8 Key Technical Advances in Ophthalmology
1. Cataract surgery techniques. Cataract surgeons have adopted several improvements in surgical techniques, says R. Bruce Wallace III, MD, founder and medical director of Wallace Eye Surgery in Alexandria, La., and current president of the Outpatient Ophthalmic Surgery Society. For example, "phaco techniques and implants are now so tiny that standard intraocular lenses are easier to put in," he says. In addition, he says smaller incisions and sutureless, self-sealing incisions cause less trauma inside the eye.
2. Equipment to improve accuracy. Dr. Wallace says the IOLMaster from Zeiss and Lenstar from Leica, used to measure patients preoperatively, have made eye surgery more precise. Another boost for precision, he says, is the Holladay IOL Consultant & Surgical Outcomes Assessment, a computer database program that reduces the surgeon's prediction error for IOL power calculation.
3. New glaucoma shunts. The intraocular shunt device for glaucoma patients has eliminated the need for eye drops, says Mark Packer, MD, a partner in Drs. Fine, Hoffman & Packer in Eugene, Ore. "The shunt reduces intraocular pressure by 25 percent, on average, and has a very low complication rate," he says. All glaucoma patients who have cataract surgery automatically receive a shunt, which, in combination with cataract extraction, reduces intraocular pressure by 45 percent.
4. Advances in ocular imaging. Advanced diagnostic imaging algorithms, based on optical coherence tomography, have virtually eliminated the need for visual field testing, Dr. Packer says. OCT is a kind of optical ultrasound, which uses imaging reflections from within tissue to provide cross-sectional images. It provides tissue morphology imagery at much higher resolution than other imaging modalities such as MRI or ultrasound.
5. Implants for macular degeneration. Dr. Packer says time-release implants with next-generation vascular endothelial growth factor inhibitors have replaced intravitreal injections as the most effective treatment for age-related macular degeneration. "General ophthalmologists usually insert these devices in the office based on optical coherence tomography diagnosis," he says. "Fluorescein angiography is now rarely used."
6. EMR systems for ophthalmology practices. Electronic medical records systems are enhancing quality and efficiency for ophthalmologists, but so far, only 12-15 percent of ophthalmologists have EMR systems in place, Dr. Packer says. A key reason is that most EMR systems do not accommodate the ophthalmology chart, which is organized in a different way from other specialties. "We're used to a very standardized format and don't like deviating from that," Dr. Packer says. To allow for this idiosyncrasy, his practice has built its own system, based on the GE Centricity EMR system, which will be licensed to GE.
7. Premium IOLs. An increasing number of patients are opting for premium IOLs, including multifocal, accommodative, toric, light adjustable and telescopic designs, Dr. Packer says. Since 2005, cataract surgeons have been allowed to charge Medicare patients extra for premium IOLs, but only 7-9 percent of cataract patients have opted to convert to premium IOLs and make the extra payment. While Dr. Packer's practice has a 25 percent conversion rate, some cataract surgeons don't offer premium IOLs at all. Many These surgeons often say they don't want to be premium IOL pitchmen, but Dr. Packer says they still need to "make patients aware of the options."
Dr. Packer says technological barriers also stand in the way of cataract surgeons offering premium IOLs. This work sometimes requires Lasik enhancement with an excimer laser, but only 40 percent of cataract surgeons perform Lasik. However, he says non-Lasik surgeons can lease a roll-on, roll-off laser, as his practice does. The cataract surgeon inserting premium IOLs also needs access to a corneal topographer and an optical biometer, but Dr. Packer says most cataract ASCs already have this equipment. In addition, diamond knives for astigmatism correction are needed in about 30 percent of premium IOL cases.
8. Femtosecond laser for cataract surgery. Femtosecond lasers, which are just now starting to be introduced for cataract surgery, "could change the way we do things in a major way," Dr. Packer says. For example, the new laser may be able to reduce complication rates when the surgeon breaks out the cataract to remove it. "The femtosecond may produce better outcomes, especially in terms of not needing glasses after cataract surgery," he says. "If you are a half a millimeter off in placement of the lens implant, you can be off by a whole diopter."
However, Dr. Packer says the device also comes with some liabilities, such as the need to find space for it in the ASC and the need to charge Medicare patients extra to pay for the half-million-dollar price tag of the femtosecond. One way for pay for it, he says, is to make femtosecond part of the out-of-pocket payments that cataract surgeons can charge Medicare patients for premium IOLs. "The femtosecond laser may be regarded as a service associated with the premium lens implant," he says. Instead of charging $2,000 an eye for the premium IOL, as cataract surgeons now charge, the charge might be raised to $3,000 for a premium IOL plus femtosecond. "This can be justified because the femtosecond would reduce the chance of a miss," he says.
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