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Baby boomers, ‘Gen Y’ to drive refractive surge
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NEW YORK – As baby boomers begin moving away from LASIK and into the premium IOL market, preliminary data indicate that lens-based refractive surgery could eventually become the second leading elective medical procedure in the United States, according to a surgeon.
 Steven J Dell |
LASIK numbers have been declining slightly in recent years. However, “Gen Y” — the 20- to 30-year-old children of baby boomers — is expected to significantly boost the number of patients seeking LASIK. The same is expected for older patients moving to IOLs, Steven J. Dell, MD, told attendees at the OSN New York Symposium.
“This is about the best that you could possibly hope for,” he said.
If only 20% of the cataract market goes premium, this will become the No. 2 elective medical procedure in the United States, he said.
New data indicate that 10% to 30% of Medicare patients want premium IOLs; in pre-Medicare patients, statistics are closer to 50%, Dr. Dell said.
“We also have the No. 1 procedure, which is LASIK, so we can’t complain, although we often do,” he said.
These items appeared originally as daily coverage from the meeting on OSNSuperSite.com. Look for more in-depth coverage of these and other topics in upcoming issues of Ocular Surgery News.
Mixing lenses may enhance refractive performances
Paired and matched presbyopic lens exchange technologies are not sufficient to satisfy all optical needs, but mixing presbyopia-correcting lenses can significantly enhance postoperative performance, J. Trevor Woodhams, MD, said.
Because the patient population is aging and starting to experience visual problems, baby boomers are going to expect the same type of outcomes from lens-based refractive surgery that they have seen for the past decade with LASIK, Dr. Woodhams said.
“That means the ante is up, and we need to deliver that level of correction,” he said.
Dr. Woodhams said surgeons today are looking for an ideal IOL that is minimally affected by different lighting conditions and offers crisp resolution, excellent distance acuity, variable magnification and performance that does not depend on pupil size.
“The crystalens (eyeonics) gives excellent distance vision night to day,” he said. “The ReSTOR (Alcon) also provides excellent vision, especially in the daytime, and the aspheric is even better.”
However, determining a patient’s worst complaint is the biggest variable when considering mixing lenses, he noted.
Toric IOLs offer greater efficacy for treating regular astigmatism
A new generation of toric IOLs now offers more precise correction for regular astigmatism because of sophisticated vector analysis software, which refines IOL power calculations and improves postoperative axis alignment, one surgeon said.
 Warren E. Hill |
Warren E. Hill, MD, said toric IOLs work best in patients with regular astigmatism. The main advantage of such IOLs over other lenses is that they solve accuracy problems by providing a more precise refractive correction.
“That’s where the toric lens really shines,” Dr. Hill said.
In comparing the lens with LASIK and limbal relaxing incisions, Dr. Hill said toric lenses are more stable and provide better, more precise astigmatic corrections. Limbal relaxing incisions lack precision, while LASIK often requires a second surgery and is more expensive, he said.
“With this new generation of toric IOLs, we can actually keep our promise to patients about precise correction. … They are the first choice of lenses in my practice for correcting corneal astigmatism,” Dr. Hill said.
Calculating risk key to determining who develops glaucoma
Risk calculators can be a useful tool for assessing the risk of developing glaucoma, according to a surgeon.
“If we can assess risk and really identify high-risk patients, we can hone our treatments to people who would most likely benefit. We have to think of people as individuals and what their risk is of developing glaucoma. What is this patient’s risk of developing not only glaucoma, but developing a visual disability?” Jody R. Piltz-Seymour, MD, said.
A model for risk calculation was created based on findings from the Ocular Hypertension Treatment Study, which identified several risk factors for glaucoma, including older age, higher IOP, thinner corneas and a higher standard deviation on visual field testing, Dr. Piltz-Seymour said.
She noted that after years of minimal-to-modest innovations in glaucoma surgery, researchers are now at the forefront of developing surgical treatments for glaucoma.
Two of the most promising are the Trabectome (NeoMedix), a handheld device with a 75% long-term success rate that is inserted through the clear cornea to the anterior chamber and protects the inner wall of Schlemm’s canal, and the Solx Gold Shunt, which drains fluid from the anterior chamber into the suprachoroidal space.
“We are now on the forefront of having efficacious surgeries with much better safety profiles,” she said.
Combining procedures may reduce vision loss in some cases
Because elderly cataract patients often are at greater risk of vision loss from glaucoma, ophthalmologists must decide whether a combined procedure is warranted for the individual patient, according to one surgeon.
Cataract surgery performed alone has many advantages, including lowering IOP, Bradford J. Shingleton, MD, said.
“Clearly we get the fastest rehabilitation [from phaco]. A single procedure is easiest and shorter, and there will be fewer [incision-related] complications,” Dr. Shingleton said, noting that glaucoma surgery can still be performed at a later time.
Phacoemulsification has some drawbacks, though. It can result in early postop IOP increases and provide less IOP control compared with glaucoma surgery. It may also affect future glaucoma procedures, he said.
However, some glaucoma patients who are at a greater risk of vision loss can benefit from combined procedures. Such patients include those who are younger, those who are using more than three glaucoma medications, those with allergy or tolerance issues, those with significant cupping and visual field loss, and those who cannot tolerate two separate procedures.
“All these things have to come into consideration when we operate on our patients,” Dr. Shingleton said.
Maintaining balanced fluidics key to successful small-incision cataract surgery
As the trend in cataract surgery moves toward increasingly smaller incisions, surgeons should expect additional challenges related to working through the narrower entries, according to Uday Devgan, MD, FACS.
“The bottom line is, we are going to move toward smaller and smaller incisions,” Dr. Devgan said. “Smaller incisions mean smaller tubing and what I call the ultimate small-incision surgery using 25-gauge flow.”
