RPS 2013: Viva Las Vegas!

Presentations on ASCs and surgery for diabetic eye disease from the 2013 Retinal Physician Symposium.

ANDREW E. MATHIS, PHD, MEDICAL EDITOR

Forty percent of the procedures performed in the 1,000 ambulatory surgical centers (ASCs) across the United States are ophthalmic procedures, and 50% of the Medicare dollars paid come from these procedures.

Michael A. Romansky, JD, reported in his presentation during the opening session of the Retinal Physician Symposium in June in Las Vegas, that this unprecedented growth comes with strings attached. Nevertheless, potential for further growth and profit exists.

MIKE ROMANSKY ON THE FUTURE OF THE RETINA ASC

Mr. Romansky, who is a senior lobbyist and vice president of corporate development for the Ophthalmic Outpatient Surgery Society (OOSS), said a reversal of loss leaders has occurred, with facility fees now greater than professional fees in many cases.

In the past, the reimburse rates for ASCs and hospital outpatient departments (HOPDs) had different bases. The HOPD rate and ASC rate are now linked. For instance, ASCs are now paid the same for innovative drugs and devices as HOPDs.

However, the percentage reimbursements for both are declining, with the ASC reimburse rate linked to the Consumer Price Index and not the Hospital Market Basket. Yet, the news is not all bad, Mr. Romansky said. For one thing, laser retina procedures are now among the highest reimbursed procedures (Figure 1).

In addition, the percentage of all ophthalmic surgical cases performed in ASCs is now 65% to 70%. Forty-one percent of ASCs now offer retina, with 20% planning to add it in the near future (Figure 2).

Legislative Initiatives

Mr. Romansky explained that Medicare Payment Advisory Commission (MedPAC) wants to “level the playing field” by bringing the HOPD rate down to the ASC rate for certain services.

The savings to HMS count amount to $590 million per year, with beneficiaries saving between $40 million and $200 million per year. The effects on ASCs would include services migrating from HOPDs to ASCs, better medical device payments, and less rate disparity, among others.

For its part, OOSS has proposed the Ambulatory Surgical Center Quality and Access Act of 2013, which Mr. Romansky explained would harmonize ASC rates with HOPD rates, as well as provide for ASC representation on advisory boards.

Mr. Romansky closed his presentation by assuring the audience that there was, in his words, “Zero percent chance of banning doctors from owning ASCs.” As a result, those retinal physicians both owning and operating ASCs need not worry about their investments.

Figure 1. Laser procedures are now among the highest reimbursed.

THALMIC OUTPTIENT SURGERY SOCIETY

TIM MURRAY ON SURGERY FOR DME

In the first presentation of the second day, Timothy G. Murray, MD, MBA, of Bascom Palmer Eye Institute in Miami, discussed the status of surgical options for DME. Dr. Murray began his presentation by exploring the “three pillars” of DME pathology: vascular damage, oxidative stress, and, especially, the inflammatory components. Reviewing this latter component, he noted every major cytokine participates in the process.

He then separated treatment approaches into acute and chronic strategies, with acute approaches consisting primarily of intravitreal drug delivery, as well as surgery to relieve mechanical traction. Chronic treatments have involved systemic control of diabetes and focal and grid laser to alter the microenvironment.

Noting changes in imaging techniques, Dr. Murray stated that while a decade ago, follow-up would have consisted of repeat fluorescein angiograms, today he only orders FA after baseline in cases of changes in VA or suspicion of ischemic events. SD-OCT, he said, has become the primary imaging approach.

Historically speaking, Dr. Murray noted that focal laser had been the treatment of choice, with treatment applied directly to microaneurysms and grid laser for diffuse disease. While the ETDRS had verified the efficacy of laser, it considered moderate vision loss to be <20/200. “I’m not interesting in 20/200 VA for my diabetic patients,” Dr. Murray said. “I’m interested in 20/40 or better.”

Turning to pars plana vitrectomy, Dr. Murray noted that the goals have traditionally included relief of traction and removal of opacities, with endolaser PRP if indicated and postoperative triamcinolone. The advances seen here have been diagnostic (SD-OCT), therapeutic (intravitreal steroid and anti-VEGF agents), and surgical, including high-speed instruments and small-gauge systems, as well as widefield systems for perioperative imaging.

To Peel or Not to Peel?

