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New column brings premium eye care to the forefront
OSN presents Mitchell A. Jackson’s new column, The Premium Channel, focusing on premium eye care.
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I would like to introduce the Ocular Surgery News readership to my new column entitled “The Premium Channel,” covering all aspects of premium eye care from new surgical technologies and advanced IOL options to pharmaceutical breakthroughs and novel patient interaction techniques.
Over the past 2 years, my series on the top 10 premium IOL outcome problems and how to remedy them, which ran as part of the Premier Surgeon supplement in OSN, covered topics like how to manage patient expectations, the preoperative evaluation and premium channel costs. In my first column for The Premium Channel, I would like to review those 10 topics, with excerpts from each article, before launching into new premium endeavors as they apply today and in the near future.
Managing patient expectations
Managing patient expectations requires a fine balance between knowledge, trust, confidence and flexibility. The end goal is to have a happy patient and happy surgeon with minimal chair time and maximum profitability.
On the knowledge side, the premier surgeon must be educated on all forms of U.S. Food and Drug Association-approved and soon-to-be-approved premium or presbyopia-correcting IOLs. Even if a surgeon’s preference is the Tecnis multifocal (Abbott Medical Optics), for example, that surgeon must know about the AcrySof ReStor multifocal (Alcon) and Crystalens AO accommodating (Bausch + Lomb) options, as well, to make sure the best possible upgraded IOL matches the patient’s visual needs in terms of job, hobby and activities of daily living.
The bottom line is to listen to your patient to gain his or her trust. If the patient is co-managed, trust the opinion of the referring optometrist who knows the patient’s needs even better.
Mitchell A. Jackson
For patient expectations, consider the phrase “listen, educate, adapt.” Listen to your patient and to referring colleagues to really understand your patient’s needs. Educate yourself on the various IOL technologies to select appropriately, and educate your patients on the plan to achieve emmetropia. Adapt and be flexible in the postoperative period, whether it be managing ocular surface disease, posterior capsular opacification, macular disease, refractive errors or just giving a little extra TLC to your premium patient.
Stay tuned for an upcoming installment of The Premium Channel that will discuss the suggested Jackson Rules when approaching patient expectations in the premium arena.
Managing the preoperative evaluation
The preoperative history typically begins with a patient questionnaire about previous refractive surgery, systemic medical conditions, systemic and/or topical medications, and occupational or recreational needs. When taken carefully, the preoperative history will illicit the visual complaints that are most demanding for that specific patient and aid in proper premium IOL selection.
For example, the elderly patient who plays bingo regularly and is afraid to drive at night will most likely benefit from a multifocal upgrade, but the younger professional who drives 1 hour each way to work the nightshift daily and relies heavily on computer usage at the work place will probably be happier with an accommodating IOL upgrade.
Previous refractive surgery will usually result in a change in spherical aberration, induction of higher-order aberrations and even residual irregular astigmatism, seen commonly in RK patients. This sets up an ugly outcome with multifocal optics but potentially a benefit with an appropriate monofocal selected for spherical aberration effect. Remember, myopic LASIK results in positive spherical aberration, and hyperopic LASIK in negative spherical aberration.
Certain medical conditions and/or medications will increase dry eye risk postoperatively and hinder accurate diagnostic data capture preoperatively. For example, a three-piece multifocal might be the best planned approach in a Flomax (tamsulosin, Boehringer Ingelheim) patient who ends up needing a sulcus or optic capture placement due to the higher posterior capsule rupture rate seen in intraoperative floppy iris syndrome (IFIS). In an upcoming segment, we will discuss solving the “-osin mystery” in IFIS cases.
Managing astigmatism
When addressing astigmatism, it is crucial to differentiate between corneal and lenticular astigmatism. As part of the premium preoperative evaluation, corneal topography is essential to make this distinction.
Corneal topography as an adjunct to corneal slit lamp evaluation will reveal conditions like forme fruste keratoconus, frank keratoconus, pellucid marginal degeneration and irregular astigmatism, such as map-dot-fingerprint, epithelial basement membrane dystrophy or post-RK.
Corneal topography is necessary to decipher whether a patient is a candidate for premium IOL placement in the first place, or if other procedures, such as laser vision correction, piggyback IOLs or limbal relaxing incisions (LRIs), are the best enhancement options for residual refractive error in the premium IOL patient. Managing corneal astigmatism then becomes the real driver to a successful visual outcome.
The next hurdle is to decide how to upgrade your patient: toric IOL or presbyopia-correcting IOL with LRIs and/or secondary laser vision correction. If the patient has moderate to high astigmatism and, for example, is a retired avid golfer, then the toric IOL might be a better selection for the patient. On the other hand, if the patient likes to read extensively, then a presbyopic IOL with LRI or laser vision correction might be a better choice.
Recently, the Alcon AcrySof IQ toric IOL gained FDA approval for the most expanded range for treatment of corneal astigmatism up to 6 D at the IOL plane and 4.11 D at the corneal plane. Using vector analysis calculation for toric IOL calculation at www.acrysoftoriccalculator.com is only part of the story. In an upcoming segment, we will discuss new rules and the rest of the story when approaching toric IOLs or femtolaser techniques regarding LRIs.
Managing PCO
Posterior capsular opacification (PCO) development typically is multifactorial due to poor cortical clean-up, retained lens epithelial cells at the lens equator and/or under the anterior capsule, and/or an irregular non-centered, non-overlapping anterior capsulorrhexis 360° over the IOL optic (Oliver Findl, MD, OSN, July 2011).
Sam Masket, MD, et al have suggested that reduced PCO rates may occur with particular attention to anterior subcapsular polishing of lens epithelial cells. David Apple, MD, reiterated that despite the popular concept of “no space-no cells” leading to no lens epithelial cells, the newer, thinner and more flexible IOLs may not withstand the distortion from posterior capsular shrinkage leading to possible lens decentration.
