Technology, industry cooperation heralded by new ASCRS president

SAN FRANCISCO – It is “absolutely critical” for physician associations to help their members educate themselves regarding new technologies, said the incoming president of the American Society of Cataract and Refractive Surgery.

Samuel Masket, MD, incoming ASCRS president, asked physicians to educate themselves regarding new technologies. Image: Mullin DW, OSN

In his inaugural speech as ASCRS president, Samuel Masket, MD, said his tenure will reconfirm that imperative.

“It is a given that ASCRS has always served as a melting pot for new ideas, and we recognize the global nature of ophthalmology, which affords us all a sharing of knowledge and expertise,” he said here during the opening ceremony of the annual ASCRS meeting.

Dr. Masket acknowledged the work done by ASCRS and its international partners to help develop and investigate new ophthalmic products. He noted that the Food and Drug Administration now accepts data from offshore international studies as part of the premarket approval information submitted for new products.

Dr. Masket said that many members “remain concerned” about the potential influence by device makers and pharmaceutical companies on the practice of medicine.

“We must recognize that industry and ophthalmology have a crucial partnership, particularly when it comes to development of devices,” he said. “The reality is that surgeon and physician leaders, working with industry, have brought us extraordinary products and procedures that benefit our patients, allow us to expand our services, and yes, add to our practice revenues.”

Dr. Masket said one of the focal points of his tenure will be dealing with the “pay for performance” initiatives facing ophthalmologists and all of medicine.

“To participate in this program, our practices will need to make large ‘voluntary’ investments in information technology and electronic medical records. However, our presently flawed physician payment system … must be fixed at the same time,” he said.

Outgoing ASCRS president Roger F. Steinert, MD, in his remarks at the session, reminded members of the successful effort by the society to repeal the 4.4% reduction on Medicare reimbursement that had been slated for 2006.

More presentations from ASCRS are highlighted in the remainder of this article. Many of these items appeared first on OSNSuperSite.com as daily reports from the meeting.

Maximizing memory, brain function possible, physician says

People can help improve their memory function and may be able “to stave off memory loss and Alzheimer’s disease,” said Gary W. Small, MD, who delivered the Manus C. Kraff Lecture on Science and Medicine. Dr. Small is a renowned physician, neuroscientist and psychiatrist who leads an internationally recognized aging and memory research team, according to ASCRS officials.

“What someone can and can’t do to delay memory loss has a lot to do with genetic makeup,” Dr. Small said. In his work at the UCLA Memory Clinic, he found thatgenetics accounts for about 33% of a person’s risk for developing Alzheimer’s disease. He added that women who use Premarin (conjugated estrogen, Wyeth) after menopause have an increased likelihood of developing Alzheimer’s disease.

Mild memory impairment – such as forgetting why you went to the refrigerator – tends to start in a person’s 50s, Dr. Small said. Mild cognitive impairment – such as forgetting keys or events – tends to start in someone’s 60s or 70s, and Alzheimer’s has a typical onset when someone is in their 80s, he said.

In the near future, “maybe 10 years from now,” science will have advanced to the point where brain health tests will be as common as cholesterol or blood pressure tests are today, Dr. Small believes. Current drugs on the market slow the progression of Alzheimer’s but do not prevent the disease. Supplements such as Ginkgo biloba or curcumin (turmeric root) are under investigation, but they have yet to be proven to improve brain health, he said.

Naproxen, an anti-inflammatory drug, has been shown in rat studies to bind to FDDNP, a protein associated with Alzheimer’s.

“We think we can predict what a patient’s brain will look like 2 years down the road,” he said, based on the amount of FDDNP activity in a person’s brain at baseline.

“So, what can we do right now to improve brain health?” he asked.

Four basic activities may help prolong the onset of cognitive impairment: stress reduction, physical activity, healthy diet and mental activity.

“People who are physically active have more memory cells and an increase in hippocampal cells compared with sedentary people,” he said. Moderate caloric intake, coupled with antioxidants, omega-3 fatty acids and low-glycemic-index carbohydrates may be beneficial as well.

He also advises people to incorporate the “Look, Snap, Connect” as often as possible.

“Look at something to focus your attention. Snap – take a mental snapshot of the item of focus. Connect the two together,” he said. Make up a story to help remember and to improve brain activity.

He said if all people did “just one thing on that list, within 5 years there would be 1 million fewer cases of dementia.”

The Manus C. Kraff Lecture on Science and Medicine was established as a forum for expanding and enriching appreciation of fields of science and medicine outside of ophthalmology.

Lane: Convergence of cataract and refractive surgery a reality

Until recently, ophthalmologists viewed cataract and refractive skill sets as separate, but the two are now converging, said Steven S. Lane, MD, who delivered the Binkhorst Lecture.

“This convergence is a bridging of skill sets and mindsets,” he told attendees. He likened it to “a merger of Barraquer and Kelman.”

