Ask Yourself These Questions....

Optometric Co-Management Centers started in the early 1980s under the corporate flag Omni Eye Services.  CEC is one of the original 'Omni Centers.'  The business plan was optometric control of an eye clinic that would provide medical and surgical services but never compete with the services provided by the referring optometrists.  No favoritism, no re-directing patients, support for the optometric community in education and advocacy at the State House.  The next time you make a referral, ask yourself:  What is the history of the practice I am supporting with this referral?

In the last 27 years, optometric referral has built CEC into the largest cataract practice in the Metro D.C. area.  John Baldinger's surgical expertise is recognized inside and outside the optometric community and is provided here in Fairfax at one of the region's top ambulatory surgical centers.  We also provide medical and surgical retina services with Dr. Randy Wong.  Cosmetic and functional oculoplastic services are provided by Dr. Soheila Rostami.  Dr. Mattern and I provide glaucoma and other consultative services, as needed.  The goal in this model is to provide integrated, top quality service that actively SUPPORTS  the referring optometrist at each personal contact in our office. We have never provided any primary care services nor will we ever provide such services in the future.   The next time you are ready to make a referral, ask yourself,  Is this the best and most convenient source of care for my patient and is the value of my role supported by the staff and doctors at this practice?

The two eye professions have very different models for the provision of eye care in the future.  Ophthalmology sees a top-down model owned by M.D.s with employed optometrists, glasses and contacts provided in-house.  (AAO now has an ophthalmic P.A. program so those pesky, independently licensed O.D.s can also be dispensed with!)  Optometry's vision is to expand the primary care roll to ultimately provide any and all services, medical and surgical, for which we as optometrists are trained.  (Ophthalmologists will provide advanced surgical care in keeping with their years of training and developed surgical skills.)

Finally, ask yourself, "What future am I supporting with the referral to this practice?"  Does this practice have an optical dispensary??  Visit the web-sites of practices you to refer to.  Cold call practices to see if the doctor you are referring to provides the same services that you provide (routine eye exams, contact lens fitting, optical dispensing)  You can learn a lot about what a practice is projecting to the general public from these sources.  Please remember, at CEC we are dedicated to putting you first, providing great outcomes and we have the track record to prove it.

James E. Powers O.D.

CEC Performing IStent Surgery

Dr Baldinger has been performing the IStent minimally invasive glaucoma surgery at the time of cataract removal and IOL placement and has been very happy with the results.  The stent placement takes about 5 minutes and is performed at the completion of the cataract procedure.  The procedure is covered by most insurance companies including Medicare and can ONLY be done in combination with cataract removal and IOL placement

In June of 2012, the iStent (Glaukos Corporation) received FDA approval for the management of mild to moderate glaucoma at the time of cataract surgery.  The iStent is the smallest medical device ever made (1.0mm X 0.3mm) The device is placed through the cataract incision under gonioscopic observation directly into schlemms canal and avoids the trauma and postoperative issues of conventional surgical filtering procedures (hypotony, endophthalmitis, pain). The intraocular pressure (IOP) lowering from the iStent is not as great as conventional filtering procedures, however multiple shunts may be able to be placed to affect the final IOP lowering (current investigations)

Ike Ahmed, MD, an ophthalmologist in Canada coined the term Microinvasive Glaucoma Surgery (MIGS) several years ago.  The procedures that are described by this term are those which have an ab interno approach, cause minimal tissue trauma (unlike conventional surgical trabeculectomy ), have modest IOP lowering capability, rapid postoperative recovery, and excellent safety and low complication profiles when compared to traditional filtering surgery.

John C Baldinger MD

           Treating Diabetic Macular Edema

Treatment for diabetic macular edema has never been better!  We now have various ways to reverse vision loss from this common complication of diabetic retinopathy.  When I started as a retinal specialist in 1993, treatment for diabetic macular edema was limited to laser treatment.  Either "focal" treatment to leaky microaneurysms or "grid" treatment was acceptable. Not every patient with clinically significant macular edema (CSME) was a candidate for laser treatment. For instance, those patients with microaneurysms located in the central macula could not be treated. But that's all we had.  Even so, results were often disappointing

Anti-VEGF for Diabetic Macular Edema

You know that anti-VEGF injections (Macugen, Lucentis, Avastin, Eylea) have revolutionized the way wet ARMD can be treated, and these same intravitreal injections are now integral to the treatment of DME as well. In many cases where laser may not work or has not worked, anti-VEGF may be used to improve the macular edema and, usually, improve vision.  In certain cases, anti-VEGF may be the first choice of treatment

Intra-ocular Steroids 

 Intraocular steroids have long been known to improve diabetic macular edema. In the 1990's, intravitreal injections of Kenalog emerged as an alternative to laser. Kenalog had two issues to overcome; 1) increase in intraocular pressure was common and, 2) intraocular injections were not commonplace in the 1990s.

Sustained Release Steroids

Ozurdex, a sustained release intraocular steroid (dexamethasone), is now FDA approved for the treatment of diabetic macular edema.  It is delivered as an injection just as anti-VEGF agents are delivered. The implant will release steroid for about 4 months and then the vehicle will absorb. The results have been outstanding as often both the macular edema and vision improves. 

Advantages to patient treatment include; 1)  Fewer office visits  2) No need for repeated anti-VEGF treatments  3) Ozurdex may work where previous treatments have failed 4) The polymer (transport device) is bioabsorbable.

Iluvien, a similar product, has also been FDA approved for DME.  This product differs in that;1) The active drug is fluocinolone  2)The drug may last 3 years  3) Transport device does NOT absorb  4) IOP may be a concern as with all steroids

What Does This Mean??

Having treatment options allows us to treat a larger variety of patients. Laser treatment is no longer the gold standard.  "Standard of Care" now includes intravitreal injections of anti-VEGF, steroids and sustained released steroids. Treatments are also more successful. Previously, the goal of laser treatment was to prevent further vision loss.  It is usual to now expect the vision to improve. In addition, with the variety of treatment options, it is clear that diabetic macular edema is the result of a complex pathway involving mediators of vascular permeability (VEGF) and inflammation. If you've got questions or comments, please email me or visit my blog 

Randy 

randall.v.wong@gmail.com

www.retinaeyedoctor.com

FDA Ophthalmic Panel Approves Alcon Restor/Toric IOL