Ophthalmology

At every Academy meeting, there’s a topic that dominates exhibit hall and hotel bar discussions. For the past couple of meetings it has been femtosecond cataract surgery, but this time it distinctly changed to health care reform. With President Obama continuing in office, the likelihood of repeal of the Affordable Care Act is quite small.

Twenty-five years ago, before I entered medical school, my uncle, John Piligian, who was a prominent pathologist in Michigan, advised me not to become a doctor. “They’re going to socialize medicine and treat doctors like a commodity,” he used to say.

How right he was! Changes in health care continue to erode the sanctity of a physician’s role and prevent us from practicing medicine the way patients deserve, although it’s taken much more time than my uncle ever predicted.

Eye care, and health care in general, is changing rapidly, as new technologies offer higher standards of care at an increased cost that the system can no longer bear. In eye care, the growing demand for cataract surgery will continue over at least the next decade while the supply of surgeons in the U.S. will slowly decline.

Something has to give.

Nearly 20 years ago, when I was a first-year resident, we approached glaucoma almost exactly the same way we do today. Sure, today we have better imaging modalities for the optic nerve and more sophisticated visual field strategies. But fundamentally we still visually inspect the optic nerve and give eye drops to lower pressure. To “cure” glaucoma, I think we need to make three fundamental changes in our approach.

In the U.S., two different corneal inlays for presbyopia are undergoing FDA clinical trials. The first, PresbyLens (ReVision Optics), is a hydrogel implant placed beneath a LASIK flap or corneal pocket, where it alters the anterior corneal shape. The second, Kamra (AcuFocus), creates a pinhole effect to increase depth of field. Both of these inlays showed very satisfactory results in earlier clinical trials and will hopefully be approved soon. I believe corneal inlays of these types will signifi...

In our careers, we will encounter many technological advances in diagnostic equipment, medicines and surgical techniques — but a few stand out as changing the way we practice every day. The transition to small-incision and eventually clear corneal cataract surgery was for me a dramatic improvement about 15 years ago. Premium implants raised to a new level the benefits we can give a patient during cataract surgery. In the diagnostic arena, I think OCT has been the most impressive advancemen...

A recent article in the New York Times highlighted the legal impact of a 2011 Supreme Court ruling on the liability of generic drug makers for damage done to patients by their products. The ruling concluded that generic drug makers are not liable for damage resulting from their failure to warn patients of specific dangers of their generic products. Instead, they may simply copy the warnings associated with the brand name "equivalent" drug.

In recent years, our specialty has seen a return to the minor procedure room for a number of new surgical procedures that have emerged. For dry eye alone, we now have meibomian duct probing, intense pulsed light, and the newest, the LipiFlow thermal pulsation system (TearScience) — all procedures that can be performed in the office. Retinal surgeons routinely perform dozens of intravitreal injections in a clean-room setting and are beginning to perform vitrectomy even in an office setting using simplified machinery for routine procedures. New corneal procedures such as collagen cross-linking also are appropriate for this setting.

As we gain greater understanding of mechanisms that affect corneal health, and awareness of the effect of even mild corneal dysfunction on vision and lifestyle, I believe three fundamental changes will continue to happen in eye care in the coming years.

However careful we are with the way we treat patients, all of us will occasionally encounter someone who is unhappy with our care. Here is a list of principles from a variety of experts that will serve you well in helping your own patients.