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Adopting advanced technologies in eye care: Are we open-minded enough to provide the best care?
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No one can stop scientific and technological progress. No patient ever thanked you for saving money on his or her eye care.
And yet, European national health systems made the decision to provide European citizens with high-volume low-cost cataract surgery, a strategy that does not take into account the Principles of European Medical Ethics because it does not provide the “best care.”
Normally, patients are not aware of this.
One example: In Italy, over the last 10 years, DRG reimbursement for cataract surgery dropped from 2,500 to 800 on average, although the continued development of new technologies for diagnosis and surgical treatment would require a proportional, consistent investment. This was the greatest political mistake in eye health management. In such conditions, it is impossible to adopt advanced technology IOLs (ATIOLs) and femtosecond laser-assisted cataract surgery (FLACS) in public hospitals, keeping pace with the evolution of standard cataract surgery. I learned to perform cataract surgery in 1979 using intracapsular cataract extraction. Then, I progressively learned and adopted extracapsular cataract extraction, phacoemulsification, foldable IOL implantation, surgery under topical anesthesia, outpatient surgery, ATIOL implantation and FLACS. This was just going with the flow of scientific development, matching patients’ expectation and the principles of good medical practice.
But the world of public health today is different. Although the loss of eyesight has a tremendous economic and social impact, little money is invested in eye care compared with other medical therapies. If on one hand it seems right to spend 85,000 yearly for a single person with cancer, it is considered normal on the other hand that cataract surgery should cost the equivalent of a single pair of Armani sunglasses. In countries where 54,000 yearly is spent for Avastin (bevacizumab, Genentech/Roche) in colon cancer therapy, ophthalmologists are not allowed to spend 100 yearly (14.20 for a single shot) for Avastin off label to treat maculopathy.
Today, the adoption of advanced technology has become more difficult than it was in the ’80s. Choices and investments in health care are exclusively driven by cost-benefit criteria, and to further delay and discourage technological advances, the professional obligation to exclusively adopt evidence-based procedures has been imposed. Health economists do not seem to be aware that this strategy takes a long time to be effective: On average, at least 10 years are needed for an innovative procedure, treatment or technology to gain evidence to support patients’ benefit and to be approved.
Achieving optimal results with a presbyopic IOL is a difficult and complex goal. You need to implement extensive patient selection protocols and spend a lot of chair time to actively listen to patients’ desires and decide on the most suitable IOL. To avoid postoperative complaints, you must achieve plano refractive results.
ATIOL detractors think that the 5% rate of unsuccessful cases represents a huge problem, but they do not consider that this rate is still related to the initial experience with bifocal technology. A 95% success rate is unusual in medicine. In order to evaluate ATIOL performance today, we need to look at the results of trifocal and extended depth of focus technologies. Trifocal IOLs, including the At Lisa tri (Carl Zeiss Meditec), have replaced bifocal IOLs, overcoming the limitations in intermediate vision. Extended depth of focus IOLs — Symfony (Abbott Medical Optics) and IC-8 (AcuFocus) — have dramatically decreased distance vision halos. We are in the presence of a third generation of ATIOLs, and this is a totally new scenario.
Today’s presbyopic and toric IOLs provide controlled outcomes and can be implanted in up to 60% of patients. Why are we still so far from achieving this rate of implantation?
In public hospitals, more than 98% of surgeons have no significant experience with the most advanced ATIOLs. In most countries, ATIOLs are not reimbursed and no co-payment is allowed. Often, the surgical centers that perform thousands of standard high-volume low-cost cataract surgeries do not inform patients about the benefits of ATIOLs to avoid being considered as a team playing in Second Division rather than Premier League. On the other hand, there are still several surgeons who are convinced that the new technology is not ready yet and causes trouble. To stand on the side of progress, we must focus on our role and mission as experts who want to provide the best care. We are aware that cataract surgery needs reimbursement implementation of 1,000 per case. How and where governments should find this money is not something we should take on our shoulders; it is not our problem and mission. What we are responsible for is providing our patients with the best surgical options, as we did until a few years ago. We are eye doctors, simply very good eye doctors.
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- Matteo Piovella, MD, is an OSN Europe Edition Board Member and the President of the Italian Society of Ophthalmology. He can be reached at C.M.A., Via Donizetti 24, 20052 Monza, Italy; email: piovella@piovella.com.
Disclosure: Piovella reports he is a consultant for AcuFocus, Abbott Medical Optics, Carl Zeiss Meditec, TearLab and TearScience.