The LASIK Blog

Broken Healthcare in America: Problems in the ER

Last week I received a letter from a hospital I am on the staff of.  The letter requested that I fill out a survey aimed to improve "both the quality and the practice environment" of the hospital.  This letter came several weeks after I observed first hand how most hospitals are out of touch with their patients' needs.

Instead of filling out the survey, I sent the following letter to the hospital's Executive Director:

March 22, 2010

                            Re: Recent survey request

Dear Dr xxxxxx:
 
I recently received a letter from you asking me to fill out a survey “aimed to enhance both the quality of care and the practice environment at our hospital.”
 
I am an ophthalmologist on staff at xxxxxxx.  Since the bulk of my practice is office based, and my surgery is done at an ambulatory cataract center, I have very little daily interaction with the hospital, other than my annual week on call for the emergency room.
 
I am therefore writing to give you some insight into xxxxxxx's “lack of quality” as seen through the eyes of a patient’s family member.
 
My father is a 79 year old cardiac patient who called me at 11 PM on Monday, February 22.  He asked me to come pick him up and bring him to the ER, as he had uncontrolled diarrhea and cold sweats.  Although he usually has his medical care at another hospital, I took him immediately to xxxxxx's ER.  It was the closest, and I am on staff.
 
After we checked in and sat in the waiting room for a while, I noticed that there was NO movement of patients, nor any communications explaining any wait.  I asked to speak with a supervisor to see if we could be treated with some courtesy, as I was on the medical staff.  I was told that there was a 7 hour wait to be seen, and assured my father would be seen within the hour.  (The 7 hour wait was never mentioned upon intake.)  This was my last communication with any of the ER staff. After waiting 2 hours, my father and I walked out of the ER!
 
This is not the type of treatment expected from a Health Care System whose motto is:  “A Legacy of Excellence.”  I have never seen such poor patient communication and quality assurance.  If I ran my practice this way, I doubt I would have many patients.  I can only imagine how the family of a non medical staff member is treated. Needless to say, I will not be recommending xxxxxx to any patients, family, or friends.
 
I will not be completing the survey as you requested, and I am enclosing it with this letter.
 
Sincerely,
 
 
Cary M. Silverman, MD
Medical Director
EyeCare 20/20

Now this hospital is a very successful hospital in the affluent suburbs.  One can only imagine how it and hospitals in poorer communities will fare with the upcoming cuts sure to come with the passage of health care reform.  Things will surely be getting worse.  Please leave me a comment to let me know what you think?

Post Menopausal Women Beware: Hormone Replacement + Alcohol = Cataracts!?

Photo courtesy of http://www.theage.com.au/news/technology/quarks-gluons-and-corroborating-emc2/2008/11/21/1226770694126.html

There is an interesting article in this month's Ophthalmology titled Hormone Replacement Therapy in Relation to Risk of Cataract Extraction: A Prospective Study of Women.

This study included 30,861 women aged 49 to 83 years who completed a questionnaire about hormone status, use of hormone replacement therapy (HRT) and lifestyle. Of these, 4,324 women underwent cataract surgery during the 98-month follow-up interval.

Results showed:

• Women who had ever used HRT had a 14% higher risk of cataract than women who had never used therapy.
• Current HRT users had an 18% higher risk of cataract than women who never used HRT.
• In women who consumed alcohol, current HRT users had a 29% higher risk of cataract extraction than those who did not use therapy.
• Current HRT users who consumed more than one alcoholic beverage daily had a 42% higher risk of cataract.

The study concluded that postmenopausal women using HRT for a long period of time may be at an increased risk for cataract extraction, especially those drinking >1 alcoholic drink daily.

It certainly makes sense for women who are or have beenon HRT to limit their alcohol intake if they wish to reduce their risk of cataract development.

Do Bifocals Slow Progression of Myopia in Children?

For years, many optometrists have touted the use of bifocals to slow the progression of myopia in children.  This treatment was generally based on anecdotal reports.  A report in this month's Archives of Ophthalmology appears to confirm the usefulness of this treatment modality. 

In Randomized Trial of Effect of Bifocal and Prismatic Bifocal Spectacles on Myopic Progression, Cheng, et al randomly assigned 135  children (73 girls and 62 boys) with myopia of at least 1.00 diopter to receive single-vision lenses (41), +1.50-diopter executive bifocals (48), or +1.50-diopter executive bifocals with a 3-prism diopter base-in prism in the near segment of each lens (46).  The results showed that myopic progression averaged −1.55 diopter  for children who wore single-vision lenses, −0.96 diopter  for those who wore bifocals, and −0.70 diopter for those who wore prismatic bifocals.The treatment effect of bifocals  and prismatic bifocals  was statistically significant.

