EyeWorld Asia-Pacific September 2015 Issue

22 September 2015 EWAP FEATURE Future of peri- and postoperative medications “Intraocular/intracameral injection of steroids, antibiotics, and perhaps nonsteroidals will be the future of postoperative medications,” Dr. Hoffman said. “We will pretreat the patients in the holding area and inject medications into the vitreous following the cataract operation, and patients will no longer be required to use preoperative or postoperative drops.” Doing this will be a major cost savings for patients and is especially relevant today because generic medications have reached prices that are similar to branded medications, he said. Role of ophthalmologist in the future Dr. Hoffman thinks there will be a shortage of ophthalmologists in the next 20 years and that adding optometrists to ophthalmic practices is the way forward into the future. “I believe ODs will be used more and more in ophthalmic practices to perform vision exams and postoperative care of surgical patients,” he said. “I see an integrated system with ODs working under the supervision of ophthalmologists.” Where surgery will take place Both Dr. MacDonald and Dr. Hoffman agreed that a shift to the ambulatory surgery center (ASC) setting for cataract surgery could be beneficial. “I believe that cataract surgery will continue to be moved into ASC settings and completely out of hospitals,” Dr. MacDonald said. “It will remain in ASCs to allow physicians to cost share and maximize investments, and maintain quality and efficiency.” “I believe it is more efficient and cost effective for cataract surgery to be performed in an ASC,” Dr. Hoffman said. “The current reimbursement is much lower in an ASC than the hospital, which should encourage the government to try to shift patients from hospitals to ASCs.” However, there are still many cataract surgeries performed in the hospital setting. “I believe that reimbursement should be increased for [surgery done in the] ASC since it can be done more efficiently there, and these ASCs should be rewarded for the increased efficiency and the lower infections and complications,” he said. Biggest surprise in the field of cataract surgery Looking back at the field of cataract surgery, Dr. MacDonald said the biggest surprise is the click fees that are being associated with different technologies. “It surprised me that as a community we would accept this, further reducing our ability to be successful business people,” she said. Dr. Hoffman is surprised at advancements in the field. “It always amazes me how quickly the field of ophthalmology and in particular cataract surgery has advanced,” he said. This includes the transitions from intracaps to extracaps to phaco and now femtosecond laser cataract surgery. “IOL technology has also had a major impact on the success and appreciation of cataract surgery,” he said. “I see continued advancement and improvement in all aspects as long as the additional costs can be covered by government reimbursement or [the] patient.” When proper reimbursement no longer covers the costs of new technology and innovation, innovation and advances will slow or stop, Dr. Hoffman said, but he remains optimistic for the future. EWAP Editors’ note: Drs. Hoffman and MacDonald have no financial interests related to their comments. Contact information Hoffman : rshoffman@finemd.com MacDonald : Susan.M.MacDonald@lahey.org The future - from page 18 What’s new - from page 21 RK eye, it’s not going to be the same 2 months later.” For those who are using intraoperative aberrometry in post- RK eyes, Dr. Hoffman warned if the device produces the same lens power the surgeon came up with preoperatively, be leery. “Patients will have great vision on postop day 1, but will rapidly regress over the next couple of months and be myopic.” He is slightly wary of intraoperative aberrometry use with toric lenses as well—“we hydrate the cornea during phaco, and that hydration can change the curvature of the cornea temporarily,” he said. While the change is transient and small, basing lens placements and power on just the intraoperative measurement may result “in more errors than if you know what your surgically induced astigmatism is and you’ve got that lens lined up perfectly on the topographic meridian without doing the intraoperative aberrometry.” In contrast, Dr. Donaldson thinks that intraoperative aberrometry has great potential. “But I think incorporating the ORA intraoperative aberrometry and helping that transition from the office into the operating room is key,” she said. “The more seamless the integration from preoperative measurement and planning, to intraoperative application and modification, to postoperative feedback of data with nomogram creation can be, the better for us as surgeons.” Improvements in wavefront analysis have impressed Dr. Hoffman. “My ability to get a post-LASIK patient close to plano has been enhanced. Five years ago, I couldn’t make that same statement,” he said. “It’s incrementally more reliable now, especially in the post-refractive patient’s data. Technology will evolve so that we’re just going to do intraoperative measurements and choose a lens off the shelf based on those measurements. We haven’t quite gotten there yet.” What about femto? Dr. Hoffman has not “jumped on board just yet” with the femtosecond laser. “It slows down the procedure, and for the average patient, I think manual techniques work just as well,” he said, adding “it does benefit a select group of patients, but I’m still on the fence.” Dr. Donaldson said incorporating these lasers into a practice “may add a significant amount of time to the procedure and will require careful choreography of the OR day.” At Bascom Palmer, the femto lasers are placed directly in the OR suites, which reduces OR efficiency. “However, with more laser experience we have reduced our extra time from 12 minutes during the learning curve to the current additional 6.7 minutes per patient,” she said. She mentioned that other groups have increased their efficiency by moving the laser outside the operating room to a separate laser suite or by having a separate surgeon dedicated to performing the femto portion of the case while another surgeon performs the phaco components. In those cases, the time to perform cataract surgery is actually reduced. EWAP Editors’ note: Dr. Donaldson has no financial interests related to her comments. Dr. Hoffman has financial interests with Carl Zeiss Meditec. Contact information Donaldson : KDonaldson@med.miami.edu Hoffman : rshoffman@finemd.com