The Z syndrome characteristic of the accommodating Crystalens is a classic example of the latter problem, often necessitating early YAG capsulotomy to avoid induced astigmatism and/or loss of the premium visual outcome. An upcoming segment will discuss additional surgical and pharmaceutical pearls in reducing and managing PCO.
Managing macular pathology
Epiretinal membranes, macular pucker, macular holes/pseudoholes and subclinical macular degenerative changes often go undetected by routine retinal examination and are discovered far too late after a multifocal optic is in place. Although accommodating IOLs may have a better place with such patients, caution is recommended as postoperative subjective visual function typically does not match postoperative quantitative snellen acuity or preoperative patient expectations.
OCT technology provides an excellent means for gauging preoperative candidacy for premium technology and/or postoperative topical nonsteroidal or steroid tapering in terms of managing cystoid macular edema.
In an upcoming segment, we will discuss the most current advancements in OCT diagnostics, as well as pre- and postoperative treatment options for macular pathology facing the anterior segment surgeon.
Managing the ocular surface
Dry eye syndrome, posterior blepharitis or meibomian gland dysfunction, ocular allergy and epithelial basement membrane dystrophy are the most common causes for poor ocular surface function in the premium IOL patient. Addressing the ocular surface with a tear layer approach will help manage and prevent many of the associated problems.
Recently, the International Delphi Panel/DEWS redefined dry eye as a multifactorial disease of the ocular surface that results in symptoms of discomfort, visual disturbance and tear film instability with potential damage to the ocular surface. Furthermore, dry eye is accompanied by an increase in tear film osmolarity and inflammation of the ocular surface.
Some common causes of dry eye are the American “fast food” diet high in bad omega-6 and low in good omega-3 fatty acids, LASIK and other corneal refractive surgery procedures, vitamin A deficiency, hepatitis C infection, and low blink rate. Other common causes include cosmetic blepharoplasty, contact lenses and certain medications. Stay tuned for an upcoming segment on the most current diagnostic and therapeutic advances in deciphering evaporative from aqueous deficient dry eye from ocular allergy.
Managing IOL calculations
A 10-year study conducted by OMIC revealed that IOL power calculations represent the single largest malpractice risk to a practicing ophthalmologist. The PHACO study demonstrated that poor data acquisition in terms of keratometry, corneal topography, and/or biometry often leads to IOL power calculation errors of up to between 1 D and 2 D.
Assuming the patient has a pristine and/or stable ocular surface, the emphasis should be on the actual biometry device utilized and IOL calculation software chosen. Add in that the patient has had previous refractive surgery and IOL calculation decisions become more challenging.
With rising patient expectations, especially in the premium IOL world, IOL calculations need to be exact or the added costs of piggybacking IOLs, laser vision correction and/or LRIs as enhancement options will become more apparent. In an upcoming segment, we will discuss post-refractive surgery IOL calculations, modifications for high axial myopia and nanophthalmos, and intraoperative wavefront aberrometry.
Managing premium channel costs
Approximately 10% of cataract surgery within the Medicare system is associated with noncovered services, such as a presbyopia-correcting IOL, astigmatism-correcting or toric IOL, laser-guided cataract surgery with intraoperative wavefront aberrometry, and/or laser-assisted femtosecond cataract surgery. The premium channel involves all of these technologies, including LRIs performed concurrently or subsequent to cataract surgery.
To complicate matters, separating the professional component from the facility component for each technology and determining where optometric co-management fits into the financial puzzle makes one wonder whether the premium channel is even worth it. In an upcoming segment, we will discuss the newest CMS rulings regarding intraoperative wavefront aberrometry, femtosecond cataract laser imaging and appropriate advanced beneficiary notice documentation.
Managing the dissatisfied patient
Various studies show that up to 25% of patients will demonstrate unhappiness in some way, either by complaining outright or by leaving the practice and seeking a second opinion. Furthermore, the old adage that a happy patient will refer one or fewer patients but an unhappy patient will tell 10 or more to avoid you still holds true.
Some tips for minimizing the agony as a premium IOL surgeon include being prepared before the patient encounter, addressing the patient complaint immediately upon entering the exam room and formulating a list of solution(s) for the patient’s problem. Additionally, never hesitate upon requesting a second opinion from a colleague of similar expertise when the patient-surgeon relationship has reached a stalling point.
In an upcoming segment, we will discuss methods in turning the dissatisfied patient into the practice’s largest ally.
Managing medical malpractice
From frivolous lawsuits to real eye injuries, malpractice can bring physical, financial and emotional turmoil to the patient and physician(s) involved. The good news is that only one in 25 patients with negligent or preventable medical outcomes result in a lawsuit, presumably due to patients’ reluctance to sue their doctor.
Medical malpractice is defined as any bad, unskilled or negligent treatment that injures the patient. A majority of states define the standard of care as that degree of skill and learning ordinarily possessed and used by other members of the profession. A physician who has met the standard as established by expert testimony cannot generally be found negligent.
In the end, there has to be negligence which causes harm to a patient to be considered medical malpractice. As a disclosure, I am not an attorney, nor do I tout myself as one, and my recommendation is to contact your malpractice carrier and/or personal attorney immediately upon threat of or filing of a medical malpractice lawsuit against you or your ophthalmic practice.
Stay tuned for an upcoming segment on malpractice strategies in preventing the lawsuit in the first place.
My next column will address the recent press and hype around femtosecond laser-assisted cataract surgery, including a summary of FDA-approved platforms, how it may or may not impact your practice and what it all really means from a practical standpoint.