The authors concede that the treatment effect of bifocal and prismatic bifocal lenses is still small. "Whether or not the effect tapers off will decide clinical significance," they write. "If the treatment effects continued over time, then the treatment could have a significant role in preventing the development of very high pathologic myopia." They conclude that bifocal lenses can moderately slow myopic progression in children with high rates of progression after 24 months. 

Although there is much more to be studied on this topic, we at EyeCare 20/20 will certainly be revisiting this treatment in children with progressive myopia.

In the Pipeline: Toric ICL Shows Promise

There was an interesting article in last month's Ophthalmology titled:  Toric Implantable Collamer Lens for High Myopic Astigmatic Asian Eyes.  This article evaluated the early results of using the Toric Implantable Collamer Lens (TICL) in the treatment of patients with high myopia and astigmatism.  The results were very encouraging: 

• 70.59% of eyes had uncorrected vision of 20/20 or better
• 68.57% of eyes had better uncorrected vision better than the best corrected vision before the surgery

When a patient presents to my office at this time with high myopia and astigmatism, and they are not a candidate for LASIK, their only option is to have an ICL implanted followed by LASEK to correct their residual astigmatism.  The results of these two procedures is excellent.  The TICL is currently unavailable in the US at this time, but once approved, the entire refractive correction may be addressed with one procedure...  Very exciting!

Surgical Innovations: When the Enemy of Good is Better

This week is the annual  Hawaiian Eye Meeting.  This is an excellent eye meeting held at an awesome location.  According to their web site:

At Hawaiian Eye 2010, you can learn from more than 80 of the ophthalmic community’s foremost experts. Speakers will use their clinical experience and subspecialty expertise to provide you with new information and fresh perspectives on the practices and procedures you use most. You’ll be learning directly from the source – the researchers and specialists revolutionizing today’s ophthalmic techniques to improve patient care.

Although I am not attending this year's meeting, I do receive daily updates through Occular Surgery News. Today I received information concerning a lecture titled: Primary posterior capsulotomy a viable option for multifocal IOLs in hyperopes.  According to the article:

Primary posterior capsulotomy with IOL optic buttonholing is a tricky surgery but can have excellent outcomes when implanting multifocal IOLs in hyperopes, a surgeon said here. "I use primary posterior capsulotomy in hyperopes to avoid secondary cataract and decentration," Michael C. Knorz, MD, said in a presentation at Hawaiian Eye 2010.

This is the perfect of taking a straightforward surgical procedure and making it a very difficult procedure with a much higher complication rate!  The doctor in this article is trying to minimize 2 relatively insignificant complications of refractive cataract surgery:

1. After cataract surgery there is a 20% incidence of getting a clouding of a capsule we leave in the eye.  If this occurs, it is easily treated with a simple laser procedure called a YAG capsulotomy.
2. There is a slight chance of decentration of the refractive IOL.  If it is mild, nothing needs to be done as there is no effect on vision.  If the decentration does effect vision, the implant can be repositioned easily through surgery, or the pupil can be moved with a laser treatment.

So, in trying to minimize these 2 easily treated sequalae, this doctor is advocating a procedure of placing a hole in the capsule at the time of surgery and trapping the implant in the hole.  With this new complications can be expected:

• increased retinal detachment
• increased inflammation of the macula (CME)
• increased vitrectomy (removal of the jelly in the back of the eye)
• dislocation of IOL

As a surgeon, we need to be wary of innovations that purport to improve outcomes.  Many times these solutions have inherent risks which far exceed the risks of those procedures they claim to improve upon!

5 Reasons Not to Get LASIK at a Corporate LASIK Center

Corporate LASIK Centers have long touted themselves as the largest providers of LASIK in the US.  I have previously blogged about why I think it is important have your LASIK at a local LASIK provider that provides diversified eye care services.

