In the correct patient, mfIOLs deliver improved intermediate and near visual acuity and greater spectacle independence when compared with monofocal IOLs. 25 The challenge in the public sector, with variable measurement quality, significant time pressures that impact patient counselling, and multiple surgeons of various expertise influencing patient selection, is to implement a pathway that optimises patient outcomes while minimizing the potential risks and hazards inherent with such a mutable system. This pilot study proposes a pathway that overcomes many of these challenges. By empowering a senior trainee with adequate training and support, and utilising a stringent pathway that minimises the potential pitfalls inherent in mfIOL implantation, 26 we were able to demonstrate favourable visual acuity outcomes with mean post-operative subjective refraction above benchmark standards observed in large scale mfIOL or monofocal audits, 27–29 high levels of spectacle independence and very high levels of patient satisfaction demonstrated through validated PROMs. This decision pathway can be adapted for use across a variety of settings and can aid ophthalmology departments in implementing mfIOL use in select patients.
There is value in considering mfIOL implantation in a public setting. The visual benefits afforded by mfIOLs are desirable as they improve the ease with which patients participate in near-vision related activities, social activities and overall activities, ultimately leading to improved quality of life. 14 There are societal benefits of mfIOL use for patients who desire to return to work30 and a reduction in indirect costs of salary loss and unemployment. 31 In older cohorts and aged care residents, cataract surgery has been shown to improve self-rated emotional wellbeing, mobility, independence32 and social interaction, in addition to visual function. 33 Improvements in these domains can facilitate social connectedness with family, friends and community and potentially slow the progression of cognitive decline. 34 Additionally, there is a reduced incidence of falls in the elderly 35–37 which are associated with significant morbidity and mortality, 38 and mfIOLs are associated with fewer falls than monofocal IOLs after first eye surgery39. The findings highlight that the benefits of mfIOLs extend far beyond their visual outcomes and can have significant impacts on the quality of life and the everyday functioning of patients and their primary carers.
The challenge of funding innovative technologies and ensuring equitable access to health care within a resource-limited health system is universal, 40–42 and has led to various price setting and funding models. 43 This cost-analysis is one of the first to consider what the projected annual cost of mfIOLs would be to the Australian Health System. A prominent payment model that is used in European countries including Germany, Ireland and France44 utilises patient co-payments, where the health system funds the cost of the basic procedure and the patient funds the upgrade from a standard monofocal IOL to a mfIOL. This model is patient-centred, focused on patient outcomes and increases access and equity in health care delivery. 45 46 A second model would see the additional prosthesis cost born by the health system and proposes allocating a fixed quota of mfIOLs for use per year. These outcomes could then be assessed to provide a larger evidence base to justify the investment, a practice that is emphasised in value-based healthcare models47,48 and is necessary for creating benchmarks for care. 49 A third alternative would see mfIOLs tendered at a similar price to monofocal IOLs, with the cost absorbed by the IOL manufacturer, similar to strategies that have been described in orthopaedic surgery. 50–52 There is benefit to the IOL manufacturer as surgeons become familiar with the brand and comfortable with the prosthesis, which can influence surgeon preferences for surgical devices53 and translate to increased usage outside the government health system. The three models presented are not mutually exclusive; elements of two or more can be combined to suit the individual hospital and health jurisdiction. The goal is to maintain cost neutrality while increasing access to newer technologies for patients and trainees and thus improving the standard of care.
Once the aforementioned barriers are addressed, it is necessary to allocate these valuable prostheses to patients who are most likely to benefit, which ensures their cost-effectiveness. This is where the selection pathway presented in Fig. 1 is of value. Clinical selection pathways are an integral tool in helping standardise decision making, 54 reduce treatment error55, ensure a high quality of care for all patients, 56,57, and are effectively utilised in glaucoma and ocular hypertension management58 and reducing the length of hospital admission for cataract patients. 59 The surgical pathway proposed in Fig. 1 is intentionally more stringent than is strictly necessary for mfIOL use to ensure each step in the pre-operative assessment is addressed to reduce error and optimise outcomes for every patient irrespective of the trainee’s prior experience, evidenced by the high visual acuity and PROMs achieved in our study. Further, our pathway can be used as a teaching guide for trainees to educate and expose them to the mfIOL process. Although experience in implanting presbyopia correcting IOLs is not yet a necessary part of surgical training, they have become an increasing part of modern cataract surgery. 11,60–63 It is likely that newly graduated surgeons will encounter these IOLs in their private practice, where expectations for optimal results are highest and there is limited or no senior supervision. Hands on experience with presbyopia correcting IOLs can prepare trainees to identify patients who would benefit from them and to build technical skills and confidence in implanting them, with visual outcomes comparable to those of more experienced surgeons. 64
This study had several limitations. The sample size was limited due to the availability of the mfIOL. Dysphotopsias were rated on a self-administered questionnaire, which is an inherently subjective. To improve the objectivity of this measure, dysphotopsias could be quantified using a visual simulator, which would also quantify their severity. We aimed to determine if mfIOLs could be effectively utilised in a public health system and with that in mind did not significantly alter the existing cataract assessment and follow-up protocols. This created limitations such as a short follow-up period where neuroadaptation for dysphotopsias were not assessed, and the use of an a-constant that was not optimised to the biometer65 or surgeon. Despite these limitations, our refractive outcomes were excellent implying that the pathway created can overcome the inherent limitations of a large tertiary referral public hospital.
To our knowledge, this is the first study to propose a selection pathway for mfIOLs that can be used by trainees in a public hospital setting. The development of the optimised mfIOL pathway was instrumental to the success of the trial demonstrating strong visual outcomes and PROMs. The additional cost for bilateral surgery is similar to the price of a single pair of glasses and their use should be considered in a government health system. The benefits to patients include improved visual acuity in the intermediate and near range, decreased spectacle dependence and high satisfaction which is commonly linked to an improvement in quality of life. 62,66 The benefit to surgical trainees is hands-on practice in the clinical assessment and management of mfIOL patients, including the nuances in selection, counselling and the management of patients with visual disturbances. Our pathway can be adapted to other training hospitals to suit the individual institutions equipment and needs and helped overcome the inherent limitations of a large, tertiary referral training hospital.