Optometry Surgical Opportunities in 2020 Our Patient’s Can’t Afford to Miss
By: Paul M. Karpecki, OD, FAAO Clinical Director – PECAA
Collaborative Care that Wasn’t Collaborative
Many optometrists involved in co-management or the collaborative care of premium IOL’s were left with the same minimal Medicare fee even though they provided far greater work, time for patient education given the education required with multifocal IOLs and their unique potential side effects, more imaging, testing and optimizing of the ocular surface, greater “hand-holding” and time in post-operative care including vigilance regarding potential CME, PCO that needed to be treated readily should they develop. Yet in many cases the surgical practice received premiums ranging from 2500 to 5000 per eye, and the optometrist received his or her usual Medicare recommended co-management fee as if it were a standard monofocal IOL. No wonder only 7% of all cataract surgeries today involve premium IOLs. Sadly new and improved technologies like the extended depth of focus (EDOF) IOL and a trifocal IOL called Panoptix with fewer side effects and improved presbyopic correcting capabilities have not moved the dial much. Now to be fair there are surgical practices that provide adequate and appropriate fees for the time, patient education and additional testing to the optometrist. I’ve seen conversion rates to premium IOLs approaching 25 and even more than 50% in those settings. Ultimately it has to be what’s best for the patient and fair and appropriate compensation for work performed by each clinician. So how do we change this for the sake of patients and clinicians alike?
Surgical Companies Are Understanding Optometry’s Key Role
We can start with the companies providing these surgical technologies. Besides having innovative surgical and IOL technologies, these companies must also educate both professions. Approximately 88% of all comprehensive eye exams are conducted by optometry. Who do you think a patient will trust more, the surgeon (or more likely the optometrist in a surgical practice) who they have known for 20 minutes who is asking them to pay more for new technologies (when they hadn’t expected any added fees) or the optometrist they have seen for the last 20 years? In fact when the primary eye care optometrist makes a recommendation such as a toric IOL, the likelihood of the patient pursuing this is north of 95% in our practice. And given the lack of true collaborative care and the limited education on new cataract technologies, few optometrists would recommend an IOL or any technology they didn’t fully understand or how to safely and effectively manage the patient.
Fortunately we’re seeing positive changes. Premium IOL’s manufacturing companies have better technologies and have begun educating optometry. J&J has provided courses on premium IOL collaborative care education and we have seen a few programs at major conferences but compared to the size of the industry and if you combined all the companies that have surgical technology, it’s still not where it could be. I lectured on a new technology (Zepto) that makes a perfectly circular and more stable capsulotomy without requiring an expensive femtosecond laser. Numerous colleagues inquired about a list of surgical practices that use this technology. If only these surgical companies realized the opportunities that develop when optometry is broadly educated. Organizations like the Optometric Cornea, Cataract and Refractive Society (OCCRS), who’s mission it is to provide this education are stepping up and have an annual Symposium in conjunction with the New Technology and Treatments Conference in Austin from April 16-19th, 2020. I’d encourage you to attend as it will provide more education in this field than any other conference this year.
Interestingly one catalyst for change has been a small micro-incisional glaucoma surgery (MIGS) company called Ivantis, that immediately recognized the role optometry plays in educating glaucoma patients about their micro-stent called the Hydrus. When a patient comes in for cataract surgery (which is the only time they can have a MIGS procedure) and is educated by their primary ECP regarding MIGS, they almost always receive it at the time of surgery. And ultimately the patient wins as over 75% of patients in the clinical trial who received a Hydrus micro-stent were medication-free and remained medication-free three years later. I’ve seen Regeneron provide significant education on DME treatments and it has resulted in far greater numbers of patients receiving an anti-VEGF injection from the retina specialist. Allergan and other large companies are seeing the need for education on future innovative surgical technologies (BrimSR) that require collaborative care, so I believe this is a trend that will fortunately continue.
An Enormous Opportunity for Change
But perhaps the greatest opportunity for change in this area will happen when three exciting surgical technologies launch in 2020. All these companies see their technologies as an opportunity for collaborate care to flourish. The RxSight light adjustable lens (LAL) requires optometry to play the critical role in the success of the technology because the LAL requires extremely accurate refractive measurements and decisions on monovision, how much, full distance correction etc. The LAL enables the patient to have a corrective uv laser procedure on the IOL after cataract surgery. For optometry this will involve contact lens trials for monovision, trial lenses, precise refractions, discussions on and the determination of what to correct, what distance and even enhancing small amounts of astigmatism such as 0.50D in addition to effective peri-operative management. This IOL is very similar in size, design, haptics, material (silicone), squared edge back surface and quality to monofocal lenses currently on the market and it would be similar in cost and reimbursement by insurance as the typical cataract surgery/IOL is today. But what makes this IOL unique is that the material is photo-reactive uv absorbing. This allows for the refractive error to be modified after implantation using an ultraviolet light source known as the Light Delivery Device or LDD. Imagine the peace of mind of not worrying about the refractive outcome after cataract surgery because it can be adjusted easily with a uv laser. Clinical trial results showed that patients receiving the RxSight LAL achieved uncorrected vision of 20/20 or better at a rate of 2 times that of patients receiving a monofocal lens and nearly 92% of patients receiving the LAL achieved results within 0.50D of the intended target. The company understands the important role of optometry and I expect surgeons and primary eye care providers to equally benefit from the effort, time and commitment required by each provider.
A second surgical technology I expect and hope we’ll see in 2020 is the ReFocus VisAbility implant for the surgical correction of presbyopia. Young eyes that can accommodate have zonules that are taught in static position but as the lens grows throughout life and enlarges, it leaves no space for zonules that now remain loose and can’t flex the crystalline lens. These VisAbility scleral micro-inserts are placed where they can expand the zonular space. The data I saw from one of the investigational sites showed reading capabilities to that of newspaper print in all 20 patients that had the surgery. There is no surgery in the visual axis or even the cornea for that matter, so the risk of visual loss should be minimal. This is another procedure that cataract surgeons will be doing in 2020 and need to partner with optometry so the proper patients benefit, receive sound education on the surgical procedure, expectations and effective peri-operative care to achieve these results.
A third paradigm shift is the move to Office Based Surgery (OBS). This is an inevitable change that can help optometry because it provides consistency, one location for pre-surgical testing and surgery, less stress on the patient compared to a hospital or ASC atmosphere, a greater experience because there is no IV and you have familiarity of the staff etc. and quicker surgical scheduling, just to name a few advantages. It will also save the health system significant money, while creating conveniences for co-managing doctors and patients alike. I’d encourage you to look for good surgeons, who value optometry’s patient knowledge and clinical insights—especially in practices that have moved to OBS.
There are great solutions ahead and optometry has to dedicate the time to be educated, be well prepared to provide the peri-operative care required and understand the importance of their knowledge, skills and the patient’s trust in doing what is best for them surrounding these exciting and innovative surgical advances.