Listening to the naysayers carry on about the inequities of managed care, shrinking cataract reimbursement, and LASIK price wars is enough to send the most confident of cataract and refractive surgeons running for cover. But if you tune in to another wavelength, you will find that behind every pessimist are three optimists who are improving their patients' quality of life while enjoying the perks of thriving practices.
Cataract & Refractive Surgery Today surveyed a diverse group of veteran cataract and refractive surgeons, as well as a handful of up-and-comers about what has had the most positive impact on their practice recently. One surgeon sang the praises of a new practice model; another spoke of the pleasures he's derived from becoming reacquainted with cataract surgery following several years devoted exclusively to LASIK; and yet another suggested that a physician-friendly company that he describes as “synonymous with laser vision correction” is the best thing that has ever happened to his practice. Most of those asked testified to the benefits provided by new or relatively new technology and techniques. Many confessed to feeling honored to have the opportunity to help restore sight. These are their stories:
Veteran refractive surgeon, Daniel Durrie, MD, of Overland Park, Kansas, has been a key player in the clinical research of refractive surgery technologies for the past 20 years. From lasers to lenses, Dr. Durrie has had the opportunity to offer his patients the newest in treatments and technology long before the FDA grants its stamp of approval. Dr. Durrie says the recent opportunity to participate in the clinical research of aberrometry and customized laser ablation has had the most positive impact on his practice of late. “The thing that has really made me look at refractive surgery differently,” said Dr. Durrie, “is being involved in research of new equipment to better diagnose patients' symptoms as well as preoperative conditions, and this entails using the aberrometers in the clinic.” Aberrometers not only can communicate directly to the laser, they can give us more information about how the patient really sees the world.
Dr. Durrie is a clinical investigator of custom ablation systems for both Alcon Laboratories (Fort Worth, TX) and Bausch & Lomb (San Dimas, CA), and also works with Nidek (Fremont, CA) and Tracey Technologies (Bellaire, TX) in the area of diagnostics instruments. “Aberrometry and custom ablation technology are very exciting and very positive, but remind me of phacoemulsification in 1978. They are good concepts, but now we need to get a lot of ophthalmologists using this technology, learning from it and sharing the information. Once that starts to happen, we'll see many discussions and contributions by physicians all around the world regarding the best way to take advantage of this technology,” Dr. Durrie said.
Dr. Durrie suspects that surface ablation will replace LASIK, and that aberrometry and custom ablation technology will facilitate the transition. “There's a growing feeling that we need to go back to the surface to get the best results, and that the LASIK flap itself may induce enough aberrations to warrant that. It may be that aberrometers and custom ablation take us back to the surface to get the best results,” he said. “On the other hand, it may force us to look at alternatives such as the IntraLase femotosecond laser to make flaps more consistent. Maybe then we can induce consistent higher-order aberrations.”Being involved with this breakthrough technology from the clinical research end has been particularly gratifying, Dr. Durrie says, because in addition to being able to obtain a bird's eye view of patient results, he's also privy to how the technology is impacting the companies that are developing it and the ophthalmologists who are implementing it, which he says all ultimately affects the patients.
“Many of these patients are LASIK patients who, when tested normally in the office, don't have residual refractive error, but when tested on the aberrometer, have obvious distortions. If we can correct those distortions with a customized laser program, not only would that be beneficial for the patients who have already had surgery, it would be excellent for people who are holding back because they're concerned about glare and other aberrations. I think knowing that they have this as a backup will open up a whole new level of people who will be interested in undergoing refractive surgery,” said Dr. Durrie.
