Optometric Physician

A weekly e-journal by Art Epstein, OD, FAAO


Volume 19, Number 31

Monday, August 5, 2019


Inside this issue: (click heading to view article)
######### Off the Cuff: The Downhill Race to Mediocrity
######### Six Months' Treatment with Lifitegrast in Patients with Moderate-to-severe Symptomatic Dry Eye: a Retrospective Chart Review
######### Weekly Changes in Axial Length and Choroidal Thickness in Children During and Following Orthokeratology Treatment with Different Compression Factors
######### Effects of Blink Rate on Tear Film Optical Quality Dynamics with Different
######### News & Notes

Click on the image for upcoming Conferences and Meetings.


Off the Cuff: The Downhill Race to Mediocrity

This past week, CMS announced substantial cuts in reimbursement for a number of surgical procedures including cataract surgery. Routine extracapsular cataract removal with IOL insertion was cut to $557.58, down from $654.47, a stunning reduction of about 15%, while complex cataract procedures were cut 6% to $765.82. Even more surprising was that these cuts were made after negotiation and agreement with the American Medical Association's Relative Value Scale Update Committee (RUC) by the Academy of Ophthalmology and ASCRS. According to an AAO advisory, this decrease was equitable relative to payments of other physician services of similar time and intensity. That is hard to comprehend considering nearly 85% of ophthalmologists charged in excess of $2,000 for cataract surgery not covered by insurance in 2017. My ophthalmologist friends are obviously unhappy, and I agree with them. These massive reductions are misguided, and set a dangerous precedent that devalues complicated and highly technical procedures.

Some of you may find it odd that, at a time when ophthalmologists in Arkansas are launching an insidious and heinous attack against optometry, I would come to ophthalmology’s defense. For those who see it that way, you’re missing the point. These cuts will have the greatest impact on the most progressive and skilled high-volume surgeons. These ophthalmologists are among those who work closely with optometry, do the most good for our patients and have worked tirelessly to perfect surgical techniques that benefit everyone. The safe and routine cataract surgery of today did not happen overnight or without incredible innovation, dedication and sacrifice. Reducing reimbursement to these levels penalizes the more skilled and innovative surgeons the most. I also expect it will have a chilling effect on future innovation.

There is nothing routine about cataract surgery. I have completed several phaco wet labs, not to develop surgical skills, but rather to better understand what the residents I was teaching were going through. Cataract surgery is incredibly technical and extremely difficult. It is also constantly evolving. Many of us practicing today remember when intracapsular surgery took an hour or more, and entailed a massive incision and sutures. The lens was plucked out with a cryoprobe and expulsive choroidal hemorrhages were not uncommon. Large post-op cylinder was frequent, and endophthalmitis was a real fear. Even the most successful patients were incapacitated for days and, once fully recovered, were still aphakic and visually handicapped. As I recall, cataract surgery back then was reimbursed at more than $2,000 an eye (about double that in today’s dollars) with an additional fee for an assisting surgeon who usually dropped BSS on the eye to keep the cornea from drying out. The development of phacoemulsification by Charles Kelman, IOLs, foldable IOLs and small incision surgery were perfected by a small number of pioneers. This ongoing advancement has led modern surgeons to be more effective and much more efficient. It seems that today’s ophthalmologists are being punished for their increased efficiency.

In calculating reimbursement for complex procedures like cataract surgery, time, skill, outcomes as well as the need to foster innovation must be factored in. The cuts proposed by CMS, and accepted by the AAO and ASCRS are not equitable. They do not reflect the true complexity and ongoing innovation implicit in modern cataract surgery. In writing this, I am also reminded that optometry and ophthalmology share common interests that extend well beyond our professional organizations. We are bound together by the patients we serve. It is important that these interests be recognized, synergy and mutual cooperation nurtured, and ways of better working together explored. I have some ideas that I will be sharing over the coming months.

Links From Last Week’s Commentary on Hubble

Unfortunately, the links in last week’s op-ed by Sally Dillehay were broken. Because reporting abuse of passive verification and the Contact Lens Rule are important to patient safety, I am including the correct links below and encourage all to report any illegal behavior. It’s worth taking the time because your vigilance does make a difference.

