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New Lens, Changing Eye, Changing Brain 

The feature story about neuroadaptation and multifocal intraocular lenses (“New Lens, Same Brain,” July/August) was interesting. News in Review in that same issue reported on the difficulty retina surgeons experience when operating through the optics of these lenses. This caused me concern. Retina surgeons are highly skilled observers, typically with healthy eyes and great corrected visual acuity—and they are having trouble! Since retina surgeons are only called upon to view through these lenses intermittently, it will be impossible for them to “neuroadapt” like a pseudophakic patient with a multifocal IOL. As more multifocal lenses are implanted, and patients live longer, there will be an increase in the frequency where this visual confusion will be an obstacle to well-executed retinal surgery (which I’m quite sure is already difficult enough).

Now consider the patients. It is generally contraindicated to implant a multifocal IOL into a patient who has age-related macular degeneration. Consider patients who receive multifocal implants who had macular drusen or normal maculas at the time of their cataract surgery. A subset of those people will develop frank AMD. Assuming these patients had already “neuroadapted” before the onset of AMD, will the multifocal optics induce visual confusion similar to that in patients who receive a multifocal IOL with preexisting AMD?

Now think about the changes of the human brain with time, various dementias, microvascular disorders and stroke. How will these patients cope with their multifocal IOLs? Will the neuroadaptative control of these patients become diminished?

Finally, the feature story states that some surgeons are finding that some patients do not adapt, necessitating IOL exchange. I suspect this surgery is not provided for free by the surgeon, the operating facility or the anesthesia provider. When CMS approved these special IOLs for billing outside of the system, I doubt they contemplated the costs of returning to the operating room. Since there is a fixed pool of CMS funds, these returns to the operating room effectively contribute to reductions of reimbursement for other services provided by CMS.

Michael S. Korenfeld, MD
St. Louis

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Keeping the Lights On 

Thanks so much for the kind words in September’s Opinion (“Our Dream Team: How Do They Keep the Lights On?”). As a solo comprehensive ophthalmologist, I am very aware of paying the bills and keeping the lights on.

As a member of the AMA’s Relative Value Update Committee (RUC), I appreciate having the RUC’s work highlighted, since so many physicians, including our ophthalmology colleagues, don’t know about it or how the process works. Without getting too technical, you emphasized the essence of the process—data. You also put in a plug for filling out surveys when we ask our members to step up.

What may not be as widely known is the cooperation among the specialties and subspecialties, including optometry and the American Society of Cataract and Refractive Surgery. Even though each has its own agenda, we are able to come together and present a united front at the RUC. They also can take some credit as being part of our “dream team.” We value their input and their ability to stimulate their members to also fill out the surveys so that we can get accurate data. 

Credit should also go to the members of the Academy’s Health Policy Committee. They are a rather diverse group from around the country and from all subspecialties. Their advice and consensus keep our team on track and focused on the appropriate health policy goals for all of ophthalmology. As industry and new technology bombards ophthalmology at an increasing rate, our committee must evaluate each new device and procedure using objective data to ensure that our patients receive access to these technologies when appropriate and that our members receive fair reimbursement.

Gregory P. Kwasny, MD
Chairman of the Academy’s
Health Policy Committee
and a RUC Member
Milwaukee


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