2007 ASCRS Summer Refractive Meeting

Reported live from
the 2007 ASCRS Summer Refractive Meeting



Editors’ note: This Meeting Reporter contains original reporting by the EyeWorld News Team from the 2007 ASCRS Summer Refractive Meeting, Aviara. Meeting Reporter is sponsored by an unrestricted grant from Advanced Medical Optics (AMO).

The 2007 ASCRS Summer Refractive meeting, was held this year, north of San Diego, at the Aviara Resort, and began, Thursday, Aug. 2, with discussions of detailed statistics and vital practice management tools to assist the ophthalmic surgeon in bettering his or her practice through the coming years. Sessions were presented in an open format, encouraging attendee participation and stimulating lively discussion of practice management pearls.

Ophthalmologist predicts upcoming cataract boom as Americans age

The opportunity for ophthalmologists to expand their cataract practice will continue to improve over the next 20 years as the number of 65-year-old Americans continues to increase by two percent every year, said Richard L. Lindstrom, M.D., adjunct professor emeritus, University of Minnesota, Minneapolis. In fact, Dr. Lindstrom said some industry experts predict there will be a shortage of ophthalmologists to perform the increasing number of cataract surgeries in the next 10 to 15 years. In addition to the aging country, a combination of technological advances, consumerism and escalating costs coupled with patient-shared billing, point to a profitable future for surgeons who can perform cataract surgery. Therefore, if ophthalmologists can add refractive cataract surgery to their practice, they could enhance the practice’s net income by as much as 10% in one year and 50% over the next five years, he said.

Editors’ note: Dr. Lindstrom has no financial interests related to his presentation.

Becoming physicians again

With the current practice model failing everyone, I. Howard Fine, M.D., clinical professor, Casey Eye Institute, Oregon Health and Science University, Portland, presented changes that need to be made to create a winning situation for patients, physicians, industry and the government. Currently, ophthalmologists practice their skills in the worst possible combination—high-volume, efficient, low-cost care. Dr. Fine said the new practice model of high-quality, personalized, patient care will be a “win-win-win-win.” Patients will benefit because they will receive better care; physicians will gain greater freedom from insurance companies and government reimbursement; the industry will see a greater return on investments; and the government will benefit because it will not have to provide as much taxes for cataract reimbursement because the “Baby Boomer” population will opt for presbyopia-correcting intraocular lenses (IOLs), he said.

Editors’ note: Dr. Fine has no financial interests related to his presentation.

Necessary steps to adapt practices for better patient care

Samuel Masket, M.D., clinical professor, Jules Stein Eye Institute, University of California, Los Angeles, followed Dr. Fine’s presentation by providing six steps to improve practices. The first of the six steps, prepared by Stephen S. Lane, M.D., adjunct professor, University of Minnesota, Minneapolis, is to create an office environment that promotes internal marketing, Dr. Masket said. Then, every office employee needs to be educated as to what the office goals are. The third step is to educate patients before they arrive with brochures and Web sites such as the new ASCRS presbyopia Web site, www.readclearlyagain.org, but Dr. Masket differed slightly from Dr. Lane by adding that patients should be educated only to the extent that it will not require additional chair time to explain why they are not candidates for some procedures. The next step is for someone in the office to assess the patient’s physical candidacy, which includes the patient’s personal vision preferences. Dr. Lane included slides about how the IOL Counselor (Patient Education Concepts, Houston, Texas, in partnership with Eyeland Design Network, Germany) is a helpful tool for patients to determine their vision preferences, but Dr. Masket said he does not use it because he prefers to undersell technology. The fifth step is for the physician to diagnose and counsel the patient. Finally, Dr. Masket recommended the office staff schedule and finalize appointments and provide fee explanations.

Editors’ note: Dr. Masket has no financial interests related to his presentation.

