Eye Health Should be addressed as a Population Management Problem

Eye Health Should be addressed as a Population Management Problem, according to a report issued by the National Academies of Sciences, Engineering, and Medicine (NASEM).

In order to avoid a public health crisis and keep up with increasing vision loss among the aging baby-boomer generation, correctable vision impairments must be eliminated by 2030, according to a report issued by the National Academies of Sciences, Engineering, and Medicine (NASEM).

“Vision loss and visual impairment is a major public health problem,” said Rohit Varma, MD, MPH, report committee member, and chairman, Department of Ophthalmology, University of Southern California, Los Angeles. “In setting this high bar, the committee wanted to stimulate innovative ways on how to use the available resources more wisely.”

Among other recommendations, the “Making Eye Health a Population Imperative: Vision for Tomorrow” report recommends that the Secretary of the U.S. Department of Health and Human Services issue a call-to-action nationwide to increase public awareness of the impending crisis should vision and eye health not be taken more seriously on a local, state, and federal level.

"Avoidable vision impairment occurs too frequently in the United States and is the logical result of a series of outdated assumptions, missed opportunities, and manifold shortfalls in public health policy and health care delivery," they said. "As a chronic condition, vision impairment remains notably absent from many public health agendas and community programs. Rather, vision is often regarded as a given—until it is not."

In the present environment of rapid health reform, HIT  advances, genomics, and revolutionary technologies, eye care has left the public awareness overshadowed by other imperatives.

The most significant advances today in eye are are in the diagnosis and treatment of age related macular degeneration, made possible by the pipeline of drugs in the anti-vegf category.

40 years ago eye care was taken over by revolutionary care in the removal of cataracts, followed by surgical procedures for refractive errors.

“We have an absolute lack of a comprehensible, sustainable, implemented, and funded surveillance system for vision loss and eye disease in the United States,” Dr. Varma said.

The committee predicts that the absence of nationwide efforts to improve eye care could result in a doubling of uncorrectable vision impairments by 2050. This increase of vision impairments could also negatively amplify the effects of other non-eye-related chronic illnesses. It also negatively effects quality of life, independence, and psychological well-being.

NASEM declares eye health a public health imperative | OphthalmologyTimes

Eye implant turns smartphone into a glaucoma monitor

A 'selfie' that might save your sight.   An implanted sensor could help people with glaucoma monitor the pressure in their eyes using a smartphone camera.

The second biggest cause of blindness after cataracts, glaucoma occurs when fluid builds up in the eye. This raises the pressure, damaging the optic nerve. Accurate pressure readings are crucial for giving the right treatment, but one-off measurements during check-ups produce variable results and can be misleading.

Vision care providers routinely monitor intraocular pressure with tonometers during eye examinations as well as observing the optic nerve.  As  glaucoma progresses there are visible changes in the shape and morphology of the optic nerve. The increased pressure damages the nerve fibers in the glaucomatous eye resulting in a 'silent' loss of peripheral vision, which is largely asymptomatic.

In some patients the intraocular pressure is read as normal during a one-time measurement, while the elevations occur between visits.   Some patients  are examined several times during  a day  (a diurnal intraocular pressure test), and in some patients the IOP  increases only during the night or early morning hours.

Yossi Mandel at Bar-Ilan University in Ramat Gan, Israel, and his colleagues have developed a pressure sensor which can be inserted into the eye during surgery to provide easy, regular monitoring from home.

A few millimetres in length, the sensor can be embedded into the synthetic lenses used to replace the natural lenses of people with cataracts. It works like a miniature barometer, and contains a fluid column that rises with eye pressure. The level can be read at any time using a smartphone camera fitted with a special optical adapter. Software then analyses the image and calculates the reading.

"Continuous monitoring is a clear unmet need in glaucoma," says Francesca Cordeiro, a glaucoma researcher at University College London.  

Several eye pressure probes have been developed since the early 1990s. These include a contact lens made by Sensimed, based in Lausanne, Switzerland, that can estimate eye pressure based on how the cornea bends. Sensimed's sensor is the only wearable pressure device that is commercially available, but it is intended for short-term use only. Mandel says his sensor could be installed in a patient's eye for many years.

Implanting the synthetic lens that contains the sensor would require invasive surgery, something only suitable for patients who need new lenses anyway due to cataracts.

"Ultimately, only a small proportion of glaucoma patients could benefit from this sensor," says Cordeiro. Developing a standalone sensor that could be implanted in front of the iris could solve this problem, suggests Mandel.

