Julia Talsma

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Dr. Shah, founder and chief executive officer of Amdavad Eye Laser Hospitals, Ahmedabad, India, described his prospective study of 25 pseudophakic eyes with residual astigmatism that ranged from 2 to 4.25 D (mean, 3.4 D) with a goal of steepening only the flat axis of the cornea to correct the problem. All the eyes had undergone cataract surgery at least 1 year before and had to have stable refractions for at least 6 months. The only corneal surgery that patients had before the CK procedure was the cataract incision. 

Treatment of residual astigmatism was conservative to avoid overcorrection, explained Dr. Shah. After the astigmatism was identified in the minus cylinder or flat axis, two treatment spots were applied to the two ends of the flat axis based on corneal topography. The treatment spots were placed at 7 mm from the entrance pupil to establish a nomogram, he said. 

Treatment spots placed at 7 mm from the entrance pupil were chosen based on previous experience with CK, he said. 

"When determining how much treatment to give a patient, one of the guidelines for CK is that the further away from the center of the pupil the treatment is placed, the less the effect of the treatment," Dr. Shah said. "Understandably, the closer toward the center of the pupil that the treatment is placed, the greater the effect." 

He therefore surmised that treating at 8 mm instead of 7 mm from the entrance pupil might result in a less effective treatment and the need for re-treatments. 

"By choosing 7 mm, we can easily titrate our nomogram by changing to either the 6-mm or 8-mm ring from the entrance pupil," he said. 

Of the 25 pseudophakic eyes, six eyes had –4 D of residual astigmatism, four had –3.5 D of astigmatism, another four had –3 D of astigmatism, three had –2.5 or –2 D of astigmatism, and two fell into the –4.25 D range. After treatment with CK, a mean reduction of 1.76 D (range of 1.48 to 2.35 D) was achieved with up to 3 months of follow-up. 

Articles

London-Conductive keratoplasty (CK, Refractec), an effective treatment for the correction of hyperopia or presbyopia, might be a useful procedure for cataract patients with residual astigmatism, according to Tejas D. Shah, MD, who spoke at the XXIV Congress of the European Society of Cataract and Refractive Surgeons.

CK may be useful for pseudophakic astigmatism

-The numbers speak for themselves. Today, there are between 4,500 and 5,000 certified ambulatory surgery centers (ASCs) in the United States-outpacing the number of hospitals offering outpatient surgical procedures. More ASCs are expected to sprout up around the country at a rate of about 8% per year. 

Many specialty physicians have moved from hospital settings to ASCs. In doing so, physicians offer patients high-quality service with the best-trained staff and the best-available equipment. Seventy percent of all cataract surgeries are now performed in ASCs, explained Stephen C. Sheppard, CPA, COE, managing principal, Medical Consulting Group LLC, Springfield, MO, who facilitated a panel discussion on ASC operations during the annual meeting of the American Academy of Ophthalmology. 

Panelists were Ronald D. Blair, a leading consultant on ASCs and president, Surgery Center Services of America, Mesa, AZ, and physicians Robert Cionni, MD, medical director, Cincinnati Eye Institute, Cincinnati; Richard A. Lewis, MD, partner with Gertz, Mocker, Lewis group, Sacramento, CA; and John Michaelos, MD, director of the St. Michaels Eye and Laser Center, Largo, FL. 

If you've been thinking about investing in your own ASC, you can learn from those individuals who already have been through the process, noted Blair, who has been involved in the development of more than 200 eye surgery centers over the past 17 years. 

"Patients expect a high-tech, high-touch approach to the services they get today," said Blair. "They are Internet-savvy and do their research ahead of time. They come to us with expectations we didn't see 5 years ago. As a result, the addition of an ASC to clinical practice creates a unique opportunity for physicians to extend the clinical experience. The ASC is not simply a free-standing entity, but has become an extension of the practice." 

Dr. Michaelos, sole owner of his ASC, has a simple business philosophy: Treat everyone as you would treat your own family. He opened his facility 7 years ago; today, about 1,500 lens and refractive cornea cases are performed per year (a total of 2,500 cases in all). 

He said he believes that patients appreciate how they are treated in a quality facility. "We don't advertise because most of our patients learn about us from word of mouth," Dr. Michaelos said. "The key is quality, having state-of-the-art equipment in place. That's what helps our practice grow." 

Other panelists echoed that sentiment, including Dr. Cionni, who said, "We want to be the highest-quality center in the region. I think we've accomplished that with what we've built." 

At Cincinnati Eye Institute, physicians had been working in a clinic and operating in a four-room ASC. Today, 42 surgeons work in a new facility with six operating rooms and a 100,000-square-foot clinic. Not all the physicians are owners, but they have the option to buy in after several years of service. 

Dr. Lewis, a general partner in his ASC with eight limited partners, emphasized the right combination of equipment and personnel as the components necessary for a successful center. "We opted for purchasing high-end equipment, including the latest microscope for each operating room and the best phacoemulsification machines," Dr. Lewis said. "When you complement that with the right staff, it's a winner." 

