May
2010 was an excellent year for Ophthalmology. I spent time over the holidays thinking of the “Best of 2010”. I was guided in my thoughts by Gillian McDermott’s excellent article in the January 2010 CRST “The Best of 2010”, a valuable survey from top ophthalmologists of their impressions of the best clinical pearls, published articles, software, technical innovation and new technology. I was grateful to be included as well.
First, where did we come up short? Presbyopia. Other than Dr. Bruce Wallace’s tip about an educational software for presbyopia correcting IOLs, none of us had anything much to say about Presbyopia. I hope that changes in 2011. Presbyopia is the most common problem for the largest number of our patients yet we have very little for them surgically. While we have good options, LASIK and PRK, for our patients under 40, as well as advanced IOLs for those with cataracts over 65 or so, we have nothing for that middle group. It is where all the Baby Boomers still are and yet we can’t help them. We truly need a “bridge” procedure to help our patients and keep them in the practices between LASIK and cataract surgery. Where did we excel?
While there were so many wonderful tips and pearls related in the article, one stood out. I believe the game changer in all of 2010 is Laser Cataract Surgery. I agree with Eric Donnenfeld, that there was “nothing as exciting in 2010 as the development of femtosecond cataract surgery”. What excites me are the benefits the technology offers to our patients, improved safety and accuracy. Safety will be enhanced by reduced phacoemulsification time and power, less time in the eye and finer, more elegant incisions among other innovations. Precision may be increased by an exact capsulotomy size, shape and position to better control the final resting place of the IOL as well as exact incisions and standardized, quantifiable astigmatic keratotomies. Further, it is an enabling technology, and could make possible so many other technologies such as injectable polymer IOLs through a tiny capsulotomy. And just like LASIK, IOLs, Femtosecond Laser Flaps, and phacoemulsification before it, Laser Cataract Surgery is stirring up a great deal of debate amongst us.
In Ms. McDermott’s article, Marguerite McDonald states “this innovation has stirred the most heated and heart-felt discussions on the ASCRS Internet Forum seen since its inception 6 years ago.” I agree, have participated in the forum, and that’s exactly what we doctors should be doing, debating the technology. Most of that debate has not been about the capabilities of the technology but the “real world” practicality of it. Will patients seek it out? Is it economical? Who will pay? I do have a unique perspective here. We have been doing Laser Cataract Surgery here in Houston for nearly a year now, commercially, on all our premium IOL patients and most of our other cataract patients. Uniquely, since LenSx delivered the laser last February, we have not been under an FDA Trial or other investigational device restrictions. The laser came fully approved to do capsulotomies with a 510K approval, then incisions, nucleus chopping, etc. approvals quickly followed. It is now the norm in our office based surgery center.
In my experience, patients do easily understand and prefer “laser” cataract surgery and do seek it out. Yes, there are added costs, but this advanced technology is not covered by Medicare so can be assumed by the patients if they so choose. In other words, patients can choose to pay for what they decide is better care. What a concept! So while my lone experience is isolated, it certainly has been “real world”. Finally, on January 1st, a unique thing happened. The first Baby Boomers turned 65 and entered Medicare. 10,000 a day will turn 65 from now on. The US population over 65 will double in 7 years. Even if we started increasing residency programs today, it would take about that long for the first added eye surgeon to hit the streets. These educated, demanding, more financially secure Baby Boomers are whom most of us will form our practices around. Time will tell, but I firmly believe Laser Cataract Surgery is in the right place for them, at the right time.
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