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What's Hot in Ophthalmic Surgery?
Find out how surgical facilities across the country feel about smaller incision sizes, premium IOLs, adding retina and more.
Irene Tsikitas
Publish Date: December 1, 2008   |  Tags:   Ophthalmology

What's hot and what's not in the ever-evolving field of ophthalmic surgery? We surveyed 126 facility administrators and physician-owners to gauge their interest in five technologies and procedures that have emerged on the scene in recent years. Here are the results, plus analysis and commentary from Wayne Bizer, DO, FAOCO, medical director of the Foundation for Advanced Eye Care Ambulatory Surgery Center and chairman of the ophthalmology department at Nova Southeastern University in Fort Lauderdale, Fla.

What's the smallest phaco incision used in your facility?

2.75mm

23.9%

2.0mm

17.0%

2.5mm

17.0%

2.65mm

12.5%

3.0mm

12.5%

1.8mm

9.1%

2.85mm

8.0%

3.2mm ?

0.0%

SOURCE: Outpatient Surgery Reader Survey, November 2008, n=88

1. Smaller phaco incisions
Nearly one-fourth (23.9 percent) of respondents said the smallest incision used for phacoemulsification at their facilities is 2.75mm. A combined 55.6 percent of respondents said the smallest incision size used at their facilities is even smaller. "Smaller than 2.8 or so is getting to ultra-small incisions," remarks Dr. Bizer, who was somewhat surprised by the findings. He notes that this technique has its advantages, such as faster healing and less risk of induced astigmatism, but is more challenging for the surgeon. Micro-incision phaco requires widening the incision to accommodate the intraocular lens, since no IOLs currently approved for use in the U.S. will fit through a 1.8mm incision. "Perhaps we are dealing with a subset of highly skilled surgeons in the United States," suggests Dr. Bizer of the survey sample. More than half of respondents who said their smallest phaco incisions were 2mm or less described their facilities as "very aggressive" about adopting new technologies and procedures (see "Who's on the Cutting Edge?" on page 60). About 17 percent of respondents were in hospitals, with most of the remaining pool operating in ambulatory surgery centers.

2. Topical anesthesia
Half the sample said their physicians are using topical anesthesia more than they were three years ago for ophthalmic cases, citing a number of reasons including a growing preference for and comfort with the technique among both newer and more seasoned surgeons.

"We've found that the topical anesthesia along with a small amount of sedation gives the patients a pain-free surgery and a quicker recovery," says Mary Wilhide, RN, clinical director of the Carroll County Eye Surgery Center in Westminster, Md. "It is also very efficient and easy to manage during the pre-op period."

But while some have found success with topical anesthesia, others noted that the decision depends on the comfort level of the surgeon and the patient. Dr. Bizer says he tried using topical as the primary method of anesthesia for a while, but eventually went back to peribulbar injections with MAC anesthesia because his patients didn't like topical. Several of the 8.9 percent of respondents who said they're using topical anesthesia less now than they were three years ago expressed a preference for blocks.

How often is topical anesthesia the primary type of anesthesia used?

Very frequently

54.0%

Somewhat frequently

18.3%

Rarely

20.6%

Never

7.1%

SOURCE: Outpatient Surgery Reader Survey, November 2008, n=126

Is topical anesthesia used more or less at your facility than it was three years ago?

More

50.0%

Less

8.9%

n/a

41.1%

SOURCE: Outpatient Surgery Reader Survey, November 2008, n=124

3. Premium IOLs
About three-fourths of respondents said they implant three types of premium IOLs — multifocal, aspheric lenses and toric lenses — at their facilities. Fifty-three percent also said accommodating IOLs are implanted at their facilities, while only 24 percent currently implant phakic lenses. Large majorities (60 percent or more) of respondents said they were very likely to begin implanting most of the different types of premium lenses over the next five years. But only 43 percent said they were very likely to add phakic lenses, and 31 percent said they weren't likely to add them at all. Dr. Bizer notes that "many surgeons are concerned about the possibility of cataract development" with these lenses. He also says there's a "limited population of patients who have refractive errors that require" phakic IOLs.

