Medical and technological advances may make glasses a thing of the past.
Like the rest of medicine, eye care is undergoing a flurry of technological advancement. Eye surgery is becoming more precise and easier to do, and long-standing diseases are being more effectively targeted than ever before. If this keeps up, it won’t be long before people will be getting rid of their glasses altogether.
In the North Bay and elsewhere, eye doctors are sifting through new technologies to see what works best for their patients. And while it can be challenging for individual practices, one thing is certain—the quality of eye care is improving in the North Bay. Increasingly, patients are finding they don’t have to go to San Francisco for surgery after all.
Like the rest of medicine, eye care is undergoing a flurry of technological advancement. Eye surgery is becoming more precise and easier to do, and long-standing diseases are being more effectively targeted than ever before. If this keeps up, it won’t be long before people will be getting rid of their glasses altogether.
In the North Bay and elsewhere, eye doctors are sifting through new technologies to see what works best for their patients. And while it can be challenging for individual practices, one thing is certain—the quality of eye care is improving in the North Bay. Increasingly, patients are finding they don’t have to go to San Francisco for surgery after all.
“Traditionally, there was a segment of the population in the upper valley that traveled to UCSF and Stanford for a higher level of care,” says Erin Jacobson, M.D., with the Eye Care Center of Napa. “But that perception is changing. People are realizing that we have the same diagnostic equipment and have invested in the same level of care as a larger university facility.”
But that changing attitude doesn’t come cheap, he adds. Often, technological advancement means doctors have to take classes to learn new procedures or shell out tens of thousands of dollars for equipment. “Sometimes you have to bite the bullet when it comes to cost in order to add state-of-the-art technology to the practice,” says Jacobson.
Let’s start with a rundown of some of the more common new eye care technologies.
Cataract surgery and multifocal lenses
The lens of the eye focuses light and makes images clear. A cataract is when the eye’s lens has become clouded. The symptoms of a cataract are fuzzy or foggy vision, trouble seeing at night or double vision. Since they develop gradually, people sometimes don’t even know that they have a cataract. The disease is common in the elderly, although young people do get cataracts as well.
In cataract surgery, a doctor removes the diseased lens of the eye and replaces it with an implant made of plastic, also called an intraocular lens. It wasn’t always done that way, however.
“There was a time when lens implants weren’t available,” says John Shin, M.D., an ophthalmologist at Marin Eyes in San Rafael. “So the surgeon would remove the person’s cataract [their natural lens] and the patient would then wear a replacement on the outside of the eye in the form of glasses. That’s why you used to see people with thick, Coke-bottle glasses. That’s mostly gone away now.”
Until recently, cataract surgery helped patients see far away, but many would still have to wear reading glasses; this was a common problem for people over the age of 45. Enter the multifocal lens, an intraocular lens that lets people see both far away and up close, much like bifocal glasses do.
Multifocal lenses not only reduce the need for glasses, surgeons can implant them without having to buy new equipment—it’s just a matter of putting a different kind of intraocular lens in the eye during surgery. But multifocal lenses can have problems, too. There’s a slight chance of glare or sensitivity to light and, in some cases, people still have to wear glasses.
“They’re getting better but they aren’t perfect for everyone and they don’t always work,” says Shin. “But I do, however, think multifocal lenses will eventually become the norm in the future.”
Glaucoma and SLT
The optic nerve carries electrical signals from the back of the eye to the brain, thus letting your brain know what your eye is seeing. When you have glaucoma, naturally occurring fluid stops draining from your eye and builds up, putting pressure on the optic nerve until it begins to deteriorate. People can have no idea they have glaucoma until they begin to lose vision.
The newest treatment for glaucoma is called Selective Laser Trabeculoplasty, or SLT. The doctor uses a laser to create a chemical signal that stimulates the body’s own mechanism to drain the eye. The procedure takes only a few minutes and can be safer than some medications, believes Jacobson.
“It’s gentle and it’s safe,” he says. “I have a number of seniors who are free from having to use eye drops for the first time in decades. I wouldn’t be surprised if SLT becomes a first-line treatment for glaucoma in the future.”
