December 2, 2016 Conference

PM session Cataract

Professional Practice Gaps:  Using feedback from NEOS members and discussion by the Program Committee, the evovling perioperative regimen for cataract surgery, the role of new minimally invasive glaucoma procedures, the recent changes in intraoperative technology, and new presbyopia correcting lens implants were identified as professional practice gaps in our membership.

Program Objectives:  The content and format of this educational activity has been specifically designed tofill the identified practice gaps in our membership's current and potential scope of professional activities.  This program seesk to:

1.  educate attendees regarding alternatives to the traditional perioperative drop schedule for routine cataract surgery using fewer postoperative or no postoperative topical medications.
2.  explore the newest multifocal lens implants and strategies to choose the most appropriate lens implant for a particular patient.
3.  review the current intraoperative technology available to reduce cataract surgery complications and provide more predictable postoperative results.
4.  present MIGS procedures tht the cataract surgeon can use to lower intraocular pressur in the patient with cataract and glaucoma.

“Dropless” Cataract Surgery – Should all cataract surgery be done this way?
Lauren J. Shatz

“Dropless” cataract surgery is a technique which eliminates or minimizes the use of topical eye drops in the setting of cataract surgery. The following questions will be explored: 1) Why adopt “Dropless” Cataract Surgery in my practice? 2) Does current evidence support elimination of topical antibiotic prophylaxis in favor of intracameral antibiotics in the setting of cataract surgery? 3) Does current evidence support methods that could replace topical steroid use in the setting of cataract surgery? 4) Does evidence support elimination of routine topical NSAID use in the setting of cataract surgery?

Minimally Invasive Glaucoma Surgery (MIGS): Current and Future Options
Mark A. Latina

Minimally Invasive Glaucoma Surgery (MIGS) are changing our philosophy on our approach to treating glaucoma patients. Historically, glaucoma surgery has been primarily performed by glaucoma specialists and was reserved as a last resort for patients with glaucoma that did not respond to other forms of therapy. The aim of MIGS is to provide a safer, less invasive means of reducing IOP than traditional surgery. MIGS are now becoming a valid alternative to medical treatment for patients with mild to moderate glaucoma. MIGS procedures are becoming part of the treatment armamentarium of all ophthalmologists with many of these procedures being performed in combination with cataract surgery. There are four main approaches of IOP reduction by MIGS. They include: 1) bypassing the trabecular Meshwork resistance, 2) increasing uveoscleral outflow via suprachoroidal pathways, 3) reducing aqueous production from the ciliary body, and 4) creating a subconjunctival drainage pathway. The current status and potential role of the Trabecutome, I-stent, Hydrus, Visco 360, Trab 360, GATT, ECP, Cypass, Zen Implant and InnFocus Microshunt will be discussed.

Incorperating Femtosecond Laser Assisted Cataract Surgery in Your Practice
Kathryn Hatch

Key functions of the femtosecond laser include precise capsulotomy formation, lens fragmentation, arcuate and clear corneal incisions. There is much discussion among cataract surgeons today as to the benefits of femtosecond laser assisted cataract surgery (FLACS) compared to conventional manual cataract surgery (MCS). The goal of this talk will be to review the clinical scenarios where the FSL could have specific advantages and limitations. Femtosecond laser (FSL) capsulotomy formation has been described to be greater than 5x the precision compared to manual capsulorhexis.1 Clinical scenarios where this could be especially relevant include cases of capsular insufficiency such as Marfan’s syndrome, pseudoexfoliation or in eyes undergoing refractive IOL placement, including TORIC and presbyopic IOLs. In these cases, precise centration of the capsulotomy on the “scanned capsule” may allow for reproducible IOL centration with less stress on zonules. Another area where the FSL has particular benefit is in the case of the brunescent dense cataract. These cataracts are fractionated and softened with the FSL resulting in reduction in effective phaco time (EPT).2 In these cases, a more routine-feeling case is achieved in an otherwise challenging cataract surgery. EPT reduction may also be of particular benefit in patients with history of Fuchs endothelial dystrophy where high EPT could lead to an increased likelihood of endothelial decompensation.3 Additionally, precise astigmatism correction can also be achieved with the FSL. Not all types of eyes with cataracts, however, are good candidates for the FSL. These clinical situations will also be reviewed, including corneal opacities, white cataract cases and very small pupils as several examples. Additionally, the role of the FSL in the moderate or low grade, non refractive cataract surgery, which as questionable benefit, will also be discussed.

