Welcome to the new Outpatient Surgery website! Check out our login FAQs.
February 17, 2022

THIS WEEK'S ARTICLES

The Strong Case for Dropless Cataract Surgery

Is Bilateral Cataract Surgery Worth It?

The Right Imaging Devices for Outpatient Procedures Are Critical - Sponsored Content

Stretcher Chairs Are a Safe and Efficient Option

Cataract Surgery Keeps Getting Better

 

The Strong Case for Dropless Cataract Surgery

Removing at-home drop regimens eliminates compliance and administration issues.

Neil Shorstein Kaiser Permanente
DROP ELIMINATOR Dr. Neal Shorstein says performing dropless cataract surgeries is an efficient procedure that reduces surgeons' concerns about patients' post-op recoveries.

After a typical cataract surgery, patients must safely and properly administer a staggering number of drops at home in the ensuing days and weeks to prevent infection and inflammation. Unfortunately, many patients don't use proper technique or stick to the rigorous schedule.

Neal Shorstein, MD, an ophthalmologist at Kaiser Permanente in Walnut Creek, Calif., says several studies show that most cataract patients instill drops incorrectly. For example, they may touch the tip of the eye drop bottle, scrape the cornea during administration or miss the eye altogether. He sees a solution to this problem in the form of the thousands of "dropless" cataract surgeries he has performed.

At the end of a cataract procedure, Dr. Shorstein injects the antibiotic moxifloxacin into the eye's anterior chamber to reduce the risk of endophthalmitis. No FDA approved moxifloxacin product is currently indicated for this use, so the drug must be compounded by a vetted 503B outsourcing pharmacy. "Ordering it, setting up shipping and having it stored properly takes some preparation and time," he notes.

While many surgeons still prescribe topical antibiotic drops in addition to administering the intraoperative injection, Dr. Shorstein says emerging research continues to favor the dropless trend, and increasing numbers of physicians are realizing topical drops aren't necessary when injections are administered.

Dr. Shorstein also injects triamcinolone, a sustained-release, long-acting steroid, into the subconjunctival space at the end of surgery to prevent post-op inflammation. He says this off-label use of an FDA approved product is as effective as administering topical steroid drops.

Two FDA approved products, Dexycu and Dextenza, have recently emerged to give surgeons another effective option for administering the steroid treatment. "Both of these products remain in place for about two to three weeks and provide long-acting steroid administration to the eye," says Dr. Shorstein. "These drugs definitely give us surgeons peace of mind, while patients love the practice because they don't need to constantly put in drops throughout the day."

Is Bilateral Cataract Surgery Worth It?

Surgeons debate the benefits of performing concurrent surgeries on the same day.

Eye Surgery SightTrust Eye Institute
DOUBLE VISION Risks of complications are rare following sequential surgeries and patients love the convenience of undergoing two procedures during one visit.

Patients with cataracts in both eyes prefer to have two new lenses implanted during a single surgical visit, according to ophthalmic surgeon Andrew Shatz, MD, owner of SightTrust Eye Institute in Sunrise, Fla. He decided to begin offering immediately sequential bilateral cataract surgery (ISBCS) after poring over the clinical evidence and finding that performing back-to-back procedures is safe and effective.

"Patients don't need to make two trips to the facility for staggered procedures performed on separate days," says Dr. Shatz. "That means they avoid two rounds of anesthesia, healing and burdensome post-op drop regimens."

He believes the advantages of ISBCS — which reportedly include quicker vision rehabilitation and reduced costs of care — outweigh the extremely small risks of bilateral endophthalmitis and blindness, thanks to surgeons using intracameral antibiotics and managing post-op inflammation of ocular tissues. Proponents of ISBCS believe poor refractive outcomes — a concern because surgeons can't benefit from analyzing the outcomes of the first procedure before performing surgery on the second eye — are also exceedingly rare based on the use of biometry to take precise eye measurements that lead to more exact determinations of the most effective IOL power to use.

However, some surgeons remain concerned about the potential for post-op complications and poor refractive outcomes when two procedures are performed on the same day. Samuel Masket, MD, a clinical professor of ophthalmology at the David School of Medicine's Stein Eye Institute at UCLA, is one of them. In an editorial published in the journal Ophthalmology, he points to the associated risks of endophthalmitis and toxic anterior segment syndrome. Although Dr. Masket concedes prophylactic intracameral antibiotics and proper sterile technique mitigate these risks, he says the potential complications are devastating to patients and their families.

Dr. Masket also points out that physicians and surgery centers are reimbursed 50% for a second eye surgery performed on the same calendar day under traditional fee-for-service Medicare reimbursements, which he says creates a significant financial disincentive for ISBCS. While he does believe that ISBCS would benefit patients who must travel great distances for surgery, require general anesthesia or have limited social support systems for recoveries, he doesn't believe performing bilateral procedures is worth the risks for most patients.

"Does the patient truly benefit?" he writes. "At present, at least with regard to surgery under traditional Medicare reimbursements, it appears as though the surgeon is financially compromised and the patient is put at greater risk, whereas the third-party payer is the ultimate beneficiary."

The Right Imaging Devices for Outpatient Procedures Are Critical
Sponsored Content

Surgeons need access to the most precise visual data and reliable, high-resolution camera systems for the best outcomes.

4K Credit: Courtesy of Panasonic i-PRO Sensing Solutions
i-PRO GP-UH532 4K ULTRA HD 3MOS CAMERA

Ophthalmic surgeons are busier than ever as the aging population and younger generations look to them for procedures that ensure good eyesight and eye health. The best outcomes for patients result from a combination of utilizing first-rate imaging devices and the continuing education of the latest techniques and technologies available today. Manish Desai, Regional Sales Director at Panasonic i-PRO Sensing Solutions Corporation of America, offers the following insights on the industry and what eye surgeons can look forward to in the future.

