The technology used in ophthalmic surgery evolves at a rapid pace. Each year, we see a dizzying array of platform advances, software upgrades and emerging treatment devices. The dilemma: how do surgeons keep abreast of these latest developments? Also, what factors should they consider when incorporating the latest diagnostic tools, a new IOL or that next-generation minimally invasive glaucoma surgery (MIGS) device?

Here, ophthalmologists discuss their approaches to successfully adding technologies that help the patient, the surgeon and the practice.

ACADEMIC VERSUS PRIVATE PRACTICE

First, there are some key differences in decision making depending on the type of practice. The specific steps required in the purchasing process at an academic center or large institution are necessarily more involved than in a private practice. One thing, however, is universally applicable: establishing the benefits prior to any purchase is key.

“First and foremost, how will this tool work for the surgeon, the type of practice and, most importantly, patients,” says William Trattler, MD, a refractive, corneal and cataract eye surgeon in private practice at the Center For Excellence In Eye Care in Miami. “Simply put, will it allow for better care?”

Academic practice has changed dramatically in recent years such that the drivers really are no different from a private office, says Sumit “Sam” Garg, MD, vice chair of clinical ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine. “At the university, every decision we make has to be very transparent. Yet ultimately, the bottom line when evaluating a new piece of technology is the same: what value does it bring? Does it provide a better outcome for patients, is it safer, is it faster or is it a differentiator?”

UNDERSTANDING WHAT IS AVAILABLE, ADDING SKILLS

Physicians find out about new technology through many resources, including meetings and their relationships with manufacturers, but it does take effort.

“Conferences are where we discover what has changed and what tools we really need,” says Dr. Garg, emphasizing that there is a big difference between a “need to have” device and a “want to have.”

“Let’s say you are interested in learning how to use a capsular tension ring, place a scleral fixated IOL or perform PRK or LASIK. ASCRS as well as a number of other conferences regularly offer skills transfer labs that provide great hands-on opportunities to try and learn different technologies as they come out,” Dr. Trattler says. (See “ASCRS: Educational resources”).

Beyond attending conferences, Dr. Trattler says he learns what’s available through discussion groups, reading articles, seeing advertisements, and speaking with colleagues and company representatives.

COST AND VALUE ANALYSIS

Taking IOLs for example, Dr. Garg says his institution looks at the cost per case for a covered lens vs a noncovered implant. “It is easier for us at the university to incorporate some of the new technology IOLs because the cost is passed on to the patient.”

For example, Dr. Garg says they brought in the Light Adjustable Lens (RxSight) and figured out how to price it appropriately within a cash-pay model. The LAL requires extra visits and staff time that had to be accounted for when determining a fair price for the patient and the health system. The Tecnis Eyhance (Johnson & Johnson Vision), on the other hand, is a monofocal lens with no additional reimbursement. “So, when we brought that in, we were looking at outcomes for our patients. Then we had to negotiate with the company and find a way to bridge the cost difference compared with a typical monofocal.”

Dr. Garg’s group will be adding the newly approved Apthera IOL (Bausch + Lomb), and the model will be similar to what it is for any premium IOL, even though he envisions them using it more for medical reasons such as irregular astigmatism after kerato-refractive surgery. “The patient-pay component makes it easier.”

With diagnostic devices, things get a little more complicated, Dr. Garg says. “We perform a value analysis, which involves a committee. We tell them about the technology, the cost, the estimated annual usage and how we think it is going to help our patients and bring value to the institution.”

Another important factor is whether the technology is reimbursable with its own code. “If you are using a code from something else, it will be a bigger challenge to get reimbursed for the amount of work it takes to implement the device,” Dr. Garg cautions. “Confocal microscopy is an example of a technology that is time intensive to perform, but there is no good code to match it. Yet, it provides such valuable information, the practice may be willing to take a loss because of the benefit to patient care or even its requirement in a research protocol.”

Dr. Garg says they also determine if something can be cut to incorporate the new technology — with the hopes of sunsetting older, often under-utilized, technology.

Additional costs need to be considered as well. In the case of an IOL, for example, it’s not just the lens cost — Dr. Garg says they need to account for if it needs a special injector, cartridge or blade to make the incision. “We can’t just add and add and add,” he notes. “We are cognizant of the fact that there is an administrative burden as well as legal concerns to consider in this university-mandated process.”

Also, on the diagnostic side, we need to consider amortization and depreciation, adding that he relies on the hospital’s buying and contracting team to assist with this, Dr. Garg says. “Even if it is a situation where a donor might be supporting the purchase of the device, we are still mindful and act very conservatively.”

