Smartphones, tablets, hot spots, and cloud storage— we are all aware of how quickly technology is changing in the consumer world, and it is much the same in the medical field. From diagnostics to therapeutics, the pace of technological improvements has accelerated. How to keep up with the advances is a concern that can keep even the most progressive ophthalmologists up at night. When has the technology proven itself sufficiently to introduce it in practice? Is it just a passing trend, or will patients appreciate and benefit from this service? Will outcomes be successful and enough so to justify the price of entry? These are just some of the questions that physicians ask themselves when evaluating a new technology. The consensus among surgeons appears to be that a technology's success is directly proportional to how invested the manufacturer is in its relationship with the doctor.

Companies can help ophthalmologists assimilate a new technology in a number of ways. The following examples show leadership roles that various ophthalmic innovators have taken to ensure physicians are successful with their products.

ORA SYSTEM (WaveTec VISION)

Jonathan Solomon, MD

A subgroup of cataract and refractive surgeons has emerged that appreciates the outcomes that are possible when surgery is moved beyond what insurance companies are currently willing to reimburse in the United States. Adopting new technologies that require a fee-for-service model can sometimes be frightening for physicians. As a player in this relatively new field, WaveTec Vision has developed a business model that allows physicians to acquire the ORA System without an outlay of capital so high that it could bankrupt a moderately sized practice. Unlike other equipment, the manufacturers of which charge a perusage click fee, WaveTec offers a unique monthly subscription that allows the physician to use the device as often as it is needed. This creates a level of comfort that encourages physicians to consider using new devices. My colleagues and I put down a deposit and received a machine in our surgery center. WaveTec worked with us to thoroughly develop our skillsets for using and marketing the use of the device to our patients.

There is always a period of adaptation when adding a new skill, especially in the case of intraoperative aberrometry, which is an entirely new field. In our experience, WaveTec has provided excellent customer support, which often is not available from small companies. The level of training is outstanding, and it has lasted as long as necessary for the surgeon to feel 100% confident about using the system. We had a period of didactic training, and the remaining education was done in the surgery center. WaveTec has sent representatives to our practice to train our staff on how to market and bill for the out-of-pocket technology as an adjunct to cataract surgery.

We have used the device since it first became available, and along with the other early adopters, we have played a role in creating a new paradigm of accuracy in IOL outcomes. A clinical liaison coordinates a network of physician users to discuss their approaches via a closed social media platform, and that has been a useful tool. The company has also shown a great willingness to share the device's advances with their clients. Although hardware upgrades require additional investment, WaveTec has been generous in terms of keeping us, its clients, in the loop regarding software updates. We have been impressed with our experience.

M22 MULTILASER PLATFORM (LUMENIS INC.)

Robert J. Noecker, MD, MBA

Ophthalmology tends to be a technology-centric field, and a public awareness of this grants a competitive edge to eye care practices that are ahead of the curve in offering their patients advanced treatment options. Although it is impossible to invest in every new tool that comes to market, physicians certainly have to consider acquiring more devices than in the past.

Being an early adopter of a new technology means that there is still a significant amount of education and disease state awareness for patients that have to be performed. Ocular surface disease is emerging as a differentiating factor in patients' satisfaction. In my practice, my colleagues and I find that treating rosacea with intense pulsed light improves the ocular surface. This is a fairly revolutionary concept that requires a shift in the treatment paradigm. Instead of opting for treatment with systemic medication, we are specifically treating the target area by applying the laser to the skin affected by rosacea.

As ophthalmologists, we tend to be very conservative in treating patients to avoid any unwanted side effects. Lumenis Inc. has a strong history of educating physicians, practices, and patients. With the Multilaser Platform, the company provided our practice with a trained nurse for a day to convey the spectrum of acceptable treatment endpoints, potential side effects, and solutions in remedies for them, along with teaching us how best to minimize the chances of adverse occurrences. Having the trainer present in our office with our entire staff to demonstrate the functions and techniques of the M22 helped lower apprehension that might otherwise have served as a barrier to implementing the treatment.

Any time there is a shift in the standard therapy, the availability of marketing materials is not trivial. Lumenis introduced selective laser trabeculoplasty for glaucoma treatment, and the company continues this leadership with IPL therapy. The company has provided an excellent combination of print and digital information that has led to a 20% increase in patients' inquiries and election of IPL treatment in my practice. I use the printed materials to explain how the technology works and how we are going to use it, but then I direct the patient to the Internet to search for specific terms and get more comfortable with the therapy. Many patients forget to follow up on their own for further information or are timid about asking questions when they are face to face with the surgeon. Having them do their own research and offering them materials allows them to learn about what is being proposed to them on their own terms. They can also share the information with family members who participate in the decision-making process.

