Ron Rajecki

home

authors

ron-rajecki-3

"The freedom of completely separating vacuum/aspiration from phaco is kind of a macrocosmic jump in the way we do phaco," said Dr. Whitman, a private practitioner at Key-Whitman Eye Center, Dallas. "It's really a different mindset. You don't know it until you've separated the two that, often, all you really need to remove the lens is vacuum." 

In addition to on-demand independent linear control of aspiration and phaco power, the dual-linear technology includes programmable foot pedal settings that can be customized to the practitioner's preferences, according to Dr. Whitman. 

Dr. Whitman performed standard phaco surgery on 37 eyes in his practice using the same phaco machine. Eighteen eyes were treated with the machine equipped with the dual-linear technology, whereas in 19 eyes the cataract was removed using the single-linear foot pedal.  

Gender mix, mean age, and mean cataract densities (2 on a scale of 1 to 4) were similar in both groups.  

He said he observed that mean phaco power was lower (4.4%) in the dual-linear group than in the single-linear group (6.7%). Mean phaco time was higher in the dual-linear group (16.2 seconds) than in the single-linear group (12.7 seconds). 

The mean effective phaco time (EPT) as a function of time of phaco on was identical in both groups, at 0.92 seconds, he said. 

"Overall, it takes the same amount of ultrasound to emulsify the nucleus with either platform, but with the control of dual-linear phaco, emulsification can take place at lower levels of ultrasound power," Dr. Whitman said. "This minimizes the cornea's and anterior chamber's level of exposure to ultrasound." 

Although mean phaco time was slightly longer using the dual-linear platform, he said he did not notice any difference in case efficiency.  

"Anytime you use a little bit more finesse with a procedure-which the dual linear enables-it also means that the procedure can take a little bit more time," Dr. Whitman said. 

The findings of his study of 37 eyes are similar to the results of a large field observation study of standard and microincision cataract surgery using a wide range of phaco techniques. In this study, the dual-linear group (49 eyes) had lower mean phaco power use of 7.7%, compared with 11.6% for the single-linear group (277 eyes) and a lower mean phaco time (25.6 seconds versus 31.3 seconds). Mean EPT in the dual-linear group was 3.2 seconds versus 4.0 seconds in the single-linear group. 

"The field study had a wider range of cataract densities than our small study and yet still found a lower level of phaco power and shorter EPT using the dual-linear platform," he said. 

According to Dr. Whitman, the dual-linear platform has the potential to increase the speed and efficiency of the phaco procedure, and it possibly may improve its safety as well, by increasing surgeon control of both phaco and vacuum.   

"The nice thing is that it can handle the whole gamut, from a rock-hard cataract to a clear lens extraction," he said. "For a clear lens extraction, you have high vacuum with this machine, and you'll find yourself working with all vacuum and no phaco power at all. And then, being a venturi machine, you have plenty of power when needed to easily break up the hard nuclei. The power is so efficient at the tip [that] you don't need a torsional handpiece. 

"In addition, with this platform I have been able to convert to a 1.8-mm incision, which means shorter healing time and less astigmatism," Dr. Whitman continued. 

He added that he still would like to compare corneal clarity and endothelial cell counts with both the single-linear and dual-linear platforms, and he hopes to conduct such a study within the next year. 

Articles

A dual-linear phacoemulsification platform (available on the Stellaris, Bausch & Lomb) separates phaco and vacuum, allowing cataract surgeons to maximize their control over the cataract removal procedure.

Dual-linear phacoemulsification platform separates phaco, vacuum

-Assessment of disease progression in patients with established or suspected glaucoma is an ongoing, multi-step, and essential process, according to Robert N. Weinreb, MD, speaking here at the 2008 World Ophthalmology Congress. 

Dr. Weinreb pointed out the importance of assessing disease progression not only in cases of established disease, but also in patients in whom glaucoma is suspected. 

Confirmation of loss of visual function also is critical, Dr. Weinreb said. 

"If you have a functional test [result] that changes, it's not sufficient to accept that change without repeating the test to confirm that the visual function test has changed," he said. 

Dr. Weinreb also reminded practitioners to be aware of the potential for variability in structural measurements. 

"It has often been said that visual function testing has a disadvantage because it's subjective, and that structural testing is objective," he said. "One should never forget that structural testing, just like functional testing, has variability." 

Ophthalmologists should determine whether the change being measured is greater or less than the variability of the testing method, Dr. Weinreb advised. 

"Very often, this can be done by comparing change with change over time with a healthy group of individuals," he said. 

Finally, use structural and functional testing together to detect the progression of glaucoma, he said. 

"In the case of healthy eyes, we use structural and functional testing to detect any change that might indicate the presence of glaucoma," Dr. Weinreb said. "The combination of the two is also valuable to monitor progression." 