The future holds many options for the refractive surgeon, Dr. Lane said.

“I believe refractive lens exchange is the future of refractive surgery,” he said, and the key to its success is careful patient selection.

“We, as surgeons, need to undersell and overdeliver” on the promise of improved near and distance vision, he said.

To achieve that goal, Dr. Lane said, new general IOL calculation formulas and a different approach to patient outcomes will be needed.

“How are we going to measure success in the future?” he asked. “I think we’ll move away from 20/20. Metrics will be more subjective, where success will be defined by less spectacle dependence, a ‘20/happy’ patient and quality-of-life surveys.”

Other trends Dr. Lane sees influencing the convergence are the use of less ultrasound energy and higher vacuum power in phaco machines; these trends make phaco “ideal” for refractive lens exchange, he said.

Heralding May 9, 2005, as the “best day in ophthalmology,” Dr. Lane spoke about the directive issued that day by the Centers for Medicare and Medicaid Services that allowed patient-share billing for presbyopia-correcting IOLs.

While the approved IOLs that were affected by that ruling – eyeonics’ crystalens, Advanced Medical Optics’ ReZoom and Alcon’s ReSTOR – have advantages in restoring near and distance vision for patients with presbyopia, there are disadvantages to each technology as well, he said. These include a potential for decreased contrast sensitivity and a potential for low-grade glare and halo, he said.

“Pupil size determines the outcome,” Dr. Lane said. Patients with small or large pupils may have decreased vision after implantation of some of the lenses, he said, and surgeons must be meticulous in their patient selection.

He also said surgeons must understand and explain neural adaptation to their patients. “Patients see better after 1 year with these lenses than after several weeks,” Dr. Lane said. “We’re just now starting to understand neural adaptation.”

On the horizon, Dr. Lane said, ophthalmologists should expect to see lenses that truly accommodate by changing their power rather than their position. He specifically referred to the NuLens accommodating IOL, the Synchrony IOL and Calhoun Vision’s Light Adjustable Lenses as potential innovators in that arena.

“The bar for visual rehabilitation has been raised,” he said. “I believe in the future we’ll be able to customize individual IOLs on a patient-by-patient basis.”

As a group, he said, surgeons may initially be mistrustful of new technologies, but he said it is his belief that accommodating lenses will eventually benefit all sectors.

“Who are we going to use these on? The patient will be under 65 years old,” he said. Because that patient will not be covered by Medicare, the surgeon will be more fairly reimbursed, Medicare will not be involved in setting rates, and industry will be rewarded as well, he said.

“It’s time to stop thinking about it, and time to just do it,” he said.

The Flomaxinators take the cataract Challenge Cup

A funny and informative presentation on how to manage intraoperative floppy iris syndrome was a winner at the annual Challenge Cup cataract session.

In the Challenge Cup, teams of outrageously dressed ophthalmologists compete to give the most amusing and informative presentations on cataract and refractive surgery. This year’s competitors in the cataract competition were the Flomaxinators vs. the Knights of See-a-Lot. The event was moderated by “referee” Roger F. Steinert, MD, and the winners were voted on by the audience.

The Flomaxinators – David F. Chang, MD; Robert H. Osher, MD; Samuel Masket, MD; I. Howard Fine, MD; and Kuldev Singh, MD – all dressed in Harley Davidson jackets, and modeled themselves after Arnold Schwarzenegger’s character in “The Terminator.”

Their presentation, on “terminating” complications during cataract surgery in patients taking Flomax (tamsulosin HCl, Boehringer Ingelheim) for treatment of benign prostate hyperplasia, was the winner in the debate on cataract challenges. Voters in the audience said they thought the team imparted valuable practical scientific information about handling intraoperative floppy iris syndrome (IFIS) as a result of Flomax use.

The competing team, the Knights – Randall J. Olson, MD; Nick Mamalis, MD; Y. Ralph Chu, MD; and William J. Fishkind, MD – discussed complicated cataract removal in their skit-presentation.

The Flomaxinator team said surgeons can use a variety of methods to prevent or manage IFIS. Dr. Osher said ophthalmic viscosurgical devices such as Healon 5 (sodium hyaluronate, Advanced Medical Optics) can be used to prevent iris prolapse in these cases.

Dr. Fine recommended using the Morcher pupil expansion ring to manage the floppy iris. He said the ring expands the pupil and prevents iris prolapse.

“You can decenter the ring for easier removal,” he said.

Dr. Chang noted that other rings are also available that might work as well.

Dr. Singh recommended the use of iris hooks to stabilize the iris. He said the hooks are flexible, making them easy to remove, and they can be autoclaved, which helps reduce the cost of surgery.

Dr. Masket discussed the use of pharmaceutical agents, such as atropine, to prevent IFIS in patients taking Flomax.

“Use pharmaceuticals to manage the potential problems, and if that fails, use devices,” he said.

