Capital Eye Consultants
 
Capital Eye Consultants   
Summer 2011 Newsletter

Capital Eye Consultants
Greetings!

We hope you find this newsletter interesting and informative of new developments at our center and in the field of eye care

 

Sincerely,

 

Clinical Staff
Capital Eye Consultants
In This Issue
Laser Cataract Surgery
Clinical Challenge
Pterygium Surgery Update
Higher Power Toric IOLS Are Here
Laser Cataract Surgery


If you have been reading the optometry/ophthalmology throw-aways or have attended any national meetings recently, you can't help but hear that femtosecond lasers will be revolutionizing cataract surgery in the near future.  These lasers utilize femtosecond technology similar to the IntraLase (Abbott) which is used for flap generation in LASIK surgery.  The femtosecond laser can make precise incisions, capsulorrhexis, limbal relaxing incisions, and soften hard nuclei.  However, aspiration of the lens material will be needed, so the eye will still need to be entered.  Serious but rare complications will still exist because of the intraocular nature of the surgery. 

 

Presently, there are 4 manufacturers in the laser cataract surgery market, LenSx (Alcon), Lens AR (Winter Park, FL), OptiMedica (Santa Clara, CA) and Technolas Perfect Vision (St. Louis, MO).  Each manufacturer has its own well-known nationally recognized ophthalmologists touting the virtues and benefits of the technology.  Some of the ophthalmic spokespersons have gone so far as to suggest that cataract surgery without such a system would be providing a patient a standard of care that is in fact substandard.  These spokespersons have 'special' arrangements with the manufacturers, unfortunately, and have a financial vested interest to see as many units sold as possible.  Consequently, it is hard to separate fact from fiction.  Head-to-head studies are lacking comparing actual outcomes, comparing phacoemulsification (the present-day gold standard) to the new laser cataract femtosecond platforms.  There is no question that the laser can perform with more accurate precision the maneuvers previously mentioned, however, there is no evidence that better outcomes will follow.  Present-day IOL technology does not require a perfectly circular 5.5mm anterior capsule opening, future IOL technology may very well require and demand that kind of precision.  The present and near future IOL pipeline will not look much different in the next three years or so....beyond that may be a different story.  The other HUGE problem with the technology is the cost.  The units will cost somewhere between $300,000−500,000 and will have a per use 'click fee' between $300−700 per eye.  Throw in $50,000 more per year for a maintenance/repair service contract.  Medicare and other insurance companies will not pay the treating surgeon or facility anything extra for the use of this technology.  Patients who are already paying extra out-of-pocket monies for premium IOLs (astigmatism-correcting and presbyopic-correcting) will be the source for the extra monies to make this technology financially viable.  National data show only 10-20% of patients that are premium IOL candidates elect to proceed with the premium route, with cost being the barrier.  The million dollar question is whether ophthalmologists and surgical facilities can convince enough patients that using femto-laser assisted surgery is worth an extra charge.  Many patients, despite written material and video presentations, already think cataract surgery is performed with a laser, so one has to wonder whether they will accept paying more for what they already think they are getting.  It is our opinion that this technology will provide the necessary means to provide cataract surgery when future generation IOLs require exquisitely accurate and repro-ducible incisions.  Our IOL technology, in other words, is lagging behind the femtosecond laser capability for lens removal.  The advantage of this technology today is it may confer a marketing edge to those that can afford the technology.  It also provides a clear advantage to a poorly skilled or neophyte surgeon who may be competing in a market with more skilled surgeons.

 

John C. Baldinger, M.D. 


Clinical Challenge

 

Every five or ten years, a complex case appears in your examining room and reminds you why 'Dr.' precedes your name on the door.  Recently, I saw such a patient who was being treated with Pred Forte for a red eye.  Interestingly, he had seen both an O.D. and an ophthalmologist for this 'red eye.'  My exam showed angle closure confirmed by gonioscopy, although IOP was only 26 mmHg.  I treated him medically and had John do a PI.  Problem solved, right?  Ten days later, he returned with his eye still red, very painful and intermittently losing vision.  Had his PI failed?  No, the angle was open and chamber deepened. 

