Putting a customized ablation system to work in a refractive practice may, by some accounts, add as much as a half hour to each patient's workup and consultation, and will cost more in terms of office space and staff training. What long-term effect this will have on patient flow and the bottom line remains to be seen, but surgeons who have done or are doing these treatments say they call for a change in the way refractive surgeons approach their procedures. 

"I'm charging $500 more per eye, and I have to," says Overland Park, Kan., surgeon Dan Durrie, who participated in custom ablation trials for Alcon and Bausch & Lomb, and who now performs it in his practice with the Alcon unit. 

"We haven't really been hearing about this part of it, since it hasn't been in the press yet. It may really slow you down, but I still think it's going to be worth it."
 ⎯Dan Durrie, MD
"The increased chair time is significant, because you're discussing extra things with the patient. There are significant equipment costs involved with the aberrometer, staff training on the aberrometer, floor space, training for the diagnostic techniques and the new language the staff has to speak. Your counselors need to know the differences [between treatments], and who's a candidate and who's not." 

He says the time cost will have to be paid by the surgeon himself. 

With custom ablation, Dr. Durrie says, "you now take an aberrometer reading and you have to trust and be personally involved with the process before [the aberrometer] talks to the laser … you have to be actively involved in all of that process of taking these photos, making sure the data points are accurate, editing them if they're not, and doing centration and registration. It's going to take significantly more of the surgeon's time in the office than people realize." 

Marguerite McDonald, MD, medical monitor for the Alcon LadarVision clinical study, says that, though making an aberration map may take up to seven minutes longer than a normal workup, explaining what wavefronts are and the pros and cons of a custom ablation will take even more time. "There's no question that it takes more explaining," she says. "I can't wait for there to be educational videotapes about this so we can sit patients down in front of a TV console to both improve and shorten the informed consent talk." 

For the Visx laser, if the surgeon chooses to cut a preview lens for the patient in order to simulate for him or her what his vision would be like after the treatment, the work-up time expands even more. 

"I would think that, on the Visx laser, [the workup] will be no more than maybe 10 minutes extra," says Houston surgeon and Visx investigator Doug Koch. "But if you get to the point where you want to cut a preview lens, that will definitely add chair time, maybe 20 or even 30 minutes. You will have to put the preview lens into a trial frame and see how the patient sees with it. My guess is that we won't be cutting preview lenses unless there is a discrepancy between the wavefront refraction and the patient's actual refraction." 

Surgeons say it will also have an effect on the day of surgery, as well. 

"On the surgery side," says Dr. Durrie, "the doctor has to realize that all the things he's done before to decide what to put into the laser go away. None of it applies. The topography, the Orbscan, the manifest and cycloplegic refractions, the old glasses prescription, the repeat refraction and the old records from the optometrist have absolutely no input into the laser at all." 

Is all this worth it? Surgeons say yes, but add that it may hurt certain practices. 

"It's worth it," says Dr. Durrie, "because you're going to have a higher quality of vision and more satisfied patients … but it won't be for discounters." He says that though practices will have increased costs in a lot of areas, they should also realize a return on investment on those costs. "I think this will restructure the cost of refractive surgery again," he says. "Pricing will be based more on value and return on investment than sticking your finger in the air to check the wind or competing with the guy's prices down the street." 

"For the high-volume, 'crank-it-out' folks, it will have a negative impact," says Dr. Koch. "Here [at our practice], we spend some time with the patients beforehand, so it won't make that much of a difference." 

"It will be worth it," says Dr. McDonald. "But I don't think it will be easy to stay financially solvent if you're one of the high-volume, discount people. I just don't know how they're going to survive getting the wavefront map performed and analyzed, and the longer informed consent time will be a stumbling block as well. The price per case will have to go up, too, no matter where you are in the price range." 

Dr. Durrie says that, after the proper education and time to work with custom ablations, there will be a light at the end of the tunnel. 

"I think there will be plenty of time to learn [about wavefront] and plenty of courses around to pick it up," he says. "There will be a lot of mentoring in which surgeons visit centers who've done it right and have incorporated it. And I think it will all work out. We haven't really been hearing about this part of it, since it hasn't  been in the press yet. It may really slow you down, but I still think it's going to be worth it."

Cool Relief for Botox Injections 
Researchers at the Department of Ophthalmology at the University of Tennessee Health Science Center, in Memphis, say that the many patients undergoing Botox therapy today may benefit from a simple, inexpensive and safe method of skin cooling to reduce the pain associated with the therapy. The report appears in the November 2002 issue of Ophthalmic Plastic and Reconstructive Surgery

The investigators studied 14 consecutive patients ages 42 to 86 years scheduled for bilateral periocular botulinum toxin A injections for blepharospasm or wrinkle reduction. One side of the face was cooled with ice or frozen mask over a gauze pad for five minutes before the injection. After five minutes the patients were injected on the cool side first. Patients then rated the pain from 0 to 10. 

Pain scores on the cool side were 45 percent lower than the noncooled side, and ranged from 0.5 to 7, average, 3.6, and from 3 to 10, average 6.5 on the noncooled side. No complications were observed. Botox is known to be stable in a cold environment, so the cooled skin does not affect potency. 

AAO's Rich Will Chair AMA's RUC 
At its House of Delegates meeting last month, the American Medical Association Board of Trustees appointed William Rich III, MD, as its 2003 chair of the AMA/Specialty Society RVS Update Committee. Dr. Rich is presently secretary for federal affairs for the American Academy of Ophthalmology. 