The first step in developing an ASC is to evaluate the regulatory environment in the state where you live, noted Sheppard. "Half the states still have certificate of need laws," he said. "Depending on where you are located, that can obviously constrain the process of getting into a surgery center." 

Sheppard advised learning as much as possible about regulations at the local, state, and federal levels, while recognizing that each state is different in terms of interpreting the regulations. 

Las Vegas-The numbers speak for themselves. Today, there are between 4,500 and 5,000 certified ambulatory surgery centers (ASCs) in the United States-outpacing the number of hospitals offering outpatient surgical procedures. More ASCs are expected to sprout up around the country at a rate of about 8% per year.

Is a specialty ASC in your plans?

Dr. Ehrlich and his co-author, Edward E. Manche, MD, both of Stanford University School of Medicine, Stanford, CA, undertook a prospective, non-randomized clinical study to determine the long-term safety and efficacy of radiofrequency energy for the correction of hyperopia between +0.75 and +3.00 D sphere and ≤75 D cylinder in 14 patients (25 eyes). The mean patient age was 55.4 years, Dr. Ehrlich reported. 

		Patients were treated at the peripheral corneal stroma with the NearVision CK probe (Refractec).			

Dr. Ehrlich then presented the long-term results of CK in his cohort of 11 eyes of seven patients who had been followed for an average of 55.3 months (range, 37 to 75 months). Preoperatively, patients had a mean MRSE of +1.47 D and at 24 months follow-up, the mean MRSE was 0.57 D. These results were similar to those published in 2003, Dr. Ehrlich said. 

"As we get close to 60 months (follow-up), there is significant regression toward the preoperative SE refraction," Dr. Ehrlich pointed out. The mean MRSE was +1.23 D at 55.3 months. 

By the last follow-up, UCVA of >20/20 was seen in 27% of the patients, >20/30 UCVA in 64% of patients, and <20/40 UCVA in 36%. One patient developed a cataract, yet no patient experienced >0.75 D of induced cylinder, he said. 

There were some limitations to the study. "Obviously it is a single-surgeon study in a single center with a relatively small number of patients," Dr. Ehrlich pointed out. "We are not evaluating the Light Touch technique, and we have not stratified our results by preoperative central or peripheral corneal thickness, which may influence stability of treatment." 

Although CK for mild to moderate hyperopia seems to be safe and effective initially, its results should be viewed as temporary because of regression toward the preoperative baseline when followed for 5 years, Dr. Ehrlich said. 

Dr. Ehrlich is continuing to gather long-term follow-up data on additional patients. His report was submitted for peer-review publication.

Stanford, CA-Refractive surgeons performing conductive keratoplasty (CK, Refractec) for correction of mild to moderate hyperopia can expect good visual results initially, but they should warn patients that CK effects might not be permanent, explained Jason S. Ehrlich, MD, PhD.

CK effects, results may be temporary

Dr. Kaiser, affiliated with the Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, reported on the subgroup analysis of the first-year results of this phase 3b clinical trial of ranibizumab during the American Academy of Ophthalmology annual meeting here. 

Patients (n = 184) with subfoveal CNV of any lesion composition were assigned randomly to ranibizumab at a dose of either 0.3 or 0.5 mg or sham treatment. They were treated with three monthly injections and then quarterly injections. The primary endpoint occurred at 12 months, he reported. 

"The predominantly classic lesions were relatively well balanced [among the three groups], but there appeared to be more occult with no classic CNV in the rani-bizumab-treated patients compared with the minimally classic in the sham group," Dr. Kaiser said. The mean lesion size was about 4 DA. 

The PIER subgroup analyses showed the anti-VEGF therapy was effective in terms of patient baseline characteristics: age, race, baseline vision, and baseline lesion size. Dr. Kaiser noted that additional PIER subgroup analyses were undertaken to determine whether retinal thickness and fluorescein leakage at specific times during the study had any prognostic significance. 

Optical coherence tomography (OCT) was used to determine foveal retinal thickness at three time points during the study: month 2, 3, and 5. Also, fluorescein angiography was used to indicate leakage at month 3 and 5. 

"We wanted to see if these data could help us in the management of patients with ranibizumab," Dr. Kaiser said. "For these analyses, we pooled the data from 0.3- and 0.5-mg dosages of ranibizumab." 

Las Vegas-Patients with subfoveal cho-roidal neovascularization (CNV) who received monthly injections of ranibizumab (Lucentis, Genentech) for 3 months and quarterly thereafter fared better than those patients receiving sham treatment in the PIER study. Vision in patients receiving the quarterly injections in this trial was not as good as that in patients who received monthly doses of ranibizumab for the duration of the MARINA and ANCHOR studies, however, reported Peter K. Kaiser, MD.

Julia Talsma

Articles

Is a specialty ASC in your plans?

CK effects, results may be temporary

Study: quarterly dosing of ranibizumab may not be as effective as monthly dosing

CK may be useful for pseudophakic astigmatism