JUL 2013

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

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16 EW NEWS & OPINION July 2013 Insights Dissonance in a femtosecond by J.C. Noreika, MD, MBA J.C. Noreika, MD, MBA T he term "cognitive dissonance" was coined by social psychologist Leon Festinger in 1956. The concept is as old as mankind. Consistency in thought, i.e., consonance, is necessary to maintain a psychological equilibrium. Inconsistencies cause dissonance. I found myself cognitively dissonant at this year's ASCRS•ASOA Symposium & Congress in San Francisco. The reason? The dialectic enveloping femtosecond laser cataract extraction. Successful new technology promises speed, safety, economy, and ease of use. In one scientific paper session, the moderator stated the femtosecond laser had moved quickly beyond "proof of concept." This is important if intraocular surgery wasn't the subject and money didn't matter. But, since I am more likely to need a femtosecond cataract extraction than to perform one, I remain blissfully immune to the pressures of its adoption. This laser fashions precise incisions, near-perfect corneal flaps, exquisitely engineered capsulorhexes (if it weren't for those pesky tags and tears), and preps the nucleus for more rapid emulsification reducing ultrasonic energy. Internationally, eye surgeons seem eager to remove cataracts using only irrigation and aspiration after pretreatment with the laser. Parlaying decreased phaco time against greater fluidic volume, data suggests that corneal endothelial cells may be preserved, postoperative inflammation decreased, and posterior capsular opacification reduced. Surgeons can manage some high-risk eyes more safely. Surgical liabilities? There is a significant learning curve, complications occur, refractive surprises and astigmatic errors happen, small pupils are challenging, dysphotopsia remains problematic, applanation lends anxiety to patient and surgeon, and a second procedural step extends the surgical time. Informing the audience of his paper's methodology, a presenter showed that a cohort of patients had an average surgery time of ninety-plus minutes while a second cohort's was longer because transportation to a different facility was necessitated. Eye surgeons will resolve these growing pains through discoveries such as gentler applanating technique and more efficient intersurgical process. The ASCRS Lecture on Science and Medicine featured Jerome Groopman, MD, and Pamela Hartzband, MD. They discussed topics culled from their book Your Medical Mind: How to Decide What's Right for You. They intimated that advertisements about drugs, diets, and treatments often contain doublespeak purporting to provide information while promoting an unfalsifiable message. For example, a television commercial reports that a specific statin medication reduces the risk of heart disease by 30%. However, after considering the patient's overall risk of heart disease due to age, weight, genetics, and medical history, the true hazard of a cardiac event may be only 2% over the next five years. The statin drug mitigates the likelihood from 2% to 1.4%. Statisticians may deem that significant; patients incurring the drug's expense and potential side effects may not. Dissonance? Insurers are not going to pay additional dollars for femtosecond lasers. Patients, many on fixed incomes, must ante up scarce out-of-pocket dollars for imaging or limbal relaxing incisions, which may provide outcomes that may not be functionally superior to manual surgery. Former CMS administrator and Brookings Institution doyen Mark McClellan, MD, followed the dialogue of Drs. Groopman and Hartzband. He stated that the demise of fee-for-service medicine is inevitable, that accountable care organizations are expanding more rapidly than Starbucks, and bundled payments for clinical "episodes" are coming to a surgery center near you. Then came the bad news: Reim- To achieve the best result and fastest visual recovery, surgeons should minimize surgical manipulation of the flap or insertion into the pocket interface to a maximum of two times in order to minimize postoperative edema. Postoperatively, antibiotics, steroids, and aggressive dry eye therapy should be used to help modulate the healing response. It is also important to remember that all new techniques have a learning curve. Excellent results are possible from the beginning, but agility with the procedure improves with practice. Overall outcomes with the KAMRA inlay are excellent. Patients on average achieve J3 uncorrected near visual acuity after a PEK procedure and J1-J2 after CLK and PLK procedures. Patients maintain a mean uncorrected distance visual acuity of 20/16 after PEK and 20/20 after CLK and PLK. In addition, for all procedure types, distance stereoacuity is maintained, contrast sensitivity remains within normal limits, and 90% or more of all patients are functionally independent from glasses. EW Optimizing continued from page 15 It is important to note that the patient's refraction does play an important role in the postoperative vision. To achieve this complete range of vision, the ideal postoperative refraction for the inlay eye is –0.75 D. To qualify for a PEK procedure, the patient's preoperative refraction should be between plano and –1.00 D. Patients with hyperopic refractions need to be corrected even if they have a very small amount of hyperopia. For CLK the refractive correction should be set for –0.75 D. For PLK procedures, patients do experience an average myopic shift of –0.60 D. As a result, the post-LASIK target refraction should be between plano and –0.25 D. Editors' note: Dr. Tomita is affiliated with the Shinagawa LASIK Center, Tokyo. He has financial interests with AcuFocus. Contact information Tomita: tomita@shinagawa-LASIK.com bursement for cataract surgery is not going to increase, the 2% sequestration cut in Medicare fees won't be restructured anytime soon, and policy wonks don't know how to derail the inevitable sustainable growth rate train wreck. Cataract surgery has been victimized by its success. Dissonance? Insurers are not going to pay additional dollars for femtosecond lasers. Patients, many on fixed incomes, must ante up scarce out-of-pocket dollars for outcomes that may not be functionally superior to manual phacoemulsification. And the federal government, committed to "fairness," must bless the evolution of a two- or even three-tiered healthcare system. My final encounter with cognitive dissonance occurred at the "Ethics Surrounding Marketing of Femtosecond Laser Cataract Surgery" presentation. Addressing the issue of informed consent, its theme supported the thesis of Drs. Groopman and Hartzband that there is no single right answer when advising patients. The age-old question "Doctor, what would you do?" is immutably shaped by the clinician's mindset firmly based on formative experience. A prominent femtosecond laser surgeon stated that if he needed cataract surgery, he would choose the laser. Drs. Groopman and Hartzman might ask if his choice is justified by the procedure's substantive benefit. Dr. McClellan might ask how it provides economic value. Ethicist John Banja, PhD, might ask how a surgeon best guide patients' decisions without concession to financial motivation. The patient might ask if there is potential for buyer's remorse. I'd ask who is the surgeon and which machine does he use. Psychologists propose that several defense mechanisms can reduce dissonance and effectively restore consonance. I hope to find one soon because rationalization isn't working. EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com

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