Summary and Conclusion:

Glaucoma is the second most common cause of blindness in the world. It is a multifactorial disease with several risk factors, of which intraocular pressure (IOP) is a primary contributing factor. IOP measurements are used for glaucoma diagnosis and patient monitoring. IOP has wide diurnal fluctuation and is dependent on body posture, so the occasional measurements done by the eye care expert in the clinic can be misleading. Here we show that microfluidic principles can be used to develop an implantable sensor that has a limit of detection of 1 mm Hg, high sensitivity and excellent reproducibility. This device has a simple optical interface that enables IOP to be read with a smartphone camera. This sensor, with its ease of fabrication and simple design, as well as its allowance for IOP home monitoring, offers a promising approach for better care of patients with glaucoma.

EyeQuick----Very slick device

EyeQuick™ Digital Ophthalmoscope Camera

by Marc Ellman, MD | September 2012

EyeQuick™ makes retinal and anterior segment imaging simple, portable, and affordable.
Modeled after a direct ophthalmoscope, the EyeQuick™ Digital Ophthalmoscope Camera is a high resolution digital device that can easily photograph both the anterior segment and posterior segment (Figure 1). Readily portable, EyeQuick records both still images and video; and its LCD screen allows clinicians to use the device at a distance from their own faces, making EyeQuick useful in a variety of clinical settings (Figures 2A and 2B). Images or video can be viewed immediately on the device or ported via USB memory drive to a computer, EMR system, printer, or email.

Why EyeQuick?
EyeQuick is less than half the price of other ophthalmic cameras, and since photographs taken with it can be billed for reimbursement (code 92250 for retinal photographs [about $75]; or 92285 for anterior segment photographs [about $25]), the return on investment should be rapid and robust.
Extremely compact and lightweight—at 12.55 oz, it weighs about as much as a can of soda—EyeQuick makes it possible to capture detailed anterior and posterior segment images in patients with limited mobility. Being able to bring the camera to the patient, rather than the other way around, can be a tremendous advantage.
Doctors who do hospital or nursing home consults, emergency room calls, or mission work will find EyeQuick very useful. Wheelchair-bound patients and those on stretchers can now be photographed with ease, and any patient can be photographed without the aid of a nurse or technician. Because EyeQuick comes in a small metal carrying case with space for additional charged batteries, bringing the device to remote areas is simple.
The camera itself has 200 MB of internal memory, with the ability to store over 10,000 pictures. Video occupies more memory; but, again, files can be downloaded to a USB memory drive for later use. EyeQuick uses a standard Welch Allyn battery and charger. Finally, the camera is very easy and intuitive to use.
Developing EyeQuick
I had the idea for EyeQuick about 10 years ago, when I was a resident; but at the time, I lacked the resources to pursue it. After I opened my practice, I revisited the notion and reached out to an intellectual property attorney and an engineer. About 5 years after that, we obtained FDA 510(k) clearance. With business now picking up, I have hired a full-time person to handle operations and have a sales team of more than 20 reps.
When I designed the camera, I thought it would appeal primarily to doctors currently without other imaging solutions; but a large number of EyeQuick purchasers already have retinal cameras. EyeQuick appeals to them because of its convenience, portability, and versatility, as well as the high quality anterior segment photos it takes.
EyeQuick in the Future
We are currently putting together a software package for EyeQuick to allow users to manage data more easily on their PCs. We are also considering other handheld ophthalmic instruments and plan to grow EyeQuick into a company with global recognition. We have received inquiries from as far away as Kenya, and I believe we offer a real advantage to practitioners in the developing world.

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Marc Ellman, MD, is founder and president of EyeQuick, LLC. He practices at Southwest Eye Institute, in El Paso, TX. Refractive Eyecare managing editor Jennifer Zweibel assisted in the preparation of this manuscript.

Advances in Cataract Surgery

 

The diagnosis of cataract with it’s ensuing visual challenges has led to a progressive step wise improvement in technique, hospitalization (or lack thereof), a brief post operative recovery period and fewer intraoperative and post-operative complications during recovery.

Intracapsular surgery with aphakia and rehabilitation with contact lenses or aspherical high diopter spectacle lenses became obsolete, replaced by extra capsular manual cataract removal, followed by the development of ultrasound phacoemulsification of the crystalline lens.  This technique allowed for the safer implantation of a  pseudophacos in the anatomical space.

Further manual refinement included capsulorrhexix of the anterior capsule, allowing for a consistent placement of the artificial lens inside the vacant lens capsule. 

Clinical experience and patient expectations motivated further refinement of pseudophacos design in materials, haptic design, and multi-focal design.

The addition of refractive surgical  techniques using arcuate corneal incisions, astigmatic pseudophacos further evolved the cataract operation to one where over 80% of patients no longer needed any correction after surgery and could return to work in 24 hours, with some exceptions for laborers or very physically active patients.

The development of YAG laser allowed for a non invasive procedure for the common occurrence of ‘after-cataract:

FEMTO-SECOND LASER for cataract surgery has added another tool, further refining and automating much of the procedure, with the assistance of advanced imaging for precision, replication and repeatability of the procedure.