Dr. Murray noted that controversy persists over peeling the internal limiting membrane, both regarding technique and the use of intraoperative dyes. “I believe you should always stain the ILM,” he said, “and for me the stain of choice is indocyanine green.” Phototoxicity remains a controversial event, but he noted he was never seen a case. Alternatives such as Trypan blue offer their own complexities.

Here, Dr. Murray turned to a 2008 Bascom Palmer study of PPV with ILM peeling for DME without intraoperative staining and demonstrated a handful of cases from that study. Twenty-five percent of eyes gained at least 2 lines of VA, 21% lost at least 2 lines, and the remainder had stable vision. Four cases of recurrence emerged. While not impressive, Dr. Murray noted that these outcomes had occurred in patients who had failed all previous treatment.

Volume Groth of VR in ASCs

Figure 2. The number of vitreoretinal surgeries in ASCs has increased.

OPTHALMIC OUTPTIENT SURGERY SOCIETY

Dr. Murray contrasted the outcomes of that study with the MOOR study of minimally invasive vitrectomy from DME, which completed in January 2013. In the MOOR study, 62% of eyes gained at least 3 lines, and only 7% lost 1 line or more. The remainder gained 1-2 lines.

A Treatment Algorithm

Next, Dr. Murray presented his algorithm for DME therapy. Normally, he begins with intravitreal pharmacotherapy and possibly applies laser, opting for PPV with ILM peeling and intravitreal triamcinolone in nonresponsive cases.

Turning to persistent controversies, Dr. Murray noted that he always peels the ILM, reiterating the importance of ILM staining to assure complete removal. He noted that triamcinolone-related glaucoma has been rare as an adverse event.

“Surgical management of diabetic macular edema is likely to play a greater role in management for complex diabetic macular edema utilizing a combination approach, including intravitreal pharmacotherapy and advanced laser techniques,” Dr. Murray said.

RISHI SINGH ON NEW LASER TREATMENTS

A presentation on new laser treatments for diabetic retinopathy, given by Rishi P. Singh, MD, of the Cleveland Clinic, followed Dr. Murray’s presentation. Dr. Singh began by noting that with the success of pharmacological therapies for DME, the role of laser is now uncertain.

He briefly reviewed the data from anti-VEGF trials for DME, principally the RISE and RIDE studies, the data from which justified FDA approval of ranibizumab (Lucentis, Genentech, South San Francisco, CA) for DME. Sixty percent of patients did not show a 3-line gain in vision, in addition to other drawbacks of the study. In addition, patients receiving laser only did not lose significant vision.

Looking at proliferative diabetic retinopathy over time, Dr. Singh said that one would expect no progression given the number of injections being given in anti-VEGF trials, but this has not been the case.

As a result, Dr. Singh summarized the drawback of anti-VEGF therapy for DME as including multiple injections, the possibility of lost vision, and the risk of adverse events, including systemic AEs. Moreover, anti-VEGF is not a monotherapy option; all anti-VEGF trials for DME also applied laser.

Why Does Laser Fail?

Continuing, Dr. Singh noted the common belief that laser generally does not improve vision. In addition to grid laser often causing long-term damage, significant vision loss also occurs. Why does laser fail? According to Dr. Singh, conventional treatment misses microaneurysms, and poor laser uptake and targeting of areas occur.

Here, Dr. Singh discussed micropulse laser, which minimizes collateral damage through greater limitation of the treatment area. He provided a few examples of patients treated with micropulse laser. He also discussed targeted laser, which allows for overlaying of imaging to preplan laser treatment. Dr. Singh has found it to be a good adjunct in training residents and fellows.

Dr. Singh discussed the data from two trials compared targeted laser combined with anti-VEGF to anti-VEGF monotherapy for DME. Combination therapy resulted in significantly fewer injections being administered. He then provided examples of navigated laser treatment from his own practice.

Dr. Singh concluded that a need for laser still exists, particularly in cases of DME with obvious tractional detachment and in unresponsive cases, even if no traction exists. It can also reduce injections and can be effective in cases of PDF with persistent vitreous hemorrhage or tractional detachment.

NEXT YEAR’S SYMPOSIUM

Plans are already under way for next year’s Retinal Physician Symposium. Keep an eye on the Events Calendar in every issue for further announcements and information on how to register and participate. RP