Textbooks traditionally have characterized glaucoma as both a structural and a functional change that correspond to one other. 

"We know from numerous studies that many of these technologies have results that don't necessarily correspond to each other," Dr. Weinreb said. "For glaucoma diagnosis, corresponding functional and structural loss can sometimes be identified. Glaucoma can also be diagnosed in individuals who have a confirmed change in visual function, even in the absence of detectable structural change." 

Similarly, in patients who have a healthy structural appearance but in whom structural change-from healthy to unhealthy-can be confirmed, the diagnosis of glaucoma can be made even in the absence of a change in visual function or an abnormality in visual function, he said. 

A parallel situation can exist for patients in whom glaucoma already has been diagnosed, Dr. Weinreb said. 

"We don't necessarily need to look for both structural and functional change to be convinced that the patient has progression," he said. "So, in the case of a patient who has existing glaucoma in which we see a change in the visual function, we might say that this patient's disease condition has progressed even though the structure has remained stable. 

"Conversely, if we can confirm a structural change in the optic disc or the retinal nerve fiber layer in a patient who has stable function, we can say, 'This patient has progressive change as well,' " Dr. Weinreb said. 

He added that such structural changes can be confirmed using a hand-held lens, at the slit-lamp, with photographs using scanning laser polarimetry, or through optical coherence tomography. 

As understanding of the multifaceted nature of glaucoma continues to grow, the steps practitioners need to take to monitor progression of the disease evolve. Key steps to take to monitor progression include confirming with repeat testing any visual function loss, remembering that structural measurements have variability, and using structural and functional testing together.

Glaucoma progression: Monitor disease with multi-step process

With patching, for example, parent-kept diaries tend to overestimate the actual patching time.

  According to Dr. Kowal, this phenomenon may explain why PEDIG demonstrates no difference between prescriptions of 2 hours versus 6 hours per day, or of 6 hours versus full-time occlusion when parent self-reporting is used to measure adherence. 

"The first thing to suspect when patching therapy isn't having the desired results is poor compliance," he said. "Don't forget that we are often placed in the situation of prescribing a treatment and waiting to see how effective our treatment instruction is, not how effective the treatment is." 

"Parents don't like parading an obviously defective child," Dr. Kowal said. "They also don't like to inflict discomfort on their children. So it's a tough situation for everyone involved." 

Patient adherence is a must if amblyopia therapy is to be successful, however, he added. 

Dr. Kowal cited one study in which 14 children who received a diagnosis of newly identified amblyopia were measured for adherence with a patch that contained an electronic sensor (occlusion dose monitor).

  The study took place over the course of 1 week, 6 months after the start of occlusion therapy.  

The mean age of the patients was 4 years. Five of the patients had anisometropia, four had strabismus, and five had anisometropia and strabismus. Adherence was measured as the percentage of electronically registered occlusion time compared with the amount of prescribed time.  

Satisfactory acuity increase following 6 months of occlusion therapy was defined as reaching any of the following criteria: acuity increase, expressed as a ratio between acuity of the amblyopic eye and acuity of the good eye, of more than 0.75; acuity of the amblyopic eye exceeding 0.5 as measured on a standard E-chart or Landolt-C chart; or a three-line increase in logMAR acuity.  

In the eight patients in whom acuity increase was deemed satisfactory, the occlusion adherence rate during the study week was 80%. In the six in whom the acuity increase was unsatisfactory, the occlusion adherence rate was 34% (

For ophthalmologists who are assured they are getting adequate patient adherence with their patching regimen but still are not achieving satisfactory results, Dr. Kowal suggested several other treatment options: 

1. What he calls "Type A" parents are going to try to be perfect parents with a perfect adherence score. These parents are the type to say, "We did the patching exactly as you asked, but on Thursday, we only patched for 5 hours, so we made up for it with 7 hours on Friday." 

2. "Type B" parents try to comply with your regimen but are busy and simply forget sometimes. 

"These parents don't want to deal with it," Dr. Kowal said. "These are the types who will say, 'My child hates it,' 'We didn't do it for the past week because the child was sick,' 'We didn't do it because we were on vacation,' or 'We only do it on school days.'"  

In these cases, it may take a little extra effort to achieve adherence, he said.  

"Sometimes we find that the best way to get your therapy to work is to find a way to help the parents maintain enthusiasm for a task that everyone finds difficult," he said. "You have to keep the therapeutic environment alive for them, even if it means your office has to call them daily," Dr. Kowal said. 

"Refractive surgery may work in a significant minority of anisometropic amblyopes," he said. "It's safe in the short term and probably safe in the medium term, but my personal experience with it is zero. And drug therapies, such as L-dopa [Atamet, Laradopa, Sinemet] or citicoline [Cognizin, Kyowa Hakko], are only anecdotally helpful in some cases of resistant amblyopia." 