Dr. Chang described a retrospective study of 167 patients taking Flomax who had undergone cataract surgery with the use of one or more of the techniques discussed at the session. He said the series included one case with posterior capsule rupture and one with postoperative cystoid macular edema, and none of the patients had permanent pupil damage. Postoperative visual acuity was 20/40 or better in 95% of patients in the study, he said.

Refractive teams tie in Challenge Cup

Avoiding lawsuits after performing LASIK and patient selection for refractive surgery highlighted the debate for the refractive teams during the Challenge Cup presentation.

The debate pitted the Juris Prudes against the Really Not Ready for Prime Time Players.

Marguerite B. McDonald, MD, as the late Johnnie Cochrane, led the Juris Prudes, while Eric D. Donnenfeld, MD, took over for Kerry D. Solomon, MD, to lead the Prime Time Players. Dr. Solomon has been recovering from recent back surgery, Dr. Donnenfeld said.

Dr. Donnenfeld implored the audience to vote for his team: “A vote for us is a vote for Kerry,” he said. During the voting process, Dr. Donnenfeld’s team held placards which read “Help Kerry Walk,” insinuating a win in the debate would help Dr. Solomon’s back surgery recovery process.

The Juris Prudes — Stephen D. Klyce, PhD, as F. Lee Bailey; Helen K. Wu, MD, as Alan Dershowitz; R. Doyle Stulting, MD, PhD, as retired Supreme Court Justice Sandra Day O’Connor; and Richard F. Callaway, MD, as Perry Foreman — advised the audience on how to avoid LASIK lawsuits. Among the advice: do not deviate significantly from the informed consent documents readily available.

“Don’t create a higher standard for yourself than you need to,” Dr. Callaway said.

Dr. Klyce recommended that surgeons learn to identify the “hallmarks of an abnormal cornea” and to look at both eyes when deciding on whether to operate. Dr. McDonald advised surgeons to “just say no” when debating whether to perform surgery on patients with an abnormal topography.

The Prime Time Players were Robert J. Cionni, MD, Stephen G. Slade, MD; Steven J. Dell, MD; and John F. Doane, MD. The said patient selection is key to safe refractive surgery, and the group presented a skit in which a “Nervous Nelly” patient wants to have presbyopic IOL implantation.

Drs. Slade and Cionni played devil and angel trying to sway Dr. Dell about the potential ramifications of performing the surgery. The core message: Refractive lens exchange patients tend to be more anxious about undergoing surgery than other refractive surgery candidates.

Attendees determined that the two refractive groups presented equally useful information. Moderator Roger F. Steinert, MD, declared both teams winners, and noted that this marked the first time in Challenge Cup history there had been a tie.

Juris Prudes teammate R. Doyle Stulting, MD, as retired Supreme Court Justice Sandra Day O’Connor, during the ASCRS Challenge Cup.	Members of the “Really Not Ready for Prime Time Players” emphasized the importance of patient selection during their skit in the Challenge Cup.
Members of the Juris Prudes (left) and the Prime Time Players as “referee” Roger F. Steinert, MD, (center) declared the two teams winners of the refractive portion of the Challenge Cup. Images: Mullin DW, OSN

Find ‘tipping point’ to convert potential LASIK patients, marketing expert says

Triggers that convince potential refractive surgery patients to move ahead with surgery are varied, and successful practices will find ways to highlight those emotions, said James M. Tenny, at the American Society of Ophthalmic Administrators meeting.

In his keynote address, Mr. Tenny polled the several hundred audience members and found that 30% spend less than 2% on advertising or marketing, and 34% spent less than 5% of the center’s budget on advertising or marketing. Overall, the administrators said they believe fear and cost are the leading two reasons why patients opt out of refractive surgery once it has been offered.

“The bottom line is consumers are generally OK with the vision correction they have,” said Mr. Tenny, who is a partner at Della Femina Rothschild Jeary & Partners marketing firm. “Until they present with a problem with their current vision, they’re not going to seek correction.”

All office personnel need to identify the potential customer, he said. Advertising should play a role in that identification.

“You need to find a trigger event; that will be the primary reason to entice someone into making a decision,” he said, even if the decision is to stop what the customer is doing, pick up a phone and call to find out more about refractive surgery.

“Advertising for your practice should focus on reminding people what they don’t like about their contact lenses or glasses,” he said.

Within a center’s advertising, “gear your message to a specific target,” he said.

Emphasis should be placed on the trigger event and first physician contact, he added. Trigger events that have worked include targeting people who play sports, who have ocular allergies or who need better vision for work.

“Fourth, you need to provide a non-threatening first step for these people,” he said. Allow the potential patient to qualify him- or herself as a potential candidate, he said.

Once the potential patient has contacted a center, “stay with them,” Mr. Tenny said. Follow up with phone calls or letters.