Robert Ritch, MD, is still ahead of the curve

The Mount Sinai ophthalmologist will receive ARVO’s highest honor this May.

By Robert Stoneback, associate editor

Robert Ritch, MD, would say his most important work is still ahead of him.

Dr. Ritch, of the New York Eye and Ear Infirmary of Mount Sinai, has been named the 2017 recipient of the Joanne G. Angle Service Award, by the Association for Research in Vision and Ophthalmology.

ARVO selected Dr. Ritch, who serves as the Shelley and Steven Einhorn Distinguished Chair in Ophthalmology at Mount Sinai, because of his track record of continuous service to the organization since 1991. He has presented more than 300 papers and posters at ARVO over the last 35 years.

For the past few years, he’s devoted his research energies to exfoliation syndrome, or XFS. In a phone interview, Dr. Ritch described his current work with XFS as some of his most critical. His nonprofit, the Glaucoma Foundation, has made a cure for XFS a long-term goal.

New thinking

Dr. Ritch, author or coauthor of 700 papers, was ahead of the curve in diagnosing XFS.

For decades, many doctors considered it a “Scandinavian disease,” due to its first recorded diagnosis in Finland in 1917. Since Scandinavians were the only ones writing about it and linking it to glaucoma, many doctors assumed it was tied to that ethnicity.

Dr. Ritch recalls that as a resident, he diagnosed a Greek woman with XFS; a professor told him he was wrong. “He said it can’t be exfoliation, she’s from Greece … It has to be something else.”

A few days later, says Dr. Ritch, he showed the professor six studies from different countries which countered that belief. “He ignored them,” Dr. Ritch says.

XFS is the most common identifiable cause of open-angle glaucoma worldwide, comprising most glaucoma cases in some countries. It is not a “form” or “type” of glaucoma, but is an ocular manifestation of an age-related, systemic disease, characterized by the production and accumulation of whitish material in numerous ocular and nonocular tissues. About 35% of people with XFS develop elevated IOP, and one-third of those develop glaucoma. A person with XFS is six times more likely to develop glaucoma. The exact pathogenesis of XFS is unknown.

Dr. Ritch was also an early advocate of checking children and teenagers for pigment dispersion syndrome and pigmentary glaucoma. About 30 years ago, most ophthalmologists believed that a glaucoma diagnosis under the age of 35 was rare. Dr. Ritch, again as a resident, was laughed at for checking the pressure of children in the pediatric clinic. He specifically recalled seeing a 10-year-old boy whose pressures were 35 mm Hg. Had the glaucoma not been caught in time, the boy could have lost significant vision by the time it was detected, perhaps years later. Instead, he later attended college at Princeton.

Finding cures

The Glaucoma Foundation started an annual, interdisciplinary think tank in 1994, the Optic Nerve Rescue and Regeneration Think Tank. Dr. Ritch considers this one of his most important accomplishments, alongside his XFS research. Meetings of the group have included physicians and specialists in fields such as nanotechnology and genetics. Many of the attendees knew little about the eye, but were interested in curing glaucoma and researching the field. The goal is to “put two fields together to make one,” says Dr. Ritch.

About a year ago, the think tank put its funding into XFS research, and it “took off like a rocket,” says Dr. Ritch. “Right now, it [XFS] is becoming hot.”

The large genome-wide association studies research group based at the Singapore Eye Research Institute recently reported the discovery of six new genes, including ones that protect against contracting XFS. With advancements like these, XFS “could be the first glaucoma to be cured,” says Dr. Ritch.

With recent advances in technology, such as stem cells, 3D printing and genetic programs, “we’ll see major advances in every field in medicine.” But, he says, one of the main reasons doctors are focusing on glaucoma now is because of the increased awareness among the medical community that it is many different diseases, a large proportion of which can occur without elevated IOP. New technology is also enabling research on factors related to these diseases.

“The only problem with glaucoma is that people ignored it for years, they thought it was nothing,” says Dr. Ritch. To a lot of physicians, it was seen as a matter of “if the pressure goes up, you make the pressure go down.”

Because of this, the fact that the disease was associated with other risk factors such as sleep apnea and low blood pressure was unnoticed, he continues.

For a long time, glaucoma was thought of as a single disorder, instead of a collection of neurodegenerative diseases, says Dr. Ritch. Each part of glaucoma has a specific set of biological mechanisms, and “we need to understand those mechanisms, not just lower pressure.”

Dr. Ritch’s other accomplishments include the “ARVO Host-a-Researcher Program,” which paves the way for researchers from underdeveloped countries to attend the association’s annual meeting. The Joanne G. Angle Service Award will be presented to him at the ARVO General Business Meeting, held May 9 in Baltimore. OM

Studies show patient education can aid practice

One study found knowledge improved informed consent; another found patients made easier decisions.

By Robert Stoneback, associate editor

Educated patients make better patients.

That’s the consensus not just from researchers, but practices as well.

