Welcome to the inaugural CAKE Magazine Radio Show! In this segment — hosted by DJ Bananaman and the CAKE Crew — we asked ophthalmologists worldwide to ‘call-in’ to our Radio Show and answer some of the biggest questions topping the charts today in ophthalmology.
Below, we explore their insights in this first-of-its-kind CAKE magazine multimedia feature.
Caller Details:
Dr. Laura Periman — Seattle, Washington, USA
Founder and Director of Dry Eye Services and Clinical Research at Periman Eye Center
Song Request: “Kiss on My List” by Hall & Oates
Dr. Cheryl Ngo — Singapore
Consultant and Medical Director at the Adult & Child Eye Clinic (ACE)
Song Request: “Happy” by Pharrell
Dr. Ehsan Sadri — Newport Beach, California, USA
CEO and Founder at Visionary Eye Institute
Song request: “Eyes Without a Face” by Billy Idol
Prof. Tim Roberts — Sydney, Australia
Clinical Associate Professor of Ophthalmology at the University of Sydney & Consultant Ophthalmic Surgeon at Royal North Shore Hospital
COVID-19: Lessons Learned
No doubt, the novel coronavirus has taken the world by storm. If it was a rising star in the music world, it would be selling out stadiums. Instead, it’s pushing people into hospitals and keeping them indoors. Of course, all industries have felt its boorish brunt, some more so than others.
How are ophthalmologists finding harmony and balance amid the pandemic? Let’s find out.
CAKE: What’s one thing in ophthalmology that you think may permanently change as a result of coronavirus?
Dr. Sadri: COVID-19 has dramatically changed many things in medicine and it will take many years to figure out its exact impact. But one striking example is the telemedicine component of interacting with patients. This is something that has been around for a long time. However, the technology was never embraced by physicians or patients. There has been a major cultural shift due to the practicality of the diagnostics. The technology allows physicians to radically enhance their practice and provide better care for patients in a remote fashion. My personal belief is that telemedicine is here to stay indefinitely.
Dr. Periman: Telemedicine! [There’s] tremendous patient satisfaction. I’m amazed at what we can diagnose with high-resolution photos and video interviews.
CAKE: That’s two for telemedicine! We at CAKE also agree that telemedicine could have a lasting impact in the medical field. What else?
Dr. Ngo: The use of slit lamp breath shields, protective eyewear and face masks when examining patients.
CAKE: You’re right! Some surgeons have reported creating their own shields, while others have purchased them. Anything else?
Prof. Roberts: I think this pandemic will permanently end the ‘carry on even when sick’ ethos that so many of us have been guilty of in the past. That’s important for several reasons. First and foremost, comes the health of our patients and other staff in the clinic. But then we also have to consider the financial implications if the clinic (and potentially a co-located day surgery) has to shut down because someone with COVID-19 has come to work. We’re talking about peoples’ lives and livelihoods. It’s a bit of a cliché, but everything really is for the greater good now — it’s not just about people as individuals.
CAKE: Another good point! In the era of COVID-19, the greater good has got to come first in order to make progress. In the spirit of moving forward, which elective procedures are you seeing return first after reopening?
Dr. Ngo: In Singapore, I’m seeing cataracts and strabismus surgeries return in which patients complain of significant visual deterioration or disabling diplopia.
Prof. Roberts: In Australia, we are seeing a very slow return to normal because many people are still worried about coming out. However, as we predicted, cataracts make up most of the procedures returning first. Although, I have also performed a handful of minimally-invasive glaucoma surgery (MIGS) operations. This is so important because of the individual, social, economic, and public health value of cataract surgery. The real issue will be clearing the backlog of surgeries in the public system, which isn’t as well placed as the private sector to expand its capacity.
Dr. Sadri: In California, most practices, including mine, have resumed elective surgeries. These include cataract and glaucoma surgeries. Laser vision correction surgery has also returned in a big way.
CAKE: That’s great these patients are returning! I wondered about which surgeries would restart faster following reopenings — cataract or refractive?
Dr. Sadri: There are some signals as far as the demand in younger patient populations that they are no longer interested, or have made a decision to get laser vision correction surgery. The elderly patients in our clinics still need good care. These patients require improvement in vision and it’s a functional necessity, and therefore the demand is certainly strong.
CAKE: That’s really interesting. What other procedures are restarting?
Dr. Periman: I only do dry eye procedures. In fact, I used the ‘Great Pause’ to start my own specialty dry eye treatment and research center. Patients are frequently calling to schedule their elective in-office treatments — IPL, iLux, TearCare, Radiofrequency, etc.
CAKE: That’s great news about the new center, Dr. Periman — and certainly a productive use of time during the pandemic.
Ophthalmology Business: Gearing Up for the New Normal
The beginning of 2020 looked bright, didn’t it? Oh, but how things can change. Many businesses are hurting — along with medical practices — thanks to the pandemic. So, what can ophthalmic industry device and equipment manufacturers expect for the rest of the year? We want to know.
CAKE: Are you, or is your clinic or hospital, planning to purchase any new equipment or devices in 2020? In 2021? And if so, what are you interested in?
Dr. Periman: I plan to purchase a new radio frequency device and a high-resolution photo and video-capable slit lamp from Eyefficient (Aurora, Ohio, USA).
Dr. Ngo: No.
Dr. Sadri: COVID-19 has strongly and negatively impacted the balance sheets for many businesses, including ophthalmologists. If I was giving advice to myself, I would say defer any major purchases for the balance of the year.
CAKE: What about premium procedures? Premium intraocular lenses (IOLs)? How do you predict the demand will go for these?
