PHAKIC FUTURE - LaserMed

14 OPHTHALMOLOGY WORLD REPORT DECEMBER 2007 SUPPLEMENT
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dominant eye at the target refraction, with residual myopia,
and have them wear it for a while. We can always do LASIK
on the eye if we leave residual and they don’t like it, but that
is an extra cost. If I were doing this with a LASIK patient,
I’d be a little more lenient. But with ICL patients I insist
that they first try out the monovision target refraction with a
contact lens.
OPTIMAL PATIENT
World Report What’s your optimal patient for the ICL?
Dr. Chang The studies are now showing that the younger
patients are less likely to develop cataract. The youngest
patient I’ve done was 20, and I’m quite comfortable doing
younger patients. When I first started I focused more on
older patients, the almost 40s. The concern is that in very
young patients the eye is still growing longer, so we want to
see stable refraction for at least one year. If it’s a patient I’ve
been following for some time, I won’t insist on one year.
I’ll accept 6 months. But if it looks like they’ve progressed,
I’ll definitely wait another six months.
LEARNING CURVE
World Report Dr. Vukich, how important is skill to the ICL’s
safety and stable performance?
Dr. Vukich There’s no question that skill plays a role. You
want to practice state-of-the-art ophthalmology, but this really
isn’t just for the extremely gifted and talented surgeon.
Any surgeon who is comfortable in the anterior segment is
absolutely capable of doing a very fine job with this lens.
World Report Dr. Chang, how would you describe the ICL
learning curve?
Dr. Chang I think it’s more of a mental issue than surgical.
We’re all cataract surgeons. We are all used to working in
narrow spaces. But to have that dilated pupil, and the endothelium
right there. I always say it’s like working between the
devil and the deep blue sea. You go one direction and hit the
endothelium; you go the other and you hit the lens. It can be
scary. But having said that, it’s really not that difficult. Once
you get over the mental block, and just get in there and be
careful, it’s really much easier than you’d expect. My average
case now is maybe 7-10 minutes.
BRIDGING CATARACT
& REFRACTIVE
World Report What are the implications of the comparison
studies for our 17,000 readers in China and 10,000 in
India—countries with 1 billion-plus people and huge gaps
between rich and poor?
Dr. Sanders Not everyone can afford an excimer laser. The
cost of the ICL is that the doctor has to learn how to put it
in, but it’s not a volume issue. In the developing world if you
want to buy an ex-cimer laser you have to know you can do
600-800 cases a year to amortize the cost. With the ICL fixed
costs are minimal. Another problem is service. In China or
India if you are away from a big city, getting your laser serviced
may be a problem. The ICL is a lens. You put it in and
you’re done. It’s not capital intensive.
World Report Isn’t this technology putting a much higher
level of refractive accuracy in the hands of cataract surgeons,
enabling them to start acting more like refractive surgeons?
Dr. Vukich That is a global trend. Cataract surgery is refractive
surgery, and it always has been. Our patients not only
want improved vision, they want freedom from glasses as an
expected result of cataract surgery! Given the opportunity to
lose their glasses, people will come to expect that as a result
of cataract surgery. The universal goal will be not just to
remove the cataract but to leave the patient spectacle free.
World Report In China there’s still a cataract/refractive firewall.
Refractive surgeons can do LASIK all day long, but few
do intraocular surgery. How should they view the ICL?
Dr. Chang Refractive surgeons should not completely separate
themselves from cataract surgery. You don’t have to be
a volume cataract surgeon to be an ICL surgeon. If you do
one or two cataracts a week it’s enough, though if you are a
high-volume cataract surgeon, it’s easy. This firewall has to
come down. We now also have multifocal IOLs. People in
the presbyopic age who are myopic will probably do better
with a refractive lens exchange than with LASIK. Nowadays,
I’ve begun moving about 10% of my LASIK patients over to
the lens exchange group. I just did a patient who was -31D
of myopia, functionally blind. I put in a multifocal and the
patient came back 20/25 uncorrected. I’ve moved a lot of my
bioptics patients over to clear lens extraction. This firewall
has to come down because the lines are really blurring between
cataract and refractive.
World Report Dr. Vukich, where do you see the balance?
