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This supplement was produced by EyeWorld and supported in part by unrestricted grants from Alcon and Abbott Medical Optics. Copyright 2013 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld or ASCRS. Reducing pseudophakic ametropia to drive improved refractive IOL outcomes 8 "That helps you from a medicolegal stand- point," he said. "From a confidence stand- point, it gives you the ability to understand what to do on a more sophisticated level." Once a surgeon has learned the tech- nique and acquired certification, the next practical question for incorporating the procedure into practice is how to charge patients—how to make it work financially. In some practices such as that of Dr. Stonecipher, the patients are charged upfront for a "facility fee." "We have to make it something that is a discussion involved in the multifocal or premium IOL platform," he said. "I tell everyone that there is a potential for enhancement fol- lowing one of these refractive procedures, and in my hands it's about 7-8%, but at the same time I tell them there will be a facility fee that we will have to charge them." According to Dr. Stonecipher, having a nominal fee that patients have to pay makes it less likely that patients will complain after. Meanwhile, Dr. Trattler bundles the cost of the enhancement ahead of time. "It's hard to tell unhappy patients they need to fork over a little bit more money," he said. "By including your initial cost, it works out better for the patient." However, with this approach, Dr. Stonecipher thinks that the 90% of patients who don't need an enhancement may feel overcharged. The nominal facility fee cov- ers the additional charges of the enhance- ment without making it explicitly about the additional procedure itself, while circum- venting the need to charge extra later on should an enhancement be necessary. Dr. Lindstrom uses an alternative, "hy- brid" strategy: He tells patients upfront that there will be a small facility fee, but waives the fee when the patient hits the target and does not need an enhancement—which is practically all the time in Dr. Lindstrom's hands. The reality is that most surgeons have a low enhancement rate anyway, said Dr. Vukich. The key is to understand the astigmatic component, perform thorough biometry, and optimize IOL calculations to reduce pseudophakic ametropia and drive enhancement rates down. But should residual refractive error even at a very low level make an enhance- ment necessary, surgeons can take com- fort in knowing that a procedure such as PRK exists to provide a safe and effective means of improving visual outcomes even after refractive IOL implantation. References 1. Woodward MA, Randleman JB, Stulting RD. Dissatisfaction after multifocal intraocular lens implantation. J Cataract Refract Surg. 2009; 35: 992-997. 2. de Vries NE, Webers CA, Touwslager WR, et al. Dissatisfaction after implantation of multifocal intraocular lenses. J Cataract Refract Surg. 2011; 37: 859-865. Contact information Chang: dceye@earthlink.net Hoffman: rshoffman@finemd.com Lindstrom: rllindstrom@mneye.com MacRae: scott_macrae@urmc.rochester.edu Schallhorn: scschallhorn@yahoo.com Stonecipher: stonenc@aol.com Trattler: wtrattler@gmail.com Vukich: javukich@gmail.com Yoo: syoo@med.miami.edu Key opinions and practice patterns from symposium attendees T hrough surveys conducted before the symposium, the ASCRS leadership identified certain areas that represent potential gaps in the practical educa- tion of ASCRS members. This symposium focusing on the impact of residual refractive error on refractive IOL outcomes reached out to 354 attendees, representing approximately 210,300 cataract procedures annually, 44% of whom are in practice in the U.S. Of the attendees, 78% said they are implanting presby-IOLs in their practice, representing 16,800 presby-IOLs implanted annually; 36% of these implanters are more than 10% converted to presby-IOLs. Forty percent of attendees do not perform laser vision correction, with another 9% performing it only occasionally. After the symposium, 18% of attendees said they are "much more" likely to per- form AI/LRIs on presby-IOL patients for pre-existing astigmatism (42% said they are "more" or "much more" likely); 42% said they are "much more" likely to perform PRK/LASIK on presby-IOL patients to address residual error (63% said they are "more" or "much more" likely). Prior to the symposium, 80% of attendees said that if a presby-IOL patient is un- happy and has 0.75 D of residual astigmatism, they would perform or refer the patient for LRIs, AIs, or LVC; the percentage rose slightly to 87% after the symposium. Meanwhile, 69% of attendees said that if a presby-IOL patient is unhappy and has 0.75 D of residual sphere, they would perform or refer the patient for LVC; the percent- age rose significantly to 83% after the symposium. Interestingly, a pre-registrant survey found that 37.78% of attendees believed that a multifocal IOL patient with no residual refractive error and a healthy ocular surface has a 1–5% chance of having significant night vision dysphotopsia; 40% believed the patient has a 6–10% chance, 20% believed in a 10–25% chance, and 2.22% believed in a greater than 25% chance. The survey also revealed that 63.04% and 64.44% of attendees, respectively, believed that the highest acceptable amount of residual refractive error is 0.50 D for sphere and cylinder.

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