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Refractive surgery a major force in cornea practice
In this report, OSN’s Cornea/External Disease Section Editor looks at the trends affecting cornea practices.
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Refractive surgery continues to have a profound impact on ophthalmology and an especially notable effect on cornea practices. Although there is an increasing spectrum of techniques, more than 95% of refractive surgical procedures are cornea-based. Hence, the complications, apart from optical variations, remain corneal. We have become increasingly familiar with such problems and have had to develop new management strategies.
There is an ever-increasing number of patients who have undergone refractive surgery, such as radial keratotomy or keratoplasty. In addition, there is an increasing necessity to perform additional refractive surgery in eyes that have had prior corneal surgery. Finally, we are witnessing an explosion in the area of refractive lens surgery. All of these lead to the fact that refractive surgery is no longer a one-technique and one-technology-driven procedure; instead, there is a much larger menu of available options.
With experience comes better judgement and better defined limits for specific refractive procedures. There are appropriate procedures to be performed for various refractive errors and age groups, and this has broadened dramatically in the last 5 years and probably will trend in that direction further.
Refractive surgery today remains predominantly corneal surgery, and the complications require particularly skilled corneal management. A significant challenge for refractive and corneal surgeons is corneal surface epithelium at the interface of a LASIK flap. Other ocular surface diseases, especially LASIK-induced neurotrophic dry eye, are prevalent. Although we have new technologies to reduce these conditions, we need to employ current strategies in dealing with many aspects of ocular surface disease, which are temporarily worsened or precipitated by LASIK.
It is also increasingly important to recognize the presence of ocular surface diseases and keratoconus in patients who are prospective laser vision correction candidates. Experience and new technologies will assist us with these patients.
New technology, treatment
| Lindstrom’s view |
| Twenty-five years ago, I was an extraordinary outlier when, as part of my training, I did a year of cornea, then 6 months of advanced cataract and 6 months of glaucoma, thus possibly starting the first anterior segment fellowship in the country. I was almost disowned by my cornea colleagues. Now most fellowships teach cataract, cornea, glaucoma and refractive. My partner, Tom Samuelson, is a glaucoma/cataract/refractive surgeon. Ten or 20 years ago, it was not that way. It is interesting how we were first trained to be broad, then we specialized, and now we are coming back to surgeons being broad in their training and practices. That is the biggest megatrend in ophthalmology that I’ve seen. Another possible trend is that the advent of phakic IOLs and accommodating IOLs is going to move corneal refractive surgeons from the laser room back into ASCs again. Richard L. Lindstrom, MD |
In terms of refractive surgery, the impact of wavefront customized ablation is inevitable. The real question is at what cost, and how will this evolve and affect the important market and economic factors?
The use of new microkeratomes and IntraLase FS laser has major implications for the performance of lamellar keratoplasty and other intracorneal procedures. The emergence and increasing popularity of the surface ablation procedure variations, such as LASEK, have with it their concomitant need for surface management, which is again within the purview of corneal and external disease.
Of particular interest to traditional corneal specialists is the application of Intacs inserts from Addition Technology Inc. for select cases of keratoconus. Also, customized ablation with the LASEK technique will allow us to avoid the invasive, expensive, long-term risk procedures such as penetrating keratoplasty in selected keratoconus patients.
As far as corneal transplantation, the U.S. market for keratoplasty procedures remains flat, with about 40,000 procedures performed a year. However, as with everything else, the costs, particularly of eye banking, have increased. In some areas, material procurement is as high as $2,000 per donor cornea, and reimbursement continues to decrease.
The resurgence of lamellar keratoplasty is an interesting development. It is a small niche to play in, but both deep anterior lamellar keratoplasty and posterior endothelial replacement lamellar keratoplasty are new waves. And now our ability to apply microkeratomes or the IntraLase laser is fascinating for the potential applications to both lamellar and penetrating keratoplasty and other stromal corneal surgical procedures.
Ocular surface diseases
The list of medications available for the treatment of ocular surface diseases is extensive. We have new fluoroquinolones, steroids, nonsteroidal anti-inflammatory drugs and a potpourri of allergy medications with multiple mechanisms, many of which are synergistic. There are more than a dozen glaucoma medications in many classes, thus decreasing the necessity for traditional glaucoma surgeries.
And with the Food and Drug Administration approval of Allergan’s Restasis (cyclosporine), there is a truly novel approach to the treatment of dry eye. Other products along the same immunosuppressive line are under development. Topical androgen therapy is likely the next advance on the horizon.
The downside of these multiple medications, which are often taken simultaneously, is the risk of toxicity and allergy. These medications may even produce limbal stem cell deficiency. My plea to U.S. ocular pharmaceutical companies is to manufacture more preservative-free medications.
It has taken 20 years to recognize so-called limbal stem cell deficiency problems. With it, we have evolved strategies for the promotion of healing of persistent epithelial defects and reconstruction of the ocular surface for example with an amnion membrane graft overlying a corneal transplant. Combining corneal transplant surgery and ocular surface surgery in high-risk cases has greatly improved the prognosis in our clinical outcomes.
Factors influencing practice
The economy and the current legal environment are affecting our practices, as does our increasing practice efficiency and ability to deliver safer, more rapid surgeries.
I believe that in our subspecialty, “stocks” are up. There is a rebound in refractive surgery volume with decreasing marketing costs. However, depending on the market, there is the equally important increased cost of acquiring new technology. This is highly market-sensitive and specific.
However, “bonds” are also way up. There is an increase in cataract volume as part of a predicted trend of the aging population, moreover we have the ability to deal with it in a far more efficient manner as technology and ASC-style surgical performance have been greatly enhanced. This allows me more time to devote to my personal professional philanthropy, the poorly reimbursed for traditional corneal and external disease practice.
Finally, I think there is a clear trend away from the “sub-subspecialist” niche that developed 20 years ago when all of us who did cornea were afraid to do cataract because it would affect our referral patterns. Now many surgeons have “compleat” anterior segment practices. We do cornea, cataract, refractive and some even do glaucoma.
All of these techniques and technologies and the overlaps of cornea/refractive/cataract demand the proverbial “man for all lesions and seasons” approach. We are starting to see that shift as well in the organization of our residencies and fellowships. For specific example, there is no cornea fellowship that calls itself legitimate these days that does not have equal emphasis given to refractive surgery.
Wallace on ASCs
The August 15 issue will feature R. Bruce Wallace III, MD, OSN’s ASCs Section Editor, discussing the impact of ambulatory surgery centers in ophthalmology.
For Your Information:
- Kenneth R. Kenyon, MD, can be reached at Eye Health Vision Centers, 51 State Road, North Dartmouth, MA 02747; 508-994-1400; fax: 508-992-7701; e-mail: kkenyon@compuserve.com.