FDA: https://www.fda.gov/safety/report-problem/reporting-unlawful-sales-medical-products-internet

FTC: https://www.ftccomplaintassistant.gov/Information#crnt&panel1-1

AOA: stopillegalCLs@aoa.org

Hubble’s “doctor verification” email: doctor@hubblecontacts.com

Arthur B. Epstein, OD, FAAO
Chief Medical Editor


Want to share your perspective? Write to Dr. Epstein at artepstein@optometricphysician.com.

The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of the editorial board, Jobson Medical Information LLC (JMI), or any other entities or individuals.


Six Months' Treatment with Lifitegrast in Patients with Moderate-to-severe Symptomatic Dry Eye: a Retrospective Chart Review
A retrospective chart review was conducted in 168 patients (111 females and 57 males) who presented with symptoms of chronic dry eye disease and were treated with lifitegrast 5% ophthalmic solution for six months to evaluate six-month treatment benefits with lifitegrast ophthalmic solution 5% in symptomatic dry eye patients. Collected symptom data included improvement of eye dryness, tearing, eye pain, fluctuation in vision, foreign body sensation, itching, grittiness, burning and contact lens intolerance, if applicable. Collected clinical signs included changes in superficial punctate keratitis, corneal fluorescein staining, conjunctival hyperemia and presence of tear debris.

Treatment with lifitegrast ophthalmic solution 5% twice daily for six months significantly improved majority of dry eye symptoms reported by patients. Improvements were also observed in corneal and conjunctival staining and tear debris for most of the patients reviewed.

Researchers concluded that treatment with lifitegrast twice a day for six months improved both signs and symptoms of chronic dry eye.

SOURCE: Atallah RT, Castanos MV, Najac R, et al. Six months' treatment with lifitegrast in patients with moderate-to-severe symptomatic dry eye: a retrospective chart review. Clin Ophthalmol. 2019;13:1033-7.

Weekly Changes in Axial Length and Choroidal Thickness in Children During and Following Orthokeratology Treatment with Different Compression Factors
Orthokeratology lenses of different compression factors (one eye with 0.75D and the fellow eye with 1.75D) were randomly assigned to 28 subjects (median [range] age: 9.3 [7.8 to 11.0] years) to determine the influence of compression factor upon changes in axial length and choroidal thickness during and following orthokeratology treatment. Ocular biometrics were measured weekly for one month of lens wear and after lens cessation until the refraction stabilized (mean duration: 2.8 weeks ± 0.4 weeks). Changes between eyes, and the associations between axial shortening and choroidal thickening with other ocular biometrics were analyzed.

There were no significant between-eye differences in the changes of ocular biometrics. After adjusting for paired-eye data, axial length initially decreased by 26μm ± 41μm at week one, then gradually returned to its original length. An approximate antiphase relationship of choroidal thickness (mean change: 9μm ± 12μm) with axial length was observed. A significant rebound in axial length, but not choroidal thickness, occurred during the cessation period. Central corneal thinning and choroidal thickening accounted for 70% of initial axial shortening.

Increasing the compression factor by 1.00D did not affect changes in ocular biometrics in short-term orthokeratology. Significant axial shortening and choroidal thickening were observed during the early treatment period. Axial shortening could not be entirely explained by central corneal thinning and choroidal thickening, which investigators wrote warranted further investigation. They added that initial axial shortening in orthokeratology was transient, and, therefore, axial length remained useful for long-term monitoring of axial elongation in children.

SOURCE: Lau JK, Wan K, Cheung SW, et al. Weekly changes in axial length and choroidal thickness in children during and following orthokeratology treatment with different compression factors. Transl Vis Sci Technol. 2019;8(4):9.