PHACO WITH FLARE
Richard Mackool, MD, Director of the Mackool Eye Institute in Astoria, New York, swears by the phaco flare tip. “In the past 5 years,” Dr. Mackool said, “the development of the flare tip has had the most beneficial impact on my practice.” He pointed out that the combination of fluidic benefits, which permit the use of incredibly high flow and/or vacuum levels, has raised safety and efficiency of the phacoemulsification procedure up another notch. “Nuclei that are not soft enough to aspirate, yet not hard enough to crack, are just not an issue anymore,” said Dr. Mackool. “The high vacuum levels enable me to simply aspirate the entire nucleus periphery, elevate the remaining nuclear plate with a spatula or chopper, and then aspirate the plate,” he explained. Dr. Mackool routinely uses well over 600 mm Hg with the 1.1 Kelman-Mackool ABS Flare tip and the Legacy Advantec system. “Grade I or II nuclear cataracts either no longer require the use of ultrasonic energy for their removal, which can be accomplished in seconds, or require so little energy that it is truly insignificant to the procedure,” he said. Nuclear segments created when dealing with more dense nuclei are attracted by the high flow rate (60 cc/min), which he uses. They are then removed, with a fraction of the ultrasonic energy that was formerly necessary. “All of this leaves this veteran warrior in awe,” says Dr. Mackool, who began performing phacoemulsification in 1973. “This procedure called phacoemulsification bears almost no resemblance to its original form, and every time I think it just can't get better, it takes another quantum leap forward,” he said.
INPUT ON NEW TECHNOLOGY
The career of refractive surgeon, Y. Ralph Chu, MD, of Edina, Minneapolis, has paralleled that of laser refractive surgery. “The development of the excimer laser has given me the opportunity to practice the way I want to practice,” he said, “because it's opened up a whole new subspecialty. I really enjoy the actual surgery itself. There's no other ocular surgery that offers such quick recovery, such minimal postop rehabilitation, and so many happy patients.” Although the excimer laser has provided a great opportunity for Dr. Chu and many younger ophthalmologists, he states that his recent involvement with the development and launch of the Amadeus microkeratome (Allergan, Inc., Irvine, CA) has had the most positive influence on his practice. “It has been extremely rewarding and challenging to be involved in the clinical research and having direct input on this new technology.” Dr. Chu said that he has learned so much working with the management and research team at Allergan. “Sharing what I have learned with other surgeons through worldwide educational forums has been most rewarding. Developing and researching new technologies as well as educating have been the most exciting developments in my practice.”
SAY YOU WANT A REVOLUTION
David Hardten, MD, of Minneapolis, Minnesota, says one of the things that he has been extremely excited about in the past year is the use of phakic IOLs in patients with extreme levels of correction. “These patients may not necessarily be good candidates for one of the other procedures, and therefore phakic IOLs are a great procedure for them,” he said. “They provide an excellent option for patients who otherwise wouldn't be suitable candidates for refractive surgery.” Dr. Hardten has been involved in clinical trials with both the Artisan phakic IOL and the STAAR intraocular contact lenses, which are two of three phakic IOLs that are in clinical trials in the US.
Although phakic IOLs are not appropriate for a large portion of Dr. Hardten's patient population, they nonetheless have a significant impact on his entire practice. “It's such an important technology to have access to because it really can drive the rest of your practice. For example, if you help out a patient who is -13, they are so happy that it makes an impression on all of their -2 and -3 friends who may be considering LASIK.” Ultimately, says Dr. Hardten, it's not that phakic IOLs are revolutionizing his practice, it's that one by one they revolutionize the lives of patients who otherwise are truly disadvantaged.
ONE SMALL STEP
“The most positive impact on my practice has been the small-incision implant,” says veteran cataract surgeon Priscilla Perry, MD, of Monroe, Louisiana. “Small-incision implants have allowed several changes that have been extremely positive for patients. We can [use] an incision that is no larger than the phaco incision, which allows for quicker healing, more predictable incision results in terms of astigmatism, and faster mobilization for the patient, as well as for clear-corneal incisions, which I think are an extreme advantage,” Dr. Perry stated. Small-incision implants have also facilitated using topical anesthesia. “You can use topical anesthesia with a larger incision, but it is certainly much easier with a small incision,” she noted. Dr. Perry relies primarily on acrylic IOLs and uses both Alcon and Allergan implants.
