Abstract
Purpose:
To determine the cost-effectiveness of an adjunctive screening optical coherence tomography (OCT) in the preoperative evaluation of a patient considering cataract surgery with a multifocal intraocular lens (IOL) implantation.
Design:
Cost-effectiveness analysis (CEA)
Subject:
The base case was a 67-year old male with 20/60 vision undergoing evaluation for a first eye cataract surgery.
Methods:
The CEA of the reference case undergoing a preoperative cataract examination with and without a screening OCT was performed, evaluating for retinal diseases including epiretinal membrane, age-related macular degeneration, vitreomacular traction, and cystoid macular edema. It was assumed that patients with macular pathologies detected preoperatively would receive a monofocal IOL and be referred to a retina specialist for evaluation and management. The Medicare reimbursable cost of an OCT was $41.81. All costs and benefits were adjusted for inflation to 2019 U.S. dollars and were discounted 3% per annum over a 16-year time-horizon. Probability sensitivity analyses and one-way deterministic sensitivity analyses were performed to assess for uncertainty.
Main Outcome Measures:
Incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR) measured in quality-adjusted life years (QALYs)
Results:
Approximately 20.5% of patients undergoing cataract surgery may have macular pathologies, of which 11% may not be detected on initial clinical exam. In the base case, an adjunctive preoperative OCT was cost-effective from a third-party payer and societal perspective in the U.S. In probability sensitivity analyses, the ICURs were within the societal willingness-to-pay threshold of $50,000/QALY in approximately 64.4% of the clinical scenarios.
Conclusions:
A preoperative screening OCT in the evaluation of a patient considering a multifocal IOL added to the costs of the cataract surgery, but the OCT increased the detection of macular pathologies and improved the QALYs over time. An adjunctive screening OCT can be cost-effective from a third-party payer and societal perspective.
Precis:
An adjunctive screening optical coherence tomography in the preoperative cataract surgery evaluation for a multifocal intraocular lens can be cost-effective from a third-party payer and societal perspective in the United States.
Introduction
Cataract surgery with an intraocular lens (IOL) implantation is the most commonly performed surgery in the world, with an estimated 7-20 million surgeries being performed annually worldwide. 1 A standard monofocal IOL is typically reimbursed by most insurance companies and focuses light at a set distance. Multifocal IOLs, however, are often not covered by most insurance companies and are pseudo-accommodative, splitting light into two or three focuses in order to decrease spectacle dependence; however, multifocal IOLs may decrease contrast sensitivity and produce glare and other dysphotopsias.2 Optimal visual outcomes with multifocal IOLs are achieved in eyes that have no sight-impairing pathologies other than cataracts. Implanting a multifocal IOL in an eye with concomitant ocular disease can result in reduced best corrected distance and near visual acuities compared to a monofocal IOL.3–5 Coupled with dysphotopsias and out-of-pocket costs, these patients may be dissatisfied with their sub-optimal visual outcomes and may subsequently undergo intraocular lens exchanges with monofocal IOLs.6,7
It is estimated that more than a quarter of patients undergoing cataract surgery may have concurrent macular pathologies.8 The American Academy of Ophthalmology (AAO) therefore recommends a comprehensive, dilated, fundus examination in patients undergoing cataract surgery.9 Unfortunately, dense cataracts may obscure the view of the retina. Optical coherence tomography (OCT) can provide quick, high-resolution images of the retina and may be more sensitive than stereoscopic fundus exams in detecting certain retinal pathologies, such as vitreomacular traction.10 Between 9%-30% of normal-appearing retinas may have subtle macular pathology that can be detected on OCTs;8,11–13 however, OCTs may be limited by media artifacts or patient cooperation, with 4-5% not being of sufficient quality to interpret.10,14,15
Some surgeons have considered screening OCTs in all patients being evaluated for cataract surgery, especially for those considering premium IOLs, in order to improve patient selection and satisfaction. According to the Centers for Medicare and Medicaid Services (CMS) payment guidelines, however, screening OCTs are not reimbursed unless there are qualifying medical diagnoses. In patients with normal OCTs, the direct medical costs and lost opportunity costs may fall on the physician or medical facility. Since it is currently unclear whether a preoperative OCT may be cost-effective in cataract surgery, and patients who pay out-of-pocket for multifocal IOLs would likely be the subgroup of people most impacted by and most unsatisfied by undetected retinal pathologies, the current study focused on multifocal IOLs, rather than monofocal IOLs.