Take the case of Northern Ophthalmic Associates, which has offices in Philadelphia and the surrounding suburbs, including Wills Eye Hospital.

New, uninformed patients choosing a multifocal lens following cataract surgery “don’t know this stuff from a ham sandwich,” says Laura Arruda, refractive surgery coordinator for the clinic.

They are not uninformed any longer. The results of this improved practice education isn’t just an easier job, but a more lucrative practice.

Studies bear this out: they have found that more education doesn’t just help put the patient at ease, it help the patient in more quantifiable measures.

In 2012, a study published in the Journal of Cataract and Refractive Surgery studied four groups of cataract surgery patients. One group received only verbal information about the surgery, a second group verbal information and a second-grade reading level brochure, a third group verbal information and an eighth-grade reading level brochure and the last group received verbal information and an educational DVD. The patients then filled out a questionnaire discussing the procedure, along with benefits and risks.

The second and fourth groups performed the best, indicating that concise information and video presentations optimized patient understanding. The study concluded that such education is not only important for patients, but can decrease the risk of indemnity payments that would be awarded due to inadequate informed consent.¹

Another study, published online in 2015 by Ophthalmic Epidemiology, examined 61 cataract patients in India. They were given a survey before and after undergoing presurgical counseling for cataract surgery; the study found that “counseling both improved knowledge and reduced decisional conflict about cataract surgery.” In addition, “increased use of high quality counseling might help to further reduce the global burden of cataract and other forms of blindness.”²

Back to Northern Ophthalmic…

When Ms. Arruda tells a patient he will see rings around lights following surgery, “they have no idea what that means.” Now, though, she can share one of several educational brochures or videos supplied by Abbott, manufacturer of the Catalys femtosecond laser and Tecnis IOL. These give patients a much better idea of what they can expect following surgery.

Anything the practice can show the patient to compare quality of sight between a standard lens and a multifocal “is huge for selling something to a patient,” she says.

This material was supplied after the clinic’s surgical director, Mark F. Pyfer, MD, purchased and installed the company’s Catalys femtosecond laser in 2013. Abbott also offered staff training in the laser and the assistance of a premium practice specialist, who helped Dr. Pyfer’s staff discuss the new treatment options with patients.

Dr. Pyfer says the practice strives for satisfied patients, and that doesn’t just come from good equipment and staff, but from informed clients.

“You don’t want an uneducated patient sitting in your exam room,” you want one who is certain he’s the right candidate for the procedure you are recommending.

Give the patient the most realistic expectations possible, says Amy Shultz, cataract surgery coordinator at Northern Ophthalmic. If you first tell a patient she will see a few halos at night, she may not want the multifocal, until you can show her a visual and she realizes the difference, she says.

“There’s been more and more [educational material] available as time goes on,” she continues.

Dr. Pyfer makes clear that high-quality products are still the main driver of the clinic’s success. That being said, the practice has enjoyed greater revenues and streamlining with the educational materials.

Eyes of York

The first hurdle for any clinic with a new device is to understand why the surgeon believes in it, says Denise Visco, MD. This is important for making techs and surgeons comfortable while using the device, but it’s also critical for communicating how the device can help patients.

Enter, once more, patient education. When Dr. Visco’s Pennsylvania clinic, Eyes of York, purchased a Lensar laser system, the company’s Business Development Management (BDM) team analyzed her patient population. Lensar concluded the most efficient course of action would be to supply an educational packet that could be given to patients in advance of their appointment. Then information activities at the time of the evaluation are more constructive and better received.

When a patient reaches Dr. Visco, the goal is for him to know what laser refractive cataract surgery is and what value the procedure has for him.

Most people come to the clinic very skittish, says Marcy Groom, COA, surgical coordinator for Eyes of York. To help put them at ease, she shows them the educational materials, including a video that reviews the surgical options.

“I think the video is a real game changer” for many patients, says Ms. Groom.

The material has freed up a lot of time that would have been spent explaining procedures, Ms. Groom says.

Lensar has “evolved to be a very wonderful partner,” says Dr. Visco, and the company is always looking for customer feedback.

Patient education and other “value-added” services have been part of Lensar’s culture and business plan since it began commercializing its technology in 2012, according to Nick Curtis, the company’s CEO and director.

“We’re very specific about partnering with the practices,” he says. “With us, it’s not about how many different practices we can partner with, it’s about how closely we work with the practices that we have.”

Ultimately, both doctors and patients want better results, says Mr. Curtis. When a company can help align the interests of both groups, “it allows the physician to have something that differentiates them and their community, and allows them to grow their practice.” OM

REFERENCES

1. Shukla AN, Daly MK, Legutko P. Informed consent for cataract surgery: patient understanding of verbal, written, and videotaped information. J Cataract Refract Surg. 2012; 38:80-84.
2. Newman-Casey PA, Ravilla S, Haripriya A, et al. The Effect of Counseling on Cataract Patient Knowledge, Decisional Conflict, and Satisfaction. Ophthalmic Epidemiol. 2015; 22:387-393.