Technology is both an opportunity and a threat; newer treatments are exciting opportunities for physicians, can generate satisfied patients, and provide a return on investment (ROI). A careful assessment must be done to ensure that the practice's service demand is large enough to generate the ROI required for the technology's adoption. Partnering with a manufacturer that is highly responsive, offers thorough product and marketing education, and has excellent customer service creates a synergy that brings success to patients and physicians.

iSTENT TRABECULAR MICRO-BYPASS STENT (GLAUKOS CORPORATION)

Nathan Radcliffe, MD

The use of a new technology requires more than patients' education. Physicians, too, often have to learn new surgical techniques when landmark devices come to market. Glaukos Corporation employs a combination of innovative and more traditional educational techniques that are designed to make the surgeon comfortable and successful in implementing this new microinvasive glaucoma surgery (MIGS) device.

The certification process for the iStent Trabecular Micro-Bypass Stent starts with a series of nine online modules that introduce the surgeon to the physiologic defects associated with glaucoma and the role of the stent as well as to the use of a gonioscope and markers that indicate correct placement of the device. The online program contains a wide selection of videos that provided the most value for me. For instance, I was concerned about the process of releasing the stent once I had placed it in the trabecular meshwork. Glaukos has a video demonstrating how the inserter works, providing a conceptual understanding of what to do with my hands during device deployment. Several other videos are given to training physicians, many of which I have saved on my iPhone (Apple, Inc.). This accessibility has turned my smartphone into an illustrative tool that I am able to show to patients when I am discussing the iStent with them.

After completing the online program, physicians can practice inserting the iStent in a wet lab. At 1 mm, the stent is the smallest FDA-approved device implanted in the human body. Glaukos has a 1-inch model of the stent and a matching, larger inserter that allows surgeons to gain tactile familiarity with the device without having to use a microscope.

Using the device is highly intuitive, but the physician must also be comfortable using a gonioscope. After the wet lab, the surgeon performs approximately 10 cases in the company of his or her sales representative. This experience was a complete add-on for me, as the sales representative was very well trained to support my cases, which were spread out over time. As I completed more insertions, I had more questions and was able to discuss them with the sales representative during my next case. Glaukos' goal for the surgeon is beyond just placing an iStent; the company also wants the surgeon to be comfortable with his or her surgical technique and to achieve excellent outcomes.

Glaukos continues to host expert panels at industry meetings that I find insightful in contributing to the ongoing conversation surrounding MIGS. The expert surgeons directly and honestly explain the challenges and complications they have faced in individual cases and share their treatment preferences for rectifying adverse events. In addition, they provide retrospective acumen on alternative ways past cases could have been handled.

Just as out-of-pocket procedures present uncertainty regarding potential ROI, new procedures have to fight through the insurance quagmire before the surgeon can receive reimbursement. Glaukos handled this aspect in a revolutionary manner that resulted in coverage's being available to 90% of my patients starting with my first case. Reimbursement has been predictable, and I have never had trouble receiving payment after the placement of the stent. Overall, I have found the company to be incredibly proactive in aiding me in all aspects, from training to payment, for a device that requires very little overhead to acquire. The iStent is likely just the beginning of the MIGS era. By introducing me to the iStent, Glaukos has given me the tools to provide my patients with a new class of safe and effective MIGS options.

LipiView OCULAR SURFACE INTERFEROMETER AND LipiFlow THERMAL PULSATION SYSTEM (TearScience)

Robert J. Cionni, MD

With the high prevalence of chronic meibomian gland dysfunction (MGD), it is not surprising that multiple new technologies were developed to facilitate the diagnosis and treatment of this pathology.¹ MGD has a progressive impact on all aspects of surgical and medical vision care, including patients' visual acuity, comfort, and function, even though dry eye disease is often a secondary complaint. TearScience strives to engage in a long-term business relationship with eye care practitioners by adding value via its Dry Eye Solution, which includes the LipiView Interferometer, the LipiFlow Thermal Pulsation System, and the Meibomian Gland Evaluator.