The purpose of the current study was to determine the cost-effectiveness of an adjunctive, preoperative screening OCT in a patient being evaluated for a multifocal intraocular lens implantation. The most common vitreoretinal pathologies, including epiretinal membrane (ERM), age-related macular degeneration (ARMD), vitreomacular traction (VMT), and cystoid macular edema (CME) from vascular occlusion or diabetes were included.
Methods
The cost-effectiveness analysis (CEA) was conducted and reported according to the guidelines set forth by Second Panel on Cost-Effectiveness in Health and Medicine. 16 The Institutional Review Board ruled that approval was not required for this study since no human subjects were involved. A decision-analytic model was constructed (Figure 1), and calculations were performed on TreeAge Pro Version 2018 (TreeAge Software Inc., Williamstown, MA).
Figure 1. Simplified decision-Analytic Model.
A decision-analytic model was used to determine the cost-effectiveness of a screening optical coherence tomography (OCT) prior to cataract surgery with multifocal IOL implantation. Each oval represents a different health state and has its corresponding cost and utility value. Transition rewards and costs were applied to passage from certain states to others. Not shown on the picture was the possibility of ERM and VMT groups to enter the “No disease” health state after surgery. Any of the groups could directly enter the absorbing state (death). The assigned probabilities of each event are detailed in the Tables and Appendix.
For the complete cost calculations in the model, please refer to the Appendix. The third-party payer costs included the current and future direct medical costs reimbursed by Medicare-payer guidelines, such as office visits, procedures, imaging, medications, and potential adverse complications. The societal costs included all the costs incurred regardless of the payer, including indirect healthcare-payer costs, patient out-of-pocket costs, patient and caretaker time costs, lost-of-opportunity costs, and transportation costs (Appendix - Table 1). All costs and benefits were adjusted 3% per annum and corrected for inflation to 2019 U.S. dollars using the U.S. Bureau of Labor Statistics Consumer Price Index (www.bls.gov/cpi). The current procedural terminology (CPT) codes for imaging and procedures were used to determine the national average payment for physician reimbursement, set forth by the CMS.17 The average wholesale prices (AWP) of medications were used (Lexi-Comp Online database, Hudson, Ohio), with the least and most expensive commercially-available prices (www.goodrx.com) used for the probability sensitivity analyses (PSAs). The average weighted incidences were determined by searching PubMed English literature studies. Multiple sources were used when available, with preference for larger studies, AAO Preferred Practice Patterns publications, and studies that focused on asymptomatic patients without known pre-existing macular pathologies (Table 1).
Table 1. Model inputs.
The weighted incidence of events and main cost (OCT), with and without a preoperative OCT, were determined. For the theoretical incidences of complications, all available literature was reviewed and the combined weight of it used for calculations using the best available evidence and the authors own experience. The detailed descriptions and cost calculations are described in the Appendix.
| Clinical Scenario | Incidence % (Range) | Final Mean VA | Utility | Reference |
|---|---|---|---|---|
| Healthy Macula | 79.5 (70-90.7) | 20/25 | 0.88 | 1,2,8,9 |
| Macular Pathologies | 20.5 (9.21-30) | 10–13,23,24,25,30,36–38 | ||
| Occult Pathologies | 11 (9-17) | 10–13,23,24,25,30,36–38 | ||
| Epiretinal Membrane | 8.94 (2.58-11.1) | |||
| Preop ERM Diagnosis | 7.95 | |||
| ERM Observed | 82.9 | 20/30 | 0.84 | 10, 12, 13, 23, 24 |
