By: Paul M. Karpecki, OD, FAAO Clinical Director – PECAA
It has been shown that optometry sees over 88% of all comprehensive eye exams, which obviously includes patients with cataracts. The knowledge we obtain on a patient over the last 2, 5 or more than 20 years is invaluable to their surgical success. Search for surgeons who share your values for patient care, utilize innovative technology for your patients and value your contribution.
When a patients is referred for cataract surgery, the surgeon (or more often optometrist in the surgical practice) sees the patient for 10-15 minutes of exam time in most cases. No matter how astute this doctor is, it is unlikely they can know as much about that patient’s particular needs, idiosyncrasies, success or failure in mono-vision contact lenses, etc. compared to the optometrist that has seen that patient for years or decades. That information is key to surgical success, especially when considering the many options available today.
The current, but especially the future, shortage of cataract surgeons is creating a paradigm shift where optometry has to take on the role of quarterback in the care of cataract patients. The most important quality is already in place— trust. The life expectancy for a patient at age 65 (a common age for cataract surgery) is in the mid 80’s. That means at least 20 years of quality vision, making this a once in a lifetime decision. Take for example the decision of correcting corneal astigmatism; glasses work but have distortions in the periphery, contact lenses have improved dramatically but still may rotate, but a correction of astigmatism closest to the nodal point with IOL’s that today don’t rotate, is often the best vision that patient will experience. And although almost 50% of the population may qualify for a toric IOL (defined as >0.75D of corneal astigmatism), only about 7-8% have pursued it. How unfortunate given the years they could appreciate this vision – especially patients with against-the-rule astigmatism, oblique or > 1.25D of with-the-rule cylinder. Likewise new presbyopic IOLs, such as the new Trifocal PanOptix or extended depth of focus, Synchrony IOL, have added considerably greater ranges of vision with fewer side effects. And views on multifocal IOL’s are rightly variable among the OD community given previous technologies, but topic IOL’s carry none of this baggage and should be at least a starting point in helping your patients with optimal vision.
It has been shown that the top reasons a patient is unhappy after cataract surgery include not treating underlying disease such as dry eye prior to surgery, residual refractive error (which could also be due to dry eye during the biometry measurements), not being aware or informed of potential options, not setting proper expectations or selecting inappropriate patients. Since we are often the first to diagnose dry eye and we know more about who is an appropriate candidate given their history, the only remaining issue is understanding and discussing the various IOL options and expectations, particularly for toric, multifocal, trifocal or EDOF lenses.
Three New, and VERY Exciting Co-management Opportunities:
Two very exciting opportunities are likely to launch in January 2020, which at the time of this publication is about 2 months away. What a great year for new technologies-2020! The first is the RxSight light adjustable lens (LAL). Patients and doctors alike know that a poor refractive outcome can negate any surgical procedure’s potential. Imagine being a +1.50 after cataract surgery, which isn’t a big miss, but has devastating consequences! You now can’t see far or near and extracting an implanted IOL is a difficult and high risk proposition. PRK or LASIK, especially over a multifocal IOL, can increase aberrations and although rare, has the potential for neuropathic pain complex issues due to multiple surgeries.
In January, a +1.50 outcome can be treated with a uv-light laser within 2-3 weeks of surgery directed at the IOL. Now it has to be an RxSight IOL that has the ability to be modified after surgery. The accuracy, unlike treating living tissue such as the cornea, is consistent, predictable and exact. The first three patients I saw were all better than 20/16 uncorrected!! The reason is that you can treat a 20/20 patient without concern if they are able to afford a laser touch-up. In fact the patient with 20/12 uncorrected vision had just undergone a treatment for a residual refractive error of +0.25-0.50×160. What an opportunity! And because your refraction and decision as to mono vision or full distance correction (via a trial contact lens for example) is more valuable than a 2 minute programable uv light laser treatment on the IOL, you should expect to receive about 50% of the procedure fee. It’s time to value your knowledge, your expertise and your understanding of the patient to position them and you for success. Partner with surgeons who value your knowledge.
The second very exciting technology isn’t one I would have predicted having seen the very first versions of this technology over 20 years ago. The ReFocus VisAbility implant is for the surgical correction of……presbyopia. Young eyes that can accommodate have zonules that remain loose in static position but as the lens grows throughout life and enlarges, it leaves no space for zonules that now remain taught. These VisAbility micro-inserts are placed where they can expand the zonular space. The data I saw from one of the investigational sites showed 100%, of all 20 patients being able to read J3 or newspaper print! An astounding 90% could see J1, which is pill bottle labelling. If you’ve ever tried to read a pill bottle, you can’t help but be amazed by this data. Now new surgeons will have a learning curve even though the process is very systematic, but if an FDA trail investigator can achieve this on 20 out of 20 patients, the data is real. And there is no surgery in the visual axis or even the cornea for that matter, so the risk of visual loss is minimal to none. This is another procedure that cataract surgeons will be doing in 2020 and need to partner with optometry both professionally and co-management fee related, so the right patients who would benefit, receive education on it. The co-management process typically starts at 1 week and the one key advice you must impart to patients is NO READING GLASSES, as their ciliary body and zonular structures return to the accommodation they had in their 20’s or 30’s.
Finally, as stated, ensure you are properly compensated for the time and extra testing (OCT, osmolarity or other dry eye testing, topography, patient education of options, post surgery CL trials etc.) that goes into an IOL assessment and especially now with LAL IOLs. Think about the time involved in educating and counseling patients that go on to have these procedures like the VisAbility correction for presbyopia or even a toric IOL.
Renumeration should not be so high it would be construed as an inducement to refer, but also should not be the 20% of the basic Medicare surgical fee alone, since it would reflect the extra pre- and post-operative work, testing and time involved for patients who go on to pursue these new technologies. Work must be performed and documented, as Stark Laws prevent receiving a fee simply for referring patients.
One interesting development that may help optometry regarding co-management is the recent strong trend toward in-office surgical suites. It makes sense as we’ve moved from in-hospital, to out-patient, to surgery centers for cataract surgery. The next logical step is in-office surgical suites, so be aware of this development in your community.
Knowing when to refer a cataract patient and for what is critical. This includes recommending glaucoma procedures that can only be done at the time of cataract surgery. These MIGS procedures are significant and the newest one, the Ivantis Hydrus, has recently shown that 80% of patients that received this micro-stent at the time of cataract surgery had low enough IOP to remain medication-free a full 3 years later. Our role in pre and post-op care, and what you need to know about IOLs and implants will help you quarterback the patient from early diagnosis and progression to IOL selection and post-op care. The end result is a more knowledgeable patient, a better prepared patient (including the ocular surface) who receives the appropriate technology and quality vision they can enjoy for the rest of their life.