Premium IOLs are expensive, and patients must pay a significant portion of the bill out of pocket, so economic and demographic conditions in different areas may impact your decision to start implanting them. "We are in a very rural area in Polk County [Fla.], and I personally think [the physicians] don't feel there is much of a market here," says Emily Duncan, RN, BS, CASC, executive director of the Lakeland Surgical & Diagnostic Center. Ms. Duncan's facility doesn't implant any of the premium lenses listed, but she says they are "somewhat likely" to in the next five years. "All the physicians have been to the training???. They keep talking about wanting to start."

4. Retinal procedures
Although a 48 percent plurality of respondents said they don't do vitreoretinal procedures at their facilities, some retinal procedures are gathering steam. Pars plana vitrectomies are performed at 41 percent of the facilities that responded; retinal laser procedures are performed at 35 percent of facilities; and membrane peels, retinal detachment repair and intravitreal injections are performed at roughly 30 percent of facilities. Among those facilities that haven't adopted retinal procedures as part of their case mixes, there appears to be some reticence to do so, even though changes to the Medicare payment system have made these procedures more lucrative for ASCs. For example, the ASC reimbursement for CPT code 67107 (repair detached retina) went from $717 in 2007 to $922.86 in 2008 and is on track to reach $1,540.44 when the rate changes are fully implemented in 2011. Sixty to 65 percent of facilities said they aren't likely to add any of the retinal procedures listed.

Still, about one-fourth of respondents said they're "very likely" to add some or all of the retinal procedures. The Capital City Surgery Center in Sacramento, Calif., isn't doing any vitreoretinal procedures at the moment, but ASC Manager Kim Russell says they'd like to add retina to their case mix. "The difficulty is attracting a retina surgeon," she says. Dr. Bizer sees an opportunity here for ASCs. "Most of the retina guys I talk to would like to get out of the hospitals because the turnaround times are so slow," he says.

Who's on the Cutting Edge?

About one-half (51.2 percent) of our respondents said they were "somewhat aggressive" about adopting new ophthalmic surgery technology, while one-third (32.5 percent) characterized themselves as "very aggressive." When considering a new ophthalmic procedure or piece of equipment, the innovation's impact on surgical outcomes and case efficiency is by far the biggest consideration, with 88.9 percent saying it's a "very important" factor. "We like to give our patients the best possible care," says Lance Shurter, surgical technologist at St. Lucy's Outpatient Surgery Center in Port Charlotte, Fla. On the other hand, several respondents said they preferred to proceed cautiously for the sake of their patients. "We want to be on the latest front, but cautious for our patient's sake as well," explains Ramin Tayani, MD, medical director of the West Coast Center for Surgeries in San Clemente, Calif.

Not surprisingly, 72.8 percent of respondents said cost was a very important factor in their decision to adopt a new procedure or technology, and 62.7 percent cited profitability as a leading factor. Surgeons appear to be a driving force behind a facility's interest in being on the cutting edge. "When our docs attend the national meetings, if they find something they think we need to implement, we certainly do it," says Shirley Ramey, RN, nurse manager at the ASC of Burley (Idaho). "We just want to be sure it isn't a passing ???fad' so we don't get stuck with lots of money invested in something that will be replaced by something even better next month."

Several of the 17.9 percent of respondents who said they weren't very aggressive about adopting new technologies described their surgeons as "conservative," and a few hinted that there's a generational divide at play. "Our surgeons are in their 50s. They are set in their ways," says Jackie Dayton, RN, nursing supervisor of the Surgery Center of Ophthalmology Consultants in Fort Wayne, Ind. "The newest partner is younger and is encouraging new ideas." But Wayne Bizer, DO, FAOCO, of Fort Lauderdale, Fla., says he's been practicing for more than 30 years, and he doesn't see his peers resting on their laurels.

Many of the respondents who said they weren't aggressive about adopting new technologies cited practical reasons. "We're limited to cataract and small plastic eye cases due to a small physician staff and budget limitations," notes Pamela Barnett, RN, BS, CNOR, clinical nurse manager at St. John Macomb-Oakland Hospital in Madison Heights, Mich.

— Irene Tsikitas

How important are the following factors when you're considering adding a new ophthalmic procedure or technology?