| ERM Treated with Combined Surgery | 9.8 | 20/25 | 0.88 | 10, 12, 13, 23, 24 |
| ERM Treated with Sequential Surgery | 7.3 | 20/25 | 0.88 | 10, 12, 13, 23, 24 |
| Delayed ERM Diagnosis | 0.98 | |||
| Delayed ERM Diagnosis, Observed | 82.9 | 20/30 | 0.84 | 10–13, 23, 24 |
| Delayed ERM Diagnosis, Sequential surgery | 17.1 | 20/25 | 088 | 10–13, 23, 24 |
| Age-Related Macular Degeneration | 7.18 (1.6-5.66) | |||
| Preop ARMD Diagnosis | 6.39 | |||
| Dry ARMD | 71.6 | 20/25 | 0.88 | 11–13, 24 |
| Dry ARMD that Converted to Wet | 8.4 | 20/30 | 0.84 | 11–13, 20, 24 |
| Wet ARMD Observed | 0.02 | 20/50 | 0.77 | 37 |
| Wet ARMD Treated | 19.98 | 20/40 | 0.80 | 11–13, 20, 24 |
| Delayed ARMD Diagnosis | 0.79 | |||
| Delayed Dry ARMD Diagnosis | 71.6 | 20/25 | 0.88 | 26, 35, 36, 38 |
| Delayed Dry ARMD Diagnosis, then converted to Wet | 8.4 | 20/40 | 0.8 | 26, 28, 35, 36, 38 |
| Delayed Wet ARMD Diagnosis, Observed | 0.02 | 20/60 | 0.73 | 26, 28, 35, 36–38 |
| Delayed Wet ARMD Diagnosis, Treated | 19.98 | 20/50 | 0.77 | 26, 28, 35, 36, 38 |
| Vitreomacular Traction | 2.91 (0.43-3.79) | |||
| Preop VMT Diagnosis | 2.59 | |||
| VMT Observed | 75 | 20/30 | 0.84 | 10, 12, 13, 25 |
| VMT Treated with Combined Surgery | 15 | 20/25 | 0.88 | 10, 12, 13, 25 |
| VMT Treated with Sequential Surgery | 10 | 20/25 | 0.88 | 10, 12, 13, 25 |
| Delayed VMT Diagnosis | 0.32 | |||
| Delayed VMT Diagnosis, Observed | 75 | 20/30 | 0.84 | 10, 12, 13, 25 |
| Delayed VMT Diagnosis, then Sequential Surgery | 25 | 20/25 | 0.88 | 10, 12, 13, 25 |
| Cystoid Macular Edema | 1.47 (0.069-5.3) | |||
| Preop CME Diagnosis | 1.31 | |||
| CME Observed, then Resolved | 9.1 | 20/30 | 0.84 | 10, 12, 13, 24 |
| CME Observed, then Treated | 3.9 | 20/30 | 0.84 | 10, 12, 13, 24 |
| CME Treated, then Resolved | 38.6 | 20/30 | 0.84 | 10, 12, 13, 24 |
| CME Treated, but Persisted | 48.4 | 20/40 | 0.80 | 10, 12, 13, 24 |
| Delayed CME Diagnosis | 0.16 | |||
| Delayed CME Diagnosis Observed, then Resolved | 9.1 | 20/30 | 0.84 | 8, 10, 12, 13, 24, 30, 23 |
| Delayed CME Diagnosis, Observed, then Treated | 3.9 | 20/40 | 0.80 | 8, 10, 12, 13, 24, 30, 23 |
| Delayed CME Diagnosis Treated, then Resolved | 38.6 | 20/40 | 0.80 | 8, 10, 12, 13, 24, 30, 23 |
| Delayed CME Diagnosis Treated, but Persisted | 48.4 | 20/50 | 0.77 | 8, 10, 12, 13, 24, 30, 23 |
Key: ARMD= age-related macular degeneration, CME= cystoid macular edema, Dry ARMD= non-exudative intermediate age-related macular degeneration, Dx= diagnosis, ERM= epiretinal membrane, IOL= intraocular lens, IOLX= intraocular lens exchange, OCT= optical coherence tomography, Preop= preoperative, Postop= postoperative, VA= visual acuity, VMT= vitreomacular traction, wet ARMD= exudative age-related macular degeneration.
The cost of an OCT for a physician and medical practice can vary significantly depending on the type of practice (academic or private), ownership or rental of equipment, and subspecialty or multispecialty-specific practice. For instance, if an anterior segment surgeon performing an average of 400 cataracts a year purchased an OCT machine specifically for patients undergoing cataract surgery, regardless of the type of IOL implanted, then the cost would be approximately $18.37 per OCT, including machine cost, maintenance, devaluation, electricity, and technician time; if the OCT was used only for patients with multifocal IOLs, however, then the cost would be 13 times higher and exceed the reimbursable amount. On the other hand, if the anterior segment surgeon was part of a multispecialty practice that already owned the OCT machine, then the cost of an OCT could be as low as $2.33 from the practice perspective. In this model, the cost of an OCT was set at $41.81, the Medicare reimbursement rate of a retinal OCT (CPT 92134), in order to account for loss-of-opportunity costs and to evaluate the model under stringent conditions.
