The IOLMaster has become the preferred method of obtaining biometry measurements for cataract surgery among the majority of surgeons in the US. This document summarizes interviews with 10 early adopter surgeons of the IOLMaster who provide feedback on the impact it has had and the newly released Version 5 software. The IOLMaster provides highly accurate measurements without touching the eye, improves patient flow and outcomes, and increases surgeon confidence in premium lens implantation. Version 5 further automates measurements and analysis.

1. The IOLMaster and its Role in ®
Modern Cataract Surgery
8 Shareef Mahdavi • SM2 Consulting • Pleasanton, CA 7
Advances in capsular extraction and lens implant technolo-
Figure 1: Preferred Biometry Method of U.S. Sugeons
gies have commanded significant attention in the world of
cataract surgery. New implants allow surgeons to provide
Applanation
even higher levels of visual outcome, including spectacle
% of U.S. Cataract Surgeons
80% Immersion
independence and a continuous range of vision covering all
IOLMaster
distances. One of the enabling technologies that makes this
60%
possible is non-contact biometry offered by the IOLMaster. In
just five years since introduction, the IOLMaster has become 40%
rapidly adopted as the preferred method for obtaining IOL
calculations among the majority of surgeons in the U.S. and 20%
is used in 7,000 locations worldwide. Manufacturer Carl Zeiss
Meditec engaged SM2 Consulting to survey ten of its original 2001 2002 2003 2004 2005 2006
customers to illustrate the impact this technology has made Source: Annual Leaming Survey of ASCRS members
on cataract surgery. These surgeons also provided feed-
back on the newly-released Advanced Technology Software Most cataract surgeons understand, however, that their results
(referred to as Version 5). are limited to the accuracy of the input variables, including
axial length, K readings, and the formula used to determine the
Introduction IOL dioptric power to be implanted. “While one perfect com-
In the year 2000, Carl Zeiss Meditec launched a novel tech- ponent won’t yield a perfect result, one poor component can
nology to perform biometry for IOL calculation that employed lead to very poor results,” commented Warren Hill, MD. The
partial coherence interferometry (PCI). Unlike the two tradi- weakest component in the system, according to these surgeons,
tional methods of obtaining anterior chamber depth and axial had been the accuracy of the biometry. Now, with multiple
length, applanation and immersion ultrasound, the proposi- years of experience, these surgeons are unanimous (10 of 10,
tion afforded by the IOLMaster was that it could gather more
accurate results without touching the eye. Since that time, the Figure 2: Participating Surgeons
IOLMaster has gradually become the preferred method among
David Chang, MD Los Altos, CA
cataract surgeons in the U.S. for obtaining these calculations, Robert Cionni, MD Cincinnati, OH
as shown in Figure 1. Ten leading cataract surgeons who were Warren Hill, MD Mesa, AZ
among the earliest adopters of the technology were surveyed Doug Koch, MD Houston, TX
to better understand how the IOLMaster has impacted their Sam Masket, MD Los Angeles, CA
Mark Packer, MD Eugene, OR
practice as well as surgical outcomes. These surgeons (see Figure
Brad Shingleton, MD Boston, MA
2) also are among the first to use the newest release of the Joel Shugar, MD Perry, FL
IOLMaster, known as Advanced Technology Software Version 5 Jack Singer, MD Randolph, VT
of the IOLMaster. Richard Tipperman, MD Bala Cynwyd, PA
Axial Length Measurement: The Weak Link Key Surgeon Demographics: Mean (range)
While cataract surgery has undergone tremendous trans- Experience with IOL Master 6 years (4 to 7 years)
formation in terms of extraction and implantation technology,
# of IOL implants per month 92 eyes (20 to 236 eyes)
the field is perhaps now at an even greater rate of innovation.
New lens technologies are allowing surgeons to provide spec- % of patients that upgrade to 22% (<5% to 30%)
Premium IOL
tacle independence for patients and achieve levels of accuracy (accommodating or multifocal)
(intended vs. actual correction) typically associated with LASIK.
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2. Figure 3: Surgeon Ratings of Ease of Use for Different Technologies “Earlier versions of the device
Extremely Extremely required our techs to figure out
Easy Difficult
1 2 3 4 5 6 7 8 9 10 how to shine the light around
A-scan
Biometry
Mean
= 4.9
opacities using the joystick. Now,
that’s not even necessary with
Immersion
Biometry
Mean
= 5.1 Version 5. It’s fully automatic.”
IOLMaster Mean
non Version 5 = 2.4 that they are much more satisfied (9 of 10,
90%) or more satisfied (1 of 10, 10%) with
IOLMaster Mean IOLMaster versus previous forms of biom-
Version 5 = 1.1
etry for IOL power prediction.