1. Awan M, Proudlock FA, Gottlob I. The effect and compliance of strabismic amblyopia monitored with the occlusion dose monitor. 

2. Loudon SE, Polling JR, Simonsz HJ. Electronically measured compliance with occlusion therapy for amblyopia is related to visual acuity increase. 

Parents of children with amblyopia may have several reasons (or excuses) for not following a prescribed patching regimen. Ophthalmologists who are following the Pediatric Eye Disease Investigator Group guidelines but are not achieving the desired results, should first examine whether patients are adhering to the prescribed therapy.

When amblyopia treatment fails, adherence is likely an issue

-A three-dimensional (3-D) simultaneous stereoscopic retinal camera that allows stereo images to be taken in one shot, offers an automatic mosaic merge function, and provides a full 45° field angle in two-dimensional (2-D) mode has been introduced by Kowa Optimed Inc. 

According to Kowa, this 3-D retinal camera is both 2-D and 3-D capable and may be used in three modes: 				

The company expects the features of its 3-D retinal camera to appeal to both ophthalmologists and optometrists-and their patients. 

"To achieve a stereo image with other cameras, a doctor or technician has to take two images of the patient's eye," said Ron Kaiser, vice president of sales, Kowa Optimed. "If the images aren't precisely aligned and oriented both horizontally and vertically, they must be adjusted to achieve a correct stereo view. The [camera] is a big time-saver in that regard. By taking one shot instead of two, it's easier for the doctor or technician, and it's also more patient-friendly because they're only being flashed once in each eye instead of twice." 

Kaiser added that eye-care professionals will appreciate the 3-D retinal camera's capability to create mosaics of nine images that can cover up to 120° of a patient's retina. 

"The camera's auto-mosaic function allows the practitioner to merge nine images into one large mosaic or montage with just the click of a button," he said. "This feature has never been available before on a stereo camera, and it's easy to use." 

Kowa expects the camera to be a "must have" for glaucoma specialists, and it is also useful for doctors who treat patients who have age-related macular degeneration and diabetes as well, Kaiser concluded. 

A 3-D simultaneous stereoscopic retinal camera that allows stereo images to be taken in one shot, offers an automatic mosaic merge function, and provides a full 45-degree field angle in two-dimensional mode has been introduced by Kowa Optimed Inc.

Retinal camera produces 3-D stereo images in one shot

'Making phone calls to remind patients about upcoming appointments-and avoid having the risk of "dead zones" in a practice's examination and waiting rooms due to missed or broken appointments-may become a thing of the past. 

) allows eye-care professionals to send customized text and e-mail messages to remind patients of appointments. In turn, the system also allows patients to confirm appointments quickly and easily via an e-mail or text message. 

Patients want to keep their appointments, but it's easy to forget an appointment that was scheduled several days or weeks in advance, said Carey Van Orden, marketing director, Smile Reminder, Lehi, UT. 

In addition to automated appointment reminders and confirmations, the system offers standard and personalized services that allow offices to simplify their daily routine and strengthen physician-patient relationships. These services include last-minute opening notices, birthday messages, e-newsletters, e-surveys, custom promotions, patient recall/re-care, e-newsletters, patient referrals, and even a video testimonial tool. 

The platform helps health-care professionals boost their practices by improving staff efficiency, reactivating lost patients, reducing no shows, increasing loyalty, building brands, filling in cancellations, and generating new business, according to Van Orden. 

The e-mail appointment reminders generated by the system are customized with the practice's look and feel. The e-mail messages also can offer several other options beyond appointment confirmations, including "Add to Calendar," "Map it with Google," "Refer-a-Friend," and "Check My Account," where the patient is linked to a patient portal to pay bills online and check scheduled appointments. 

"[The automated appointment reminder system] provides office staff with extra time to handle more important business by eliminating the time commitment associated with confirming appointments and gives patients easy access to pertinent information without having to ask someone for it," Van Orden said. 

Such positive feedback has been the case at Clear Advantage Vision Correction Center, of Portsmouth, NH. The practice has two optometrists and one ophthalmologist, N. Timothy Peters, MD. LASIK, bladeless LASIK, or PRK is performed on about 1,000 of the 3,000 to 4,000 patients seen each year at the center, according to Holly Venetos, center director. About 90% of patients have given the practice permission to contact them via e-mail. 

"It definitely cuts down on the number of missed appointments, and it cuts down on the time we spend making phone calls," Venetos added. "It also allows us to fill missed appointment space with enough advance notice so that the doctor isn't sitting around. 