Not all doctors agree, however. Windsor-based ophthalmologist James Hunt says sometimes SLT works, but often it doesn’t. “I haven’t been convinced that it’s significantly better than ALT [the older laser used],” he says. “The machine costs about $70,000, and I’ve found those who’ve bought the machine tend to be partial to the procedure.”
LASIK: IntraLase and wavefront
As most people know by now, LASIK surgery, or Laser-Assisted in Situ Keratomileusis, is an elective surgery that eliminates or reduces the need for glasses. Doctors cut a circular flap in the outer layer of a person’s eye and then use a laser to reshape the cornea before replacing the flap.
When LASIK was introduced in 1995, it was immediately popular. LASIK centers popped up everywhere from office buildings to shopping malls. Today, about 1.4 million LASIK procedures are performed every year in the United States alone, costing from $1,400 to $2,900 per eye, according to the Washington Post. Since LASIK is considered an elective surgery, it’s not covered by insurance.
Lately, new technology has improved and refined LASIK, making it possible for people who weren’t candidates for the surgery in the past to qualify for it now. One of these advancements is wavefront LASIK, a custom-guided approach to the surgery. Instead of the old way of doing the surgery, which used the patient’s glasses prescription to shape the cornea, a computer now maps out the surface of the patient’s eye down to the very last detail.
“Wavefront takes a picture of every optical abnormality you have in the eye,” says Daniel Rich, M.D., from the Eye Care Institute in Santa Rosa. “So if the eye is steeper at the top of the eye and flatter below, we can see to take more from the top and less from the bottom—it’s customized based on each person.”
IntraLase is another new LASIK technology. Instead of using an oscillating blade to cut the cornea, IntraLase Femtosecond technology uses a laser to make small plasma explosions under the cornea so bubbles appear at a specific depth in the eye. The doctor then separates the tissue where the bubbles have formed so the corneal flap can be folded back for the second step of the surgery.
Among other benefits, IntraLase creates a smooth, even cut that heals better, believes Tom Tseng, M.D., from LaserVue Eye Center in Santa Rosa.
“Many of the problems we’ve had in the past have been due to irregularity in the flaps,” he says. “For instance they might be too thin or too thick, or it might be an irregular cut that allows dirt or debris to get under the flap. With IntraLase, the flap is customized to the unique profile of each individual’s cornea, so this isn’t an issue any more.”
Studies show that IntraLase works best when combined with wavefront technology. Because both technologies are more exact, they reduce some of the risks that come with LASIK surgery. In 2001, roughly 30,000 people reported long-term vision problems as a result of LASIK, such as double vision or having trouble seeing at night. Around that same time, patients who experienced serious vision loss from LASIK began winning multimillion-dollar malpractice suits against doctors.
The cost of equipment for both wavefront and IntraLase is nearly $1 million.
Drugs and macular degeneration
Not all eye care improvements are technological; there are also new advancements in medication. Last summer, Genentech released Lucentis, a drug that treats wet macular degeneration, the leading cause of blindness in the United States.
Wet macular degeneration is caused from rampant blood vessel growth in the back of the eye. The blood vessels leak fluid and blood, which over time destroys the retina. (The macula is the central portion of the retina responsible for perceiving fine visual detail.) Lucentis stops the proteins that trigger the growth of the blood vessels. In two separate studies, 95 percent of patients given Lucentis over the course of a year had no further deterioration of their vision. Another 35 to 40 percent actually experienced improvement in their sight.
“Previous treatments for wet macular degeneration have been pretty underwhelming,” says Shin. “But Lucentis seems to work. It’s an antibody-type drug that prevents abnormal blood vessels from growing into the macula.”
The drug is given by injection five to seven times a year. It costs about $2,000 per treatment, but is covered by insurance.
Expensive equipment
In some cases, once doctors invest in a particular technology, they’ll promote their choice even if it isn’t always the best thing for the patient.
“It’s important to consider where people are coming from when they recommend a procedure,” warns Hunt.
Other procedures are simply unpopular. Hunt, for example, sometimes uses a tiny stainless steel shunt, called an Ex-Press Eye Implant, to treat glaucoma. “I like the procedure because the drainage hole is always the same diameter, so it makes the results more predictable than the traditional trabeculectomy,” he says. Also, the surgery is much easier and the post-operative course is generally less difficult for myself and my patients.”