Effects of Blink Rate on Tear Film Optical Quality Dynamics with Different Soft Contact Lenses
The aim of this study was to investigate tear film optical quality dynamics for four types of silicone hydrogel contact lenses (SHCLs) for daily wear over a 15-day period and for different blink rate (BR) patterns. A prospective, randomized, double-blind, cross-over pilot study including four SHCLs (A: lotrafilcon B [Air Optix plus HydraGlyde, Alcon Laboratories]); B: samfilcon A [Ultra, Bausch + Lomb]; C: comfilcon A [Biofinity, CooperVision]; and D: filcom V3 [Blu:gen, Mark'Ennovy]). Serial measurements of Objective Scatter Index (OSI) using the HD Analyzer (Visiometrics S.L., Terrassa) were taken at different blinking patterns: blinking every 2.5 seconds (high BRs) and every nine seconds (low BRs). They were performed during the first visit before CL insertion (baseline), after 20 minutes of CL wear (day 1), and during the last visit after eight hours of CL wear on day 15 of use (day 15).

Normal young healthy subjects were recruited and fitted with the four lenses. For low BRs, the mean OSI value increased over time for all CLs, and the slope of the curve also increased for all CLs, except for CL D. However, for high BRs, the mean OSI value increased only for CLs B and C, and the slope of the curve did not change over time for any of them.

Investigators wrote that the results suggested that tear film optical quality dynamics after wearing SCHLs for 15 days seemed to undergo a slight deterioration only for lowest BR.

SOURCE: García-Montero M, Rico-Del-Viejo L, Martínez-Alberquilla I, et al. Effects of blink rate on tear film optical quality dynamics with different soft contact lenses. J Ophthalmol. 2019;2019:4921538.

News & Notes
B+L Initiates First Clinical Trial for Technolas Teneo Excimer Laser in US
Bausch + Lomb announced that it initiated the first in a series of U.S. clinical trials to evaluate the safety and efficacy of the Technolas Teneo excimer laser for vision correction surgery for myopia and myopic astigmatism. The trial is a multicenter, prospective, open-label, non-randomized study being conducted in the United States, evaluating the effectiveness of the Technolas Teneo 317 (model 2) excimer laser in LASIK surgery for myopia or myopic astigmatism. Participants in the study will undergo safety and efficacy evaluation at the time when refractive stability has been achieved (study endpoint). Read more.

Johnson & Johnson Vision Launches New Surgical Vision Experience Center
Johnson & Johnson Vision launched the Surgical Vision Experience Center at the Johnson & Johnson Institute in Jacksonville, Fla. The center will serve as Johnson & Johnson Vision’s premier physical training space and laboratory setting for various experiential educational programs offering hands-on, in-depth training for practicing ophthalmic surgeons, ophthalmology residents and optometrists. Trainings will cover best practices for personalized approaches to intraocular lens selection for cataract procedures, using topo-integrated, wavefront-guided LASIK procedures. The curriculum will span the company’s full line of products and equipment for cataract and refractive surgery, along with ocular surface health. Read more.

Hillrom Introduces Retinal Imager
Hillrom introduced the Welch Allyn RetinaVue 700 Imager handheld retinal camera as part of the RetinaVue Care Delivery Model, enabling remote ophthalmologists to diagnose diabetic retinopathy in individuals with diabetes during routine primary care office visits. The imager is the first handheld camera capable of capturing high-quality retinal images in a fully automated fashion in pupils as small as 2.5 millimeters, according to the company. With a 60-degree field of view and image-quality assessment algorithm, the imager enables remote eye specialists to efficiently review up to 75 percent more retinal area compared with cameras with a standard 45-degree field of view, the company says. The device includes Hillrom's HIPAA/HITECH-compliant RetinaVue Network, featuring encryption of data in transit and at rest, along with secure client-server authentication. Read more.



Optometric Physician™ Editorial Board

Chief Medical Editor
Arthur B. Epstein, OD, FAAO

Journal Reviews
Shannon Steinhäuser, OD, FAAO

Contributing Editors
• Katherine M. Mastrota, MS, OD, FAAO
• Barry A. Weissman, OD, PhD, FAAO (Dip CL)

Editorial Board
• William Jones, OD, FAAO
• Alan G. Kabat, OD, FAAO
• Bruce Onofrey, RPh, OD, FAAO
• John Schachet, OD, FIOS
• Joseph Shovlin, OD, FAAO



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