"The center director is always looking for us to appeal to the 'X' and 'Y' generations," Dr. Peters said. "[The automated appointment reminder system] seemed like an easy and inexpensive way to keep in touch with our patients. The investment to start up was just a few hundred dollars, and it costs just a couple hundred a month to keep it going. Because it also can do mass e-mails and newsletters, I'm convinced it saves us money in postage and printing alone." 

According to Dr. Peters, people are increasingly turning to technology, and appointment card reminders and phone calls quickly are becoming "old ways" of doing business. It's still important to ask patients for their preferred method of contact, however. 

"A LASIK patient, for example, may be more likely to request text or e-mail messages, while [a] cataract patient still may prefer a phone call," he said. 

Venetos added that the reminder system has helped the practice increase its referral marketing. 

"Most refractive practices-and probably most medical practices, in general-are horrible about asking for referrals. I don't know if we don't know how to or if we're not sure of the most opportune time," she said. "With [the reminder system], there's a 'Refer a Friend' icon on every e-mail it sends out. All patients have to do is click on that icon. Now our satisfied patients can refer their friends and family to us with just the click of a button." 

Making phone calls to remind patients about upcoming appointments may become a thing of the past.

Reminder service brings smiles

-Although heuristic factors will always be a part of the art of ophthalmology, we are now in an era in which payments for medical treatments are going to be increasingly scrutinized for therapeutic effectiveness. Therefore, ophthalmologists may be well-advised to focus on an evidence-based approach to identifying high-risk glaucoma cases. That's the word from Ivan Goldberg, MBBS, FRANZCO, FRACS, clinical associate professor, University of Sydney and head, glaucoma unit, Sydney Eye Hospital, Australia. 

"We must focus on the why, when, what, and how as we try to tailor our treatments to the risk of future disability," Dr. Goldberg said. "We base that on a number of things, such as the stage of the disease when we make our diagnosis and start our treatment, our determination of the risk factors for progression, and an analysis of the patient's overall heath status and life expectancy." 

"As practitioners, we must always be asking ourselves, 'Is there damage, structurally or functionally, that can be demonstrated? Is there new damage that demonstrates progression? Is there a change in the patient's general status?' Those are the changes that affect the risk profile," Dr. Goldberg said. An analysis of these factors, in turn, drives the aggressiveness of therapy. 

In patients with suspected glaucoma, a high prevalence of the following factors represents those at highest risk of conversion to primary open-angle glaucoma (POAG): ocular hypertension, increasing age, gonioscopic evidence of suspected primary angle closure, pigment dispersion syndrome (even with normal IOP), glaucoma-like discs, and family history of glaucoma. 

Conversely, less important factors for the conversion of suspected glaucoma into POAG are steroid use, myopia, peripapillary atrophy, non-insulin-dependent diabetes mellitus, uveitis, and systemic hypertension. 

According to Dr. Goldberg, patients with suspected glaucoma may be considered at moderate risk of conversion to POAG if they have these risk factors: a fellow eye with established glaucomatous optic neuropathy (GON); ocular hypertension with multiple risk factors such as thin central corneal tissue, high IOP, and glaucoma-like discs; gene mutations associated with severe GON; recurrent retinal nerve fiber layer hemorrhages; and pseudoexfoliation syndrome. 

Patients with suspected glaucoma at high risk of conversion, and patients with POAG at moderate 5-year risk of progression, include those who have mild GON with early visual field loss and high IOP, mild-to-moderate GON with a low pre-treatment IOP, and primary angle closure with elevated IOP and peripheral anterior synechiae. Younger patients with these factors are at particular risk of conversion or progression, Dr. Goldberg said. 

Finally, patients with POAG with the highest risk of 5-year progression and visual disability include those who have moderate to advanced GON with visual field loss, along with any of these factors: demonstrated progression over a short period; high IOP; bilateral visual field loss; pigmentary or pseudoexfoliative glaucoma; advanced visual loss or threatened fixation; younger age; secondary glaucoma; and primary angle-closure glaucoma. 

Dr. Goldberg said that although control of IOP is important, IOP should not be the sole focus of assessments and therapies. 

"Measure pressure in terms of corneal parameters such as central corneal thickness, assess cup-to-disc ratios in terms of disc size, look at pressures treated versus pre-treatment, all the while remembering the patient's general status and looking for other things that may be contributing to the risk of progression or conversion, such as variable volatile blood pressure levels and sleep apnea," Dr. Goldberg concluded. 



Dr. Goldberg is a consultant for and receives research support and lecture fees from Alcon Laboratories; is a consultant for and receives lecture fees from Allergan, Inc., and Pfizer; and receives lecture fees from Ellex Medical Lasers.

Although heuristic factors will always be a part of the art of ophthalmomology, we are now in an era in which payments for medical treatments are going to be increasingly scrutinized for therapeutic effectiveness.