Eyeworld

MAY 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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24 EW NEWS & OPINION May 2012 Ethical issues in everyday ophthalmologic practice Surgeons brainstorm ways to talk finances with patients by Jena Passut EyeWorld Staff Writer In this session, doctors brainstormed ideas on how to interact with patients when the patient wants to discuss fees and finances. For a surgeon, talking about John D. Banja, Ph.D., Ethical issues editor D iscussing fees likely isn't top on the list of a sur- geon's favorite part of the workweek. In fact, it may be one of the most awk- ward positions she finds herself in during her career. Now that premium lenses are on the market, more ophthalmologists have delved into the roles of sur- geon and salesperson. Clinicians came together at the 2012 ASCRS Winter Update in Riviera Maya, Mexico, to discuss that quandary during a highly interactive breakfast symposium. The session was one of two titled "Breakfast With the Ethicist." Phaco continued from page 23 stabilize the bag during phaco. The capsule retractors should be left in place during CTR insertion to reduce zonular trauma (Figure 5). The Henderson modified CTR (FCI Ophthalmics, Marshfield Hills, Mass.) has a scalloped contour that facilitates cortical removal following placement. If one area of cortex is difficult to remove because the Henderson CTR impinges on it, the ring can be rotated slightly until one of the gaps overlies the cortex. Capsule retractors In addition to enlarging a small pupil, flexible iris retractors can be used to support the capsular bag in the presence of extremely loose zonules. However, because the hooked ends are very short and flex- ible, iris retractors may tend to slip off of the anterior capsular edge during phaco and will not support the equator of the capsular bag. Richard Mackool, M.D., designed capsular hooks that are elongated enough to support the peripheral capsular fornix and not just the cap- sulorhexis edge. In this way, the re- tractors function as artificial zonules to stabilize the entire bag during phaco and cortical cleanup. Unlike capsular tension rings, capsule re- tractors provide much better support in the anterior-posterior direction and do not trap the cortex (Figure 4). The disposable nylon capsular retractors from MicroSurgical Technology (Redmond, Wash.) are a newer alternative to the Mackool Capsule Support System (Figure 1). Packaged three to a container, the former feature a double-barreled design that creates a loop at the tip, which is less likely to puncture the equatorial capsule. Capsule retractors can be in- serted through limbal stab incisions at any stage including midway through the capsulorhexis step. By anchoring the bag to the eye wall, the additional antero-posterior sup- port and rotational stability facilitate hydrodissection and nuclear rota- tion. The self-retaining capsule re- tractors are also strong enough to center and immobilize a capsular bag that is partially subluxated due to a severe zonular dialysis. Finally, they restrain the peripheral anterior and equatorial capsule from being aspirated and dehisced by the phaco or I/A tip. As a single strategy for severe zonular deficiency, capsule retractors are significantly more effective than capsular tension rings at preventing posterior capsule rupture. Because CTRs can only redistribute instru- ment and mechanical forces to the remaining intact zonules, the greater the zonular defect or deficiency, the less effective a CTR is at stabilizing the bag. However, a CTR can be used in conjunction with capsule retrac- tors, particularly if there is a sizable zonular dialysis. If after first insert- ing retractors the unsupported equa- torial regions of the capsular bag tend to collapse inward toward the phaco tip, a CTR can be inserted to distend the equator of the bag to its proper anatomic configuration. Although the tip of the capsule retractor is dull, it is possible for the hooks to tear the capsulorhexis mar- gin during surgery. There is a ten- dency to over tighten the capsular retractors because the tension is ini- tially adjusted with a soft eye. Insert- ing the phaco tip with irrigation suddenly displaces the nucleus and capsular bag posteriorly, which effec- tively further tightens the retractors (Figure 3). After inserting the phaco tip, it is therefore important to mo- mentarily assess whether the capsule retractors have become so taut that they tent the capsulorhexis edge. If so, they should be loosened slightly so that the capsular rim does not tear during phacoemulsification. This is particularly important if the capsulorhexis diameter is on the small side. Read Part 2 in the June issue of EyeWorld. EW References 1. Chang DF. Strategies for the difficult capsu- lorrhexis. In: Chang DF, ed. Phaco Chop. Chapter 12. Thorofare, NJ: Slack; 2004. 2. Little BC, Smith JH, Packer M. Little capsulorhexis tear-out rescue. J Cataract Refract Surg 2006; 32: 1420-1422. Editors' note: Dr. Chang is clinical professor, University of California, San Francisco, and in private practice, Los Altos, Calif. He has no financial interests related to this article. Contact information Chang: dceye@earthlink.net money with a patient can be quite uncomfortable, especially when a patient asks about a lens that the surgeon wouldn't have implanted in himself. On the other hand, some physi- cians dislike having discussions about money in general. Not only are many not trained to do it, they sometimes may unintentionally give wrong information. Thus, some physicians will steer clear of such conversations, claiming they don't have the information or that they don't want to appear to have a con- flict of interest. Instead, they will lay the options out to patients without recommending one premium lens over the other and not discuss costs; or they'll let patients know that pre- mium lenses cost more but they won't get into details; or they'll in- stead have a "surgical counselor" discuss costs. "Doctors are not trained sales- people and until premium lenses, [they] didn't have to be," said attendee Frank Burns, M.D., Louisville, Ky. "I've found that it's beneficial to have a trained coordi- nator to handle that." Many of the physicians agreed that printed material stating various fees is helpful and almost always necessary. Some said the field and the na- ture of services ophthalmologists can offer is growing such that many patients are not surprised that they have to pay more out-of-pocket ex- penses for premium services, much like they have to pay baggage fees when they fly. However, many pa- tients are naturally upset to learn about hidden fees. Thus, the recom- mendation was to put the informa- tion out there as completely as possible. Canadian surgeons, in fact, are required by law to post their fees in the waiting room so that patients can see them, according to two prac- titioners who attended the breakfast. Most physicians agreed that they would only discuss premium IOL fees with patients, leaving other financial discussions for trained office staffers. One recommendation was that the physician could discuss how ophthalmic fees for cataract surgery have been reduced by payers, and especially Medicare, by nearly 90% over the last two decades. This might trigger a feeling of collegiality with (or sympathy from) patients who believe they are paying too much by way of co-pays or out-of- pocket expenses, as they can recog- nize how physicians themselves have had to bear financial burdens by way of reduced reimbursement rates. R. Doyle Stulting, M.D., Woolfson Eye Institute, Atlanta, said he often tells patients how far reim- bursements have fallen over the years. "If [patients] ask me about service fees, I use that as an opportu- nity to educate them," he said. "I really think they get it." As for counseling patients about paying above and beyond what in-

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