1. Impact of ORA on Refractive Cataract
Surgery and the Premium Channel Offering
8 Shareef Mahdavi • SM2 Strategic • Pleasanton, CA 7
Intraoperative Aberrometry, a term receiving toric IOLs and/or present-
Table 1: Surgeon Demographics
describing the use of a wavefront-sens- ing as post-refractive patients. In
ing device during cataract surgery, has # Surgeons in Survey: 101 2010, the company changed its busi-
been available in the US since 2008. ness model and now allows surgeons
Cataract Cases per Month:
First commercialized as the ORange® Average No. of Cases: 73 unlimited use of the device for a
System, developer WaveTec Vision (Aliso Range: 8 to 350 fixed monthly fee of $3,000. (Note:
Viejo, CA), has continued to develop the Orange/ORA Cumulative Experience
in both models, the device was first
technology through a series of software Average No. of Cases: 365 acquired as a capital purchase or
and hardware modifications to improve Range: 10 to 4,000 lease). This revised approach wid-
utility of the device during cataract sur- ened the appeal to surgeons; survey
gery. Its ORA System® was launched in respondents perform anywhere from
late 2011; since that time, the company’s Table 2: Percent of Time ORA 8 to 350 cataract cases per month
installed base of sites and users has Affected IOL Power Selection and use ORA on a population of
expanded nearly five-fold. n = 21 90-100% patients that include all patients hav-
SM2 Strategic was asked to conduct ing refractive cataract surgery. Some
n = 35 50-80%
a survey of ORA users to better under- surgeons have opted to use the ORA
stand the impact of the technology on n = 25 11-50% reading as a quality control check-
the cataract practice. Given that ORA is n = 9 DK/NA point on IOL selection over a wide
a technology that surgeons are using to range of cases.
n = 8 < 10%
enhance their premium refractive cata- All surgeons continue to per-
ract practices, most surgeons using the n = number of surgeons form pre-operative diagnostics and
device are performing refractive cataract Average Among Surgeons= 59%
Average Among Surgeons = 59% begin surgery with an IOL selection.
surgery as part of the “premium channel” However, when they use ORA, they
offering to patients in their practice. are then modifying the surgical plan based on the intra-
This survey focused on how ORA is influencing surgeon operative ORA recommendation the majority of the
behavior in the operating suite and, consequently, how time (59% across the survey sample). Further segmenta-
surgeons are using the device to make refractive cataract tion of the surgeon sample reveals that 1 in 5 surgeons
options more attractive to patients coming in for surgery. do this 90% of the time or more when using ORA.
Of 215 surgeons invited to participate, 47% (101 of 215) According to Denise Visco, “I tell my patients, ‘I am
provided data in an online survey. 15% more accurate in selecting
Twelve surgeons also took part in a Figure 1: Frequency of ORA your IOL when I use ORA versus
telephone interview to further under- Saving Surgeons from when I do not.’ I tell other sur-
stand surgeon motivation to acquire Refractive Surprises geons that you get better at it the
and use ORA. Additional demographics more you use it.” The distribution
of the survey sample can be seen in of usage of ORA over pre-op read-
Table 1. The key findings can be sum- ings is shown in Table 2.
marized into three main themes, each Similarly, the ability of ORA
of which will be explored in the follow- Weekly At Least to prevent a refractive surprise
34% once/month
ing sections: from taking place is occurring
36%
with greater frequency. As shown
From Niche to Mainstream in Figure 1, 14% of surgeons
Initially offered as a “pay per Daily reported that ORA has kept them
Rarely
use” technology that would cost 14% from choosing the wrong lens “a
14%
$150 per case, the first surgeon lot,” meaning every week and
users tended to be highly selective perhaps daily. Another 34% of sur-
and used the technology on patients n = 93 Never 2% geons indicated this was occurring

2. “regularly,” meaning once per week. Only 2% of surgeons with other services. The remaining 9% of surgeons do not
said that ORA has never prevented a refractive surprise. include a charge for ORA in refractive packages either
“I strongly recommend ORA,” noted Michael because of limited access (e.g., ORA is only available at a
Woodcock, who has used ORA in more than 3,600 cases. secondary surgery center) or have chosen to use it on all
“It’s required for post-refractive patients without charging separately
patients and I will not perform surgery Figure 2: Learning Curve for it.
on them if they aren’t willing to have The average fee, weighted across
ORA.” 1 MO. all surgeons in the survey regardless of
Mitch Jackson, with nearly half his < 30 TIME/NO. OF CASES whether or not they have a separate
CASES TO REACH COMFORT LEVEL
cataract volume being post-refractive fee, was $337 per eye.
patients, agrees: “ORA changes out- 35 Surgeon conversion of patient inter-
comes. I am using it on all my post- est to a toric or presbyopic implant has
refractive surgery cases so as not to 30
increased significantly, moving from
worry about what we used to think of 31% to 38% of all cases (see Figure 4).
