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Over the years, cataract extraction and refractive corneal ablation have occupied their own spheres of surgical practice. But recently, converging technologies, shared objectives and a bearish economy have conspired to blur boundaries between these two subspecialties.
Not so long ago, most cataract surgeons and refractive surgeons treated distinct patient populations, used separate ophthalmic techniques and instrumentation, and adhered to different financial and patient-care models. Sure, they mixed it up a bit at national meetings, but their profession, their peers and their patients perceived them—with few exceptions—as very separate entities, orbiting their own worlds.
And then came a big bang, when economics, technology and patient demographics all exploded and recombined these once-distinct subspecialties into a new entity: the refractive cataract practice.
THE ECONOMY. The lingering recession has had a huge impact on physicians whose practice has primarily been performing elective surgical procedures such as LASIK and PRK. “For some doctors, their number of cases dropped by half,” said William B. Trattler, MD, in private practice in Miami.
Kenneth J. Rosenthal, MD, agreed. “LASIK doctors were particularly hard hit when the economy changed. Discretionary income dropped, especially for younger people in their 20s and 30s, who are the primary market for LASIK procedures.” Suddenly refractive surgeons were losing patients in a dramatic fashion. Dr. Rosenthal is in private practice in Great Neck, N.Y., and associate professor of ophthalmology at the University of Utah in Salt Lake City.
TECHNOLOGY. But before the economy began tanking, presbyopia-correcting intraocular lenses had begun to gain steam in the cataract market, with four different types of FDA-approved lenses available in the United States: the ReStor (Alcon), the ReZoom (Abbott Medical Optics), the Tecnis (AMO) and the Crystalens (Bausch + Lomb).
It was not simply the introduction of presbyopia-correcting IOLs that changed the landscape—it was the timing of their introduction. “While younger folks tend to be conservative when discretionary income decreases, older people don’t mind spending money if it is something they want,” explained Dr. Rosenthal.
DEMOGRAPHICS. In addition, these were not just stereotypical “older folks.” They were a new breed who brought the concept of senior citizen to a new level. “It is often said that the baby boomers are the first generation in history to think that death is only an option,” observed Marguerite B. McDonald, MD, in private practice in Long Island, N.Y. “While people who were veterans of World War II felt destined for an increasingly sedentary future of false teeth, wigs and walkers after age 50, this generation expects to stay mentally and physically active into their 90s and perhaps beyond,” Dr. McDonald said. “Boomers will pay a premium to have excellent uncorrected vision; they want to stay free of the unattractive, cumbersome and inconvenient accessory devices we associate with old age, such as canes and bifocals.”
REFOCUS ADAPT COMBINE
The arrival of presbyopia-correcting IOLs is just the beginning of the story. While this technology has marked a new era in cataract surgery, oftentimes a laser touch-up to the cornea is needed to get patients to 20/20. Cataract surgeons have one of two options: they can refer out the patient to a refractive surgery colleague, or they can cross train and learn to do the refractive enhancement themselves.
At the other end of the spectrum are the refractive surgeons whose LASIK patients are aging: their natural crystalline lenses are opacifying, and they are ready for cataract surgery. These patients, members of the first LASIK generation, are fully expecting the same spectacle-free vision they experienced with laser vision correction. These refractive surgeons also find themselves with one of two options: refer these patients to their colleagues with IOL expertise, or obtain the skills necessary to do 21st-century phacoemulsification through clear corneal incisions.
INCORPORATING CATARACT INTO REFRACTIVE
More and more ophthalmologists are choosing to incorporate both refractive and cataract surgery into their practice, a shift that requires learning new skills. Depending on your point of departure, it’s not always a two-way street. “From a practice and marketing perspective, it may be easier to incorporate cataract surgery into a refractive practice than vice versa,” said Dr. McDonald. “Refractive surgeons and their staff are used to asking patients to pay for an elective procedure, and they understand that it takes a lot of chair time to help manage patient expectations. The ‘corporate culture’ is already in place. So it’s a natural for LASIK surgeons and their team members to discuss premium IOL options, as well, and spend the chair time necessary to be sure patients are satisfied with their results.”
Young ophthalmologists can enjoy an early start. Lisa Martén, MD, a refractive surgeon who is incorporating more cataract cases into her practice, exemplifies the next generation of refractive cataract surgeons intent on blending the two subspecialties. Dr. Martén completed a one-year fellowship in refractive surgery recently in Nashville. “During my fellowship, we focused a lot on complex cornea cases, including transplants, and did a lot of refractive surgery,” she said.
