Policy initiatives may create ophthalmology ‘manpower shortage’

William L. Rich III, MD, delivered this assessment at the AGS meeting. Here are the meeting highlights.

SARASOTA, Fla. — Health policy initiatives that discourage specialization have not only failed to reduce health care costs, but they will ultimately create a manpower shortage in specialties such as ophthalmology, according to a health policy expert speaking here.

Since the 1970s, health policymakers have attempted to control the cost of health care by rewarding generalists, said William L. Rich III, MD, secretary of federal affairs for the American Academy of Ophthalmology (AAO).

Ophthalmology is an example of the failures of these policies, he said here at the meeting of the American Glaucoma Society (AGS).

Data show that ophthalmologists are losing an increasingly greater market share of eye care procedures to optometrists, who benefit from Medicare reimbursements that encourage in-office procedures rather than surgical procedures, according to Dr. Rich.

He said that in ophthalmic practices in years past, established patients made up a steady 85% of the patient mix. But in the past 3 years, the percentage of established ophthalmic patients has fallen to 78%. This decline indicates that more patients are seeking routine care from optometrists, he said.

Specialists are particularly hard-hit during economic downturns, when patients are more likely to seek care from generalists, he added.

Ophthalmologists, meanwhile, are providing 8.6% more services per patient, he said.

These and other factors have contributed to a falloff in the number of medical students applying for residencies in ophthalmology, Dr. Rich said. If this trend continues, as the population ages patients will be faced with a shortage of trained ophthalmologists, he said.

Use of generalists instead of specialists does not necessarily reduce health care expenditures, Dr. Rich noted. Optometrists, for instance, are 10% more likely to bill for level 4 procedures than ophthalmologists.

“I think we have a bad business model,” he said, adding that reimbursement changes have created “de facto centers of excellence.”

Forensic consultants at risk

Before serving as medical experts in malpractice cases, physicians should be aware of the liability risks to themselves, said B. Thomas Hutchinson, MD, a board member of the Ophthalmic Mutual Insurance Company.

While most physicians called as expert witnesses or forensic consultants act responsibly, an increasing number of lawsuits are being brought against them, Dr. Hutchinson said here at the meeting. These lawsuits have ranged from claims of libel to medical misconduct, he noted.

In addition, forensic consultants might not be covered by their own malpractice insurance in these circumstances, he said.

Dr. Hutchinson advised physicians to familiarize themselves with the AAO’s ethics guidelines for expert witnesses before agreeing to testify in court.

He added that strategies to minimize risk include purchasing additional insurance coverage, gaining a complete understanding of the immunity privilege, seeking indemnification from accrediting and credentialing bodies and consulting with an attorney.

Dr. Hutchinson also noted that, in general, glaucoma specialists are much less likely to face medical malpractice suits than their cataract and refractive counterparts.

“It’s a chronic disease, and we follow our patients for a long time and they get to know us pretty well,” he said.

What follows are highlights from this year’s meeting.

Advances in diagnostics

Chris A. Johnson, PhD, who has studied automated perimetry since it was developed in the 1970s, delivered the AGS Lecture on recent advances in diagnostic tools for glaucoma.

“One of the things I think is very important is variability,” he said. “If you look at glaucoma in multicenter trials, you know that there’s a lot of variability … and this is something that has to be built into the evaluation of glaucomatous field loss.”

Dr. Johnson said glaucoma diagnostic tools must become more reliable, less variable, less cumbersome for patients and better in terms of sensitivity, specificity and validity.

He also acknowledged that diagnostic tests, especially perimetry, have made great strides in the past 30 years, allowing earlier detection of glaucomatous damage, faster results, better generation of predictive values and better monitoring of progression.

Keratoplasty and glaucoma

Careful and aggressive management of glaucoma is essential to avoid graft rejection in keratoplasty patients, said Ramesh S. Ayyala, MD, FRCS, FRCOphth.

The incidence of glaucoma in the early postoperative period after keratoplasty ranges from 9% to 31%; in the late postoperative period, the incidence rises to 18% to 35%, according to Dr. Ayyala. Patients face complications that include hypotony, graft rejection and vision loss, he noted.

“The reason why we miss glaucoma is because we concentrate so much on the cornea,” he said.

To reduce postoperative complications and graft rejections, Dr. Ayyala suggested that glaucoma patients undergo filtering surgery before keratoplasty; bleb revision can then be performed if needed during the corneal transplantation procedure.

In patients who develop glaucoma after keratoplasty, Dr. Ayyala said, surgeons should follow the standard glaucoma protocol, starting with medication, then moving to laser procedures and finally more invasive surgery.

While following keratoplasty patients, physicians must also take into account their irregular corneal surfaces when performing tonometry, he said.

Topical steroids, while important for controlling ocular inflammation, should be used in limited amounts to avoid corneal epithelial toxicity, he noted.

Glaucoma in American Indians

American Indians have a higher incidence of normal-tension glaucoma than white patients, according to results of the Northwest Trial Vision Project.

While vision loss is known to be the second leading cause of impairment and the sixth leading cause of disability for American Indians, the vision project is the first to calculate the incidence of glaucoma in this population, according to Steven L. Mansberger, MD.

The vision project included 289 participants at least 40 years old who were randomly selected from three tribes. All participants received a full physical examination and an ophthalmic examination that included refraction, perimetry using frequency doubling technology, measurement of limbal anterior chamber depth, confocal scanning laser ophthalmoscopy, nonmydriatic digital imaging and tonometry.