Dr. Periman: As a dry eye specialist, I think we will see an uptick in dry eye severity — people are at home, with increased screen time and dietary changes. We will need to be more mindful of tuning up the dry eye prior to offering premium IOLs, since we know dry eye has a significant impact on visual performance and patient satisfaction, no matter how perfect the surgery, IOL or equipment was.
CAKE: That’s true. More time at home can certainly lead to more screen time.
Prof. Roberts: It will be interesting to see how premium IOLs fare throughout this period. Premium IOLs are not for everyone — patient selection is critical with these lenses because of the visual trade-offs. I’ll continue to have comprehensive discussions about lens options with my patients, but only time will tell whether they feel premium lenses still offer value in a pandemic setting. This will mostly depend on how motivated they are to be spectacle-free. The personal decision to have refractive lens surgery with a premium IOL is not affected by the pandemic — rather it is access to surgical facilities as the government is restricting the type of surgery performed to preserve PPE.
CAKE: I see. So in this instance, it’s not decreased patient demand, it’s lack of access to facilities.
Dr. Ngo: [Regarding premium IOLs, I think there will be] more demand as patients are more aware of their choices and have greater visual demands — and they want the convenience of spectacle freedom. We are now seeing the group of patients who previously had laser refractive surgery and now need cataract surgery. They are especially difficult to manage as their lens calculation is tricky and yet they still want spectacle freedom and good quality of vision.
CAKE: Right, patients want good vision and to remain spectacle-independent if possible.
Dr. Sadri: Premium services or the advent of advanced lens implants will always remain strong in the hands of practices that are great at conversions. There’s a certain art to this. Patients who elect to have this procedure have the means, and will certainly have it done regardless of the economics. This is where I believe education of physicians is really vital.
CAKE: Certainly, patient education is vital when it comes to premium IOLs — and it’s encouraging to hear optimistic predictions for this market.
Anterior Segment in the Spotlight
The pandemic aside, it is an exciting time to be in ophthalmology. Breakthroughs in medical and surgical treatments could deliver improved outcomes to patients — an ideal outcome for any therapy.
CAKE: In your opinion, what do you think is the most important topic today in anterior segment disease or treatment?
Dr. Periman: From the perspectives of sheer prevalence, visual performance and quality of life impacts, I think the most important topic today in the anterior segment is dry eye.
Dr. Ngo: It may not be the most important topic, but allergic conjunctivitis causes significant problems. Patients are often disabled or troubled by it, especially during an acute flare-up, as it causes significant discomfort and reduction in vision. And is often recurrent. In children, long-term treatment with steroids has to be balanced carefully against potential side effects. There are now steroid sparing agents for long-term treatment, and immunotherapy is a potentially promising treatment option.
Dr. Sadri: I believe the management of glaucoma using advanced and two-segment surgeries is the most important. This field is growing rapidly and will have an immense impact
Prof. Roberts: Restoring sight has positive impacts for those suffering from cataracts and their caregivers. However, despite the evidence that cataract surgery brings significant patient value and financial value to society as a whole, this is not widely understood or appreciated by the general public, policymakers and funders, the healthcare community, and many clinicians. Our challenge, then, is to better communicate the social and public health benefits of cataract surgery to key stakeholders and the wider community with the final goal of improving funding and patient access to cataract surgery, delivering more efficient use of healthcare resources, providing higher quality patient care, and achieving greater community wellbeing.
CAKE: Wow, all great points — and certainly all conditions that not only affect patients’ quality of vision but their quality of life as well. We’re looking forward to hearing more about these upcoming treatment options. So, let’s talk about MIGS. Of the various instruments and procedures available now, do you have a preference for any one in particular?
Dr. Sadri: I believe it’s case-by-case. The exciting news in MIGS is that there are many options today. When I was first designing the original I sent with my mentor Dr. Hill in 2003, there was only one. Now there are half a dozen and growing.
Prof. Roberts: I prefer to assess the patient’s needs as a whole before selecting the most appropriate MIGS procedure — assuming MIGS is the right option. That means looking at how advanced the glaucoma is, whether it’s progressing, the IOP decrease we’re looking to achieve, how the patient is coping with eye drops from both an adherence and a tolerance aspect, etc.
CAKE: Right, so it’s a bit like finding a good MIGS ‘fit’ for each patient. What are some other benefits to these less invasive techniques?
Dr. Periman: I’m a huge fan of how MIGS helps preserve the cornea by minimizing or eliminating ocular surface offending glaucoma medications. I’m excited about the injectable prostaglandin analog options coming to market.
CAKE: From a corneal and ocular surface standpoint, MIGS does offer benefits. So, on that corneal note, let’s switch gears to refractive surgery. Which procedure do you perform most often and why?
Dr. Periman: I am cornea and refractive surgery trained. From a dry eye disease expert perspective, I am interested in the corneal nerve sub-basal plexus sparing options of small incision lenticule extraction (SMILE) and photorefractive keratectomy (PRK).
Dr. Sadri: I love SMILE and laser-assisted in situ keratomileusis (LASIK). I would probably state that LASIK is more readily down in my practice than SMILE.
CAKE: As a newer procedure, it seems like SMILE is certainly gaining some speed, thanks to its reported corneal biomechanical advantages.
Unfortunately, that’s all the time we have for the inaugural CAKE Magazine Radio Show. We’d like to thank the “callers” who participated — and don’t forget to visit www.cakemagazine.org for the recorded video show!
EDITOR’S NOTE:
Answers to these questions were submitted via email by the surgeons interviewed. Responses have been edited for length and clarity and edited into a Radio Show transcript. And while the CAKE Radio Show did not occur in real time, the answers are real.