100%) in their belief that IOLMaster is the standard of care for Reading Through Dense Cataracts
biometry and strongly agree that they would recommend the One of the early concerns of surgeons when they first
IOLMaster to other surgeons. As seen in Figure 1, this feat has acquired the IOLMaster was its ability to read through dense
been achieved through increasing adoption by surgeons over the cataracts. The surgeons were asked how often they had to
past seven years. use an alternative method to perform biometry. The range of
responses is shown in Figure 4 both before and after the intro-
Ease of Use duction of Version 5. Before Version 5, surgeons needed to use
In 2001, applanation biometry was in use by the majority an alternative method 12 percent of the time on average. With
of practices, mainly due to its ease of use relative to immersion Version 5, that need has dropped to 3 percent on average.
biometry (which was considered the “gold standard” at the
time). “Now, we have a technology which is both the easiest to Automation of Scan Analysis
use and the best for our patients,” according to Samuel Masket, Given their long tenure with the IOLMaster, these surgeons
MD., who viewed this as an unusual combination of events. literally marveled at the technical expertise and intelligence that
The relative ease of use of each of the technologies was rated has been progressively added to the device. Today’s IOLMaster
by each of the surgeons, as shown with Version 5, they exclaim, has
in Figure 3. While the IOLMaster made the data capture virtually
has traditionally been easier to Figure 4: Percent of Time Alternative foolproof, as it gives technicians
Device Required (Cataract Too Dense)
use than either of the ultrasound feedback using a green-yellow-
techniques, surgeons feel the new red (i.e. traffic light) system to let
Version 5 takes ease to a whole (Each color represents a different MD in the survey) them know that accurate read-
new level. “Every office had one 30%
ings are being taken. By using
Mean = 12%
tech who was best at applanation; sophisticated signal-to-noise
25%
this pressure was relieved with the analysis, the device software is
IOLMaster,” noted Mark Packer, 20%
able to automatically exclude
MD. “Earlier versions of the device bad readings and create a com-
required our techs to figure out 15% posite best measurement for each
how to shine the light around eye. “We used to be left with a
opacities using the joystick. Now, 10%
packet of A-scan images, trying
that’s not even necessary with Mean = 3% to decide which one is best,”
5%
Version 5. It’s fully automatic.” remarked Dr. Packer. “That bur-
As a result of this technology 0%
den has now been taken away.”
and its ease of use by technicians, Prior to Version 5 Version 5
this group of surgeons responded
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3. Use in Keratometry Figure 5: IOLMaster Return-On-Investment “Doctors often fail
Readings
Another early concern Time Via IOLMaster Via A-scan and Manual Keratometry
to recognize the costs
was the accuracy of K read- they incur with poor
ings obtained from the device. to perform results”
Biometry and 5 minutes 30 minutes
According to surgeons, Keratometry
IOLMaster's automated
keratometry has continuously Intangibles “Peace of mind” Return-On-Investment
improved with each release. “Much less frustration” Calculating return-on-
Dr. Jack Singer MD believes K “Confidence” investment (ROI) is an
readings from the IOLMaster “WinWin” important decision when
have always tended to be evaluating capital equipment
more accurate because of the skill and calibration issues associ- expenditures. All ten surgeons in this survey were unanimous in
ated with manual keratometers. “Ks are foolproof and faster their statement that the IOLMaster has provided a meaningful
using IOLMaster.” Dr. Hill, whose practice has a Javal Schiotz ROI for the practice. Using current reimbursement in the U.S.,
Ophthalmometer for performing keratometry, has stopped using the payback period for these surgeons ranged from under six
it and relies solely on the IOLMaster Version 5. Their sentiment months to two and one half years. In addition, the time savings
is shared by 60% of these surgeons who rated the IOLMaster using IOLMaster (5 minutes) versus A-scan and manual K read-
as either more accurate than (4 of 10) or equivalent to (2 of 10) ings (up to 30 minutes) serves as an important component in
manual keratometry. The remaining 4 surgeons felt manual Ks the ROI equation.
are more accurate. Two additional questions were asked to help assess return
on investment: When asked how this device compared in terms
“Dr. Hill, whose practice has a Javal Schiotz of relative value to other diagnostic devices in the practice, such
as topography and visual fields, 90% (9 of 10) said IOLMaster
Ophthalmometer for performing keratometry,
was more useful than these other devices and the remaining
has stopped using it and relies solely on the surgeon viewed it as equally useful. To assist surgeons who
IOLMaster Version 5” already own an IOLMaster, these surgeons were also asked to
use their experience with the new Version 5 and comment on its
Throughput and Quality value relative to its cost. All 10 surgeons indicated it was worth
Surgeons were adamant about how the device has improved the cost, with 4 of these 10 rating its value as higher and “defi-
overall quality of the cataract surgery process as well as out- nitely” worth the cost.
comes. All surgeons either agreed strongly (8 of 10) or some- Surgeon’s comments in the survey revealed an intangible
what (2 of 10) that the IOLMaster has significantly improved ROI that can’t be measured using standard accounting or time
patient flow in their practice due to its accuracy, speed and and motion methods. “Priceless” is how one surgeon described
convenience for surgeons, technicians and patients. Beyond this, the peace-of-mind the device has given, citing less frustration
however, many of the surgeons interviewed brought forth how and greater confidence in determining the right measurements
IOLMaster has helped solve a deficiency in the overall process: prior to selecting the IOL power.