Consider enhancements post-presbyopic surgery for successful procedure

There are five A’s to consider with presbyopic intraocular lens (IOL) selection, Dr. Masket said, but enhancements need to be used as well. The five A’s are astigmatism control, accurate biometry, appropriate formulae, adjusting for outcome and asphericity. But after those considerations, enhancements are a salient part of the visual rehabilitation of the presbyopic patient, Dr. Masket said pointing to his personal rate of 10% of his presbyopic patients. He also noted that the rate is more than likely at least 20% for most ophthalmologists. In his own practice, Dr. Masket said all enhancements he performed resulted in improved uncorrected visual acuity (UCVA), and all enhanced cases achieved spectacle independence in patients with bilateral ReSTOR IOLs (Alcon, Fort Worth, Texas). Dr. Masket also said that all of his enhancement cases also achieved at least 20/25 and J2.

Editors’ note: Dr. Masket has financial interests with Alcon (Fort Worth, Texas).

Pearls for improving office Web site

About 113 million Americans use the Internet to search for health-related topics or information, said Ray Isco, senior account manager, Mojo Interactive, Orlando, Fla. To help ophthalmologists better prepare to inform these Internet users, Mr. Isco provided several tips about Web site content. First, the Web page should have strong headlines and interesting lead paragraphs that sell services and avoid providing too much biographical information, or as Mr. Isco referred to it, “we” sentences. In contrast, the information should be “you” language as in what benefits patients will enjoy after undergoing the procedure. Information on the Web site also should set the practice apart from the competition. The information should be presented in an informal, conversational style that uses simple language that everyone understands, and it should be presented in the inverted pyramid format, which is putting all of the most important information on the top of the page and the less important on the bottom. To improve the Web site’s search engine optimization (SEO), Mr. Isco said to update the site at least two to four times per year and to keep out-of-date information off the page.

Editors’ note: Mr. Isco is an employee of Mojo Interactive (Orlando, Fla.).

Friday, Aug. 3, sessions were focused on PRK and other refractive procedures, a continued dialogue on intraocular lenses (IOLs) as well as malpractice claim statistics from one insurance provider. And as part of the Summer Refractive Congress’ tradition, many of the presentations were case reports offering attendees the opportunity to interact with the faculty.

PRK dominates second day of discussion

While the general public may recoil at the pain and length of recovery associated with PRK, Lt. Col. Scott D. Barnes, M.D., chief of ophthalmology and refractive surgery services, Fort Bragg, N.C., explained why the U.S. Army prefers PRK to other refractive procedures. For the military, the problems with LASIK include the potential for flap dislocation, buttonholes, epithelial ingrowth and diffuse lamellar keratitis, and partial cuts, Dr. Barnes said. At Fort Bragg, Dr. Barnes reported five dislocated flaps for a rate of one in every 500 cases. He also said there were two cases of dislocated flaps in Iraq resulting in one soldier being sent back to the States for treatment. Dr. Barnes said the current approach to refraction is to perform PRK on patients with less than 4 D and to perform LASEK on patients with more than –4 D. While he does not use nonsteroidal anti-inflammatory drugs (NSAIDs) or mitomycin C (MMC), but he does use antibiotics, steroids, artificial tears, Percocet (acetaminophen and oxycodone, Endo Pharmaceuticals, Chadds Ford, Pa.), vitamin C and bandage contact lenses (BCL). Simon P. Holland, M.D., clinical professor, University of British Columbia, Vancouver, provided details of a patient who did not heal after PRK. In the 26-year-old woman, one eye did heal, but the other one did not and at three weeks post-op, she was showing a 6 mm defect, Dr. Holland said. He treated her with Zovirax (acyclovir, GlaxoSmithKline, Middlesex, U.K.) and Viroptic (trifluridine, GlaxoSmithKline) after determining she had herpes simplex virus (HSV) keratitis. After she healed, an HSV scar formed, and Dr. Holland said he used phototherapeutic keratectomy (PTK) with MMC. He suggested that perhaps physicians should consider using questions about HSV and cold sores as screening questions for PRK because HSV is a potential cause of unilateral delayed epithelialization following PRK surgery.

Editors’ note: Neither Dr. Barnes nor Dr. Holland has financial interests related to his comments.

