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Cataract surgeons recalibrate to treat presbyopia as vital issues loom
OSN Cataract Surgery Section Editor William F. Maloney, MD, looks at presbyopia correction, reimbursement issues.
Presbyopia correction is about to be baked into the refractive cataract surgery cake. This places surgeons on the verge of a series of challenges, the scope of which is not yet fully appreciated, in my view. The treatment of presbyopia will have a profound impact on every cataract surgeon, and at this critical juncture it is not clear that the outcome will necessarily be all positive. That depends on what we do from here.
The refractive expectations of our patients and the demands on the surgeon are about to jump by a quantum leap. My experience has taught me that success with presbyopia involves far more than reaching for one of the new “reading vision” IOLs from the consignment shelf. Recalibrating for the tighter tolerances demanded by presbyopia correction will be the most challenging transition for cataract surgeons since the shift from extracapsular cataract extraction to phacoemulsification 20 years ago.
We’re all refractive surgeons
The advent of the IOL just over 50 years ago eventually recast cataract surgery as a procedure that corrects not only obstructive impairment but also the refractive impairments of both ametropia and astigmatism.
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After steadily incorporating increasingly refined refractive improvements, today’s state-of-the-art refractive cataract surgery is arguably the most accurate means to correct a large refractive error. Is it any surprise that distance vision without glasses is increasingly the benchmark for successful cataract results?
Presbyopia correction is now about to be folded into this mix. The day is coming, likely more rapidly than most now anticipate, when this higher standard of refractive results is expected and cataract surgeons are required to address presbyopia over and above ametropia. I am convinced that we are not fully prepared for the surgical challenges and the inevitable impact on the financial bottom line.
We have allowed cataract surgery to become, de facto, a refractive procedure, and therein lies our dilemma. To anyone looking at the big picture, it is clear that the concept of refractive cataract surgery is a double-edged sword. For re.imbursement purposes, the cataract and refractive components of our surgery ought to have been clearly decoupled at the outset. Instead, the opposite occurred.
On the one hand, elevating refractive cataract surgery to the next level is to achieve our highest surgical goal. Reaching the Holy Grail of presbyopia correction is an achievement unmatched in the history of our profession. It was the ultimate goal of Ridley and Kelman and all of us who have followed in the trajectory of their vision.
However lofty and rewarding this achievement may be as a surgical accomplishment, it has profound and far-reaching financial ramifications that must be addressed. Thus far, that has not happened.
Reimbursing refractive component
Because the typical cataract patient increasingly expects full correction of distance vision, the origin of most malpractice claims for cataract surgeons now relates to a “refractive surprise.” As more and more patients approach their cataract surgery with implicit expectations of eliminating their need for distance glasses, a “surprise” is fast becoming any result that fails to meet that expectation.
Yes, we are all refractive surgeons now in every sense of the word, except one. We are still cataract surgeons only when it comes to reimbursement.
How did this happen? In retrospect, at least for those of us old enough to have been part of the process, it suddenly becomes jarringly clear. While steadily improving the refractive aspects of cataract surgery, we created an inflationary “bracket creep” of refractive expectations in the face of drastic reductions in reimbursement over the same period.
In retrospect, we probably squandered an important opportunity when we began to consistently correct ametropia. All of the additional refractive elements necessary to reduce dependence on glasses probably should have been presented to the patient as a value-added option from the outset. Now they are inextricable woven into the refractive cataract equation to stay.
Legal analysis under way
Perhaps we can be forgiven for not foreseeing the ultimate consequences of this refractive bracket creep. Like monetary inflation, from which my analogy is borrowed, it is so insidious and gradual that each minor monetary recalibration simply becomes the new norm. But this inflation steadily debases the value of the currency and is ultimately unsustainable. Somewhere ahead, a tipping point always looms.
With presbyopia, our own tipping point has arrived. If we allow this refractive bracket creep to debase the value of our surgery and envelop the highly valued treatments for presbyopia, then we have no one to blame but ourselves.
This is the rationale for our decision to highlight this as the most important issue we cataract surgeons face this year. Clear thinking and far-sighted leadership are vital. Sure-footed regulatory guidance is also essential as we address this issue.
Alan E. Reider, JD, OSN Regulatory/Legislative Affairs Section Editor, Allison Weber Shuren, MSN, JD, OSN Regulatory/Legislative Affairs Board Member, and their legal team at the Washington law firm of Arent Fox have agreed to review this issue and to help us negotiate our way through this process. They have been at work for some time now. Their final report will be published in Ocular Surgery News in early 2005. This will be one of the most important articles that you read in these pages this year.
Wavefront cataract
It is increasingly evident that Snellen acuity, even with some form of glare testing, is inadequate to assess the functional visual impairment resulting from the progressive lens changes that increase with age. Wavefront analysis is now being employed in the effort to address these anachronistic limitations.
Wavefront analysis is timely and important clinically. A pilot study from Sachdev and colleagues in a recent issue of Journal of Cataract and Refractive Surgery suggests that early lenticular opacities induce different specific wavefront aberration profiles. This may be an important first step toward viable new surgical criteria.
While this report measured wavefront aberrations of the entire eye, a similar study in which I am participating isolates lenticular aberrations and may provide a more specific correlation. This move toward a more functionally accurate definition of treatable cataract is important for cataract surgeons, and we will report on it as it unfolds.
From a broader perspective, however, it seems to me that while we attempt to reclassify those patients with early lens changes as having treatable cataract, we also need to be mindful that this makes having a viable answer to the refractive bracket creep dilemma that much more important.
Other important issues
Needless to say, this does not exhaust the list of important issues for cataract surgeons today. We have not forgotten the significant changes in phaco technology surrounding power modulation. The phaco technique continues to evolve, especially in regard to new approaches in soft lens removal. Improved instruments have made pre-chopping increasingly popular, as is the vertical quick-chop technique. We are planning to discuss them all in the coming months.
We also plan to report on the “wavefront IOL,” particularly in regard to the goal of removing spherical aberration from IOLs. It turns out this may not be advisable in every situation. Spherical aberration is likely the primary source of pseudoaccommodation, which is increasingly recognized as an important source of accommodative effect in lens implant presbyopia correction.
Although microincision cataract surgery may seem to be much ado about nothing, at least until some form of injectable IOL is effective, I am beginning to think that particular IOL technology is closer than many now believe. We will cover these issues as well in the months ahead. However, we intend to keep our primary focus on the critical issue of incorporating presbyopia correction into cataract surgery. In the end, if that dilemma is not resolved positively, I suspect none of these other issues will matter all that much.
Reider on compliance
In the December 1 issue of Ocular Surgery News, Alan E. Reider, JD, will discuss trends in regulation and compliance.
For Your Information:
- William F. Maloney, MD, an associate clinical professor at the University of California, Irvine, and head of Eye Surgery Associates of Vista, Calif., is a well-known teacher of cataract and lens-based refractive surgery techniques. He can be reached at 2023 West Vista Way, Suite A, Vista, CA 92083; 760-941-1400; fax: 760-941-9643; e-mail: maloneyeye@yahoo.com. Dr. Maloney has no financial interest in any ophthalmic product and has no financial relationship with any ophthalmic company.