The incremental cost-effectiveness ratio (ICER) was determined by dividing the additional costs of surgery with a screening macular OCT by the theoretical increased detection of retinal pathology. The incremental cost-utility ratio (ICUR) was determined by dividing the additional cost of the screening OCT by the improvement in quality-adjusted life years (QALYs). There are limited studies quantifying QALYs in ophthalmology, so the time-trade off technique for vision was used to determine the ICURs,18,19 which can limit the generalizability to other subspecialties in medicine. The utilities represented the years left in a patient’s life that they would theoretically be willing to trade in order to achieve a perfect health state. A utility value of 1 is a theoretical perfect health state with 20/20 vision in both eyes, and 0 is death.18 A binocular vision of 20/50 equaled 0.77 and 20/30 equaled 0.84.19 In patients whose operated eye had significant retinal pathology, such as the patients with exudative ARMD that progressed to 20/200 or worse despite intravitreal injections,20 the vision in the remaining non-operated, better-seeing eye was used in the calculations.
The base case was a 67-year old male who underwent a preoperative examination with an OCT for a first-eye cataract surgery with a potential multifocal intraocular lens implantation; his vision improved from 20/60 preoperatively to 20/25 postoperatively. The mean age, 16-year time horizon, and mean vision were based on the average life-expectancy and demographics of a patient undergoing cataract surgery, similar to previously published studies. 9,12,21 A preoperative dilated fundus examination was performed by an ophthalmologist. The patient’s out-of-pocket cost for a premium IOL was approximately $2500, which was included in the societal costs but not in the third-party payer costs.22 It was assumed that any macular pathology detected preoperatively would be referred to a retina specialist before surgery, and the patient would not receive a premium intraocular lens; however, patients whose diagnoses were delayed until after surgery would still have received a multifocal IOL.
As per the current literature, the majority of patients undergoing cataract evaluation had no macular pathologies (approximately 70-90.8%, Table 1). The most commonly detected concurrent macular pathologies were epiretinal membranes (ERMs, approximately 8.94%), age-related macular degeneration (7.18% ARMD), vitreomacular traction (VMT, 2.91%), and cystoid macular edema (CME, 1.47%) from diabetes or retinal vein occlusions (Table 1).8,10–13,23,24 Up to a third of ERMs may progress over time, but some patients may defer surgery; therefore, a more conservative 17.1% of patients with ERMs were assumed to undergo surgery, with 82.9% being observed.25 Similarly, the majority of those with vitreomacular traction were observed (75%), but a quarter underwent combined or consecutive vitrectomies with membrane peels. The majority (80%) with ARMD were non-exudative/dry and were started on Age Related Eye Disease Study 2 vitamins (AREDS2 vitamins) per the National Eye Institute recommendations, with approximately 10.5% progressing to exudative ARMD during the course of the study.26 It was assumed that the 20% with exudative ARMD would be treated with intravitreal anti-VEGF injections, initially bevacizumab every 1 month for 3 months, then aflibercept or ranibizumab every 1 month for 3 months, then treat and extended to every 12 weeks for the next 10 years. The majority of patients (87%) with new onset postoperative cystoid macular edema were treated primarily with topical steroids and topical non-steroidal anti-inflammatory drugs (NSAIDS), and the rest had persistent CME that required intravitreal injections. Of those with chronic CME from vein occlusions or diabetes, the patients were assumed to receive intravitreal bevacizumab every 1 month for 3 months, then aflibercept or ranibizumab every 1 month for 3 months, then treat and extended to every 3 months for 2 years, with some patients requiring supplemental steroids. The weighted cost of complications, including endophthalmitis, retinal detachments, and glaucoma were included in the calculations (Appendix).
For delayed diagnoses of epiretinal membranes and vitreomacular tractions, the option for a combined surgery with faster recovery was not available; however, the costs of sequential surgeries and the final visual acuities were the same. In general, it was assumed that the vision improved 2-3 Snellen lines after a membrane peel.25,27 As detailed in Table 1, a delayed diagnosis for most diseases had no significant effect on the final visual acuity. For wet ARMD and CME, however, the cost of a delayed diagnosis and intervention was assumed to result in slightly worse final visual acuity, based on previously published studies.28–30 The baseline risk of a subsequent intraocular lens exchange (CPT 66986) due to patient dissatisfaction was conservatively estimated at 0.1%,31 with an additional 0.05% increased risk due to missed retinal pathologies. Table 1 and Appendix summarizes the estimated costs and incidences.