Dr. Martén focused so much on refractive surgery that when she decided to purchase her solo practice in 2008, the primary selling point was the fact that the practice had its own laser, allowing her to treat her refractive surgical patients. In the meantime, an increasing number of her refractive surgery patients were also candidates for cataract surgery and expressly interested in presbyopia-correcting IOLs. “So now I find that I am starting to perform more and more cataract surgeries, and educating myself about all of the IOL alternatives,” Dr. Martén said. “It is a new marketing challenge that we are learning more about. Cataract surgery is, after all, a refractive surgery, and we have to inform those patients about IOLs in the same ways we educate our refractive patients about the best laser technology. Education for myself, my staff, and, most important, the patients, helps them make a more informed decision about their vision after cataract extraction.”
She finds that while the challenging parts of LASIK are the pre- and postoperative concerns, the challenging aspect of cataract procedures is the surgery itself. “I think I have a unique experience in that while we are all exposed to cataract surgery as residents, I got to learn a lot more about refractive surgery while doing my fellowship,” she added, “and this background really helps me when determining the optimal surgical procedure for my patients.”
When circumstances force your hand. James R. Kelly, MD, in a private practice with offices in midtown Manhattan and Long Island, N.Y., took a path similar to Dr. Martén’s but almost 10 years earlier. It was the 9/11 attacks that convinced Dr. Kelly to begin incorporating cataract into his dedicated LASIK practice. Indeed, Dr. Kelly came of age professionally during the pioneering years of refractive surgery in the mid-1990s. After completing his residency at the Manhattan Eye, Ear & Throat Hospital, where he performed many cataract surgeries, he was drawn to refractive surgery and took it upon himself to train with pioneering LASIK surgeons, piecing together self-designed mini-fellowships. “In 1998, I started my own practice devoted exclusively to refractive surgery,” Dr. Kelly recalled. “Interestingly, at the time I received a lot of negative criticism from my peers. They could not fathom how I could earn a living just doing refractive surgery.” And, in fact, Dr. Kelly’s practice was slow in taking off. But once the refractive techniques started gaining widespread popularity and demonstrating excellent results, market acceptance grew and his practice expanded rapidly.
The economy, which was already anemic from the dot-com bust, went into a tailspin after 9/11 and Dr. Kelly saw his patient volume drop by as much as 60 percent. “I almost didn’t have a practice, and that is when I started realizing that I needed to diversify my practice and go back into the eye.”
Back-to-basics. Dr. Kelly found himself training alongside colleagues who were expert in cataract surgery. “In truth, it was a bit nerve-wracking,” Dr. Kelly recalled. “I hadn’t done cataract surgery in more than three years. The night before my first cataract procedure, in 2002, I felt like a resident again performing one of my first cases. Of course, it eventually all came together.” From that point, Dr. Kelly started incorporating cataract surgery into his practice. When presbyopia-correcting lenses were introduced a few years later, he felt ahead of the curve. “I was used to marketing elective LASIK procedures, so it was a natural for me and my staff to market premium IOLs to my cataract patients,” Dr. Kelly said. “In fact, this expertise has helped increase my premium IOL practice, and now about one-half of my cataract procedures are done with premium lenses.” In addition, Dr. Kelly said his expertise in refractive surgery puts him at an advantage when helping his patients achieve emmetropic vision. “Unless general ophthalmologists can help their presbyopic patients reach emmetropia with adjunctive laser correction, they will be slower to embrace premium lenses because their patients just won’t be happy.”
BRINGING REFRACTIVE INTO CATARACT
Robin R. Vann, MD, assistant professor of ophthalmology and chief of the comprehensive ophthalmology service at Duke University, is at the opposite end of the spectrum from Drs. Martén and Kelly. He has been at Duke for 11 years and is bringing refractive surgery into his cataract practice.
Like Dr. Martén, Dr. Vann, who currently performs cataract but not refractive surgery, noted that cataract surgery is refractive surgery. “Removing patients’ natural lens gives me an opportunity to change their prescription,” he noted. “It is a very exciting topic for patients who come to me thinking they are getting cataract surgery but did not know I could improve their uncorrected vision—and they don’t have to be nearsighted anymore.”
Earlier in his career, Dr. Vann was exposed to PRK and LASIK. But at the time, in the late 1990s, it did not fit into his comprehensive practice so he did not perform any of the laser refractive procedures. Cataracts kept him busy, and he did not miss the refractive surgery until the advent of presbyopia-correcting lenses. “As careful as I am with the premium lenses, some of my patients need a touch-up, so I send them to a colleague.”
Having one surgeon suits patients. But Dr. Vann’s results call for a very low enhancement rate, and he only sends a patient for LASIK touch-up every three to four months. Referring out even those few patients has posed challenges. “Patients tend to feel skittish having to be treated by a refractive surgeon whom they never met after establishing a relationship with me,” he said. “I am finding that it is much better from a patient satisfaction perspective if I can take care of the entire experience.”
Toward that end, in 2009 Dr. Vann sought LASIK training so he would feel comfortable delivering that procedure himself when necessary. “If a patient ends up a little bit nearsighted after premium IOL implantation, it doesn’t make sense to reopen the wound or put in another lens implant,” Dr. Vann said. “Instead, laser surgery represents a much safer, more precise alternative. By being able to do laser enhancements, I can offer the best option for each patient.”
