Puliafito: Next-generation, ‘spectral-domain’ OCT will enhance ocular imaging, diagnosis

The ASCRS Innovator’s Lecturer said technology will lead to the betterment of ophthalmology.

WASHINGTON – A next-generation optical coherence tomography system currently in development has the potential to produce cross-sectional imaging of the eye employing as many as 60,000 A-scans per second, said Carmen A. Puliafito, MD, MBA, speaking here.

“OCT enables us to assess our patients in a dynamic way – and the technology is only getting better,” Dr. Puliafito said at the American Society of Cataract and Refractive Surgery meeting. “In the near future, we will be able to assess in-vivo histology of the eye with higher resolution images, faster scans and larger data sets.”

Dr. Puliafito was honored this year with the Charles D. Kelman Innovator’s Award for his career achievements, including his co-development of optical coherence tomography (OCT) and his pioneering work in the clinical development of the Nd:YAG, diode and excimer lasers for ophthalmic use. He presented this year’s Innovator’s Lecture at the ASCRS meeting.

“It is a particular honor to be given this award,” Dr. Puliafito told Ocular Surgery News. “It is the first award that has been given since Dr. Kelman’s passing last year. Dr. Kelman was a friend of mine, someone who greatly encouraged my career in ophthalmology and ophthalmic lasers.”

Dr. Puliafito, who is the OSN Retina/Vitreous Section Editor, said that Dr. Kelman’s philosophy of striving against adversity and looking toward the future and modern technology to guide scientific advancements is crucial for the betterment of ophthalmology.

“Technology is an unstoppable force,” Dr. Puliafito said in his presentation. “The future of ophthalmology will illustrate that advances in technology produce advances in therapy.”

He said that current OCT imaging, which enables clinicians to correlate the structure and anatomy of the eye to functional visual problems, “drives” clinical decision-making for retinal, cataract and glaucoma surgeons. However, the time-domain imaging currently used, which was first developed by Dr. Puliafito and colleagues in the early 1990s, is just the first opto-electric imaging system developed for the eye, he said.

The next-generation model, on track to be commercially available in 2 years, will enhance in-vivo imaging of the eye by using spectral-domain technology.

“Spectral-domain OCT uses a camera to gather large amounts of information,” Dr. Puliafito said. “The image is a pictorial-like mapping of the macula, with depth and clarity, to help us better understand what is happening in the eyes of our patients.”

Binkhorst Lecturer looks ahead

A new cannula design for aspirating cortical material during phacoemulsification can improve fluidics by limiting aspiration during use of high vacuum settings, said Graham D. Barrett, FRACO, delivering this year’s Binkhorst Lecture.

“Intelligent tubing will allow our bimanual microincision phaco to become safer and more efficacious by increasing flow in the aspiration cannula without compromising chamber stability,” Dr. Barrett said.

Dr. Barrett, a cataract surgeon from Perth, in Western Australia, was the 2005 recipient of the Binkhorst Medal. His lecture was entitled “Improving safety and efficacy in phacoemulsification: a matter of balance.”

The cannula tubing proposed by Dr. Barrett is different from conventional tubing because it has a fluted, spiraling interior lumen, rather than the traditional cylindrical interior. The design creates more resistance to flow at higher rates of vacuum, he said, keeping the chamber stable during surgery.

“The tubing has a spiral interior, with longitudinal flutes arranged diagonally,” Dr. Barrett said. “This cross-sectional form adds resistance to gravity and produces a nonlinear flow.”

In the lecture, Dr. Barrett proposed other modifications of bimanual microincision phacoemulsification (MICS) that he said would add to the procedure’s safety and efficacy. He said a coaxial irrigation cannula with an elastic sleeve could enhance fluidics, while a coaxial phaco tip with a titanium sleeve might prevent wound burn.

Additionally, creating a microincision of 2.6 mm or smaller would help reduce leakage at the surgical site and reduce astigmatism, he said.

“An incision of 2 mm or less would produce a neutral astigmatism, but in achieving this goal we should not compromise our safety and efficacy,” Dr. Barrett said. He noted that while bimanual MICS is an exciting new surgical option, before adopting it surgeons should be sure that its outcomes match, if not exceed, those of coaxial phaco, to provide the best care for the patient.

ASCRS ‘Year of Inclusion’

“Inclusion” will be a theme for the ASCRS during 2005, incoming ASCRS President Roger F. Steinert, MD, proclaimed.

“Uncle ASCRS wants you!” he joked in his inaugural address at the meeting’s opening general session.