WAITING IT OUT

Drs. Trattler and Garg both point out that sometimes a surgeon may not want to be the first in line for a new technology. It might make more sense to wait and see, letting others gain more experience or delaying until a newer version comes out.

“The key is investigating what works great now vs what is not quite perfected just yet,” says Dr. Trattler. When a new technology becomes available, speaking to a colleague who has some hands-on experience can help determine whether the new technology would be a good fit for the practice. For example, some devices might have a longer learning curve and therefore may be more difficult to incorporate.

“For MIGS devices, there are now many different technologies that are currently available — I have not even tried them all yet,” Dr. Trattler says. “Surgeons have to evaluate what is working well and whether a new MIGS technology provides safety and efficacy advantages for their patients over what they are currently using. For example, updates and/or a more user-friendly design with the iStent inject (Glaukos) or the OMNI (Sight Sciences) is often a straightforward and easy transition for surgeons performing MIGS.”

Private practice surgeons can rest assured that they do not need all the new technologies right away, and sometimes even opting for used diagnostic devices can be a good decision.

“New technologies are exciting when they impact our ability to improve patient care. However, practices have to evaluate these new technologies to see if they are a good fit,” says Dr. Trattler.

The IOLMaster 700 biometer (Zeiss), for example, is excellent, but may be expensive for a clinician who is just opening their practice, Dr. Trattler says. “For new practices, the previous iteration, the 500, still provides very good clinical results. As a practice grows, they can then look into upgrading to the 700.”

UPGRADING

Sometimes it isn’t a brand new piece of hardware, rather it is a matter of adding a new capability or software onto an existing machine.

For example, “as epithelial mapping has evolved, our practice realized that this diagnostic technology would provide additional information to help evaluate patients prior to refractive surgery,” Dr. Trattler says. “Our practice was able to upgrade our Zeiss OCT device, rather than having to purchase a new stand-alone device.”

PATIENT CARE AND PRACTICE FIT

As a practice evolves, one has to always think about whether a new technology purchase — be it an upgrade or a new advance — will allow for better patient care. A technology like a corneal topographer, for example, is useful for the early diagnosis of keratoconus. “If a surgeon is planning on getting involved in corneal crosslinking or treating patients with more advanced keratoconus, these devices can be important additions,” Dr. Trattler says.

A final consideration with incorporating technology in a large institution, especially a major platform such as an OCT or a phaco machine, is the lag between when a purchase order is released and when the device is actually delivered, says Dr. Garg. Given internal bureaucracy and supply chain issues, the time between ordering a device and taking delivery can sometimes be 6 to 9 months depending on the device. “When you order the system, you may think you are getting the latest and greatest technology available. But in the meantime, something more advanced may become available.”

SUCCESSFUL INTEGRATION

Once the decision has been made to add a technology at an academic institution, the education and incorporation is usually championed by the division requesting it, Dr. Garg says. “We also need to make sure our front office and entire staff know about the device or treatment, as well as update our website to reflect the current technologies we offer.”

Ultimately, private and academic practices count on the manufacturers and their teams to come in and provide education. “Relying on the company’s support is part of incorporating a piece of equipment or a lens,” Dr. Garg says.

To make sure the team is getting the most out of a device, the university often sends users to meetings such as ASCRS, where they can learn best practices. “We are also not shy about asking company representatives to spend time ‘refreshing’ people on technology when and if they need it,” Dr. Garg adds.

Ensuring users are maximizing all the bells and whistles a tool offers can be a challenge, Dr. Trattler says. “There are often features surgeons and technicians are not aware of. Again, this is where talking to the sales rep and to colleagues pays off.”

For example, with the Oculus Pentacam, “surgeons might not make use of all of the features right away, but they can slowly add them as they get more comfortable using the system,” Dr. Trattler explains. “The OPD-Scan III (Marco) and the iTrace (Tracey Technologies) are also examples of devices that have basic topography features as well as advanced features, including the ability for these devices to determine in the early postop period whether a toric IOL is on axis or slightly rotated.”

Product reps will review with the practice’s technicians exactly what display to use and what buttons to push to perform a given platform’s functions, Dr. Trattler says. For instance, “The IOLMaster and the Argos Biometer (Alcon) have formulas for patients who have had prior LASIK. This is an integrated feature; one just has to be aware of these features and know how to use them.”

CONCLUSION

Although knowing what technology is available and understanding all of the options can seem like an overwhelming task, those interviewed say the mindset for surgeons should simple: focus on what improvements the diagnostic or treatment device adds. The primary question to consider is always, will this help provide better patient care? OM