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Cover Stories | Jun 2005

5 Questions With Paul S. Koch, MD

Dr. Koch candidly addresses various political issues of ophthalmology and how he became a producer of “B movies.”

What are your thoughts on the recent Centers for Medicare & Medicaid Services (CMS) ruling pertaining to the insertion of presbyopia-correcting IOLs? The ruling is a sign that the CMS has wonderful leaders who understand the situations ophthalmologists face. Patients have been denied new technologies under the government-pay-all system because of their high cost. The late Senator Chafee from Rhode Island, a former chair of the Senate Finance Committee, hated the idea of letting patients pay for anything, because he felt it would lead to a two-tiered medical system. He was right, but such a system is necessary to let patients decide their own priorities. Whether they decide to pay $500 per month for a car, $3,500 for a dental implant, or $2,500 for a new focusing system, the choice should be theirs. Getting rid of an artificial ceiling on fees for vision restoration will permit all sorts of innovative ideas to flourish, not just for presbyopia.

What does the future hold for steroid injections in the treatment of cataract patients? The one thing patients hate most about cataract surgery is the necessity of eye drops. Most patients will be instructed to use between 150 and 200 drops before completing their treatment. The biggest frustration surgeons have with medicating patients is patient compliance. Clearly, if we can eliminate the eye drops, everyone will be happier. The combination I use now, 1.5mg of Kenalog and 100mcg of gatifloxacin per 0.10mL, works well. Most of my patients see about 20/30 the next day, and 94% do not need eye drops. The other 6% require supplemental steroids. One day, researchers will arrive at the best postoperative dosage and package it in a tiny sustained-release vehicle, making eye drops and compliance problems a thing of the past. Years ago, a pellet was developed to slowly release dexamethasone, but it could not be commercialized because surgery centers were not reimbursed for its cost. Perhaps the recent CMS ruling will also facilitate a new discussion about patient payment for specialized medication delivery systems.

What is the most challenging aspect of your profession? The biggest challenge ophthalmologists face right now is developing a magic bullet for open-angle glaucoma, by which I mean a single-shot definitive cure. One already exists for narrow-angle glaucoma, peripheral iridectomy, but physicians still struggle with patient compliance and efficacy for open-angle glaucoma. A single-treatment procedure that will reduce the IOP to 14mmHg in more than 95% of eyes and hold it there for 20 years is necessary. Surgeons know where the problem is anatomically, so we should be able to develop a treatment. The suture-supported viscocanalostomy developed by Robert Stegmann, MD, brings us a lot closer. His operation opens both Schlemm's canal and the trabecular meshwork the full 360º and improves filtration dramatically. I believe the long-term answer lies in Schlemm's canal surgery, not external filtration or photocoagulation.

As the winner of four ASCRS International Film Festival awards, how did you become involved with the production of educational and entertaining medical videos? I love B movies. You know the type: monsters, beaches, cheap production values, and ridiculous plots. In another life, I would have made great movies for drive-ins. Rob Rubman, MD, one of ophthalmology's great gadgeteers, helped me begin videotaping cases in 1979. Back then, we only had linear editing, and there were technical limitations to what we could produce. I did not like the typical medical education videotapes of that era; they were boring, with long footage narrated by a slow, quiet voice better suited for televising golf matches. I believed teaching tapes should be fun to watch, so I decided that medicine needed a producer of B movies. If some of the stuff I have put into my videos has been viewed as a little weird, imagine what was left on the cutting room floor!

What is unique about your facility in Warwick, Rhode Island?
Koch Eye is a real family practice, and over the years I have run the joint with my brother, sister, father, uncle, aunt, nieces, nephews, son, and daughter. Right now, among our 140 employees, we have nepotism galore. Many of our staff members have relatives working here, too. Our Christmas parties are famous for their creativity and sometimes go on for 18 hours straight. One tradition of ours is that every year on July 29, the anniversary of my dad's passing, we close all of our offices and assign every employee to work in a local charity for the day. This year, we will supply a day's manpower to help 23 different charities. If not for our community, we would not be successful, so we subscribe to “noblese oblige,” the obligation to return the favor. 
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