ALCON , known for it’s ophthalmic products and commitment to cataract removal has developed the “LenSx Laser” platform integrating a robotic system which consist of the microscope, coupling device, femto-second laser, integrated ocular coherence tomography (OCT) combined with a three dimensional imaging system which images the entire anterior segment down to the posterior capsule.

Once the image is obtained and the metrics are computed  the resulting combination allows for corneal entrance incisions, arcuate astigmatic corneal incisions, anterior capsulotomoy, and nuclear quadrantic dissection without surgeon intervention.

The last steps, phacoemulsification and placement of the intra-ocular lens require the use of a phaco-emulsifier, a technique which has been used for about 30 years.

Modern state of the art cataract removal has been facilitated and has been highly effective in improving outcomes, and reducing the cost of this surgery (which is done over 2 million times/year in the United States.

Previously the cost including surgeon’s fees, three days of in patient hospitalization has been reduced from over 4500 per eye to a one hour surgery as an outpatient with a cost of under 1800 dollars to Medicare.

Ophthalmology has had this in place for 30 years !

Technorati Tags: femtosecond laser,phacoemulsification,pseudophacos,ppaca,outcome studies,medicare budget,cataract,outpatient surgery,capsulorrhexix

Owning the Problem(s) on The Health Train Express

 

Quote of the Day:
 

Quote of the Day:
When you come to a fork in the road...take it.
--Yogi Berra

Dr Thulasira Ravilla speaks about efficient methods of delivering surgical care and creating an environment of change process at a T.E.D. conference.

This is a timely subject given that in the United States an attempt is being made to reduce costs, and deliver more care by placing additional burdens upon the healthcare system, physicians, hospitals and other caregivers.

Necessity has a way of driving improvement and reducing costs, however we have chosen the easy path.

His talk outlines the deep understanding of what up-regulates health care costs which is totally ignored in the equation for the United States.

The US health system has exhibited inflation, and we are told its rate of inflation exceeds that for the overall economy. It is estimated that it represents over 16% of the economy.

Healthcare institutions, medical clinics, hospitals all must operate in a general economy and thus compete with not only other health providers for patients, and also for durable medical goods, utilities, operating space, personnel costs, taxes, training and education.

Dr Ravilla explains in the T.E.D. video how his organization,      , has become not only efficient, but how they deal with the side of the equation not addressed in the United States, overhead.

Currently large medical institutions will ask for RFIs or offer competitive bidding to obtain volume discounts.  Smaller entities will form or joking a  buying group to scale their purchasing power.

What is not addressed is the control of escalating cost for producing items. 

In health care (which in some ways is like the military) there is a constant obsolescence factor for technology, in diagnostic equipment, therapeutics, new facilities and R & D. This cost is significant not only to manufacturers but to medical business.  Recently we are adding Electronic Medical Records and Health Information Exchange, purportedly to improve efficiency and deliver improved outcomes.  This will be subsidized by an incentive program for the federal government for almost 20 billion dollars. The immediate effect is to stimulate adoption of EMR, necessary because most entities can little afford this jump in technological advance, at the same time as maintaining technical competence in medical equipment.

While a significant amount it appears to be inadequate to offset the adoption and long term support for EMR. The additional expense will fall upon each medical clinic and hospital. The incentive program is a dual edge sword, both incentive and penalty if users do not convert to EMR with certain basic meaningful uses spelled out by HHS. The incentive program ignores continuing maintenance cost and periodic software and/or hardware updates and replacement.

The net effect is to increase operating expense and fuel further health care inflation. The $ 20 billion stimulus attracts new industry to health care in a massive manner. Health care’s primary goal is patient health.  All other businesses surrounding this goal are a cost of delivering services. Adding another layer of bureaucracy, or personnel adds to operating cost.

Also change itself creates expense. The adoption and transition form one paradigm to another interrupts business productivity, requires personnel training and capital investment.

How would you like it?

 

 

g-speak overview 1828121108 from john underkoffler on Vimeo.

Historical Perspective in Ophthalmology Part I

Ophthalmology has been no stranger to disruptive technology and  innovation that have altered the landscape for practitioners, hospitals, industry and the most important component….patients.

The quick view;

Retinal laser photocoagulation

Coaxial Operating Microscope

Conversion to extra capsular cataract removal

Phacoemulsification, small incision surgery

Viscoelastic

Development and refinement of intraocular lenses

Transition to Outpatient Surgery

Retina:  Development and refinement of the BIO. Operating microscope with Image Inverter. Intraocular gas, silicone oil and intraocular pharmacology, including antibiotics, anti-vegf compounds, corticosteroids.

These developments were fueled by translational research, and each innovation fueled further improvements in diagnostic equipment and therapeutic options