket price, often around $5,000 per eye.

There’s a perception that the more expensive version is better, but ophthalmologists are warning that’s not necessarily the case.

Multifocal lenses aren’t right for everyone, they told MedPage Today, and some patients who aren’t good candidates can end up unhappy with the results, often leading to the need for revision surgery.

“If you have a perfectly healthy eye, you get a perfectly good surgery, and you hit the target exactly, it’s amazing,” said Christina Prescott, MD, PhD, who specializes in complex cataract and corneal surgery at NYU Langone Health in New York City. “But if your eye has any pathology, or your surgery doesn’t go well, or you’re not on target, then you lose a lot of quality of vision.”

Ophthalmologists also raised concerns that economics may drive practices to steer patients toward the pricier lenses. And these practices may not be as meticulous about proper patient selection.

When Prescott’s aunt was pitched a multifocal lens years ago, her physician equated it to car brands: “They said, ‘Do you want the Toyota or the Lexus?’ She said, ‘I drive a BMW, so of course I want the Lexus version,'” Prescott told MedPage Today.

“She was a terrible candidate,” she noted. “She had post-LASIK dry eye, a lot of astigmatism, and the lens was off target. She had to have one of my colleagues exchange it because it was the wrong choice for her.”

Types of Multifocal Lenses

About 4 million cataract surgeries are performed in the U.S. each year, according to the American Academy of Ophthalmology.

About 80% of these surgeries are done with standard, monofocal lenses that are covered by insurance and provide patients with one type of vision, usually distance. Patients still need glasses for reading or other close-up activities.

Multifocal lenses give patients a broader range of vision, but they have to be paid for out of pocket.

Ophthalmologists now have about two decades of experience with these newer lenses, though the technology has evolved over time.

Prescott says the real boost in popularity came from the development of extended depth of focus (EDOF) lenses about 10 years ago, which offered an even wider range of vision and minimized complications like nighttime glare and starbursts that were more common with the original multifocal lenses. This often made driving at night a challenge.

Now there are trifocal lenses that offer even less glare, along with a larger range of vision, including distance, intermediate, and near, she said. Nighttime driving can still be affected, but to a lesser extent.

Paying extra to be able to toss the reading glasses is appealing to some patients. But they shouldn’t do it if they’re not a good candidate, she warned.

The Right Candidate

Patients with conditions like macular degeneration, epiretinal membrane, or diabetic retinopathy are not good candidates for multifocal lenses.

“Retinal problems do not let the lens function as it’s supposed to function, and as a result, they don’t have the vision they were expecting,” Dimitra Skondra, MD, PhD, a retinal surgeon also at NYU Langone Health, told MedPage Today.

Skondra said she has seen patients from New York travel to Florida for the winter, where they’re pitched cataract surgery with these premium lenses. When they return to New York, they’re disappointed with their vision.

“If things would have been explained to the patient before, many of them probably would have made a different choice,” she noted.

Other conditions can impact the performance of multifocal lenses, Roberto Pineda II, MD, of Mass Eye and Ear in Boston, told MedPage Today, including corneal issues such as irregular astigmatism, or “maybe a scar from a minor infection with a contact lens in the distant past, or prior laser vision correction surgery.”

“I do a lot of lens exchanges for unhappy patients,” added Pineda, who specializes in corneal, refractive, and complex cataract surgery. “The technology works well, but it doesn’t work well for everyone.”

He said he completes a thorough ocular biometry for every eye ahead of cataract surgery, to calculate the correct power of the lens for the patient. He also does a macular optical coherence tomography to rule out retinal diseases and get a thorough evaluation of the anatomic appearance of the macula and fovea.

“We spend a lot of time doing preoperative testing,” he said. “In the past we didn’t do that as much because it wasn’t really needed, but with the new lenses we have to identify any pre-existing condition that might impact the performance of the lens.”

High-Volume Practices

It’s not clear that all patients receive such thorough preoperative testing, experts warned.

Sometimes patients only receive information about lenses from a “lens coordinator,” rather than a physician.

“As part of the new era of high-volume practices that do many different lenses … the consent process is a little more complicated and more time-consuming than it was 20 years ago,” Skondra said. “Some of the doctors … designate someone in the practice so they get a bit of training and experience discussing the different lens options, but obviously they are not the doctor.”

Prescott said she sees “a lot fewer patients per day by design than a lot of cataract surgeons do, because I tell people the longest part of this whole process is talking about lenses and figuring out the right lens for you.”

“I don’t think a lot of people spend that much time on that part of it because they’re seeing a lot of patients, and they have their private practice, they have overhead, and they need to see a certain number of patients,” she added.

Pineda pointed out that sometimes patients only see the surgeon on the day of surgery.

“If the surgeon is doing 20 cases, they have to look through all of those cases and see if there are any issues … that would not make them a good candidate,” he said. “Telling them on the day of surgery that they’re not a good candidate — patients don’t like to be told that.”

“I do think that sometimes economics wins,” Pineda noted. “There’s a push to encourage patients to select one of these new lenses.”

Prescott suggested that’s bad for business overall. “In the long run, that’s worse for the multifocal lens companies,” she said. “If they’re put only in patients who are appropriate candidates, I think they’d be considered a wonder of modern technology.”

She noted that her aunt’s poor results with her multifocal lens almost dissuaded her mother from getting one. But her mother, who was a much better candidate, ultimately got an EDOF lens and has been thrilled with it.

“We’re kind of hurting ourselves by overdoing it,” she said.