Very important

Somewhat important

Not very important

Not important at all

Cost

72.8%

25.6%

1.6%

0.0%

Impact on surgical outcomes and efficiency

88.9%

11.1%

0.0%

0.0%

Profitability

62.7%

34.1%

2.4%

0.8%

Surgeon preference/demand

55.2%

43.2%

1.6%

0.0%

Opportunities to recruit and retain surgeons

36.0%

41.6%

15.2%

7.2%

Research/study

13.3%

34.2%

33.3%

19.2%

SOURCE: Outpatient Surgery Reader Survey, November 2008, n=126 Note: Respondents could check all that apply.

5. Safety blades
Everyone can agree that safeguarding surgeons, staff and patients from sharps injuries is of the utmost importance, but survey respondents were divided over whether technology — specifically, ophthalmic surgical knives that come with a retractable shield for the blade — is the best way to achieve that goal. A plurality of respondents (41.6 percent) said they never use ophthalmic safety knives, while a combined 43.4 percent said they use them very or somewhat frequently.

The Madison Street Surgery Center in Denver, Colo., uses safety blades very frequently because they're "safer for staff" and "meet OSHA requirements," explains Director of Nursing Donna White, RN, MSN, MHA. Many respondents indicated that surgeon preference is the main driver behind their decision whether to implement safety blades. "Our surgeons have not felt the need with our current safety techniques," says Steven D. Williams, MD, FACS, medical director of the Riverside Ambulatory Surgery Center in Bourbonnais, Ill. Dr. Bizer agrees that good communication and a consistently safe method of passing instruments are the real keys to avoiding sharps injuries. Still, more than half of respondents said they were very or somewhat likely to adopt ophthalmic safety knives sometime in the next five years.

Which of these premium IOLs are implanted at your facility?

Multifocal (Alcon's ReStor; Advanced Medical Optics' ReZoom)

78.5%

Toric (Staar Surgical Toric Intraocular Lens; Alcon AcrySof Toric IOL)

76.9%

Aspheric (B&L's SofPort Advanced Optics; Alcon's AcrySof SN60WF; Advanced Medical Optics' Tecnis Z9000)

73.6%

Accommodating (B&L's Crystalens)

52.9%

Phakic (Staar Visian; AMO Verisyse)

24.0%

None (we don't do premium IOLs)

7.4%

SOURCE: Outpatient Surgery Reader Survey, November 2008, n= 121
Note: Respondents could check all that applied.

How likely are you to implant these IOLs in the next five years?

Very likely

Somewhat likely

Not likely

Multifocal IOLs

70.5%

20.5%

9.0%

Accommodating IOLs

61.0%

23.7%

15.3%

Aspheric IOLs

67.1%

22.9%

10.0%

Toric IOLs

69.4%

19.4%

11.2%

Phakic lenses

43.1%

26.1%

30.8%

SOURCE: Outpatient Surgery Reader Survey, November 2008, n=85

Which of these vitreoretinal procedures do you perform at your facility?

None

47.9%

Pars plana vitrectomy

41.2%

Retinal laser procedures (focal or panretinal photocoagulation)

35.3%

Retinal detachment repair

31.1%

Membrane peel

29.4%

Macular hole repair

28.6%

Intravitreal injections

28.6%

SOURCE: Outpatient Surgery Reader Survey, November 2008, n=119
Note: Respondents could check all that applied.

How likely are you to add these retinal procedures in light of the changes in Medicare reimbursement?

Very likely

Somewhat likely

Not likely

Pars plana vitrectomy

27.4%

9.5%

63.1%

Membrane peels

24.4%

11.0%

64.6%

Macular hole repair

22.0%

13.4%

64.6%

Retinal detachment repair

24.4%

10.5%

65.1%

Retinal laser procedures (focal or panretinal photocoagulation)

28.6%

11.9%

59.5%

Intravitreal injections

24.7%

13.6%

61.7%

SOURCE: Outpatient Surgery Reader Survey, November 2008, n=91

How frequently do you use ophthalmic safety knives at your facility?

Very frequently

30.1%

Somewhat frequently

13.3%

Rarely

15.0%

Never

41.6%

SOURCE: Outpatient Surgery Reader Survey, November 2008, n=113

How likely are you to adopt ophthalmic safety knives in the next five years?

Very likely

18.6%

Somewhat likely

35.6%

Not likely

29.7%

We've already adopted them

16.1%

SOURCE: Outpatient Surgery Reader Survey, November 2008, n=118

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