After several years devoted solely to corneal refractive surgery, Brian Boxer Wachler, MD, of Los Angeles, California, has reincorporated cataract surgery into his practice, and he's reveling in it. “I started to do cataract surgery again a little over a year ago, and I'm enjoying it,” said Dr. Boxer Wachler. “In fact, I'd forgotten just how much fun it is. It requires tremendous surgical skill, and it challenges you mentally as you approach each step of the case.”
Dr. Boxer Wachler's favorite cases are treating people who are undergoing cataract surgery on eyes that have previously had refractive surgery. “It becomes a challenge in terms of their IOL calculation, and I enjoy that,” he said. I like using my hands as a surgeon. It's not like my interossei muscles were atrophying during LASIK, but cataract surgery requires extensive use of the hands,” he said.
Once he started to perform cataract surgery again, Dr. Boxer Wachler simply stopped referring out those cases. Next thing he knew, refractive surgery patients were being referred to him for cataract surgery. Today, approximately 10 to 15% of his cataract cases represents removing cataracts from people who have previously undergone refractive surgery.
One might assume that Dr. Boxer Wachler brought cataract surgery back into his practice because of the drop in refractive surgery procedures, but that does not appear to be the case. “As an investigator for two phakic IOLs,” he said, “I wanted to make sure that I kept my intraocular skills honed.”
“One of the best things I've implemented in my practice, other than sutureless cataract surgery and topical anesthesia,” said Mike McFarland, MD, “is the use of endoscopic cyclophotocoagulation (ECP).” ECP combines an illuminated endoscopic probe that fits through a phaco incision with a diode laser that selectively targets the ciliary epithelium. In most cases, it reportedly either eliminates or reduces the need for glaucoma medications even in intractable cases.
Dr. McFarland, Medical Director of the McFarland Eye Centers in Pine Bluff and Hot Springs, Arkansas, says ECP has the power to drastically change the way cataract patients who also have glaucoma are treated. “With other cyclocryo procedures and other glaucoma surgeries, I felt frustrated, I felt defeated; I felt that I had little to offer these glaucoma patients as a long-term solution. I was lacking artillery,” said Dr. McFarland. “Now that I've started doing the ECP procedure, I have a powerful weapon to battle glaucoma. You start feeling confident that you can really help these patients control their pressure and reduce their drops. Many of my patients simply can't afford all the glaucoma medications, and become noncompliant. After doing ECPs for 4 or 5 years, it's definitely one of the best things I've found to offer to my patients. It's a great feeling to know that this procedure can help most of them. That's what it's all about.”
A ONE PRODUCT COMPANY
New Mexico refractive surgeon, Stephen Coleman, MD, says something that has had the most positive impact on his practice is not a piece of equipment or a piece of software. It's a company—VISX, to be exact. “What doctors truly understand,” said Dr. Coleman “is that when you buy a laser system, in essence, you are a buying a company. The technical support and the people answering the phone when you have a question about your laser are as important as the actual laser sitting in your office.” This, aside from the laser platform itself, is the area in which Dr. Coleman feels that VISX truly excels. He points out that they have people who know the product inside and out and are able to gracefully pass this knowledge along to their primary customer: eye surgeons. Being a one-product company (the VISX Star laser) for so many years has really worked to the advantage of the hundreds and perhaps thousands of doctors using the Star system, he suggested. They have been dedicated to the approval process at the FDA to increase the pool of potential patients based on prescription. Another feather in the company's cap, according to Coleman, is VISX University, a series of meetings directed toward staff education on how to effectively deal with refractive surgery patients. “At its inception it was a forward-thinking idea that in a sense jump-started the industry as a whole,” he said. ASC ASAP
When asked what's the best thing to happen to his practice in recent years, Louis “Skip” Nichamin, MD, replied: “Without any doubt, it's the construction and opening of my ambulatory surgery center. From A to Z it's had a tremendous impact on both my professional career as well as my personal life, because the two are so intricately related.” Dr. Nichamin says he has become immensely more efficient since opening an ASC 2 years ago. “In the hospitals that I've worked in, there is so much bureaucracy, inefficiency and mismanagement; decisions are made for reasons that do not directly affect patient outcomes. Now we're able to conduct our OR in ways that are specifically designed to improve outcomes and the patient experience,” he said.