Q: For today's eye surgeon, how important is the image when performing a variety of outpatient procedures?
There is a direct correlation between the resolution and color reproduction expected from the cameras that are employed for outpatient procedures and the level of precision provided during the procedure. The images are essentially visual data, providing physicians the information they need to perform various tasks. It is critical that physicians have access to the most precise visual data possible to ensure the best patient outcome when performing any procedure. High levels of image detail and color reproduction are also essential for students' education.

Q: What should the eye surgeon look for when deciding on a particular system?
Aside from high-imaging performance, an eye surgeon should look for camera systems that are easy to set up, reliable and provide the greatest overall value for their capital investment.

Q: What part does compatibility with various microscopes play in the surgeon's ability to perform?
Microscope compatibility is imperative to ensure the surgeon can maintain the proper field of view and focus for anterior, posterior and glaucoma procedures. This is critical when evaluating imaging solutions.

Q: How important is the imaging system for patient safety?
Patient safety is not affected by imaging devices used to perform eye procedures. The ability to provide patients with a high-resolution video of their eye procedure helps reinforce patient confidence that builds strong patient-physician relationships, reputations and growth.

Q: What are the technology trends you are seeing for eye procedures in the future?
Cameras with high dynamic range provide an advantage for physicians performing eye procedures, as they allow surgeons to view both dark and bright areas within the same frame. This is not possible with conventional cameras that do not have this feature. Another emerging trend is performing procedures using a 3D digital microscope. The 3D imaging allows surgeons to use a heads-up display while operating on patients. This reduces neck strain, which is a prevalent issue with surgical microscopes. As a result, companies that produce surgical microscopes are investing in developing new 3D digital microscopes to benefit surgeons and improve patient outcomes.

Q: How does a good camera system aid in building an eye business?
High performance and reliable camera imaging devices are most important to eye surgeons and physicians. It's somewhat ironic that high-resolution camera technology has become one of the most pervasive tools used to treat, correct and maintain the organic vision quality of patients' eyes. With the proliferation of 4K camera technology, more and more surgeons are seeking 4K camera and recorder solutions for their practices.

For more information visit https://i-pro.com/us/en/medicalimaging.

Stretcher Chairs Are a Safe and Efficient Option

A single patient surface for the entire perioperative episode helps prevent transfer injuries while boosting operational throughput.

For ophthalmic patients who make many stops during their episode of care, stretcher chairs make the journey much simpler and safer. Staff also appreciate the mobile devices, which eliminate the risks associated with multiple transfers between surfaces.

Victoria Wiltshire, RN, MBA, vice president and chief operating officer at SightTrust Eye Institute in Sunrise, Fla., says her staff utilizes stretcher chairs to move patients through four stations during their care: pre-op, the phacoemulsification laser suite, OR and PACU. "From the moment the patient checks in until they are discharged, that one chair is theirs," she says. "Because they remain in one chair, that's four missed opportunities for falls and staff injury."

SightTrust's chairs possess another handy feature: a remote with four pre-programmed positions, which reduces the possibility of human error when positioning patients at each station of their care. In pre-op, the center's staff hit number one, which places patients in Semi-Fowler's position. Numbers two and three are used to position patients correctly for the laser and phaco portions of their surgeries, and when patients arrive in the PACU, number four restores them to Semi-Fowler's.

When it's time for discharge, a staffer simply presses a button to return the patient to an upright position. "We let them sit up and make sure they're not nauseous or dizzy so they don't get up and fall on the floor," says Ms. Wiltshire, who adds that the center's stretcher chairs are so easy to use that they don't require lengthy staff training. "There's no user error or learning curve," she says.

Ms. Wiltshire adds that stretcher chairs also make her practice more efficient. In the turnaround between patients, staff simply wipe down the entire chair, including its blood pressure cuff and pulse oximeter, to prepare it for the next patient. The upfront investment is around $15,000 per chair, according to Ms. Wiltshire, but she says their long-term benefits have far outweighed their initial cost.

Cataract Surgery Keeps Getting Better

New technologies are enabling surgeons to provide demanding patients with nearly perfect vision.

The days of patients being thrilled merely to see clearly again after a traditional cataract surgery are gone. Today, more of them show up for surgery expecting to leave (or head home) with the same 20/20 vision friends and family told them they received from their eye surgeon.

Ralph Chu, MD, CEO of the Chu Vision Institute in Bloomington, Minn., feels that increased pressure to deliver exceptional results. Fortunately, he says, advances in extended depth of focus and trifocal intraocular lenses (IOLs), the interconnectivity of pre-op diagnostic devices with femtosecond laser platforms and new ways to administer intraocular medications that prevent post-op complications have helped surgeons like him rise to the challenge.

"Our techniques and technologies weren't always good enough to stay ahead of the aging process and talk to patients about turning back the clock on vision quality," says Dr. Chu. "Now we're getting to the point where we can start to have those conversations."

Dr. Chu was one of the first adopters of femtosecond laser assisted cataract surgery, and he continues to embrace it as a superior option for making a consistent and perfectly shaped capsulorhexis — especially in denser cataracts that are difficult to visualize — before using phacomulsification to extract the fragments. He expects femtosecond platforms will evolve to become increasingly user-friendly and easier to integrate into cataract surgeries.

"Surgeons are faced with numerous new options and must decide which make the most sense for their practice," says Dr. Chu. "That involves honest assessments of the clinical benefits that the platforms, tools and medications provide, understanding how to integrate them into established surgical routines and deciding if they can improve outcomes for more demanding patients."

DID YOU SEE THIS?