The RUC recommends work values for CPT codes to the Centers for Medicare and Medicaid Services. The RUC is well-respected by CMS and almost all of its recommendations are accepted. Dr. Rich will assume his new two-year position in May 2003. 

The appointment, says Dr. Rich, "represents the culmination of the Academy's decade-long commitment to advocacy in the area of reimbursement. I am only the figurehead for the excellent Academy staff in the DC office put together by Cathy Cohen, VP for governmental affairs, and the Academy's superb 'RUC team' of doctors: Trexler Topping, MD, Steve Kamenetzky, MD and Greg Kwasny, MD."

Smoke Affects Tear Protein 
Ischemic, toxic and oxid-ative effects of cigarettes are thought to play an important role in damaging ocular tissue. Changes in tear protein patterns of smokers in comparison to nonsmokers are correlated with an increase in dry-eye-related subjective symptoms in smokers, according to a new German study. 

Research at the Department of Ophthalmology at the University of Mainz analyzed and compared electrophoretic patterns in tears of 29 smokers, 26 severe smokers and 50 nonsmokers. Each patient was asked for subjective symptoms such as burning, itching, and foreign-body sensation. Tear proteins were separated by gel electrophoresis and digital image analysis was performed. 

Tear protein patterns in smokers (p<0.05) and severe smokers (p<0.05) were different from those of nonsmokers. There were significantly more protein peaks in the severe smokers group (p<0.005) than in nonsmokers. 

Nerve Bundles Slow to Recover After LASIK 
Certain nerve fiber bundles in the corneal flap decrease by 90 percent immediately after LASIK. During the first year postop, some bundles gradually return, although by one year their number remains less than half of the preop level. 

PA O.D.s Acquire Steroids and Glaucoma 
In early December, Pennsylvania Gov. Mark Schweiker made that state the 49th to allow optometrists to use topical steroids adn the 46th to permit O.D.s to treat glaucoma.
The Pennsylvania House and Senate had both unanimously passed the legislation in November.
"This law is written to allow patients in Pennsylvania to receive comprehensive eye care including glaucoma treatment from their optometrist. With this bill, Pennsylvania optometrists now have the authority to use most available topical and oral medications in the treatment of ocular disease," says optometrist Melvin Lily, Pennsylvania Optometric Association director of state and national affairs.
Keystone State optometrists will be required to complete 18-hours of continuing education in glaucoma (and hold a therapeutic license) before treating glaucoma. 

Researchers from the Mayo Clinic, Rochester, Minn., performed sequential, quantitative measurements of nerves viewed by confocal microscopy in vivo of 17 eyes of 11 patients who had undergone LASIK to correct myopia from -2.0 D to  -11.0 D. Eyes were treated with an excimer laser with a planned 180-µm flap. Central corneas were scanned throughout their full thicknesses by confocal microscopy before and at one week and one, three, six and 12 months after LASIK. Their findings appear in the December 2002 Investigative Ophthalmology and Visual Science. 

The number of nerve fiber bundles was determined in the subbasal region, the full-thickness stroma, the stromal flap (layer between the most anterior keratocyte and the flap interface), and the stromal bed (layer between the flap interface and the endothelium). 

In the subbasal region, the number of nerve fiber bundles decreased by more than 90 percent one week after LASIK and was significantly lower at all times after surgery than it was before surgery (p< 0.001). It increased six and 12 months after LASIK, but remained less than half of the preoperative value. In the stromal flap, the number of nerves at all times after surgery was also significantly less than before surgery (p< 0.001) and did not increase significantly by one year. In the stromal bed, there were no significant differences among any of the nerve measurements before and after LASIK (p= 0.24). 

Beta Blockers Risk Respiratory Obstruction 
Topical beta blockers are known to exacerbate bronchospasm in asthma and chronic obstructive pulmonary disease. A study in London reported in December 2002's British Medical Journal examined whether topical blockers are associated with excess respiratory disease in elderly patients not considered to be at excess risk. 

The researchers identified patients with no previous diagnosis of airways obstruction. They defined exposed patients as patients who had used ophthalmic topical beta blockers for the first time in the period 1993-7. Unexposed patients were randomly selected (loosely matched by age and sex to exposed patients). 

They defined patients who had excess respiratory disease in two ways. Definition A patients were those who in the 12 months after treatment with topical beta blockers were given for the first time a drug used for the treatment of reversible airways obstruction (2 agonists, inhaled corticosteroids, theophyllines, and inhaled anticholinergics). Definition B patients combined definition A patients with patients who in the 12 months after treatment with topical beta blockers were diagnosed with asthma or chronic obstructive pulmonary disease. 

Exposed patients (n=2645) were slightly older than unexposed patients (n=9094) (68.6 vs. 67.5 years). Exposed patients were less likely than unexposed patients to smoke and to use systemic beta blockers and were slightly more likely to visit their general practitioner (median six vs. five visits). In definition A patients the researchers found an adjusted hazard ratio at 12 months after treatment with topical beta blockers of 2.29 (95 percent confidence interval 1.71 to 3.07). 

Of the 3358 patients (including patients with previous airways obstruction) begun on a topical beta blocker during the study period, 148 (4.4 percent) had used drugs for airways obstruction within the previous year. Airways obstruction had been identified as an active problem (definition B) within the previous year in 316 subjects (9.4 percent). 

"Ophthalmologists, general practitioners, physicians and pharmacists need to be aware of the possibility of iatrogenic airways obstruction in patients taking topical beta blockers for glaucoma," the authors conclude. "When eyesight cannot be threatened within their expected lifetime, many frail elderly patients may be better off left untreated than risk airways obstruction."  REVIEW