Here are my top 5 reasons NOT to go to a corporate LASIK Center:

1. Here today, gone tomorrow.  Corporate LASIK centers are large companies.  They are subject to all the external pressures facing corporate America today.  If our banks and auto industry have difficulty in an economic downturn, imagine the problems corporate LASIK centers face with diminishing consumer spending.  A case in point:  TLC, at one time a darling on Wall Street and one of the largest corporate providers, filed for bankruptcy in December.
2. One trick ponies.  Most corporate LASIK centers specialize in LASIK only.  Many times a different procedure, such as ICL or Refractive Lens Exchange (RLE), may provide a superior outcome.  If the corporate center does not do these procedures, they are not offered.  By going to a diversified eye care practice, the correct procedure is paired with a patient's needs.
3. Revolving doors.  The LASIK surgeon at a corporate center is generally an employee.  The turnover at these centers is very high.  One of the centers in my area is on their third surgeon in 5 years.  I know continuity of care is important for my patients.  I still see LASIK patients that I originally treated in 1996, 14 years ago!
4. Commoditization.  Corporate LASIK centers would like you to believe that LASIK is a commodity.  They would like you to believe that LASIK surgery can be done by anyone, and the most important decision a patient can make is to find the best price.  I beg to differ!  Surgical experience and expertise go a long way in achieving superior outcomes.  I always tell patients to shop results, not price.  It is often difficult for a patient to shop outcomes.  The best way to do so is to do your homework.  Ask around and find that practice that has people raving about how well they see, how easy the procedure was, and how well they are treated every time they are seen.  This is who should be doing your LASIK!
5. Lifetime Guarantee?  A great selling point that corporate centers give is the Lifetime Guarantee.  These Lifetime guarantees come with many strings attached.  The Laser Eye Center of Carolina recently blogged about many of these strings:

• The lifetime guarantee only applies to patients within certain parameters. They typically are not available for farsightedness, or for patients with more significant amounts of nearsightedness or astigmatism. The lifetime guarantee only applies if you get an excellent outcome on your initial LASIK procedure.
  
• The guarantee is void if you need an enhancement or “touch-up” procedure. 
• The guarantee only applies if your vision changes to significantly more nearsightedness (worse than 20/40). What if you drift to 20/30 or become farsighted as you age? Sorry, you’re on your own.The guarantee allows only for additional LASIK procedures. Of course, there is a limit to the number of times a LASIK procedure can be performed and the guarantee does not apply to procedures such as conductive keratoplasty which may be a better option for you as you age. 
• The center determines the advisability of further LASIK. This does not allow for the participation of the patient in the decision making. The “lifetime” referred to may be the lifetime of the center. With the current economic downturn, most LASIK-only centers are operating in the red. One large center in Charlotte, NC recently closed its doors. We have seen several patients who were patients of now defunct laser centers who found that their lifetime guarantees were worthless.
• You may be required to undergo yearly exams at an affiliated doctor’s office. Miss one of these mandated exams and your guarantee becomes void. But what difference does it make how often you go in for an exam or where you go? The truth is, unless you have diabetes, glaucoma or some other eye condition, eye exams every two to three years may be sufficient according to the American Academy of Ophthalmology. Such restrictions are an unnecessary burden and expense making it difficult and in some cases, impossible for a patient to meet their obligation under this arrangement.

My Favorite 10 Blog Posts of 2009

As 2009 winds to its end, it is very common to see lists of the year's best and worst.  From songs to movies, from news makers to sporting events.  Here is my list of the 10 best posts of The LASIK Blog for 2009.

1. LASIK for the Gold's Katherine Reutter Loves Colbert Nation.  Stephan Colbert made the news this year when he decided to sponsor the US Speed Skating team in next year's Olympic Games.  Katherine Reutter, a member of LASIK for the Gold, had a great appearance on the Colbert Show.  She even had her leg signed by Colbert!  LASIK for the Gold is a program that offers free LASIK to our US Olympic athletes.
2. Vision Harvest 2009 Featured on Fox' Good Day New York.  Dr Sapna Parikh, medical corespondant for Fox 5 news did a story featuring EyeCare 20/20's involvement in providing free cataract surgery to those in need.  The result, 20 patients underwent the procedure for free on the day before thanksgiving.  Our hope is to make Vision Harvest an annual event.  I will keep you posted.
3. LASIK the Refs!  is an ongoing segment that features bad calls in sports.  LASIK the Refs offers professional umpire or referee a chance to improve their performance through free LASIK surgery.  So far 2 have taken me up on the offer.
4. Avastin vs Lucentis:  Why our Gov't Will Never Manage Healthcare Efficiently!  My continued lements concerning the costs in treating macular degeneration.
5. The Flomax-Cataract Controversary, Continued.  My effort to change the treatment protocols when Flomax is prescribed.
6. US Healthcare run Amok:  Conjunctivitis treated for a mere $2500!  A story of crazy overspending in healthcare.
7. DIVERSIFICATION:  7 Reasons to Get LASIK at a Full-Service General Ophthalmology Practice.  Important considerations in chosing where to go for your LASIK surgery.
8. Twitter, Blogs, and LASIK.  Social media and how I use it in my ophthalmology practice.
9. ReSTOR +3.0 Now Available!  The second generation IOL that has vastly improved the results for refractive cataract surgery.
10. Free Mini E-Book Download: Today's Facts About LASIK.  Useful resources for those interested in having refractive surgery.