25
as ‘difficult’ cases. Fewer enhancements “ORA gives me a lot more confidence,
3 MOS.
mean less chair time and less time spent 20 50-100 4-6 MOS. especially with the toric lens. I feel
on ‘fixing' the primary procedure with CASES 100-150 more comfortable treating post-refrac-
CASES
NOT
either an IOL exchange, piggyback 15
THERE
tive eyes as I am better able to triangu-
IOL, LRIs, and/or laser vision correc- YET late thoughts with other diagnostics,”
10 12 MOS.
tion (PRK or LASIK), all of which lead > 150 said Richard Burns. “My results over-
to additional patient dissatisfaction.” CASES all are better with ORA.”
5
Likewise, surgeon time spent man-
The Learning Curve aging unhappy patients and performing
This utility is achieved only with n = 84 surgeons associated enhancements has changed
commitment and focus by the surgeon significantly, decreasing from 10%
to understand the technology and how to use it. Kevin to 5.3% of cases on average (see Figure 5). For some sur-
Waltz contends “you will adjust surgical technique as you geons, the overall enhancement rate has not changed dra-
learn how your technique impacts the refraction. This takes matically; while the tighter results have reduced the need
time, but it’s well worth it and you will find it impossible to for enhancement, the better outcomes have led to surgeons
give up (ORA).” Surgeons were asked about their learning being more aggressive overall during primary as well as
curve; 38% of surgeons felt comfort- enhancement cases as a function of
able within the first month or 30 cases, Figure 3: Additional Surgeon greater confidence throughout the pro-
Fees for ORA
while 10% say they are still in their cess.
learning curve. “It takes 2-3 months to
get used to it; you have to have faith, Time Efficiency
$337 average per eye
and you come to realize how heav- A concern of some surgeons has
ily you have relied on IOLMaster and 30 been impact on patient flow and over-
S U R G E O N S
29
OPD,” remarked Jonathan Solomon. 25 all time spent in the operating room.
“Having this tool available during sur- 25 There is a wide variety of surgeons’
20
gery has allowed me to be much more reports of how much time is added.
aggressive in treatment.” The range of 15 17 Some say it adds only 15-30 seconds,
O F
responses is shown in Figure 2. 10 while others say it doubles the time to
N U M B E R
5
perform a 5-6 minute case. “It takes
The Numbers Make Sense me five extra minutes per case, which
0
Given the elective nature of the $50-250 $300-499 $500 + means the outcomes have to be much
patient’s decision to have ORA as part n = 101 surgeons; 71 have a separate line item on their fee schedule
better, which they are,” remarked
of their cataract surgery, surgeons need Kevin Waltz.
to determine the value of intraoperative aberrometry and Maria Scott, who routinely does 40 cataracts in a ses-
how much to charge for this added component of premium sion, initially saw efficiency drop with ORA from 5.5 cases
cataract surgery. to 4.5 cases per hour. A software upgrade in August 2012
70% of surgeons offer ORA as a separate line-item; made a big improvement in capture and processing time ,
21% do not break out the fee and choose to include it and case flow is now back up to between 5 and 5.5 cases

3. per hour. “My partner and I struggled with the original time in the OR to get it right the first time is worth every
hardware (ORange); I didn’t like it very much. The ORA second.”
System and the upgrade have been a complete turnaround. According to Rob Weinstock, who was one of the very
I’m much more confident and now first users of the ORange System and
offer LRI (for a fee) along with ORA; Figure 4: Change in works closely with WaveTec’s engineers
the results are that good.” Conversion Rate to improve the platform, indicated
“ORA is now much more bulletproof.