Dr. Vukich Let’s say, for sake of argument, that the risk is 5%
in someone who is -20D. You can turn that around and say
that 95% of the time you are going to have a patient who is
absolutely thrilled with an excellent quality of vision. One
out of 20 times there is a possibility that they may require a
lens extraction that still will leave them emmetropic; cataract
surgery is well within the skill set of these surgeons who are
capable of using these implants. So rather than do a refractive
lens exchange or clear lens extraction in the first place,
you’ve got a 95% chance of having an out-standing quality
of vision. And if it turns out that there something more than
needs to be done, the solution is readily available and executable
by the same surgeon and it will lead to the patient being
where they wanted to be anyway—with good emmetropic
vision—by doing cataract surgery with an implant. We don’t
want that to be the case in a high percentage of patients, but
the fact is, if it’s a problem that can be readily addressed and
fixed, it’s not as big a problem as if you have corneal instability
or ectasia or intractable night glare or other problems
that you’d get with high myopic LASIK treatment. Yes, it’s a
problem but it’s a problem that can be fixed.
World Report What’s your advice for the refractive surgeon
who doesn’t do much cataract?
Dr. Vukich This is a challenge. Keeping your intraocular skill
set current requires that you work inside of the eye at some
frequency. Anyone who is trained to work inside the eye
can quickly reestablish that comfort level. But if you haven’t
worked inside the eye for several years, having concentrated
primarily on LASIK, it’s going to feel awkward going back
in. Probably the biggest challenge for the LASIK-only surgeon
is that they may not have a readily available intraocular
surgery suite. We do these lenses in the same setting as
cataract surgery—a clean, sterile environment for intraocular
procedures. One of the beauties of the ICL is that if you do
cataract surgery, you already have an operating room ready,
you have a routine where you are in the eye anyway. The ICL
can just flow right in.
POSITIONING IN PRACTICE
World Report Dr. Sanders, what do you see as the practical
implications of these studies?
Dr. Sanders The people who have been doing these studies,
whether it’s Dr. Vukich and Dr. Schallhorn, do
a lot of LASIK. They have no particular reason
to want the ICL to look better, given that their
practice is mostly LASIK, not ICL. We are not
saying that the ICL should replace LASIK. But
we are saying it should be an active consideration
in every patient who falls within the range of its
approval status. Phakic IOLs in general are an
excellent option because you don’t have to worry
about healing as a part of the equation. You can
get more accuracy and more predictability. It’s a
faster procedure. In LASIK, wound healing gets
in the way.
World Report Some US surgeons are saying
you need to cannibalize your LASIK practice to
build your ICL practice. Dr. Chang, are you in
that camp?
Dr. Chang Financially, LASIK is better for
me than ICL. I do ICL as a service. It’s a great
lens and works very well, but if you are talking
about cost-wise, both for the patient and the surgeon, at least
in my practice, LASIK is more cost-effective. Putting cost
aside, with the ICL you don’t have to worry about regression.
The quality of vision is better. If the patient is not concerned
about cost, ICL is the way to go. For India and China the
cost factor will be the major issue. Ironically, as you get out
into the countryside, the need for the ICL is probably greater
because of the issues of glare and halo, but the affordability
becomes a major issue. It definitely makes sense to add ICL
if you have a patient base that can afford it.
World Report Do you market the lens?
Dr. Chang Hong Kong is quite conservative and we are not
allowed to market, but I’ve been using the ICL for about five
years and I’m starting to get good word of mouth business.
This year I expect my ICL volume will have doubled. It’s
a simple fact that more patients have done it and they refer
their friends. It’s definitely a workhorse lens in my practice.
World Report Dr. Vukich, are you in the cannibalization
camp, promoting ICL over LASIK?
Dr. Vukich The right word is not cannibalize, but supplement.
They are synergistic and grow one another, and you develop
a reputation of providing excellent quality of care. Patients
don’t want LASIK and they don’t want an ICL. They want to
see better. Once you change your focus to say, OK, we are going
to provide you with the best quality of vision and here are
the different options and tools we have to achieve that goal,
we are going to customize our selection based on what your
needs are, that really grows the practice. People come to know
that you are not just a LASIK surgeon. In fact, my LASIK
practice has grown as we have continued to offer the ICL.