I have enjoyed talking with you all this past year, and hope that you have enjoyed reading this blog.  I look forward to continued blogging in 2010.  If there is anything in health and eye care you would like me to discuss, please leave me a comment.  I will do my best to answer in a timely manner.

Have a Happy New Year!  I will see you all in the next decade!!

No Proof in ABC's GMA Claim to Link Between Nearsightedness and Texting

There was an interesting story this morning on ABC's Good Morning America:  Study Finds More Nearsighted Americans.  This story was based on a recent National Eye Institute Story.  The lead in to this story claimed a link between our kids texting and myopia.

Also called myopia, nearsightedness is a refractive error that produces clear vision for near objects but blurs objects seen in the distance. Nearsightedness is caused by an abnormally steep curvature in the cornea or by an elongated eyeball. As a result, light rays passing through the cornea converge at a point before the retina.

Several interesting points were made in the piece:

• Myopia in the US increased from 25% in the 1970's to 41% today.
• Myopia effects 40 to 50 million Americans.
• Costs of treatment is $2 to $3 billion annually.

The story further went on that there is a genetic predisposition to develop myopia and suggests that close work may be a contributing factor, however, there is no scientific proof if this linkage.  Adding the fact that there are over 110 billion text messages sent annually just clouds the issue.  Many more people eat sushi today than in the 1970's, maybe this is the cause of myopia development?!?

It might simply be that nearsighted patients like to do close tasks more because it is easier for them.  The question becomes:  What comes first the task or the condition?, just like the chicken and the egg story.

In my opinion there is no correlation between myopia development and close work, computer work, or texting.  Further study is certainly warranted to determine environmental causes.  I do agree with the takeaway message:  Regular eye exams are required to maintain eye health!  If there are no problems, get that eye exam every 2 years..

Avastin vs Lucentis: Genentech Co-Pay Card Program Not Nearly Enough!

I received an e-mail this week from Genentech BioOncology, introducing their new Co-Pay Card Program.  Genentech is the maker of the two drugs I have blogged about involved in the current macular degeneration treatment controversy, Lucentis and Acastin.

According to the e-mail:

"We are committed to ensuring that all eligible patients have access to the therapies they need. That is why we created the Genentech BioOncology Co-Pay Card Program, a program that gives eligible patients help with their BioOncology product co-pay."

This program will basically pay the 20% co-pay for those patients that financially qualify.  I think this is wonderful for certain treatment modalities, but not so in the case of Lucentis to treat macular degeneration.  The co-pay would be around $400.  What a nice gesture, what great marketing...  In my opinion, this is a joke.  What Genentech should be doing is seeking approval for the treatment of macular degeneration with Avastin!  Then let the patient handle the $10 co-pay themselves!!  Shame on you Genentech, hiding behind charity where corporate profits are the real issue!

Download Genentech Co-Pay Card Program

Low Fat Diet: See Better and Look Better

Here is another reason to watch the fat intake.  We have known for years that a low fat diet can aid in weight reduction.  A new study reported in this month's Archives of Ophthalmology, Association Between Dietary Fat Intake and Age-Related Macular Degeneration in the Carotenoids in Age-Related Eye Disease Study (CAREDS)An Ancillary Study of the Women's Health Initiative, reports that a diet rich in polyunsaturated fats is associated with a two fold increase in the incidence of macular degeneration.  Those eating a diet rich in monosaturated fats had a lower than average incidence of macular degneration.

The study concluded:

"These results support a growing body of evidence suggesting that diets high in several types of fat may contribute to the risk of intermediate AMD and that diets high in monounsaturated fatty acids may be protective."