Physicians discuss malpractice concerns

James J. Salz, M.D., clinical professor, University of Southern California, Los Angeles, provided attendees with statistics from Ophthalmic Mutual Insurance Company’s (OMIC, San Francisco) malpractice claims. Dr. Salz noted that between 1993 and 2006, malpractice claims more than tripled for OMIC with the average cost per claim totaling about $50,000. With malpractice claims—despite a positive or negative outcome, the physicians will take a financial hit as Dr. Salz showed data that the average indemnity in 2006 for OMIC was $29,823 and the average expense for attorneys, experts, etc., was $24,600. The common misconception is that LASIK malpractice cases were most prevalent; however, Dr. Salz reported that cataract cases had more malpractice claims than LASIK and that this trend has been consistent at least since 2002. In fact, LASIK malpractice claims peaked in 2002 at 55 claims and had progressively declined through 2005. However, there has been a slight up-turn in 2006. Dr. Salz said the average settlements since 2003 has been comparable for LASIK and cataract cases (at about $120,000) with oculoplastics having the highest average rate (about $220,000) for OMIC.
The faculty and attendees continued the discussion by evaluating a clinical case presented by Parag A. Majmudar, M.D., associate professor, Rush University, Chicago, and how much information should be provided to the patient when a mistake is made. In the provided example, a physician began performing LASIK on a 36-year-old man with –6 D, but was treating the peripheral cornea instead and had completed 60% of the surgery before realizing the mistake. Dr. Majmudar concluded that deceiving the patient is harder to defend in a malpractice claim and therefore, the physician should be upfront with patients when a mistake is made. Dr. Salz agreed relaying a similar story in which he corrected the mistake, and even though the patient still sued the practice, the patient did not suffer any real damages and received little money in the settlement. Speaking from the audience, Marguerite B. McDonald, M.D., clinical professor of ophthalmology, Tulane University, New Orleans, and in private practice, Lynbrook, N.Y., suggested that physicians provide the essence of what went wrong without providing the exact details of what course of action led to the mistake.

Editors’ note: Dr. Majmudar has a financial interest with Advanced Medical Optics (AMO, Santa Ana, Calif.), Allergan (Irvine, Calif.) and Inspire Pharmaceuticals (Durham, N.C.). Dr. McDonald has financial interests with AMO, Alimera Sciences (Alpharetta, Ga.), Allergan, Refractec (Irvine, Calif.) and Santen Pharmaceuticals (Napa, Calif.). Dr. Salz has a financial interest with OMIC (San Francisco).

IOL conversation spills into second day of meeting

Despite spending the first day of sessions discussing patient cases dealing with intraocular lenses (IOLs), the faculty continued the discussion to a lesser degree on Friday. Jack T. Holladay, M.D., M.S.E.E., clinical professor, Baylor College of Medicine, Houston, commenced with tips on achieving accurate IOL calculations. Dr. Holladay gave five pearls to attendees: 1) attain accurate biometry, 2) attain accurate, repeatable keratometry, 3) use fourth generation formulas that take into consideration white-to-white (WTW), 4) personalize the lens constant and do not use the manufacturer’s, and 5) eliminate corneal astigmatism through LASIK, piggybacks, limbal relaxing incisions (LRIs), etc. James J. Salz, M.D., clinical professor, University of Southern California, Los Angeles, furthered the discussion by citing a clinical case of a late complication with piggyback IOLs. Dr. Salz suggested surgeons should perform a surgical peripheral iridectomy for high hyperopes with axial lengths less than 20 mm. However, even with this procedure, there still is a risk for developing “malignant glaucoma.” If such is the case, a posterior core vitrectomy and visco-dissection or a tube shunt likely may be needed to deepen the anterior chamber.

Editors’ note: Dr. Holladay has financial interests with Advanced Medical Optics (AMO, Santa Ana, Calif.), Nidek (Fremont, Calif.) and Oculus Innovative Sciences (Petaluma, Calif.). Dr. Salz has no financial interests related to his comments.

Editors’ note: Dr. Faktorovich does not have any financial interests related to her comments.. Dr. Randelman has financial interests with Alcon (Fort Worth, Texas), Allergan (Irvine, Calif.) and Ista Pharmaceuticals (Irvine, Calif.).

Sunday, the final day of keynote lectures and clinical case presentations was dedicated to addressing ectasia and post-op astigmatism.