OSN Associate Medical Editors discuss key innovations of 2000s
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To celebrate the 40th anniversary of Healio/Ocular Surgery News, the Associate Medical Editors are sharing what they think are the most important ophthalmic innovations of the 2000s.
Advent of SLT
Leon W. Herndon Jr., MD: I completed my fellowship in 1996 and joined the faculty at the Duke Eye Center immediately out of fellowship. At that time, argon laser trabeculoplasty was the second line of glaucoma treatment after maximally tolerated medical therapy failed. I remember that due to the high energy delivered to the trabecular meshwork and the risk of IOP spikes, we would treat just half of the trabecular meshwork per laser session. Selective laser trabeculoplasty was approved for commercial use in the U.S. in 2001. SLT superseded ALT by virtue of the facts that it used a larger spot size, making it easier to perform; it used about 1% of the energy of ALT, making it better tolerated and reducing the rate of uveitis and IOP spikes; and it caused no mechanical damage, allowing it theoretically to be performed repeatedly.
SLT was developed by Latina and Park, utilizing a mechanism of action that relied on selective targeting of pigmented trabecular meshwork endothelial cells with a very short laser pulse duration. It is performed using a frequency-doubled (532-nm) Q-switched Nd:YAG laser, which is shorter than the thermal relaxation time of melanin. We published a paper documenting the results of our first 94 SLT patients, which showed a poor response with treating just half of the angle per session. I have since treated the full angle in one SLT session.
After 20years, SLT has established itself as an effective and safe modality for managing glaucoma. It is simple to perform with a well-described side effect profile, long-lasting and repeatable. It is comparable to topical medication in its IOP-lowering effect, without any of the side effects commonly seen with eye drops. This has led to SLT becoming a preferred management strategy for primary or adjunctive therapy of glaucoma for many clinicians, and its use is likely to be sustained into the foreseeable future.
- References:
- Latina MA, Park C. Exp Eye Res. 1995;doi:10.1016/s0014-4835(05)80093-4.
- Song J, et al. J Glaucoma. 2005;doi:10.1097/01.ijg.0000176939.43681.c2.
CMS ruling on advanced lens implants
John A. Hovanesian, MD, FACS: The most disruptive innovation of the 2000s was not a drug or device at all. It was the May 3, 2005, CMS ruling allowing patients on Medicare to have access to presbyopia-correcting and toric implants.
The first presbyopia-correcting implant was the AMO Array, approved in 1997. Although this lens provided some range of vision, it was not available in a toric version, and it created limitations on visual quality. Furthermore, surgeons were not routinely focused on a high degree of refractive accuracy, and maybe most importantly, there was no financial model to reward the extra work required for a favorable result.
In November 2003, the eyeonics Crystalens was FDA approved as a presbyopia-correcting implant, and the Alcon ReSTOR and AMO ReZoom implants followed shortly after. These early-generation lenses offered greater promise for patients, but their cost was about $900, and there was no mechanism for the Medicare patient to pay any portion of this. At that time, all IOLs were considered by CMS to be the same, and reimbursement could only come from the bundled facility fee, which earmarked about $150 for the lens. We simply could not afford to offer these lenses to Medicare beneficiaries.
Then, in May 2005, smack dab in the middle of the decade, a remarkable announcement came. Supported by then Congressman Christopher Cox with assistance from Andy Corley and others, CMS released a ruling allowing Medicare beneficiaries to pay out of pocket to have access to advanced lens implants, which were now considered in a separate category from monofocals. Toric and presbyopia-correcting lenses now effectively had two purposes: to correct aphakia and to provide an elective refractive outcome. Medicare would pay for the first (as before, about $150 from the bundle), and the patient would pay the rest, along with any noncovered services provided by the practitioner that were necessary to achieve success with the implant.
This one simple rule allowed physicians to begin offering everyone the most advanced lens implants. It effectively ushered in the era of refractive cataract surgery, which led to many new implants, femtosecond lasers for cataract surgery, tools such as Zepto (Centricity Vision) and intraoperative aberrometry. Technology is only useful if it can be accessed, and by making refractive IOLs available to all and inspiring other innovations, the CMS ruling of 2005 was arguably the most important innovation of its decade.
IOL innovations
Elizabeth Yeu, MD: The 2000s brought forth a plethora of IOL innovations. In 2000, specifically, the first foldable IOL was injected into the eye through a self-sealing 3.2-mm wound. The advancements in foldable single-piece acrylic IOLs allowed for smaller temporal wounds, making the sub-2.4-mm self-sealing wound possible. This led to various innovations in foldable lens materials and asphericity of IOLs. An emphasis on refractive cataract surgery was blooming, with newer generations of presbyopia-correcting IOL technologies, leading to the pseudoaccommodative IOL, Crystalens (Bausch + Lomb), and the Tecnis (Johnson & Johnson Vision) and ReSTOR (Alcon) multifocal IOL platforms over this decade. The importance of surgical astigmatism management was brought to light by Doug Koch and others. The Wang-Koch nomograms to manage corneal astigmatism at the time of cataract surgery and after laser vision correction were popularized. Furthermore, more accurate management of toricity was introduced to both monofocal and multifocal IOL platforms during this decade.
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