Dr. Nichamin practices in a relatively rural area of Pennsylvania. He and his partners have several satellite offices, and he says since opening the ASC, many of his patients are now gravitating toward that centrally located facility. “Because it's a dedicated facility for ophthalmic care—where in addition to cataract and refractive surgery we also perform all of our own subspecialty surgery—patients get the utmost in surgical treatment. The patient experience and patient outcomes have benefited greatly,” he said.
From a personal standpoint, Dr. Nichamin said, his time usage has dramatically improved. “I can complete 35 to 40 cases and be home playing with my kids or on the golf course by midafternoon rather than laboring through 12 or 14 cases in some of my local rural hospitals. We built the surgery center with the expectation that even if it financially broke even, it would be well worth it just to be more efficient and provide a better patient experience in a better atmosphere. It's turned out to be a very successful business venture, as well.”
The surgery center is about 7,000 square feet and houses two operating rooms as well as a refractive laser center. “The project of bringing this to reality was actually a lot easier than we anticipated. Not to sound cavalier, but it was nearly a turnkey operation. You don't have to re-invent the wheel. One goes out and obtains good consultants and architects. As long as you do your homework before going into it, it's not that daunting. It boils down to whether or not one has the surgical volume to justify it, and if so, it's certainly the way to go.”Daniel S. Durrie, MD, is in private practice with the Hunkeler Eye Centers in Overland Park, Kansas, and is Clinical Assistant Professor of Ophthalmology at the Kansas University Medical Center in Kansas City, Missouri. He is a research consultant for the companies mentioned in the article. Dr. Durrie may be reached at (913) 497-3737; firstname.lastname@example.org
David R. Hardten, MD, is Director of Refractive Surgery for Minnesota Eye Consultants and is Clinical Associate professor of Ophthalmology at the University of Minnesota, in Minneapolis. He has done research and has spoken for Refractec. Dr. Hardten may be reached at (612) 813-3632; email@example.com
Mike McFarland, MD, is Director of the McFarland Eye Centers in Pine Bluff and Hot Springs, Arkansas. Dr McFarland may be reached at (870) 536-4100; firstname.lastname@example.org
Brian S. Boxer Wachler, MD, is Director of Refractive Surgery at UCLA, Los Angeles, California. Dr. Boxer Wachler may be reached at (310) 794-7216; email@example.com
Y. Ralph Chu, MD, is Clinical Assistant Professor of Ophthalmology at University of Minnesota Medical School, and is the Medical Director of Chu Laser Eye Center in Edina, Minneapolis. Dr. Chu may be reached at (952) 835-1235; firstname.lastname@example.org
Stephen Coleman, MD, is Director of Coleman Vision in Albuquerque, New Mexico. Dr. Coleman may be reached at (505) 821-8880; email@example.com
Priscilla Perry, MD, is Associate Clinical Professor of Ophthalmology, LSU School of Medicine in Shreveport, Louisiana. She may be reached at (318) 388-2020; Pperry20@aol.com
Louis Nichamin, MD, is Medical Director of the Laurel Eye Clinic in Brookville, Pennsylvania. He may be reached at (814) 849-8344; firstname.lastname@example.org
Richard J. Mackool, MD, is Director of The Mackool Eye Institute and Laser Center in Astoria, New York. He holds a proprietary interest in the Mackool System/Flare tip, and is a consultant to Alcon. Dr. Mackool may be reached at (718) 728-3400; Mackooleye@aol.com