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Our standard glaucoma treatments have existed for decades: prescription eye drops, extra-ocular laser treatments and such surgical interventions as trabeculectomy. We recently began offering our patients endoscopic cyclophotocoagulation (ECP). Here are some reasons you may want to do so as well.
Adding ECP to phaco
ECP is a method to directly photocoagulate the ciliary body under endoscopic guidance. It is not to be confused with transscleral laser procedures that are very uncomfortable, require a peribulbar block and destroy tissue, making a future trabeculectomy more difficult, less effective or impossible to perform.
The goal of glaucoma treatment is to reduce intraocular pressure. In patients with cataracts and glaucoma, sometimes phacoemulsification alone is enough to reduce IOP and let patients decrease drop use. These patients are often on only 1 type of drop. As the number of prescriptions increases, we've found that adding ECP to phaco during cataract extraction in patients with IOP below 40mmHg lowers IOP and, after about 8 weeks, significantly reduces or eliminates the expense and inconvenience of an eye drop regimen. Follow-up appointments aren't necessary, patients have reported high satisfaction levels and we've had no complications.
A 2-minute procedure
Other than the steady hands commonly found among surgical ophthalmologists, there are no additional talents required to perform ECP. The learning curve to do so safely and effectively is neither steep nor lengthy. Performance of ECP requires the use of an endoscopic laser system. In our practice, 10% to 20% of our patients will benefit from ECP so on any given surgery day we might perform 4 to 8 ECPs. Try not to schedule them back to back so that you have enough time for chemical sterilization of the laser probe. This will increase probe life from about 20 uses you'd get using steam sterilization to more than 60 cases.
You prepare patients as you would any other cataract patient undergoing surgery: under topical anesthesia with the addition of 2% xylocaine gel just before entering the operating suite. Occasionally a patient might require small additional amounts of IV sedation or analgesia. After cataract extraction (where we also use intracameral xylocaine), you insert the laser probe through the clear corneal incision. Our system provides video that gives a unique view of the inside of the anterior chamber (a digital video recorder is also available for documentation and educational purposes).
Shrinkage and whitening of the ciliary bodies are easily seen as they are "painted" with laser energy in a variable and controlled fashion. This technique allows for treatment in a 300 ? arc. Use of ECP preserves other ocular structures in case the patient requires a trabeculectomy in the future. The procedure takes about 2 minutes to perform before lens placement, so no additional viscoelastic or other supplies are needed. The lens is placed, the incisions made watertight without sutures and the patients exit the OR.
Less medication
One large study has reported that after 3 years, on average, patients undergoing cataract extraction and ECP will lower their IOP by 3mmHg and require 1 less medication. We've had somewhat better results. The cost savings for patients and taxpayers comes from the reduction in costs for topical glaucoma medications, as each drop can cost as much as $100/month.
In 2005 ECP was given its own procedure code: 66711. Since then, the number of procedures performed nationwide, though still relatively small, has nearly doubled. We've performed more than 600 procedures in the last 2 years. Initial equipment costs are in the $40,000 to $50,000 range for the system and several handpieces. Replacement handpieces can run around $1,800. At Medicare rates, reimbursement for facilities and surgeons are increased 40% to 50% when billed as a second procedure (in addition to cataract extraction, 66984). Anesthesia reimbursement is increased by 1 base unit.
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Single-Use or Reusable Ophthalmic Blades? |
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Now that CMS says that single-use surgical blades are not approved for reuse, is it more cost-effective for your eye surgeons to use reusable products or to keep using (and disposing of) single-use blades? Ophthalmologist Richard J. Ruckman, MD, FACS, medical director and CEO of The Center for Sight in Lufkin, Texas, says it's more cost-effective to equip a center with diamond knives, which for him cost less per case than disposable blades. "The most important factor in determining whether your facility should invest in diamonds is the number of surgeries in which they'll be used," says Dr. Ruckman. "The higher your case volume, the lower your cost-per-case for diamond blades and repairs." Compare the cost per unit of single-use blades over time. The cost-effectiveness of a single-use blade is determined largely by the best price you can negotiate for it, though convenience may play a role, says Dr. Ruckman. "The amount of time saved in not having to reprocess the items contributes to cost reductions in OR and personnel costs." There are 3 types of reusable blades, each made from different material and with a different lifespan. Dr. Ruckman provides this rundown:
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With more than 1.5 million Americans identified as having glaucoma, perhaps an equal number as yet undiagnosed and an aging population, there are a lot of eyes out there that will require one form of glaucoma treatment or another. ECP offers a safe, effective, cost effective and financially sustainable therapy for patients, facilities and ophthalmology practices alike.
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