Quick Hits

The more iStents, the better.

Multiple iStents can lower IOP levels in patients

By Robert Stoneback, Associate Editor

The results of two recent studies show that the Glaukos iStent can reduce IOP on its own. The iStent, approved in the U.S. in 2012, is indicated for use in conjunction with cataract surgery.

In one paper, published in December, a group of glaucoma patients were divided into three sets.¹ One group received one stent, another two stents, and the last group three stents. Taken off all medication, all patients nevertheless achieved the primary end point of unmedicated IOP of less than 18mmHg at 12 months; the percentage of patients achieving that ratio increased with the number of implanted stents. At 18 months, 14 of the 119 patients required IOP medication, with the most, seven, in the one-stent group. The study’s authors, comprised of researchers from Wills Eye Hospital and Glaukos along with others from Turin, Barcelona, Berlin and Armenia, said the iStent can be titrated as the “sole procedure” for IOP control.

In November, a three-year prospective pilot study came to the same conclusion using a similar methodology.²

Thirty-nine subjects underwent the two-stent surgery, and by month 12, 36 eyes achieved the primary efficacy endpoint, which was a reduction in IOP of more than 20% from baseline and without medication. At the 36-month mark, subjects sustained a 37% IOP reduction from their unmedicated, baseline IOP. The subjects had a 26% reduction in IOP when compared to pre-operative, medicated IOP.

During the 36-month follow-up period, four of the subjects required medication. Nearly 90% of all eyes did not need any medications after two stents were implanted.

David F. Chang, MD, clinical professor at the University of California, San Francisco, a study participant, says because this study on phakic and pseudophakic eyes did not involve concomitant cataract surgery, any IOP-lowering is attributable to the iStent implantation. The fact that the IOP-lowering is sustained over a three-year period is also significant, he says.

Glaukos sponsored this study and is conducting several others, which will be published over the next one to three years, according to Dr. Chang.

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Diabetes rates decrease, but eye disease shows no signs of stopping

Despite lower rates, chance of retinopathy and other ailments is still high

By Robert Stoneback, Associate Editor

While diabetes rates in America are still high — leading 38 developed nations, in fact — in recent years they’ve been slowly, steadily declining. According to a study from the U.S. Centers for Disease Control and Prevention, the number of new diabetes cases dropped from 1.7 million in 2009 to 1.4 million in 2014.¹

The decrease has been consistent, with 1.67 million cases reported in 2010, 1.53 million in 2011, 1.5 million in 2012 and 1.44 million in 2013, according to the CDC study. The lowest numbers, 493,000, were reported in 1980, the first year tracked.²

However, even with new cases dipping, it’s not time to celebrate.

“Even though the incidence of newly diagnosed diabetes has decreased, the incidence [of diabetes-related eye diseases] is still high,” according to Rahul N. Khurana, MD, clinical spokesperson for the American Academy of Ophthalmology.

“Nearly one-third of people with diabetes remain undiagnosed, leading to an increased risk for diabetic retinopathy. Furthermore, studies have found that people with diagnosed diabetes are not getting the appropriate eye care from screenings to treatment,” he says.

According to Dr. Khurana, while a lower incidence rate could demonstrate an improvement in prevention, “there is still much work among those who have been diagnosed, so I don’t anticipate that this will change the ways in which ophthalmologists work with their patients with diabetes.”

An article published in the fall on the website Occupational Health & Safety predicted diabetic eye disease to continue rising. Currently, more than 8 million Americans have diabetic retinopathy and at current rates that number will increase by 35% by 2032. People with diabetes are also 25 times more likely to become blind than those without it.³

Data from the CDC listed 4 million diabetic adults diagnosed with visual impairment in 2011, the most recent year available. In 2010, 3.9 million diabetic adults reported visual impairment, with 4 million listed for 2009. The first year of the study, 1997, listed 2.7 million diabetic adults with visual impairment.⁴

According to the CDC, incident rates for diabetes in America is still greater among blacks and Hispanics than it is among whites, though rates have decreased among all three groups since 2009. For 2014, the diabetes rate for whites was 6.4 per 1,000 people, 8.4 per 1,000 population for blacks and 8.5 per 1,000 population for Hispanics.⁵

REFERENCES

Cataract surgery co-management stats

Figures show about 11% of cases co-managed, but rate could rise with increased efforts.

By Karen Auge, Contributing editor

For years, co-management of cataract surgery patients between ophthalmologists and optometrists has been discouraged, disparaged, debated yet, in some circles, desired. Now, for perhaps the first time, the practice has been broadly quantified.

In 2012, 10.9% of all cataract surgeries among Medicare patients nationwide were co-managed by ophthalmologists and optometrists, according to research findings by the AAO.¹ In 2013, the national average rose slightly, to 11.1%.

The study’s findings closely follow the September 2015 position paper on co-management jointly issued by the Academy and the American Society of Cataract and Refractive Surgery. As reported in Ophthalmology Management’s October 2015 issue, the paper eased up on the organizations’ firm stance against co-management 15 years earlier, reminding ophthalmologists that they bear ultimate responsibility for patient outcomes while outlining certain acceptable circumstances for co-management, such as distance.

When broken down by state or region, the Mayo Clinic research team found variations in the billing data extracted from Medicare. For example, in Wyoming, 63% of cataract surgeries were co-managed while Vermont had a co-management rate of 0%.

Nevertheless, mapping the research findings showed obvious regional variations. In the Northeast and Southwest, for example, joint management rates were typically less than 10%, while the highest rates were found in the Plains states and Southeast.

Yet the explanation for the extreme variation lies not in geography, but attitude, says Jay Erie, MD, at the Mayo Clinic’s Rochester, Minn., Department of Ophthalmology and the study’s lead author. “Current evidence suggests that practice variation primarily reflects differences in surgeon attitudes about surgical indications and management, and the extent that patient preferences are considered in the decision processes.”

While Medicare data may be an effective tool for examining co-management rates — more than 80% of cataract surgeries are performed on patients 65 and older — the researchers acknowledge a few limitations inherent in extrapolating information from Medicare claims.¹ For example, billing procedures in practices that include both ophthalmologists and optometrists under one roof may preclude identifying co-management. In addition, Dr. Erie says, Medicare Advantage Plus plans, which comprised some 28% of Medicare beneficiaries in 2013, were not included but may have resulted in an across-the-board undercounting of co-management.

In addition, the researchers only examined billing that reflected post-operative co-management. Instances of pre-operative co-management, including a physician not personally examining a patient prior to surgery, were not assessed. Larry Patterson, MD, Ophthalmology Management’s chief medical editor, warned against such “risky” practice in his October 2015 editorial. OM

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