“Doctors often fail to recognize the costs they incur with poor
results,” commented Richard Tipperman, MD. “This affects us Patient Expectations
both in having to spend additional time hand-holding unhappy Surgeons in this survey commented that patient expectations
patients and the negative word-of-mouth it creates. To measure for outcomes have changed dramatically in recent years. LASIK
this impact, surgeons were asked to estimate the direct impact outcomes and the availability of advanced IOL technology have
on their time of an unhappy patient whose end result is one clearly impacted the typical patient consultation for cataract
diopter away from intended. The surgeons in this survey indi- surgery, with patients increasingly seeking to be spectacle free
cated that such a patient would require nearly one additional for distance vision and, when choosing to have a premium IOL,
hour of surgeon management time. (average of responses: 3.7 at near and intermediate as well. “Patients judge the quality of
visits averaging 14.3 minutes per visit). surgery by the refractive outcome, and anything that improves
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4. this is a win-win,” remarked Dr. Figure 6: Surgeon Confidence With embraced on a widespread basis.
Tipperman. This sentiment seems to and Without IOLMaster While not perfect, the IOLMaster
apply to all types of cataract surgery, Version 5 can be summed up as
1-10 Rating Scale (1= Lowest, 10= Highest)
as noted by Dr. Masket: “They may “pretty darn close” by this group of
not be willing to pay more (for a pre- 10 surgeons. The one caveat with the full
mium IOL), but they definitely expect 9 Mean automation offered by Version 5 is
= 9.0
more.” that surgeons may view it literally as a
8
When it comes to the premium plug-and-play device. Dr. Hill believes
IOL category (defined in this survey as 7 it is important for surgeons to ini-
accommodating or multifocal technol- 6 tially supervise measurements so they
ogy), surgeons attribute even greater Mean understand the entire process. And
5
= 5.3 Dr. Packer recommends that surgeons
4 who have invested in an IOLMaster
“The IOLMaster has also invest in one of the new state-of-
3
allowed me to optimize the the-art formulas rather than rely on
2
Haigis formula as part of one of the free ones available, which
my calculations”
1
he likens to “driving a brand new car
Rate your overall Assume your IOLMaster on old tires.”
confidence today in was taken away from
offering premium you. Now, rate your The IOLMaster is making a sig-
IOL implants to overall confidence in
value to the IOLMaster, where the your patients. offering premium IOLs nificant difference in both the surgi-
without the use of the
need to reach the target refraction is IOLMaster. cal process as well as outcomes for
more critical given the additional fees With Without
cataract patients. It is a tool that has
paid by patients. Dr. Singer, whose arrived at the right time, allowing sur-
practice is focused exclusively on intraocular refractive surgery, geons to extract greater value out of the lenses that are and will
believes the IOLMaster has been an integral part of his surgical be available in the future.
system: “The IOLMaster has allowed me to optimize the Haigis Those who would argue that the IOLMaster is a “nice to
formula as part of my calculations,” he said. This in turn has have” rather than a “have to have” need to keep in mind that
allowed him to consistently deliver superior outcomes, which the cataract market of today and tomorrow is vastly differ-
Dr. Singer believes has led to significant growth in his refractive ent than that of just a few years ago. In addition to innovative
lens exchange procedure volume. technology, patient expectations have similarly risen to the point
The impact on each surgeon’s premium IOL offering was where cataract surgery is truly another form of refractive surgery.
assessed by asking them to rate their confidence in offering This report was designed to help cataract surgeons evalu-
IOLs both using and without using the IOLMaster. As shown ate whether they should acquire the IOLMaster or upgrade
in Figure 6, surgeon confidence is significantly higher (mean to Version 5. Hopefully, the passion and commitment among
of 9.0 out of 10) when using the IOLMaster than without it the surgeons participating in this project are self evident. They
(mean of 5.3). want to see cataract surgery become increasingly effective in
step with improvements in safety. They view the IOLMaster as
Discussion a “surgical imperative” that helps increase patient satisfaction
The role of technology in improving surgical outcomes can- and decrease risk of litigation (given that cataract surgery is the
not be underestimated in the ophthalmic profession. Cataract top reason for lawsuits filed against ophthalmic surgeons). In a
surgery in particular has benefited from numerous innovations world where consumers have greater choice, it seems reasonable
over the past 50 years. What’s remarkable about the IOLMaster to conclude that any patient who understands the difference
is that it has become a standard in such a short period of time, between ultrasound and IOLMaster would insist on the latter. It
unlike both phaco-emulsification and the intraocular lens, each appears that most surgeons agree, and we expect the IOLMaster
of which was available for several decades before becoming to continue its penetration in the surgical marketplace.
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