COMING FULL CIRCLE
Robert D. Beitman, MD, has been in private practice in the Detroit area for more than 25 years. Though trained as a cataract surgeon, Dr. Beitman was a very early adopter of LASIK, the first to perform the procedure in Michigan in 1996 after training with Luis Ruiz in Bogotá, Colombia. He has since performed thousands of corneal correction procedures. “My refractive surgery eclipsed my cataract surgery, which became a sort of side show to the main event—LASIK,” Dr. Beitman said. “But I never lost my skills and continued occasionally to do cataract surgery.”
Economic growth down; patient age up. Two trends prompted his decision to increase the number of cataract surgeries he performs in his practice. First was the recession, which hit the Detroit area very hard; Dr. Beitman saw his LASIK business drop 75 percent in 2008. Second, former patients who had undergone refractive surgery 20 years prior were now ready for cataract surgery. “These patients were highly interested in premium lenses because they were not used to wearing glasses,” Dr. Beitman said. “Since I had been doing cataract surgery for the last 25 years, it was a smooth transition to begin offering premium lenses. And I had the added advantage of doing the laser enhancement procedures in my practice.”
Dr. Beitman observed that general ophthalmologists may have some challenges learning refractive surgery techniques. “Cataract surgery is a technical procedure, whereas refractive surgery is really an art. You can be technically proficient in the science of cataract but not proficient in the art of refractive.”
Dr. Trattler suggested, however, that the acquisition of either one is quite attainable. “Surgeons just need to take the time, go to courses and observe their colleagues in surgery. All it takes is the desire and the willingness to become skilled at a new technology.”
FEMTOSECOND LASER: A PIVOT POINT
According to Dr. Trattler, the next step in the blending of refractive and cataract practices has arrived: the introduction of femtosecond laser cataract surgery. The procedure has proved of great interest at regional and national professional meetings throughout the past few years, and in February 2010, Stephen G. Slade, MD, in private practice in Houston, made history by performing the first series of femtosecond refractive cataract procedures in the United States.
“The femtosecond laser is the ultimate blend of refractive laser and cataract surgery,” said Dr. Trattler. “As we move into 2011, you will see the introduction of the laser femtosecond at a number of sites. It truly represents a new era in refractive cataract surgery.”
Dr. Slade uses the LenSx laser, which received FDA 510(k) clearance to perform lens fragmentation, anterior capsulotomy and corneal incisions. By the end of June, he had already performed more than 100 procedures. “The femtosecond laser has really lived up to my expectations,” Dr. Slade noted. “It has allowed us to cut our phaco times and phaco powers. It is the ideal tool for premium lenses cases.”
Dr. Slade highlighted several advantages to the femtosecond laser, including the ability to make precise, reproducible clear corneal incisions, limbal relaxing incisions to correct astigmatism, a standardized capsulotomy that takes the guesswork out of effective lens position, and lens segmentation and softening that results in material that can be aspirated with a phaco tip, reducing or even eliminating the need to use ultrasound. “For the longest time, refractive and cataract surgery have been strangely separated and that can’t be the case any longer,” he said. “Cataract patients will demand good refractive outcomes. The femtosecond laser is a turning point for the ophthalmic community. It will allow us to standardize the surgical procedure and provide excellent refractive outcomes.”
MEET THE EXPERTS
ROBERT D. BEITMAN, MD In private practice at the Beitman Laser Eye Institute in Detroit. Financial disclosure: None.
JAMES R. KELLY, MD In private practice at the Kelly Laser Center in midtown Manhattan and Long Island, N.Y. Financial disclosure: None.
LISA MARTÉN, MD In private practice at the South Texas Eye Institute in San Antonio. Financial disclosure: None.
MARGUERITE B. MCDONALD, MD In private practice at Ophthalmic Consultants of Long Island, N.Y. Financial disclosure: Allergan, AMO, Bausch + Lomb and Vistakon.
KENNETH J. ROSENTHAL, MD In private practice at Rosenthal Eye Surgery in Great Neck, N.Y., and associate professor of ophthalmology at the University of Utah in Salt Lake City. Financial disclosure: AMO and Bausch + Lomb.
STEPHEN G. SLADE, MD In private practice at Slade & Baker Vision in Houston. Financial disclosure: Alcon, AMO, Bausch + Lomb, LenSx and NuLens.
WILLIAM B. TRATTLER, MD In private practice at the Center for Excellence in Eye Care in Miami. Financial disclosure: Consultant for Alcon, AMO and LensAR.
ROBIN R. VANN, MD Assistant professor of ophthalmology and chief of the comprehensive ophthalmology service at Duke University in Durham, N.C. Financial disclosure: Alcon.