Most patients have probably never heard of MGD prior to visiting their eye care provider, and it is a “new” disease to some physicians as well. In the past, physicians concentrated on aqueous-deficient dry eye disease. Recent research, however, has refocused physicians on MGD.¹ TearScience provides extensive education for physicians and patients. For the practice, marketing tools are available in the MyTearScience Kit, and additional online resources at MyTearScience.com provide training for doctors and technicians that encompasses how and what to communicate to patients, how to manage the dry eye workflow, best-in-practice tips, marketing pearls, and tools for communicating with and educating patients. There is also a TearScience hotline to field patients' calls. A knowledgeable team of dry eye experts who also function as practice advocates provide clinical training at the time the equipment is installed. There is also a first-rate service team.

MGD can negatively affect patients' quality of life. It is best to deal with dry eyes before handling surgical issues, but only recently have practitioners begun treating MGD. Based on my experience, the tools that TearScience provides dramatically increase the probability that eye care providers will be able to successfully integrate this service into their practices.

KAMRA CORNEAL INLAY (AcuFocus, INC.)

Wolfgang Riha, MD

Presbyopia is ubiquitous, but its surgical solutions have been limited until recently. Although a variety of solutions are in various stages of development, one of the most promising is the Kamra corneal inlay (not approved for use in the United States). As the market leader (the inlay is now approved in 47 countries across Europe, the Asia-Pacific region, the Middle East, and the Americas, with recent approvals in Canada, according to the company), AcuFocus, Inc., has a unique opportunity and responsibility to provide education about a novel approach to presbyopic correction using a smallaperture corneal inlay. AcuFocus approaches education by partnering with surgeons and their staff to integrate the inlay into all aspects of the practice from optimizing surgical integration alongside individual physicians' techniques to marketing and branding.

I started using the inlay in 2007, and I became a trainer for the company in 2010 based on my belief in the technology and my appreciation of the opportunity to be a part of a very exciting development in the refractive space. AcuFocus uses a multimedia approach that includes an online learning center, customized tablet applications for practices' and patients' education, smartphone applications for patients, and high-definition surgical training videos in addition to comprehensive support for wet labs and proctored surgeries. The training does not end after the proctored surgeries. Biannual users' meetings are complemented by a data analysis platform established so that surgeons may share their results, compare outcomes, and refine their techniques and the overall procedure. This is perhaps the most valuable tool for surgeons who wish to improve their outcomes as well as for encouraging feedback for AcuFocus. Because corneal inlays are still relatively new, it is critical for the company to partner with surgeons so that the procedure can evolve and improve based on in-practice experiences. The company values this first-hand knowledge and facilitates sharing it with other physicians, in turn assisting the refractive community as a whole in achieving highly refined outcomes. I find that AcuFocus' small corporate size allows it to act quickly and to maintain a direct line of communication with its practicing surgeons.

Equally important to surgeons' training is learning how to attract presbyopic patients who can benefit from this procedure. AcuFocus has created more than 100 different marketing tools to help practices recruit and educate potential patients and train staff. These include guidance on hosting press conferences, editable news releases, form letters to be mailed to patients, and radio commercials. The company makes noteworthy efforts to immerse their customers in valuable resources to expedite their success with the Kamra.

CONCLUSION

Many manufacturers have made significant strides in improving disease state awareness, practice management solutions, surgical techniques, and more. These efforts represent the continually increasing standard of ophthalmic care sought by patients and physicians across all subspecialties.

Robert J. Cionni, MD, is the medical director of The Eye Institute of Utah and an adjunct clinical professor at the Moran Eye Center of the University of Utah in Salt Lake City. He acknowledged no financial interest in the product or company he mentioned. Dr. Cionni may be reached at (801) 266-2283 rcionni@theeyeinstitute.com .

Robert J. Noecker, MD, MBA, is in private practice at Ophthalmic Consultants of Connecticut in Fairfield. He is a consultant to Lumenis, Inc. Dr. Noecker may be reached at (203) 366-8000; noeckerrj@gmail.com .

Nathan Radcliffe, MD, is an assistant professor of ophthalmology and director of the Glaucoma Service at Weill Cornell Medical College, New York-Presbyterian Hospital, New York. He is a consultant to Glaukos Corporation. Dr. Radcliffe may be reached at (646) 962-2020; drradcliffe@gmail.com .

Wolfgang Riha, MD, is an ophthalmologist at Sehkraft Augenzentrum, Cologne, Germany. He is a consultant to AcuFocus, Inc. and receives clinical research funding from the company. Dr. Riha may be reached at wriha@acufocus.com .

Jonathan Solomon, MD, is surgical/refractive director of Solomon Eye Physicians and Surgeons in Greenbelt and Bowie, Maryland, and McLean, Virginia. He is a consultant to and speaker for WaveTec Vision. Dr. Solomon may be reached at jdsolomon@hotmail.com .

1. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478.