 

Back to the differential diagnosis of a red, painful eye, with vision loss...his hyperemia looked very much like venous engorgement and he had edema extending into his lower lid.  My worse-case scenario would be a carotid cavernous sinus fistula.  I decided to get a STAT MRI/MRA.  Unfortunately, the patient was not scanned until 7 p.m. that evening.  He went home after his MRI and awoke around midnight with no vision and a painful eye.  I received a call from him at 1 a.m.  He was concerned and so was I.  He told me that no fistula had been found which was a relief to us both but still, I didn't have an explanation for his symptoms.  What else can cause severe orbital pain with a congested eye?  Orbital pseudotumor was my next choice.  A little late night Internet search gave me further confidence.  I would get the MRI report in the morning and see my patient again.  I asked him to rest sitting upright, as he said that helped restore his vision.

 

The next morning's review of the MRI showed choroidal effusion with retinal and choroidal detachments, lacrimal gland and retrobulbar inflammation.  Dilated exam of the patient revealed the detached retina which was secondary to uveal effusion. When the patient sat upright, the fluid would settle inferiorly and vision returned.  Treatment was oral prednisone and Indocin. The patient's signs and symptoms slowly resolved.

 

Clinical pearls from this case are many.  First, signs and symptoms that aren't consistent should raise caution and concern.  This patient's angle closure was secondary to uveal effusion.  A similar process can occur with the use of Topamax, a drug used to control migraine.  Also, keep an open mind and always listen to your patient.  Continued pain and swelling after the angle is open is not consistent with primary angle closure.  You always need to keep a differential diagnosis in mind. Obtain further testing as needed and finally seek help when all else fails.

 

James E. Powers, O.D. 


Pterygium Surgery Update

 

Medicare now allows pterygium surgery with donor amniograft tissue to be performed in our office procedure room. Performing the procedure in the office simplifies matters as there is no need for pre-operative medical clearance and an EKG that would be required at the Fairfax Surgical Center.  The patient also doesn't need to fast after midnight.  Unfortunately, other insurance companies have not yet adopted this policy.  Hopefully, this will change in the near future.

 

We also perform pterygium surgery on self-pay patients in our procedure room using state-of-the-art adjuncts, mitomycin and Tisseal bio-adhesive tissue glue.  We can offer this procedure at a total cost that is much less than taking the patient to the ambulatory surgery center.

 

Dr. Baldinger is one of the busiest pterygium surgeons in the Northern Virginia area and was the first doctor in the area to use Tisseal glue instead of sutures.  Tisseal allows a faster, more comfortable post-operative healing, compared with sutures. Dr. Baldinger has worked extensively with other eye doctors, including Georgetown University eye residents, teaching his suture-less pterygium technique.  This past winter, he organized a pterygium surgery mission to Nicaragua where he worked closely with local ophthalmologists, teaching them his latest techniques.

 

 

 


The Higher Power Toric IOLS Are Here

 

Higher power toric IOLs manufactured by Alcon Surgical are now available!  These high quality monofocal aspheric IOLs have been available in the T3-T5 variety, able to correct up to 2 diopters of corneal astigmatism at the corneal plane for about 5 years.  The new higher power torics will allow as much as 4.11 diopters of corneal plane treatment.  In conjunction with limbal relaxing incisions (LRI), we may be able to treat up to 5 diopters of astigmatism.  These lenses are used in both cataract and refractive lens exchange patients.  Presbyopic higher power astigmats and higher power hyperopes, with and without cylinder, will get a more stable, higher quality of vision than is possible with LASIK or PRK.  We have had considerable success with these patients.  Feel free to call us with further questions.

 

 

 

 


About Us

Founded in 1986 by doctors of optometry in Northern Virginia, Capital Eye Consultants has provided 25 years of quality and comprehensive consultative/surgical co-management services for the optometrists and their patients in the Northern Virginia area. 

 

Capital Eye Consultants
3025 Hamaker Court
Fairfax, Virginia 22031
(703) 876-9630