10 minute read
JCRS highlights
THOMAS KOHNEN European Editor of JCRS
VOL: 46 ISSUE: 5 MONTH: MAY 2020
TRIFOCAL COMPARISON Trifocal intraocular lenses (IOLs) are now being implanted in cataract patients as well as those with presbyopia. A new randomised, prospective study compared two diffractive trifocal toric IOLS. Sixty patients were randomised to receive bilateral implantation of either the FineVision Pod FT toric IOL (PhysIOL) or the AcrySof IQ PanOptix toric IOL (Alcon). At three months the study found no significant differences in uncorrected and corrected distance and near visual outcomes between the groups. Contrast sensitivity, quality of vision scores and the level of spectacle independence were similar in both groups. Levels of IOL axis misalignment and magnitude of error of astigmatic correction were also similar. The incidence of photic phenomena was low for both lens types. The study did find significantly better values of uncorrected intermediate visual acuity and distance corrected intermediate visual acuity in favour of the PanoOptix lens. FJ Ribeiro et al., “Comparison of visual and refractive outcomes of 2 trifocal intraocular lenses”, 46(5):694-699.
ANGLE KAPPA AND TRIFOCAL IOLS
Does a large angle κ contribute to decentration and poor outcomes in multifocal IOL patients? Researchers evaluated 63 eyes of 63 patients that had bilateral implantation of a diffractive trifocal IOL (POD F, PhysIOL). Pupil offset was used to estimate of angle κ using the Pentacam (Oculus) preoperatively and at three months postoperatively. There was a significant decrease in pupil offset values postoperatively. The study showed no statistically significant difference in any of the refractive and visual acuity outcomes between eyes with small pupil offsets and eyes with large pupil offsets. All but one IOL were perfectly centred. The majority of patients (14 of 16) complaining of significant halos had eyes with small pupil offsets. The researchers hypothesise that the tolerance to larger pupil offset might be due to the IOL optical design, with the first diffractive ring being larger than other commonly used multifocal IOLs. N Garzón et al., “Influence of angle κ on visual and refractive outcomes after implantation of a diffractive trifocal intraocular lens”, 46(5):721-727.
COLLAMER LENS SIZING WITH SS OCT Anterior segment swept-source optical coherence tomography appears to provide reliable sizing information for patients being considered for collamer lens implantation. Investigators obtained preoperative OCT scans for 81 eyes of 41 patients and used NK-formula version 2 (NK-formula V2) data to calculate lens size. Three-month follow-up results indicated that optimisation approach has an ‘excellent ability’ to select an appropriate ICL to be implanted regardless of the value of other ocular parameters and age, other than anterior chamber width. A majority, 91.2%, achieved a moderate degree of vaulting. T Nakamura et al., “Optimization of implantable collamer lens sizing based on swept-source anterior segment optical coherence tomography”, 46(5):742-748.
High-volume surgery, FE WER COMPLICATIONS
Swedish study finds lower complication rates may be due to lower case mix. Howard Larkin reports
Lower capsule complication doing a lot of complicated cases.” rates often seen among Similarly, the study found that case mix risk the high-volume cataract scores declined slightly from 2007 through surgeons, as well as for most 2016. This suggests that improving case surgeons in recent years, may mix may also be a factor in improvements be due to more favourable case mixes, in capsule complication rates seen over the according to a Swedish National Cataract period, Dr Zetterberg added. Register study.
Speaking at the 37th Congress of the DEVELOPING A RISK SCORE ESCRS in Paris, Madeleine Zetterberg MD, PhD, reviewed a study based on data from more than 118,000 cataract surgeries performed in Sweden from 2007 through 2016. It found that surgeons doing fewer than 1,000 procedures annually had higher mean posterior capsule rupture rates than those doing 1,000 or more – 2.15% for those doing 10 to 99 cases, 1.32% for 100 to 499 cases and 0.59% for 500 to 999 cases, compared with 0.48 and 0.47% for 1,000 to 1,499 and 1,500+ cases respectively. However, the study also found that high-volume surgeons had significantly lower mean case mix risk scores – 1.34 for those doing 10 to 99 cases, 1.49 for 100 to 499 cases, and 1.28 for 500 to 999 cases, compared with 1.15 and 1.14 for 1,000 to 1,499 and 1,500+ cases respectively. High-volume cataract surgeons have a slightly lower case mix, which may explain their lower rate of capsule complications, said Professor Zetterberg, of the University of Gothenburg, and Sahlgrenska University Hospital, Mölndal, Sweden. “The difference was not all that great, though. The high-volume surgeons are still To perform the analysis, Professor Zetterberg and colleagues first developed a risk score for assessing case mix difficulty. Logistic regression analysis of data on a range of demographic, clinical and operative difficulty parameters found several that were significantly linked with increased posterior capsule rupture. These were preoperative best correct visual acuity of less than 0.1, or 20/200; pseudoexfoliations; sightthreatening ocular comorbidity; use of trypan blue, which is a marker for dense cataracts; mechanical pupil dilation, which is a marker for small pupils; and iris hooks at the rhexis margin, which represent zonular dehiscence. “These were all very highly associated with increased capsule complications,” Dr Zetterberg noted. A composite risk score was created based on these parameters by multiplying out the odds ratio for each parameter. A score was assigned for each cataract case. Individual risk scores were averaged for each surgeon and for each volume group. For surgeons with 100-499 cases, per surgeon mean risk scores ranged from 1.01 to 5.19, with individual risk scores for patients in this group ranging from Madeleine Zetterberg MD, PhD
The difference was not all that great, though. The high-volume surgeons are still doing a lot of complicated cases Madeleine Zetterberg MD, PhD
1.00 to 62.90. For surgeons with 500- 999 cases, per surgeon mean risk scores ranged from 1.00 to 2.02 with individual patient risk scores from 1.00 to 62.90. Surgeons with 1,000 to 1,499 cases saw per surgeon risk scores of 1.01 to 1.27 with individual patient case scores of 1.00 to 46.59. Surgeons operating more than 1,500 cases had per surgeon mean scores of 1.06 to 1.26 with individual patient scores of 1.00 to 46.59.
