Quick Hits

The year in ophthalmology

Big data, new treatments, refined tools — to sum it up, 2014 was all about the patient.

Advancing patient care was surely on the minds of many in the ophthamalogy field this year. In a year-end summary of those achievements, Medscape (Dec. 29, 2014) cited the major advances — some new, some refined, some just achieving more popularity — that share the common denominator of better serving patients.

In their summary, Ronald C. Gentile, MD, et al. looked at:

Cataract surgery. Previously used to create corneal flaps for LASIK surgery, femtosecond lasers have gained a significant role in cataract surgery. Supporters feel that these lasers can reduce complications, such as vitreous loss, and bring added value to already successful surgeries that involve IOLs.

Intraoperative aberrometry. This instrument takes the guesswork out of measuring residual refraction. The surgeon can change the IOL’s power or type, among other things.

Big data. In the spring, the AAO announced that IRIS was ready for physicians to download their patient data, in hopes that one day ophthalmologists could use the data for research and, after analysis, to share quality improvement strategies, among other goals. The AAO says the number of enrollees have exceeded expectations: 5,000 U.S. ophthalmologists have inputted 10 million patient visits.

New treatments. The FDA contributed to the year’s advancing patient care focus with the approval of three new intravitreal medicines for diabetic macular edema (DME). The three are: aflibercept (Eylea, Regeneron), an anti-VEGF molecule, and two steroid-based implants: sustained-release dexamethasone (Ozurdex, Allergan) and fluocinolone acetonide (Iluvien, Alimera), designed to last for 36 months.

The Bionic Eye. Formally known as the Argus II retinal prosthesis system (Second Sight Medical Products, Inc.), this prosthesis has now been installed onto the retinas of about 12 patients. These patients had either retinitis pigmentosa or another hereditary photoreceptor disease. The prosthesis, prompted by electrodes, is designed to function like a patient’s photoreceptor cells.

Noninvasive retinal imaging. Optical coherence tomography (OCT): the more physicians use it, the more ways they find to appreciate it. OCT, for example, can show better anatomical information — including angiographic images without needing extraneous dye. Through OCT, they can view detailed, 3-D images of large retinal vessels and capillary networks to study multiple depths of the retina.

Glaucoma surgery. Microinvasive glaucoma surgery (MIGS) is defined as surgery that improves aqueous humor outflow by using limited surgical intrusion of the sclera or conjunctiva; the end result is that IOP is lowered. Generally performed with a small incision into the cornea, MIGS works best when treating mild to moderate glaucoma. Its safety profile is very good.

Gene therapy. Ophthalmology has come slowly to gene therapy. Just 2% of all current gene therapy clinical trials are devoted to ocular diseases.

Cataract projections

(2010-2030-2050)

In 2010, 24.4 million people had cataracts, and the baby boomers were just starting to come of Medicare age. On Jan. 1, 2011, the eldest, at a rate of 10,000 a day, started turning 65 - hitting a daily milestone that won't stop until 2030. Boomers comprise 26% of today's population.

The cataract numbers don't get better. By 2050, the number of those with cataracts is expected to double the 2010 figure. The question is: Will enough ophthalmologists be available to meet the potential demand for surgeries? The manpower issue is worthy of thoughtful discussion; please read about it on page 28.

Sources: NEI, Pew Research Center, US Bureau of the Census.

LEGISLATIVE ROUNDUP

Doctor “sorry” laws gaining momentum

Another state considers bill to protect physicians.

By René Luthe, Senior Editor

Ohio may soon join a growing number of states that have enacted legislation shielding physicians who acknowledge responsibility for a medical mistake to patients or families from having that conversation used against them later in court. According to supporters, doctors having these discussions with patients can reduce malpractice lawsuits, as patients often sue to get answers about what went wrong.

Arizona, Colorado, Connecticut, Georgia, Massachusetts and South Carolina already have similar laws. Though the bill passed the Ohio state house in November, a state Senate committee did not complete hearings on it before the end of the legislative session in December, so it’s back to square one when the new session begins this month.

The Ohio State Medical Association, which supports passage of the bill, wants to encourage these kinds of physician/patient conversations for a number of reasons, including reducing the incidence of lawsuits and fostering better physician-patient relations, according to Tim Maglione, the group’s senior director of public relations. American Medical Association President Robert M. Wah, MD, agrees with those objectives. “When an unforeseen health care outcome occurs, patients have questions, and physicians want to provide answers,” he says. “Unfortunately, the fact that such a conversation can be used by personal-injury lawyers in a medical liability lawsuit often impedes open dialogue before it starts. Apology inadmissibility laws remedy this problem.”

Not surprisingly, Ohio trial attorneys oppose the bill. Columbus attorney Rick Topper points out that no other profession is permitted to keep admission of mistakes from a judge or jury. But supporters note that nothing in the bill would prevent lawsuits against doctors, should patients or their families decide to file one.

“These laws are sometime described as shielding doctors from liability, but that’s inaccurate,” Mr. Maglione says.

Though the doctor’s admission is not permitted to be entered as evidence in the event of a lawsuit, he explains, patients can still file a lawsuit and attempt to prove malpractice by calling expert witnesses and proving that the standard of care was not met.