Uncertainty was assessed with one-way deterministic sensitivity analyses and probability sensitivity analyses through Monte Carlo simulations using 10,000 second-order parameter samples. Parameter and structural uncertainty were assessed by varying the incidences and costs of multiple macular pathologies and incorporating data from several large studies. The societal willingness-to-pay threshold (WTP) was set at the lower $20,000/QALY, but the more commonly reported value of $50,000/QALY was also included, as recommended for comparison (Figure 2).32
Figure 2. Probability Sensitivity Analysis.
The stacked bar graph represents the probability of each intervention being cost-saving and cost-effective at different willingness-to-pay (WTP) thresholds from the societal perspective.
Results
In the base case of a 67-year-old male undergoing a preoperative evaluation for cataract extraction with a potential multifocal IOL, the addition of a screening OCT was cost-effective, and potentially cost-saving (dominated) for the ICUR analysis from a third-party payer and societal perspective (Table 2). The ICERs represented the increased cost per additional macular pathology detected ($1,071, range: $393 to $2,385).
Table 2. The cost-effectiveness of preoperative OCT for cataract surgery with a potential multifocal IOL in the base case with from the societal and third-party perspective.
The range was calculated from the extremes of the one-way sensitivity analysis. The preoperative OCT increased the overall costs, but it also increased the effectiveness. For the ICERs, the third-party and societal costs were the same.
| OCT Group | No OCT Group | Differences | Outcome | |||||
|---|---|---|---|---|---|---|---|---|
| Perspective | Cost (USD) | Effectiveness | Cost (USD) | Effectiveness | Incremental Cost | Incremental Effectiveness | ||
| ICUR | ICUR | ICUR range | ||||||
| Third-Party | $4,305 | 8.5899 | $4,290 | 8.5887 | $14.96 | 0.0012 | $12,467 | Cost Saving - $57,672 |
| Societal | $10,885 | 8.5899 | $10,882 | 8.5887 | $2.80 | 0.0012 | $2,245 | Cost Saving - $72,692 |
| ICER | ICER | ICER range | ||||||
| Third-Party | $3,206 | 0.205 | $3,182 | 0.183 | 24.16 | 0.023 | $1,071 | $350-$2,159 |
Key: ICER = incremental cost-effectiveness ratio, ICUR= incremental cost-utility ratio, OCT= optical coherence tomography, USD= U.S. dollars (adjusted for inflation to 2019)
The ICURs represented the increased cost of the OCT per change in QALYs accrued over time. In the PSAs for the ICURs from a societal perspective, the preoperative OCT was cost-effective in 64.4% of clinical scenarios, with 48.7% being cost-saving, assuming a WTP of $50,000/QALY (Figure 2). The one-way and probability sensitivity analyses were most affected by the costs of exudative and non-exudative AMD treatment, potential differences in the overall prevalence of underlying macular pathology, followed by variations in the proportion of delayed diagnoses.
In threshold analysis of the ICURs from a societal perspective, the model was cost-saving when the prevalence of macular pathology was increased to 23.2% or higher, and it was cost-effective even with a theoretical minimum incidence of macular disease of 10.7%, with a WTP of $20,000/QALY. If the prevalence of macular pathology was assumed to be 20.5%, then a screening OCT was cost-effective if at least 5.1% of previously undiagnosed macular pathologies were detected, and the preoperative OCT was cost-saving if 12.9% of occult pathologies were detected. The screening OCT was still cost-effective in the current model if the non-adjusted cost of the OCT was less than $90.00 and cost-saving below $35.70, with a WTP of $20,000/QALY.
