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The burden of technology: Breaking the comfort zone

Premium surgeons need to stay current with technology in order to keep providing the best outcomes for patients.

Issue: May 10, 2015

ByMitchell A. Jackson, MD

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The multitude of challenges faced by most premium surgeons — from implementation of electronic health records and satisfaction of Meaningful Use and PQRS criteria to meeting patient expectations and avoiding malpractice in 20/20 unhappy patients to maintaining practice efficiencies and meeting overhead expenditures — definitely adds to the burden of adding new technology, both diagnostic and therapeutic. Many surgeons are in a comfort zone in both medical and surgical approaches to patient care and are in no hurry to change their practice patterns despite advances in technology.

Surgeons stay the course

The advances in ocular surface management, refractive cataract surgery and corneal transplantation techniques have made the most progressive anterior segment surgeon best in class in terms of patient outcomes. However, despite the LASIK-like outcomes being achieved in cataract surgery, the stay in course by most surgeons is evidenced by only up to 22% in most surveys performing femtosecond laser-assisted cataract surgery, for example. A 2013 surgeon survey revealed the utilization of intraoperative aberrometry increased the conversion rate to premium IOL usage by 22% and reduced enhancement rates by 47%. Again, the numbers are not staggering in terms of surgeons straying from their comfort zone despite the advantages of advanced technology. Corneal transplantation techniques have already evolved from DSEK to DMEK and now PDEK for posterior corneal disease and big bubble DALK for anterior lamellar disease. It was just 5 years ago when surgeons were considering lid margin disease in terms of anterior and posterior blepharitis having any true impact on visual outcomes. The Prospective Health Assessment of Cataract Patients’ Ocular Surface study revealed that the majority of patients about to undergo cataract surgery were subjectively asymptomatic, but more than 50% showed objective signs of dry eye. The end result was patients having IOL calculation errors due to improper keratometry readings from ocular surface disease.

Leaving the comfort zone

The time has come for premium surgeons to step up, break from the comfort zone and identify which technologies can improve their patient outcomes. The recent passings of my friends and colleagues George Waring III and Rob Rivera should only encourage us as premium surgeons to stay current and progressive. Both of these surgeons extraordinaire elevated refractive surgery to new heights in terms of laser vision correction, implantable contact lenses, phakic IOLs and ICLs, and the nearly approved Light Adjustable Lens (Calhoun Vision). These two surgeons were not only pioneers but also inspiring examples of how to be proactive and progressive with the desire to improve patient outcomes.

In the cataract arena alone, the development of integration technology to make cataract astigmatism management seamless, wireless and markerless has finally arrived with Cassini (i-Optics), TrueVision and Lensar; Verion, ORA and LenSx (all Alcon); Cirle and Victus (Bausch + Lomb); and Callisto and IOLMaster (both Carl Zeiss Meditec). Advanced vector analysis such as the Barrett toric calculator (ASCRS website) and advanced IOL calculation software for post-refractive surgery patients such as Haigis-L (Carl Zeiss Meditec) are just the tips of the iceberg needed to be a true refractive cataract surgeon. Utilizing Cassini and/or other devices such as intraoperative aberrometry (ORA, Alcon; Holos, Clarity) that can calculate posterior astigmatism effect has changed the way premium surgeons approach astigmatic treatment nowadays.

In the ocular surface arena, advances in looking at the various ocular tear layers in a quantitative way give credence to managing meibomian gland structure and function via devices such as the LipiView II interferometer with dynamic meibomian imaging (TearScience), tear osmolarity (TearLab) and MMP-9 enzymatic inflammatory activity (InflammaDry, RPS).

In the corneal transplantation arena, helping patients achieve visual outcomes closer to 20/20 with endothelial disease comes from advancements in technique, from DSEK to DMEK and soon PDEK. Although more surgically challenging and progressive, visual outcomes are clearly improved with the latter techniques over traditional PK and the first-generation DSEK approach.

My advice is for all premium surgeons to stay ahead of the curve, keep current, be progressive, learn from the past and improve upon the future. Do not fall victim to the burden of technology based on a false sense of “comfort zone” security.