Among the study’s other findings were that ocular comorbidity increased from about 30% of cases in 2007 to 37% in 2016, while cases with BCVA ≤ 0.1 decreased from 20% of cases to about 10%.
In addition to the case mix and complication correlations, the study found that the proportion of cases performed by surgeons doing 1,000 to 1,499 and 1,500+ cases increased significantly in recent years, to about 21% and 12% of total volume respectively in 2016.
Those doing 500-999 cases increased slightly and accounted for the biggest slice of volume at about 35% in 2016. This mid-volume group edged out in 2014 those doing 100-499 cases, which declined from a 60% market share in 2007 to about 30% in 2016.
Ophthalmology in crisis
Confronting new realities is key to successfully reopening after COVID-19. Howard Larkin reports
In times of great trials, Eric D Donnenfeld MD reflects on the words of Admiral James Stockdale, who spent seven years as the most senior US Naval officer in a North Vietnamese prison camp and received the USA’s Medal of Honor for his leadership.
“You must never confuse faith that you will prevail in the end – which you cannot afford to lose – with the discipline to confront the most brutal facts of your current reality, whatever they might be.”
Such is the essence of leadership required of ophthalmologists returning to practice in the face of COVID-19, said Dr Donnenfeld, of New York University, at the ASCRS Virtual Annual Meeting 2020. “We must care for our patients, we must preserve and improve vision, and we must do no harm.”
That means not only providing technologically advanced eyecare. It also means straightforwardly addressing new realities, such as enhanced infection control, virtual medicine, and financial and management stress, required to provide patients with the safety they expect and deserve.
“Hope is on the way. I look forward to a new dawn in managing ophthalmic care,” said Dr Donnenfeld, who co-chaired two symposia on reopening practices after one-to-three months away due to the COVID-19 pandemic.
LEADERSHIP QUALITIES The job of a practice leader is three-fold, said Bruce Maller, founder and CEO of BSM Consulting, based in Incline Village, Nevada, USA, and specialising in healthcare practice management: protect the integrity of your business; responsibly manage your team to the other side; and stay connected with patients, colleagues and strategic partners. That means ensuring practice finances and business arrangements are preserved as much as possible while doing right by employees and others critical to reopening.
Mr Maller identified several important qualities of a successful leader. Stay calm at all times. Educate yourself on the challenges – and opportunities – you face. Act the part – what you do and say and how you say it affects other people. Be decisive; this is not time for paralysis by analysis. Be selfless; many are leading the way by cutting their own salaries to help employees.
Effective leadership also requires hope to inspire yourself and your team, Mr Maller said. “We got this. I’m confident we as a team can appropriately manage our way.” Be clear and concise in your communication, including business essentials such as how much cash the practice has and how it is being used. And always demonstrate empathy for the trials of others.
MITIGATE FEAR Cultivating courage and confidence among staff and patients is a critical leadership skill for emerging from the current crisis, said psychologist Craig Piso PhD, president of ophthalmology management consultants Piso and Associates, based in Larksville, Pennsylvania, USA. “The linchpin question is will people feel safe enough to re-engage in their previous roles.”
The answer comes in two steps. First, practice leaders must find within themselves the courage and strength to face the deadly virus itself as well as all the physical, financial and psychological challenges that come with it. Second, leaders must provide influential leadership that instils that courage and strength in patients and staff.
“Courage is not the absence of fear, it is taking deliberate, effective action even when
We must care for our patients, we must preserve and improve vision, and we must do no harm Eric D Donnenfeld MD
your knees are shaking,” Dr Piso said. He recommended stoicism as a philosophy and a practice to gain internal courage. It entails shifting focus from external circumstances over which we have no control, to managing internal thoughts, beliefs and expectations.
The resulting internal victories in managing attitudes, emotions and exercising personal will pay off in enhanced tranquillity, fearlessness and freedom in the face of adversity, Dr Piso said. “This will exude a vibe that helps your people.”
Dr Piso also referenced what he called the Stockdale paradox as a touchstone for crisis leadership. Through years of torture “he maintained an unwavering sense that he would prevail in the end, details to follow, not knowing when or what would happen, but believing in the end that victory was his to have”.
For the public victory, shift from “I” to “We,” engage staff in developing a detailed action plan and empower people with information, Dr Piso said. “Inspire loyalty and followership.”
IT TOOK A PANDEMIC TOO… Leadership also means taking the opportunity to re-evaluate professional and personal goals, said John P Berdahl MD, of Sioux Falls, South Dakota, USA. It took a pandemic to bring home first principles.
Just as in the military where officers eat after their troops, “we need to put our team and those that are most vulnerable first”, Dr Berdahl said. He also realised the rules of the game of life and practice are shifting rapidly, requiring constant attention and more-adaptable responses. “The goal is to keep playing and keep playing better.”
On a more personal level, the pandemic has given Dr Berdahl time to build a nonophthalmology dimension to his life. “Life has slowed down enough that we can seek out whatever it is to be a normal family.”
That includes getting a puppy, learning guitar and walking an hour a day with his wife, which has become a powerful grounding force in Dr Berdahl’s life. “Working 20% less for 30% less pay is probably a good trade.”