Nanotechnology Approaches to Ophthalmic Drug Delivery
Peter McDonnell

Topical ophthalmic drug delivery has been the predominant mode of administration for decades, but analysis of patient behavior shows that often the medications are not applied as intended. Alternative approaches to drug delivery, including nanotechnological solutions, offer the appeal of greater predictability, more precise targeting of the drug to the tissues of interest and fewer complications because of the avoidance of toxic preservatives. Among examples discussed is a suture partially composed of antibiotic that can prevent infectious complications in animal models.

Intraoperative Aberrometry
Nicoletta A. Fynn-Thompson

The expectations in visual outcomes following cataract surgery have increased, and so have our options for newer technology to help achieve this. We traditionally use biometric formulas and measurements to guide our IOL power selection to achieve the intended refractive error following cataract surgery. Intraoperative aberrometry technology is a new modality allowing us to obtain aphakic and pseudophakic refractive measurements to determine IOL power selection and placement. The data supporting predictability and effectiveness of using intraoperative aberrometry in cataract surgery cases which are routine, post-refractive surgery, astigmatism correcting, and presbyopia correcting will be reviewed. We shall investigate variables affecting intraoperative aberrometry that occur during cataract surgery and discuss how they affect the accuracy of this new technology.

The Integrated Cataract Surgery Suite
Alan E. Solinsky

The integrated cataract surgery suite is a recent technological advancement in planning and executing more precise cataract surgery. Cataract refractive diagnostics include aberrometry, topography and ocular reference image capturing devices. Ink marking the limbus is far less accurate than utilizing the digital marker to locate iris landmarks and limbal scleral vessels to precisely apply femtosecond laser arcuate incisions. Intra operative microscopic utilization permits manual incisions and capsulotomies to be precisely placed and locates the exact center of the visual axis or the dilated or undilated pupil to centrally place a multifocal lens as well as the exact axis to place a toric lens. Implementation of this advanced technology leads to improved outcomes.

Endophthalmitis: Risk Factors and Progression
Peter McDonnell

Endophthalmitis remains a rare but potentially devastating complication after cataract surgery, intravitreal injection and other ophthalmic procedures. The increasing prevalence of multiple drug-resistant bacteria and the uncertain role of antibiotic prophylaxis (the FDA has not approved antibiotics for this use in ophthalmic surgery) add to uncertainty regarding how best to manage patients in the perioperative period. The experience at the Wilmer Institute with a cost-effective approach to minimizing the risk of endophthalmitis will be reviewed.

Focusing on Yesterday, Today and Tomorrow: Presbyopic IOLs, where are we?
Roberto Pineda II

The first presbyopic IOL was introduced nearly two decades ago (AMO Array 1997). Both mechanical and multifocal IOL strategies have been applied to create an extended range of vision after cataract surgery. Refractive optics have been replaced by diffractive and apodized optics. Alternatively, accommodating IOLs have yielded only adequate results. Currently, a range of diffractive multifocal IOLs are available depending on lifestyle but with compromised visual quality. However, a recently FDA-approved extended depth of focus (EDOV) lens mitigates some side effects at the expense of near vision. Overseas, trifocal IOLs are available including the Zeiss’ AT LISA tri, PhysIOL’s FineVision and Alcon’s Arcysof IQ PanOptix. These IOLs have less intermediate vision dip while maintaining reading vision. Also, these IOLs have less halos/glare and rates of dysphotopsia similar to EDOV IOLs. Additionally, newer accommodative IOLs are coming which change focus by changing lens curvature or through dual optics such as the Power Vision’s in-the-bag FluidVision, NuLens’ sulcus-fixated DynaCurve and Akkolens Lumina. As presbyopic IOL technology progresses, outcomes will improve and side effects will decrease.

a.m. Ethics and Risk Management

Professional Practice Gaps:

Using feedback from NEOS members and discussion by the Program Committee, understanding the repercussions of healthcare reform on ophthalmology was identified as a significant professional practice gap in our membership.

Program ObjectivesThe content and format of this educational activity has been specifically designed to fill the practice gaps in the audience’s current and potential scope of profession activities by:

1.  Increasing attendees’ competence in understanding:
     - the overall state of the healthcare system under national healthcare reform.
     - ophthalmology landscape changes under national healthcare reform.
2.  Improving attendees’ performance in complying with national policy changes and mandates.
3.  Improving attendees’ outcomes in quality reporting and reimbursements.