But use of the shunt hasn’t caught on with the general ophthalmologist population. At a recent conference, Hunt mentioned to some other surgeons that he uses the shunt. Their reaction was less than enthusiastic.
“In medicine, there are often many ways to accomplish the same result,” he says. “I’m just often surprised by the negative reaction physicians have to procedures they’re unfamiliar with.”
Some technologies do better than others because they’re easier for doctors to integrate into their existing practices. The newer multifocal lens implants, for example, are more likely to find wider acceptance not only because they potentially eliminate the need for glasses, but also because surgeons can incorporate them into their practice without major changes to their current surgical technique. The earlier multifocal lenses required significant modifications in surgical technique, which limited their adoption by surgeons. This, in turn, limited the availability of these lenses to patients.
This isn’t always the case. Some products demand too many changes—too quickly—from surgeons. For an investment in new technology to payoff for a clinic or practice, the positive changes have to be significantly better than existing methods. The Eye Care Institute admires IntraLase technology, but the clinic isn’t sure the benefits it offers are worth the monetary outlay to buy the machine.
“It’s tricky,” says Rich. “An IntraLase machine costs $400,000. Our [traditional] mechanical keratome offers superb results and tremendous safety. Any advantage of IntraLase technology comes at a very high cost for the patient. These are the kinds of things we must consider when purchasing new technology.”
Even when a new procedure does pay off for patients, the equipment can still be too expensive to make it cost-effective for the doctor. For example, Hunt recently went to Florida to learn how to perform a new kind of corneal transplant called Stripping Endothelial Keratoplasty (DSAEK). The traditional way to transplant a cornea is to cut it out of the eye and then sew another cornea, called the donor cornea, in its place. With DSAEK, doctors strip off the diseased cells from the inner lining of the cornea and then replace them with a thin membrane of donor cells. Unfortunately, Hunt discovered too late that the machine cost $30,000 and the procedure was only partially reimbursed by insurance.
“Corneal transplants aren’t that common of a procedure, and I’m having trouble convincing the local surgery centers to invest [in a machine],” he says. “It’s understandable, because they need to be able to recoup the cost of the machine. And with insurance reimbursements being what they are, it may not be cost effective.
“When I got to Florida and found out what it was going to cost for the machine, I was heartbroken. I had a few patients waiting for me to do this procedure for them.”
A future without glasses?
As the baby boomers get older, eye doctors are starting to see demand for their services increase. Our largest generation, boomers will increase the need for glasses—particularly reading glasses—as they succumb to the frailties of age. At the same time, there will be increased market demand for LASIK, multifocal lenses and other things that let people stop wearing glasses.
“Cataract and refractive surgery are going to be something else in the future,” says Shin. “It won’t simply be about restoring vision so people won’t have to wear glasses, but about making it as good or better than it had ever been. In the future, a patient will come in for cataract surgery, and their vision will be restored to what it was like in their 20s or better. I don’t know anyone who wouldn’t want that.”
Already there’s a blurring of the lines between elective and medical eye surgery. For the first time ever, Medicare has started letting people combine the two. Cataract surgery is covered by insurance and multifocal lenses are not. Medicare covers the cataract surgery, and if people want to get the premium multifocal lens instead of the regular intraocular lens, they can pay extra for it. So, instead of having to pay for the whole surgery out-of-pocket like people do for LASIK, cataract patients only have to pay the extra $1,000 to $2,000 for the multifocal lens.
As the market demands techniques aimed at perfecting vision and getting rid of glasses, some experts are concerned that other, more serious ocular diseases will be ignored. Eye diseases that small populations suffer from could be ignored while money for research and development is funneled into other more common, but less serious, problems such as curing astigmatism. As such, some doctors worry that the priorities for developing new technologies can be driven too much by money, and not enough by what’s most needed from a medical point of view.
Still, the future looks bright for the eye care profession.
“We’re approaching an exciting time,” says Shin. “We’re not just going to be able to restore vision, we’re going to be able to provide patients with super vision—jet fighter pilot kind of vision—while at the same time making people less reliant on glasses. That’s the sort of thing that’s on the horizon.”