“The only problem is that it is really small because we are using such small incisions, so the challenge is that you are working in a very tight space,” he said.
Although basic phacoemulsification systems are straightforward to use, such devices may not provide adequate protection against post-occlusion surge when using high vacuum levels unless the surgeon uses a special phaco tip that allows for aspiration bypass.
Phaco fluidics is particularly important in small-incision surgery because it essentially determines the safety of the procedure, Dr. Devgan said. Thus, surgeons must decrease fluid outflow to maximize efficiency, he said.
Because tubing sizes make a big difference, Dr. Devgan recommended keeping inflow bottles high to maintain a reasonable inflow rate. Also, using smaller tubing to restrict outflow can help prevent surge and improve stability, he said.
Maintaining balanced fluidics is one of the keys to successful surgery, he noted.
“To decrease that surge and [improve] efficiency in the eye, just make sure you are keeping the inflow [rate] significantly higher than the outflow,” Dr. Devgan said.
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Surgeon: Femtosecond laser delivers superior outcomes, improved vision
Femtosecond laser flaps combined with custom ablation offer patients dramatically superior outcomes, better uncorrected visual acuity and improved quality of vision, according to a speaker.
“One of the concerns we have when we do LASIK is complications such as buttonholes, incomplete flaps or large abrasions,” Eric D. Donnenfeld, MD, FACS, said. “These complications create issues for all of us when we use a keratome.
“Since I have started using the IntraLase femtosecond laser (Advanced Medical Optics), these [issues] have essentially disappeared and the issue of safety has been extraordinarily better,” he said.
According to Dr. Donnenfeld, flap creation with the IntraLase femtosecond laser addresses safety concerns such as epithelial ingrowth. Other advantages include thin and uniform flaps that create improved biomechanical stability, have a lower risk of ectasia and help maintain overall structural integrity of the eye. Femtosecond lasers cut thin, planar flaps with a more precise depth and predictable diameter, while the microkeratome cuts deep in the periphery, with poor diameter and centration control, he said.
Recent studies also support the Intra Lase as offering better predictability, which results in lower enhancement rates, Dr. Donnenfeld said. “That is something we strive for as refractive surgeons,” he said. “You want lower enhancement rates. Lower enhancement rates mean happier patients and happier surgeries.”
Dr. Donnenfeld said he believes that femtosecond lasers will eventually replace the microkeratome during the next evolution in refractive surgery.
“As far as safety is concerned, the femtosecond, in almost every regard, is significantly better than the microkeratome. For me it is not a question of whether it is better. The only question is when, and it will clearly happen over the next several years. The microkeratome as we know it will essentially cease to exist,” he said.
Be aware of legal rights during an investigation
It is critical for ophthalmologists to know how they and their staffs should respond in case they ever come under investigation, and many are unaware of their rights, Alan E. Reider, JD, said.
Mr. Reider, who has defended many ophthalmologists in court cases after raids of their offices, discussed how surgeons can respond to search and seizures. Although physicians have a right not to speak to agents, they should never instruct their staffs not to cooperate during an investigation because they can be charged with obstruction of justice for impeding a federal investigation, he said.
“I have been in practice for 27 years, and this happens occasionally,” he said. “Right now it is happening a lot, and it is very disturbing. From my discussions with clients, they really don’t know what to do.”
Office staffs, however, are not required to speak with authorities even when presented with a subpoena, he said.
“The only time you as an individual or anyone else for that matter are required to speak is if you are subpoenaed to appear before a grand jury or a trial. Even then you have something called the Fifth Amendment, which allows you not to speak and incriminate yourself,” Mr. Reider said.
Physicians have 30 days to respond to a subpoena. During that period, they may consult with an attorney, who will advise them on the best procedures to follow. In instances in which a search warrant is presented, however, physicians have no choice but to cooperate and release patient records.
“A search warrant is a very serious proposition,” Mr. Reider said. “Sadly, a number of your colleagues have gone through them, and it is totally disruptive. Because documents can be altered, the government feels that if they wait 30 days, they won’t be the same. It is a horrible situation, and you won’t have a choice. Do not get in their way. It is classic obstruction of justice.”
Legislation seeks to restrict some billable services
Congress has introduced legislation that will create significant changes in how surgical practices will be conducting business in the coming year. Specifically, it is proposing restrictions on services physicians bill outside their areas of expertise and planning to make changes to current Medicare laws, according to Allison Weber Shuren, MSN, JD.
Congress has proposed changes to the Stark Law. The law seeks to prevent physicians from referring patients for services in which the physician has a financial stake. The changes to the law seek to further limit physicians referrals when those physicians have a stake in leased property and equipment.
“In the past, the government has said we’re going to allow you to do those leases,” she said. “‘I will rent you my laser and refer patients and the hospital will pay me rent based on the amount the laser is used.’ It makes the risk of taking on that laser more palatable. Sometimes the lease is more favorable for the physician, but the government has proposed to take that away.”
The government is also proposing legislation that will restrict the ways that physicians can be paid on percentage-based compensation and is looking to limit certain in-office ancillary services, such as radiology and pathology.
In addition, hospital associations are urging Medicare to evaluate ASC coverage because of concerns that physicians are moving outside of their specialty areas.
“The government is getting very nervous that physicians are moving outside their scope of specialty practice areas by bringing in services they are billing for but really aren’t within their expertise,” Ms. Shuren said. “They have asked for commentary within the industry as to how they can limit this.”
A note from the editors:
To facilitate bringing news to readers rapidly, for OSN SuperSite articles and meeting wrap-up articles, OSN departs from its editorial policy and typically does not send these items out for source corrections.