Mr. Maglione believes the Ohio state legislature will be able to pass the bill in 2015 as supporters plan to begin the process again early in the year.

Research links statin use, cataract development

Data open the door to educate primary care doctors of potential effects.

By Zack Tertel, Senior Associate Editor

Researchers found strong evidence of a link between cataracts and statin use, according to a recent article in the Canadian Journal of Cardiology.

Data from the British Columbia Ministry of Health databases from 2000-2007, which matched 162,501 cases with 650,004 controls, showed a 27% increased risk of developing cataracts requiring surgical intervention. Another patient cohort from the IMS LifeLink showed a 7% increased risk. In this group were 45,065 patients; the control group had 450,650. Study participants were between 40 and 85 years of age.

“Past evidence [was] very nebulous on whether there is a solid relationship between statin and cataracts because there are many other confounding variables,” says Veeral S. Sheth, MD, MBA, FACS, director, Scientific Affairs at University Retina and Macula Associates, and clinical assistant professor at University of Illinois at Chicago. “We’re talking about an elderly group in general that has other risk factors for cataracts, such as age, vascular disease, diabetes and other system diseases. This helps move us in the direction of thinking that there certainly is a link.”

Dr. Sheth says ophthalmologists should talk to patients about their medications, including statins, and explain the high risk of developing cataracts to patients using statins.

“If the patients are younger, have cataracts and have been on statins for five to 10 years, it gives us a better answer as to why they have the cataracts, and I think in the end that helps patients,” he says.

Also, Dr. Sheth says this data provides an avenue for ophthalmologists to educate colleagues on the connection of statin use and cataracts and other risks associated with patients’ medications.

“Cardiologists and primary care doctors might not understand what it means to have an increased risk of cataracts or may not know what a cataract does or how it effects the patients.”

Doctors: CDC study wrong

Surgeons want report on keratitis retracted.

By Bill Kekevian, Senior Associate Editor

The Refractive Surgery Alliance (RSA), a private group of surgeons whose aim is to promote refractive surgery through education, research and patient care, wants the CDC to retract its study regarding the burden of keratitis in the US.

The report, “Estimated Burden of Keratitis — United States, 2010,” contains administrative data based on ICD-9 codes and billing data to measure the problem of keratitis in general, says the study’s lead researcher Sarah Collier. The RSA claims the CDC “attempted to tie keratitis [office] visits to infectious keratitis, specifically from the misuse of contact lenses,” says RSA president Lance Kugler, MD. The group is concerned about the CDC’s use of a 1991 study involving 91 eyes from 61 patients, and how the public is interpreting the data.

The CDC specified “keratitis and contact-lens-related diagnostic codes,” but the public apparently mistook that to mean “contact lens related diagnostic codes.”

CDC response

Says Ms. Collier, “We referenced this study solely to provide support for [the following]: ‘The largest single risk factor for microbial keratitis is contact lens wear.’ We did not use the 1991 study to make our estimate or to tie keratitis visits to infectious keratitis.”

Bacterial keratitis.

The CDC’s Jennifer Cope, MD, MPH, another study author, says the idea behind the work was to define the problem’s scope. “We say multiple times, our keratitis estimate is not all due to poor contact lens wear and care.”

The CDC has launched www.cdc.gov/contactlenses.

Operating shorthanded? Communication is paramount

tip of the month

Ideally, your office will always be fully staffed. However, the inevitable reality is every office will be shorthanded at some point. Allan Walker, a director at BSM consulting, offers this advice for getting by while trying to fill any vacancies:

“Regular communication is essential when working shorthanded. This is especially true when several staff members are combining to fill a vacant role or filling the role on separate days or shifts. It is critical that everyone involved knows exactly what needs to be done and who is responsible. Never assume anything. Otherwise, necessary steps and actions will slip through the cracks and directly impact patient care, practice efficiency, patient satisfaction and employee morale. Best practice protocol suggests meeting every morning with affected staff for two reasons: It identifies the specific needs of the day and it reminds team members that they are not alone in picking up the additional duties and responsibilities. Ongoing communication should take place throughout the day, as necessary. No one should ever be too busy to help confirm that the vacant role is being filled in the most complete and efficient manner possible. Also, management needs to regularly acknowledge and praise everyone’s extra effort.”

Study compares DALK, PK

Research evaluates safety of macular corneal dystrophy procedures

In a study on the comparative visual acuity, clinical outcomes, complications and risk factors for graft failure after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) for macular corneal dystrophy, DALK was superior to PK in its safety against postoperative complications. The retrospective comparative case study, published in the December issue of Cornea, looked at 130 eyes of 104 patients. The PK group was made up of 109 eyes of 84 patients whereas the DALK group consisted of 21 eyes of 20 patients. For the PK group, graft rejection that was the most common cause of graft failure was seen in 27 eyes (25%), of which 55% occurred within one year. Graft failure in the DALK group was mostly associated with either intraoperative or early postoperative complications. The research concluded DALK is a viable surgical option in cases with macular corneal dystrophy.¹ OM

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