“We need to do a better job of including all our members in various ways and degrees,” Dr. Steinert said. He noted that ASCRS was to host a reception at the meeting specifically for first-time attendees and new graduates. Dr. Steinert said he hopes to facilitate an “idea generation” forum where younger and older ophthalmologists can freely discuss ideas, research and treatments.

The mission of ASCRS, he said, is to “advance the art and science of ophthalmic surgery and promote the quality of eye care.”

One new educational initiative Dr. Steinert described is e-learning. As part of this effort, abstracts from ASCRS meetings will be available online.

“We want to do more,” he told attendees. “Let us know what you want and how ASCRS can help you.”

Dr. Steinert noted that he was “deeply honored and equally humbled” in taking on the role of ASCRS president.

Outgoing ASCRS President Priscilla P. Arnold, MD, spoke about her year in office in a separate address. She said that during the year ASCRS members developed an increasing political awareness regarding the scope-of-practice issue now facing ophthalmologists nationwide. But the group’s accomplishments to date are not enough, she stressed.

“You need to be involved,” Dr. Arnold said. Two political issues of utmost importance to the membership remain Medicare reform and the introduction of “pay for performance” initiatives, she said.

Dr. Steinert likened the pay-for-performance issue as a “set of new clothes on the emperor.”

“It’s still payment reduction,” he said.

He also asked members to contribute heavily to EyePAC, the ophthalmic political action committee.

“Optometrists who makes less than you are contributing more than you” to lobbying efforts aimed at changing optometric scope-of-practice laws around the country, he said.

“The stakes have never been higher,” he said.

The opening session also included the induction of three new members into the Hall of Fame: Gholam A. Peyman, MD, noted for his work in vitreoretinal surgery and intraocular drug delivery; Jules Francois, MD, PhD, for his work in detailing the anatomy of the central retinal artery and the optic nerve; and Robert M. Sinskey, MD, for his research and development of J-loop IOLs and surgical instruments.

Senator calls for involvement

Physicians must become involved in politics and play a role in reforming the U.S. health care system, said a physician and senator who was a featured speaker at the meeting.

“I believe we need less government in health care,” said Sen. Tom Coburn, R.-Okla., who in addition to his duties in the Senate is also a practicing obstetrician.

“For the health of this nation, you have to make a difference,” he told the audience.

The first-term senator said the medical community should be driving the reform of Medicare and Medicaid, rather than the reverse — having changes in medical practice driven by government bureaucrats.

Sen. Coburn said physicians should be the ones outlining how best to achieve outcomes.

“Who knows about those things better than physicians? We need to decide that, not the government,” he said.

“We’re never going to solve this problem if you don’t become active with health care reform. We care most about patients and make a difference in people’s lives. It’s no longer possible for physicians not to participate in politics,” he said.

Sen. Coburn listed five goals physicians “need to insist on” in future negotiations regarding health care reform: an emphasis on prevention in health care, focusing on retention of health rather than treatment of disease; liability reform, to prevent the “negative drive on the economy” caused by the use of “defensive medicine”; real competition in the pharmaceutical industry; involvement of physicians in the determination of “best practices” rather than the government; and a return to individual responsibility of the physician in health care decisions.

Physicians should be more involved in liability reform efforts, Sen. Coburn said. In 2001, physicians ordered $130 billion worth of tests solely to protect themselves from potential liability, not for medical reasons, he said.

Patients should also be encouraged to take an active role in their health care, he said, referring to health care savings accounts.

McLaughlin Group debates

Change is coming to the U.S. health care system, and the Washington insiders who make up television’s McLaughlin Group gave attendees here a taste of what may be to come.

Members of Congress are already talking about changes to the Medicare Modernization Act, which was made law only 2 years ago, one member of the Group said. And the newly appointed head of the Centers for Medicare and Medicaid Services said he envisions changes in the mission of that agency, according to commentator John McLaughlin.

Mr. McLaughlin and other members of the McLaughlin Group debated health care, Medicare and economic issues in a lively session here at the meeting. The participants, in addition to Mr. McLaughlin, were Eleanor Clift, Lawrence O’Donnell, Tony Blankley and Pat Buchanan.

Much of the debate centered on possible changes in the Medicare program. The talk in Washington is that Medicare reform is necessary, but reform could mean cuts that would be painful for physicians and patients, said Ms. Clift.

She said that Sen. Bill Frist, MD, R-Tenn., and Sen. Ted Kennedy, D-Mass., have both said they are interested in relieving bureaucracy in the health care system. She also said that the Medicare Modernization Act of 2003, which introduced prescription drug discount cards and the prescription drug benefit slated to begin next year, may be revisited by Congress. It may be that the Department of Health and Human Services will be given the authority to negotiate better drug prices with manufacturers, a provision that was not included in the original plan, she said.

