American Academy of Ophthalmology Web Site: www.aao.org
News in Review
A Look at Today's Ideas and Trends
ROP Crisis Near, Survey Says
Even though only half of pediatric and retina specialists currently treat retinopathy of prematurity, a fifth of those plan to stop taking these infants as patients, according to a survey commissioned by the Academy.
This impending shrinkage in the numbers of physicians screening or following ROP babies didn’t surprise Academy leaders, who have been warning of a looming crisis. But the survey accomplished its objective of putting some firm numbers onto the problem, said Randy L. Johnston, MD, the Academy’s senior secretary for Advocacy.
“It’s one more piece of ammunition on this [medical liability] issue,” said Dr. Johnston, a vitreoretinal specialist in Cheyenne, Wyo. “I’m not an ROP expert, but it’s clear that those who do treat this disease are going to get more and more overwhelmed.”
Indeed, the potential ROP population in the United States has been increasing. By 2003, 12.3 percent of all births, or 500,000 children, were premature. Multiple births—more than 60 percent of which are premature —rose to 3.3 percent of births in that same period. Yanovitch et al. found an ROP incidence of 4.2 percent in babies who weighed between 1,250 and 1,800 g at birth.1
But the difficulties of running a practice that includes screening or treating these infants are making more and more ophthalmologists reluctant to do so, the responses from 224 pediatric or retina specialists showed.
Half of the doctors who currently don’t handle ROP cases gave up the practice within the last 10 years. The most influential reasons for their decisions were largely legal and economic; for instance, 67 percent cited malpractice issues, such as the high cost of liability insurance, refusal of hospitals to cover it and the fact that parents can sue until the child reaches age 19. Another 37 percent ranked poor reimbursement as extremely or very influential in the decision. The complexity of scheduling care for such children also was rated as an important factor by 50 percent of these physicians.
Among those who expect to join the ranks of nontreaters, there were two top reasons: outside the physician’s areas of interest or expertise (10 percent) and high liability (7 percent). Another 7 percent cited their own lack of specialization and the availability of retina specialists to treat ROP, or said they don’t treat enough ROP to be good at it.
The survey, prepared by consulting firm Bruno and Ridgway, of Lawrenceville, N.J., was done in February by mailing questionnaires to 600 ophthalmologists. They were randomly chosen from the 3,000 pediatric or retina specialists in the Academy. There was a response rate of 37 percent, yielding an error range of ± 5.5 percent at a 90 percent confidence level.
Dr. Johnston said he hopes the survey’s statistics will help the Academy, the AMA and other groups show Congress how the lack of medical malpractice reform threatens the sight of children.
“Unless something dramatically effective comes along in terms of treatment, it’s going to get harder and harder for parents of children with ROP to find ophthalmologists to treat them,” he said. “People are going to have to travel farther.”
Cataract Surgery Riskier for Younger Patients
There’s a new speed bump on the road to widespread early pseudophakia.
The “go slow” signal comes from a long-term, population-wide study in which the rate of rhegmatogenous retinal detachment (RRD) nearly quintupled for patients younger than age 50.1
Independent of axial length, phaco patients under age 50 had a 5.17 percent risk of retinal detachment in the 10 years after surgery, the study concluded. This compared with the overall risk in the study of 1.17 percent.
“In light of this finding, the requirement for cataract surgery in this group should be reassessed,” the authors of the New Zealand study write.
The retrospective study examined the results of 1,793 consecutive phacoemulsification surgeries at a single, regional hospital. The researchers carefully reviewed every cataract surgery by 10 ophthalmologists, and then examined public and private vitreoretinal registries for evidence of any RRDs over the subsequent 10 years (or until the patient died, as 26 percent did).
This comprehensive methodology made it possible for the researchers to rule out complicating factors that limited the statistical reliability of earlier, smaller studies. They also could isolate the effect of age from that of other known risk factors, and could make the statistical adjustments necessary, for instance, when patients died.
The study concluded that:
This new evidence for added risk from early pseudophakia comes at a time when the availability of presbyopic IOLs has led some surgeons to advocate phacoemulsification as a refraction-correcting procedure in younger people for whom LASIK isn’t an option.
But ophthalmologists must go carefully along this new road, according to an editorial Douglas D. Koch, MD, wrote last year.2 New IOL options and the known ocular risks of refractive lens exchange necessitate “a uniquely complex process” of informed consent—one in which this latest study is likely to play a part.
In the ASC
How to Reduce Surgery Cancellation Rates
Ophthalmic surgeons would save money for both themselves and their ambulatory surgery centers if they helped patients remember the rules of surgery, a study at Massachusetts Eye and Ear Infirmary concluded recently.1
The study showed a cancellation rate of just 5 percent for routine cataract surgery, but the procedure is so common that these patients accounted for the great majority of total cancellations at MEEI’s outpatient surgery center (261 out of 379 over a two-year period).
Furthermore, 41 percent of all cancellations within 24 hours of surgery could have been prevented “with proper preoperative counseling and instructions,” they write.
“One of the biggest reasons for canceling surgery at the last minute is that the patient ate,” said Bonnie A. Henderson, MD, director of comprehensive ophthalmology at MEEI and lead author of the study. “We need to remember that many patients are elderly and can be forgetful. We need to develop systems to aid them in remembering important details,” such as staying NPO before surgery.
The study estimated that cancellations cost the MEEI’s outpatient surgery center at least $100,000 a year during the two years they studied. Other findings included:
It might reduce cancellations if doctors’ offices called elderly patients to remind them about appointments, surgery instructions and the need to take cardiovascular medicine on the day of surgery, the researchers say.
Dr. Henderson added that she saw another effective approach while visiting Rotterdam Eye Hospital in the Netherlands. “All preoperative patients must have a friend or family member accompany them to the preoperative appointment,” she said. “This is a great policy because often the doctor will discuss many important issues about risks, benefits, procedures and expectations, as well as scheduling details. If the patient is alone, they may only remember a small portion of the discussion.”
Encouraging a second set of ears at the preoperative visit also would strengthen the informed consent process, reducing misunderstandings and possibly also lawsuits, Dr. Henderson suggested.
Eye on Research
Does Mozart Improve Perimetry Scores?
Does the music of Mozart boost performance on an automated perimetry test? A recent study concluded that hearing 10 minutes of Mozart made 30 normal subjects perform better on an automated perimetry (AP) test than did an equal number of comparable controls (P < 0.05).1
In the current study, researchers in the medical school of Santa Casa of São Paulo, Brazil, suggest that Mozart’s Sonata for Two Pianos in D Major somehow made the subjects’ brains more receptive to test stimuli. (It’s possible that the headphones on which the test subjects listened to music, or the anxiety of 10 minutes in a silent room for the controls, could have affected the results, they add.)
“In order to express a particular combination of properties in the visual field at a specific time point, independent groups of neurons have to be momentarily associated with each other,” they write. “. . . [W]e could assume that listening to the Mozart sonata can either ‘prime’ the pathways responsible for visual images, possibly shape or colour (as in the round white stimulus of AP) or improve attention to some extent.”
Or the whole thing could be a combination of the failure to mask the two groups, and the controls not paying attention during testing, said Steven A. Newman, MD, a neuro-ophthalmologist and clinical professor of ophthalmology at the University of Virginia, Charlottesville.
He noted that informed consent was obtained from all the subjects. “So they knew that the presence of music meant they were the test group, and they probably paid better attention than the others,” Dr. Newman said. “This study may just be another way to find out that someone isn’t paying attention.
“Those of us who have been doing automated perimetry since the beginning know that you have to make really sure the patient is paying attention,” Dr. Newman added.