Expanding the Category by Surgical outcomes are better and the bar
Creating Value 35 38%
is being raised. This can be leveraged in
In refractive cataract surgery, the exam room and in the community,
30
ORA is not being used by itself but 31% which creates a very high value proposi-
typically in combination with one 25 tion for surgeons.”
or more elements that together com-
prise the premium channel category 20 Discussion
of cataract surgery. Along with other 20% There is little question that the addi-
advanced diagnostics and the femto- 15 tion of ORA has meaningfully impacted
increase
second laser, surgeons are using ORA the surgeon’s ability to communicate the
10
to make better decisions around IOL benefits of refractive cataract surgery.
power and placement. These tools 5 Surgeon confidence from improved out-
work synergistically to improve out- comes is translating to what is discussed
comes, the core premise of refractive % during pre-operative education and
cataract surgery. Before ORA With ORA counseling. As a result, patients better
Surgeons in this survey reflect a n = 101 surgeons: 49 reported no change in conversion rate understand the value of refractive cata-
sense of optimism about the contri- ract surgery and accepting that they will
bution of ORA to their field. Nicolas share in some of the cost directly in order
Batra, whose practice has doubled “taking the extra time in the to achieve the results associated with pre-
in size in recent years, says the addi- OR to get it right the first mium cataract surgery.
tion of ORA has made a meaningful The survey data are very clear in
contribution to the premium segment: time is worth every second.” showing how this “product promise,”
“Patient acceptance of our premium and ORA’s role in helping achieve it, is
offering has grown tremendously and increasing acceptance for the premium
gave me the resources to buy the FS Figure 5: Change in segment within cataract surgery.
Enhancement Rate
laser on my own. I believe that ORA Like all new technology, there is a
is the new ‘gateway’ for refractive learning curve associated with ORA.
cataract surgeons.” 10% The path to successful integration by cat-
aract surgeons needs to avoid the “plug
Is ORA Worth It? 8 and play” mind-set enabled by some of
Analysis of the data from the today’s medical devices. ORA is a pow-
open-ended comments added by sur- erful tool that provides something sur-
6
geons and from the interviews make geons have never before had: refractive
clear that the investment of time and 5.3% data to make decisions during surgery
money into ORA is well worth it and 4 47% that differ from pre-operative planning
decrease
justified by the improvement in out- and can meaningfully impact patient
comes. Surgeons have come to trust outcomes. “Surgeons must pay attention
2
the readings taken during surgery, when first starting,” noted John Berdahl.
and the resulting outcomes have led “They need to respect the art that comes
to increased “confidence”, “comfort” % along with this technology.” There is
and “trust,” words which appeared in Before ORA With ORA also a cost associated with integrating
responses from 41 of the 72 surgeons n = 69 surgeons: 22 of 69 reported no change in enhancement rate the device, in terms of time and money,
who wrote them in on the survey. The but the overwhelming sentiment of users
positive comments span a wide range, including that ORA is that it is well worth the investment and requirement to
is an “essential surgical step” and that “taking the extra adjust surgical thinking as part of the process.

4. While some of the improvement observed with regard comes, safety and demand for advanced technology that
to fees, conversion rates, or enhancement rates may be is not a covered service. This perspective is similar to that
attributable to other factors besides ORA (e.g., a more edu- shared by Rob Weinstock: “How does anyone do refractive
cated staff, the presence of a femtosecond laser), one gets cataract surgery without all this technology? This is where
the sense from the interviews and the open-ended responses it's all going.”
that ORA is carrying its weight in terms of its value relative “All this technology and its automation of certain steps
to its cost. This holds true both on a relative basis (when allows the surgeon to spend time thinking and doing other
compared to the cost to obtain a femtosecond laser) and on things to make results even better,” commented Jonathan
an absolute basis (when compared to outcomes obtained Talamo. “ORA readings cause me to really understand the
prior to having ORA). As more and more of these technol- impact of every move I make during surgery.”
ogies find their home in the refractive cataract practice, it In terms of the future, ORA's relationship with other
will become increasingly difficult to precisely determine the devices – diagnostic as well as laser – is symbiotic in nature.
exact contribution of each. Each one supports the other. As more surgeons adopt ORA,
As an alternative, refractive cataract surgeons need to it will be exciting to see how the bar gets raised even fur-
look at the overall picture and the ability to drive out- ther in helping cataract surgery achieve refractive outcomes.
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