2004 a banner year for refractive surgery
In this report, OSN’s Refractive Surgery Section Editor gives an expert overview of the state of the art in refractive surgery.
Earlier this year Ocular Surgery News convened a summit meeting of the Section Editors of our Editorial Board to review the state of the ophthalmic profession and industry. As part of the meeting, each section leader presented to the group an overview of his subspecialty, surveying both recent developments and prospects for the future. Beginning with this issue, we present transcriptions of the section editors’ remarks. Look for more updates in upcoming issues of Ocular Surgery News.
Recent developments and approvals have made this a huge year for refractive surgery. We are benefiting from our increasing experience with wavefront technology, both for diagnostic applications and for guiding laser ablations. We have new choices in microkeratome technologies. We have the recent approval of conductive keratoplasty for treatment of presbyopia, which may be the start of a whole wave of surgical treatments for this visual defect. And we have new refractive IOLs approved and pending approval.
Ocular Surgery News has been following all of these developments and will continue to report on them in the coming months.
Daniel S. Durrie, MD
Wavefront devices will have a huge impact, not only in refractive surgery but in all ophthalmic specialties, including glaucoma and retina. Occasionally, a retina specialist will request that I make a wavefront map of a patient to try to determine whether their problem is macular or optical. Glaucoma specialists are starting to think about using wavefront technology to determine if a visual defect is from the cornea and lens or from nerve fiber layer defects.
Wavefront devices are easy to use and are getting dramatically better. Every machine I have has been updated multiple times in the past few years, and there are more technologies to come. The phoropter is going away, a development that should really shake up our industry.
With wavefront devices, we measure the aberrations in the eye. It is then possible to analyze those aberrations electronically, come up with a defect map, and then transfer that information to the laser, a contact lens or even an intraocular lens. Automation allows us not only to find more defects, but also to reduce the number and amount of errors in the transfer of data.
I am intrigued by the IntraLase femtosecond laser for the making of the LASIK flap. With the laser we can control a lot of factors, including the location and thickness of the flap. There is the added benefit of a perfectly dry bed, as the excimer laser beam can be blocked by fluid introduced by blade microkeratomes. We have spent the last 20 years making microkeratomes safer, now we are starting to look into what devices give us the best quality vision. Early studies are starting to show that the IntraLase laser keratome may result in better vision.
In March, the Refractec ViewPoint CK System received approval by the Food and Drug Administration for the treatment of presbyopia with conductive keratoplasty. This is a significant step for refractive surgery.
CK is the first surgical procedure approved to improve near vision in this very large and frustrated group of patients. The CK technology changes the shape of the cornea by the administration of radio frequency waves through a probe. It is not a difficult procedure. In the studies I have conducted on CK, one interesting point is that there is no loss of contrast sensitivity or depth perception like we see with monovision, although we do not know why.
We will soon have access to phakic IOLs. This new technology will require new skills and new diagnostic equipment. The Visian ICL (STAAR Surgical) and the Artisan/Verisyse (Ophtec/Advanced Medical Optics), which we are just now being introduced to, have a significant amount of international experience. These lenses have been recommended for approval by an advisory panel to the FDA, but they are still pending final approval.
We also now have access to an accommodative lens. The Crystalens (eyeonics) is starting a whole new business model. That is, how do you work that premium-price IOL into your practice?
With other lenses coming, including Alcon’s ReStor multifocal IOL, we need to advance our understanding of both multifocal and accommodative IOLs.
For the next 6 years, refractive surgery will be the most rapidly growing field in ophthalmology, both in the number of cases and total dollars spent. With 2004 being a watershed year, Ocular Surgery News will increase coverage in this area in response to this anticipated growth.
I have watched the IOL industry for 20 years, and in that time the leading IOL manufacturer changed six times. While everyone thinks that there is a dominant player in refractive, I believe it is totally up for grabs as to what company is going to dominate refractive surgery in the next 10 years.
Richard L. Lindstrom, MD
The good news is that we have access to tremendous technology. Also, our fees are going up. They’re being forced up. Manufacturers are charging us more for better technology, so we are raising our fees. I think manufacturers need to think about the fact that they control our fees by what they charge us.
Every surgeon I talk to is raising fees, and the patients don’t seem to mind. Ophthalmologists have a tough time saying the fee, but the patients seem willing to pay for it if it gives them better quality vision. I hear many ophthalmologists saying, “My patients won’t pay that.” Remember, we used to charge patients $2,000 for PRK with a 5-mm optical zone with no astigmatism correction, and the patients were fine. Patient interest is up.
The bad news is that we have a lot of confusion. Surgeons are trying to apply what they know about one laser to another or from one aberrometer to another aberrometer, and as a result they are inducing errors. There is also a lot of confusion in the minds of patients. They have heard that there is something new, but they don’t know how it applies to them.
Also, I believe, as a group, physicians have poor business skills. In part, this is because there is currently no business training for medical students or residents. Surgeons need to know their costs and business model before setting their fees. We have too many surgeons that are setting their fees by looking at what the guy down the street charges.
The dispensable surgeon
For the past 20 years, refractive surgeons have worked on their skills at manifest refraction; reading topography; designing nomogram adjustments; and increasing their comfort level with their outcomes. But new technologies like wavefront essentially wipe these skills out. One machine talks to another machine, and the surgeon is out of the loop, and that bothers us. If we are not careful, refractive surgery may become oversimplified. The most important parts of refractive surgery will continue to be careful patient selection, excellent surgical technique and good quality follow-up care.
When you look back at why the optometrists backed out of the battle to do refractive laser surgery several years ago, it was when the microkeratome came into play. When the procedure of choice was PRK, they were all over it. As soon as we brought the microkeratome in, they backed off for a darn good reason, because they didn’t want to use it.
With the introduction of all this new automation into LASIK surgery, we are now seeing a new push by organized optometry to do surgery. This is a major step backward in the cooperation that refractive surgery introduced between the two specialties. This is a serious threat to the safety of our patients and to our specialty. All ophthalmologists need to support the AAO program to educate patients, legislators and the government about the important difference in the training between MDs and ODs.
Time for education
With all this change, now it is more important than ever for surgeons to keep up to date on what is happening in this field. Read all you can, attend meetings and visit with other refractive surgeons. It is an exciting time – don’t get left behind!
Levine on oculoplastics
The July 15 issue will feature OSN Oculoplastic and Reconstructive Surgery Section Editor Mark R. Levine, MD, discussing oculoplastics for both the specialist and the comprehensive ophthalmologist.
For Your Information:
- Daniel S. Durrie, MD, can be reached at Durrie Vision, 5520 College Blvd., Suite 200, Overland Park, KS 66211; (913) 491-3737; fax: (913) 491-9650; e-mail: firstname.lastname@example.org.