Patients with abnormal results and 30% of patients with normal results then underwent full dilated exams.

Investigators found that 31% of patients had a complete screening pass with no detectable abnormalities, 23% had diabetes and 11% had a visual acuity of 20/40 or worse.

None of the patients had an IOP greater than 21 mm Hg, and the mean IOP was 12.9 mm Hg. American Indian patients also had a higher cup-to-disc ratio than white patients, Dr. Mansberger said.

Portable imaging of Schlemm’s canal

A portable noninvasive ultrasound device can provide surgeons with valuable information about Schlemm’s canal, according to Richard A. Lewis, MD.

A limited ability to image Schlemm’s canal is one reason there has been “a lack of understanding and progress” in glaucoma surgery, Dr. Lewis said. He described a device developed by iScience Surgical Corp.

The 70 MHz ultrasound machine provides real-time feedback at a higher resolution than ultrasound biomicroscopy, he said.

Dr. Lewis and colleagues successfully scanned Schlemm’s canal in 26 of 27 patients. Scanning failed in one patient who was severely hyperopic, with an unusually small eye, Dr. Lewis said. The average exam lasted 4.6 minutes.

The device has the potential to increase scientists’ understanding of aqueous outflow, as well as to determine why some procedures work in certain patients but not others, he said.

He noted, for instance, that investigators found that Schlemm’s canal seems to shrink after surgery, perhaps because of atrophy from disuse.

“It’s a much more dynamic device than I had envisioned,” he said of the new ultrasound machine. “Hopefully in the years to come, we’ll have more understanding of the canal.”

5-FU success rates

Additional data released from the Collaborative Initial Glaucoma Treatment Study (CIGTS) suggests a role for antimetabolites in glaucoma surgery but also raises questions for investigators.

Paul R. Lichter, MD, reported that the CIGTS results suggest that the use of 5-fluorouracil (5-FU) during trabeculectomy is associated with a higher success rate in white patients than black patients.

CIGTS included 600 patients who were randomized to either surgery or medication. Of 284 patients who underwent trabeculectomy, 42% received 5-FU intraoperatively and 58% underwent the procedure without the use of antimetabolites.

With 5 years of follow-up, investigators found that the addition of 5-FU during surgery resulted in IOPs that were 5% lower than when no antimetabolites were used. Moreover, complications were less common in the 5-FU group, and the use of 5-FU did not appear to increase the risk of endophthalmitis, Dr. Lichter noted.

But he added that surgical techniques in the study were not standardized, and some surgeons were more likely to use 5-FU than others. Black patients also received 5-FU more frequently than white patients. Therefore, he said, some of the disparities may be attributable to center- and surgeon-specific differences, and further analysis of the data is necessary.

Electrosurgical trabeculectomy

Initial results with electrosurgical trabeculectomy are “encouraging,” and the procedure might provide a more affordable approach to glaucoma management, George S. Baerveldt, MD, told meeting attendees.

Dr. Baerveldt presented phase 1 data using the NeoMedix Trabectome, a 19.5-gauge electrosurgical device that is used to remove a strip of trabecular meshwork overlying Schlemm’s canal. The study included 19 Hispanic patients who were taking an average of 1.2 medications preoperatively.

Surgeons achieved success in 89.5% of patients, Dr. Baerveldt said. Only two eyes required a subsequent standard trabeculectomy, either because of IOP that was not controlled with two medications or because of recurrent hyphema.

All patients experienced transient hyphema, which usually resolved in the early postoperative period, according to Dr. Baerveldt. Other complications included localized Descemet’s membrane changes in 18% and transient localized nasal sub-Descemet’s heme in 14%.

Mean postoperative IOP, which was 26.2 mm Hg at entry, dropped to 18.9 mm Hg at 1 day postoperative and to 16 mm Hg at 4 months.

“I believe that the Trabectome studies are very encouraging,” Dr. Baerveldt said. He added that the relatively inexpensive procedure might be ideal for use in patients in developing countries.

Genetics fellowship

The AGS named Wallace L.M. Alward, MD, as the fifth recipient of an AGS clinician-scientist fellowship for his research in the molecular genetics of glaucoma.

In accepting the fellowship, Dr. Alward said the way in which researchers identify genes associated with glaucoma has moved from educated guesswork to a more statistical approach. The challenge for the future, he said, will be to further improve the mathematical formulas being used to this end.

“Finding the myocilin gene involved a lot of time and also a lot of luck,” Dr. Alward said, referring to the trial and error that went into discovering one of the genes known to be associated with glaucoma. “Today we prioritize genes based on what we think they do, but we’re often wrong.”

Douglas R. Anderson, MD, a founding member of the AGS and past president of both that society and the Association for Research in Vision and Ophthalmology, was named the guest of honor at this year’s meeting.

Interdisciplinary theme

The AGS meeting took an interdisciplinary approach this year – in more ways than one.

For the first time, the meeting featured minisymposia that looked at glaucoma in the context of a range of topics, from business and legal issues to cataract and refractive surgery.

This year also marked the first time that surgeons had the opportunity to share not only their glaucoma expertise but also their hobbies. Outside the meeting rooms, members displayed projects such as art and photography for their colleagues to peruse during breaks.