Patient Safety and Cataract Surgery
Michael G. Morley

Cataract surgery is a safe procedure but serious reportable events (SRE) remain a persistent, low-grade problem troubling to patients, ophthalmologists, and regulators. There is pressure to reduce error rates, in part due to provisions in the Affordable Care Act, which prioritizes Patient Safety as a mechanism for improving quality of care. Wrong IOL is the most common SRE associated with cataract surgery, accounting for about 50% of all errors. The remaining 50% of errors include operating on the wrong patient or side, and performing a wrong procedure. Anesthesia errors, especially wrong side injections are not uncommon. A recent cluster of anesthesia-related globe perforations generated intense public discussion about patient safety during cataract surgery. Ophthalmologists can reduce SRE’s by communicating with their clinical and administrative teams, learning about the causes and sources of error, actively performing time-outs, and understanding that safe care is an indispensable element of quality.

Big Data and Other Uses of the Electronic Health Record
H. Peggy Chang

The Health Information Technology for Economic and Clinical Health (HITECH) Act, signed in 2009, committed federal resources to support the adoption of electronic health records (EHRs). The goal of this program is to leverage information technology to improve individual patient care and public health. For patient care, EHRs assist physicians with improving accessibility of patient records, facilitating communication and information sharing between providers and patients, alerting to critical test results, averting known drug allergies or potentially dangerous drug interactions, recommending up-to-date guidelines in care, and more. By facilitating data exchange and the creation of registries, EHRs will also hopefully transform public health by advancing big data collection for surveillance and research purposes.

Cyber-security and Liability Issues
Bradley Fouraker

Cyber-security entails taking steps to protect against the criminal or unauthorized use of electronic data. In the medical office it means protecting electronic protected health information (ePHI). The Department of Health and Human Services (HHS) has stated: “One of the biggest current threats to health information privacy is the serious compromise of the integrity and availability of data caused by malicious cyber-attacks on electronic health information systems, such as through ransomware. The FBI has reported an increase in ransomware attacks and media have reported a number of ransomware attacks on hospitals.” HIPAA privacy and security regulations make it imperative that ophthalmology practices begin to take steps to prevent, mitigate and recover from cyber-attacks. This includes establishing security practices in your office, including having adequate insurance coverage, and specific steps to take in response when a cyber attack occurs.

IRIS Registry: History, Current Benefits and Future Direction
William Rich III

In 1985 the American Academy of Ophthalmology was one of three specialty societies who developed evidence-based guidelines, also known as the AAO Preferred Practice Patterns. Within ten years it was obvious if we wanted to demonstrate the impact of these guideline on patients outcomes it had to be measured. In 1997 the AAO launched NEON, the National Eye Outcomes Network, the second specialty surgical outcome registry. Unfortunately participation in NEON required practices to laboriously record data on paper that was submitted to the AAO for analysis. It completely disrupted the workflow of both private practices and academic medical centers. Shockingly, no one wanted the data. NEON folded two years later. Jump forward to 2012. With societal demands on the profession to demonstrate quality and outcomes, the expanded use of electronic health records and the emerging technology to extract data from EHRs, the AAO developed a plan to launch a new registry, IRIS, Intelligent Research in Sight. It was launched in April of 2014 with the goal of serving the needs of 2,200 ophthalmologists and includes eight million patients by 2017. Today IRIS has over 14,000 participating members with over thirty million patients and 100 million visits. It is the world’s largest clinical registry. In summary, IRIS is currently improving the quality of ophthalmologists while meeting Federal regulatory demands to avoid penalties and achieve bonuses. It is the major vehicle to inform public policy, evaluate trends in care, measure the prevalence of eye disease and will shortly be a major source of ophthalmic peer reviewed literature and research.

Ethical Issues in the Health Care Reform Environment
Charles M. Zacks

Although the Affordable Care Act of 2010 is a legislative expression of pressure for health care reform that began at least two decades ago, it is now undisputedly the most important catalyst for an era of unprecedented change in domestic health care systems. While basic precepts of medical ethics remain constant, the changing environment in which we practice presents some new challenges as we strive to maintain our standards of ethics and professionalism. Upholding these standards as we adapt to changes in recording and communication of medical information, a new emphasis on cost-driven patient engagement, and perhaps most importantly a reconfiguration of physician incentives (“pay for performance”), with the associated potential for new conflicts of interest will be discussed.