Discussion
A comprehensive eye examination is an important component of the preoperative evaluation of cataract surgery; however, OCTs may further help detect macular pathologies, leading to earlier evaluation and treatment by a retina specialist and improved preoperative counseling. A preoperative diagnosis of macular pathology may lead a patient towards selecting a more adequate IOL, influence a patient’s decision to undergo a combined or consecutive surgery, and help set patient expectations of the postoperative outcomes. 11–13,24,33
In the base case of a 67-year-old male undergoing cataract evaluation for a potential multifocal IOL, the ICURs for a preoperative screening OCT were cost-effective and potentially cost-saving from the third-party payer and societal perspectives in the United States. The model was robust, with approximately 64.4% of clinical scenarios being cost-effective from a societal perspective with a willingness-to-pay threshold of $50,000/QALY (Figure 2). While the OCT increased the cost of the preoperative evaluation, the supplemental OCT theoretically detected an additional 11.0% of macular pathologies prior to surgery compared to a dilated fundus examination alone. Despite the increased costs, the slightly increased detection of disease resulted in decreased overall costs, slightly improved visual gains, and slightly improved QALYs for the patient over time. The greatest impact of preoperative detection was the money that the patient and society saved from deferring a multifocal IOL and from the potential savings of a combined rather than delayed surgery. For the majority of retinal diseases, including ERM, dry ARMD, and VMT, a delayed diagnosis did not affect the final visual outcome. For certain diseases like exudative ARMD and CME, however, the delay may or may not result in slightly worse vision; the visual outcomes were therefore varied in the PSAs to include no difference compared to prompt preoperative diagnoses.
The limitations of the current study include the theoretical nature and assumptions made in the model. The detection of retinal pathologies with a fundus examination assumed that a careful biomicroscopic examination was performed by an experienced ophthalmologist and that the combination of an OCT with a careful fundus examination would detect all visually significant macular pathologies; however, the sensitivity may differ with media opacities, different OCT machines, training institutions, or with different patient populations. The mean visual acuities were based on previously published literature, but variations in patients’ disease severities, patients’ responses to treatment, and physicians’ thresholds for treatment may result in different visual outcomes and treatment costs for individual patients;34–38 some patients may need more or less frequent injections or different medications. The incidences of the macular pathologies and costs of treatment were therefore varied in the PSAs, with more conservative estimates used in order to evaluate the model under different conditions. While the costs were estimated, they were similar to those of previously published studies. The estimated non-discounted third-party payer cost of a cataract surgery without a premium IOL in the current study ($5,4331.71) was similar to the previously published Medicare claims cost (adjusted for inflation) of $5351.27 for cataract surgery, and the cost of ERM surgery and ARMD were similar to previously published studies. 25,39,40 Due to the complexity of the current model, some diseases like macular telangiectasias or central serous chorioretinopathies were not included due to their relatively lower incidences, patients were assumed to have only one macular pathology, and cystoid macular edema was not differentiated into the underlying etiologies since the treatments for vascular occlusions and diabetes were similar. There were also certain factors, like patient satisfaction and future referrals, that were difficult to quantify and incorporate into the model. The determination of changes in QALYs was also based on a non-traditional method of visual trade-offs, which limits the comparisons with other medical specialties and limits the use of the standard willingness-to-pay thresholds. Furthermore, the current cost-effectiveness analysis was limited to the small percentage of patients with the resources for a premium IOL and did not apply to those without health insurance coverage or those receiving a standard monofocal IOL; the economic cost of a preoperative screening OCT for all patients considering cataract surgery with monofocal IOLs might be significantly different.
In conclusion, a screening OCT for cataract surgery evaluation with a multifocal IOL can be cost-effective and potentially cost-saving from a third-party payer and societal perspective in the United States. The decision to perform a supplemental OCT, however, should be tailored to the individual patient, considering their risks, preferences, and resource availability. Careful examination of the retina and preoperative detection of retinal diseases may help with preoperative counseling and lens selection.
Supplementary Material
Acknowledgments
Financial support: The study was supported by an unrestricted grant from the NIH Core Grant P30EY014801, Department of Defense Grant #W81XWH-13-1-0048, a Research to Prevent Blindness Unrestricted Grant, and an unrestricted grant from the Sid W. Richardson Foundation. The sponsor or funding organization had no role in the design or conduct of this research.
Footnotes
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Meeting Presentation: None
Taxonomies: Cost-effectiveness, cost-saving, cost-utility, optical coherence tomography, multifocal intraocular lens, cataract surgery
Conflict of Interest: No conflicting relationship exists for any author.
Address for reprints: 1977 Butler Blvd, Houston, TX 77030
Online Material: This article contains additional online-only material. The following should appear online-only: Appendix.
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