According to Mr. McLaughlin, the new administrator of the CMS, Mark McClellan, MD, PhD, foresees a different focus for Medicare in the future. Mr. McLaughlin said that in an interview he conducted with Dr. McClellan, the CMS administrator said that the government insurance program should focus on prevention of disease and promotion of health care, rather than curing disease.

“It’s hard to see how cost-containment will be part of [coming reforms],” Mr. McLaughlin said.

Mr. McLaughlin discussed some of the concerns that ASCRS has expressed in lobbying efforts in Washington, including the flawed formula for updating physician reimbursement.

“If the fee schedule remains as is, [physicians face a] 33% decrease [in reimbursement,] which is indefensible,” he said.

Also discussed was the Medicare pharmaceutical benefit scheduled to take effect next year. Mr. McLaughlin noted that the drug benefit, which may cost the government as much as $1.2 trillion over the next decade, according to one estimate — more than double the amount originally estimated — has recently dominated discussions of Medicare reform.

Panelist Mr. O’Donnell, who was a congressional staffer during President Bill Clinton’s attempt to reform health care in the 1990s, referred to that period several times in his remarks. He said current attempts at Medicare cost-containment are similar in many ways to the efforts undertaken in the ‘90s.

Ms. Clift said that, although the Clintons’ attempt to reform health care failed, it may be that pressure from the aging baby boomer generation will produce a better result from current efforts.

“Democracy has trouble reacting unless there’s a crisis,” she said.

The baby boomer generation’s large population will be a problem for Medicare, Mr. McLaughlin said.

Few perceive HIPAA’s value

Only 17% of patients believe the federal medical privacy laws are of value, according to results of a small survey.

Ralph Falkenstein, MD, said 83 patients were given a survey when they checked in at an ophthalmologist’s office. They were questioned about what forms they filled out, what the Health Insurance Portability and Accountability Act (HIPAA) is and what the HIPAA laws do.

“Only 49.4% knew that HIPAA was about a privacy issue,” Dr. Falkenstein said.

Dr. Falkenstein also found that 85.4% of those surveyed did not read the information they were given about HIPAA. He said 64% of the respondents said they “look at HIPAA as just another form to sign.”

He said that these findings are consistent with other published surveys on patients’ attitudes toward HIPAA.

Lifetime Achievement award

Richard L. Lindstrom, MD, received Bausch & Lomb’s Lifetime Achievement award at ASCRS. The award ceremony, held at the Ronald Reagan Building, preceded a reception in his honor featuring a performance by Motown recording artists the Temptations.

In an interview with Ocular Surgery News, Dr. Lindstrom said of this award, “One of my personal goals is to be an industry advocate. I’m a firm believer that the physician can’t do it alone, and industry can’t do it alone. I have been able to work collaboratively with industry. It’s been good to be able to get useful technology to market and to be able to help people. It’s been a positive experience.”

Dr. Lindstrom is Chief Medical Editor of Ocular Surgery News.

Data on ASCs needed

Ambulatory surgery centers may be better able to lobby for changes in fees and procedures if they align themselves with hospitals in these efforts, said Michael Romansky, JD.

ASCs are growing in popularity, noted Mr. Romansky, a lobbyist for the Outpatient Ophthalmic Surgery Society. He spoke here at the annual meeting of the OOSS, held during the ASCRS meeting.

In the past 10 years, Mr. Romansky said, the number of ASCs in the United States has grown from several hundred to several thousand. But in spite of the growth of their patient base and increased patient satisfaction, ASCs have been “punished” for this success by the Medicare Payment Advisory Panel, Mr. Romansky said. MedPAC has instituted a 5-year rate freeze on ASCs, using rates initially based on data from a 1986 study, he said.

ASC owners need to become more involved in educating Congress and the public, Mr. Romansky said.

“We don’t have data to support our claims that we save the government money,” he said.

ASCs should also think about partnering with hospitals to lobby Congress for fairer fees, he said.

“Hospitals get updates every year. [It would be] more likely for ASCs to get annual updates [through] joint lobbying by hospitals and ASCs,” he said.

ASCs have much to gain by these efforts, including the recovery of some 288 procedures deleted in 2003 by the Center for Medicare and Medicaid Services, Mr. Romansky said. Ideally, ASCs should not have a list of allowed procedures but rather a list of procedures that should not be performed in the center, he said. He added that an end goal should be to preserve physician ownership of ASCs.

“We are going to change the regulatory system,” he said.