Low Income Patients and ACA Provider Adequacy with PCP and Specialty Care
Benjamin Sommers

This talk will present recent research on the effects of the Affordable Care Act on coverage and access to medical care, including both primary and specialty care, among low-income Americans. The results will include information from several states taking distinctive approaches to the ACA, and will address both Medicaid and private insurance changes.

Patient Satisfaction Made Simple
Jeffrey L. Marx

Patient satisfaction is increasingly becoming an important factor both for loyalty to a practice as well as published metrics that are disseminated to insurance companies, government agencies and the patients themselves. Patient satisfaction has been shown to influence patient loyalty, improved patient compliance and decreased medico-legal risk. However, its role in improving patient outcomes is still under scrutiny. Drivers of "likelihood to recommend practice" have been studied in various clinical departments and include: 1. Wait time 2. Amount of time care provider spent with you 3. Ease of scheduling appointment. We engaged in a study with Press Ganey to review over 100,000 patient satisfaction surveys from practices in the United States. Drivers of patient satisfaction likelihood to recommend practice will be discussed.

Specialty Networks in the ACA Environment
Benjamin Sommers

This talk will present evidence on provider networks in the new health insurance products being sold on the ACA marketplaces; discuss the policy and health implications of so-called "narrow networks"; and address some of the policy options to respond to consumer and physician concerns about such plans.

The Mysteries of Physician Payment Revealed
Cynthia Mattox

The development of Medicare payments for medical procedures is complex and convoluted. This talk will explain the process by which a new procedure code is born and subsequent payment amount is determined. Areas where physicians can influence and advocate for their patients will be discussed.

Impact of MACRA on Ophthalmology
William Rich III

When physicians and health policy mavens are asked to name the Federal legislation with the greatest impact on domestic retinal practice most would suggest the passage Medicare in 1964. Yes, Medicare greatly expanded access to the elderly and the disabled, increased physician revenues, and stimulated investment in new technology. However, it had little disruption on day-to-day practice. In reality the 2015 passage of the Medicare Payment and CHIP Reauthorization Act (MACRA) is far more impactful. The MACRA (aka as the SGR fix bill) Notice of Propose Rule Making published in the Federal Register in April of 2016, if implemented as written, will dramatically change the practice and reimbursement for all US physicians. New MACRA policies include: ? Repeal of the sustainable growth rate (SGR) methodology ? +0.5% updates for 5 years (retinologists will never see a $1!) ? Fundamentally changes the way Medicare determines and updates payments to physicians. MACRS has two major goals. First, the elimination of traditional fee for service with future payments based on the ability of physicians to provide services under risk contracts. The proposed revenue targets or patients from risk contracts (alternative payment models) are 25% in 2019, rising to 75% in 2013. Sheer fantasy. Second, an emphasis on improvements in the “quality of care” by measuring physician performance on quality reporting, use of information technology, clinical practice improvements and cost. MACRA provides two pathways to avoid cuts and achieve bonuses: participation in alternative payment models (APMs) and MIPS (Merit Based Incentive Payment System). The schedule of payment bonuses and penalties is outlined in the legislation. • Adjustment factor plus or minus: – 2019 4% – 2020 5% – 2021 7% – 2022 9% Physicians with less than 100 Medicare patients and $10,000 in charges are excluded. That would cover zero retinal specialists. The APM pathway transfers financial risk from the US Treasury and Medicare Trust fund to physicians by incentivizing the development and physician participation in risk contracts called Alternative Payment Models (APMs). APMs provide a yearly 5% bonus on Medicare payments from 2019 to 2024 that then decreases to 0.75%. However, there are no APMS available for the retinal specialty. For ophthalmologists the MIPS pathway is the only viable option. MIPS is a complex program that measures your performance in following four areas with weights in 2019 based on 2017 performance. -Quality measures 50% in 2019 -Cost (Resource use) 10% in 2019 -Clinical practice improvement 15% -Advancing Care Info.(MU) 25% Weights can change over time. When 75% of eligible professionals achieve MU (meaningful use) the weight could be reduced to 15% to emphasize other categories. Resource use will increase to 30%. The presentation will delineate how ophthalmologists integrated with the AAO IRIS Registry are positioned to navigate and succeed in the incredibly complex changes mandated by MACRA.