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Clinical News
OD PARTNERS’ LETTER
Quarterly clinical update information
SPRING 2005
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PRACTICE NOTES
We hope you found the winter edition of our OD Partners’ Letter of some value to your practice. This is the spring edition and there is a lot to update you on technology-wise and regarding developments at Nicolitz Eye Consultant (NEC).
Over the past year many of you have gotten to know David Mills professionally and personally. He has become part of the family at Nicolitz Eye Consultants. As you may recall us explaining when David first arrived last year that he would spend one year with us and then take a 2 year leave to complete a special fellowship in comprehensive oculofacial plastic surgery in New York. When he returns to us, this specialized training will make NEC one of the most advanced oculofacial plastic surgery practices in the southeastern US.
To continue to serve your practices with the highest quality surgical and consultative services, we have recruited another ophthalmologist, Dr. Lenka Champion who has finished her residency at the U. of Florida and will join us in July. She has a special interest in glaucoma and will be doing most of the glaucoma consults and laser procedures. We are looking forward to introducing you to Lenka in the near future.
Finally, we are excited and proud to share with you the progress on our new 30,000 sq, ft. office building and ASC (Southpoint Surgery Center) which is now under construction at Southpoint Pkwy. and Belfort Rd. opposite St. Luke’s Hospital.
The building is now under construction and scheduled for completion in spring of 2006. Over the coming months we look forward to talking to our OD partners about the unique role we will be inviting them to play in this new multidisciplinary facility. We believe it will represent a special opportunity for you, your practice and your patients.
Ernie,David,Chiel,Jennifer,Lou &Lenka
CASE OF THE MONTH
Patient: 28 year old
History: Soft lens extended wear for 10 years
Referred to NEC with continuing severe pain OS after 10 days of topical treatment
Treatment included Tobradex and Zymar
No objective or subjective improvement
Examination:
OS white eye upon examination @ 20/80
Central corneal infiltrate (oval, eroded edges)
2+ anterior chamber reaction
Impression: Resistance to 10 days of antibiotics strongly suggests acanthamoeba (severe pain) or fungal kerattitis
Plan: STAT corneal scraping and culture (under insurance, results would take 10 days. Patient strongly urged and accepted self- pay, 24 hour response process.)
Lab Results: Fungal keratitis
Plan: Referred to Frank Bowden for Natamycin Rx
Take home pearl:
1. “Masking effect” (white eye on steroids)
2. “Dx ex juvantia” (can rule-out bacterial infection thru non-response to antibiotics)
TECHNOLOGY UPDATE
For the past few years we have been talking extensively about PRELEX, refractive lens exchange, lens-based refractive surgery and the numerous other synonyms being applied to clear lens extraction for refractive purposes. Nicolitz Eye Consultants has led this field in Northeast FL since 1998.
Over the past 2 months, two landmark developments have moved this evolving area of eye care to a new level. The first is the FDA’s approval in March of 2 new multifocal IOLs; and the second and most monumentous is the Center for Medicare Services’ (CMS) new ruling regarding balanced billing for presbyopic correcting IOLs in cataract surgery.
The 2 new multifocal IOLs approved by the FDA for use in clear or cataract lens surgery, bring the number of approved specialized IOLs to 6. Each of these technologies has their own strengths and weaknesses, but collectively, they represent a set of options which can fit an increasing range of patient needs and desires in post-operative intraocular lenses and presbyopic correction.
The major features of each include:
1. Alcon’s ReStor (Diffractive multifocal, acrylic)
+ Near dominant, apodized optics
– Distance and near vision only
2. AMO’s Array (Zonal multifocal, silicone)
+ Distance, intermediate and near
– Halos in dark illuminations
3. AMO’s Array 2 (Zonal multifocal, silicone)
+ Powers start at – 10.00 to + 36.00
– Halos in dark illuminations
4. AMO’s ReZOOM (Zonal, multifocal, acrylic)
+ Reduced halos thru blended optics
– Limited powers
5. AMO’s Tecnis (Monofocal, ant. prolate, silicone)
+ 40% reduction in spherical aberration
– Monofocal optics
6. Eyeonics Crystalens (Accommodative, silicone)
+ Distance, intermediate and near
– Limited near vision (~ + 1.50 max.)
The second major development regards the CMS ruling issued May 3, 2005 that gives Medicare beneficiaries the choice to pay out of pocket for presbyopic-correcting IOLs. This is an unprecedented ruling for CMS which has always disallowed such balanced billing.
The fact that Medicare will now allow surgeons and facilities to be paid for the differential costs of these new presbyopic-correcting technologies and the additional services associated with them is sure to fuel expanded research and development in this evolving area of vision care. It was stated during the CMS hearings on this ruling that “…The net result will be an explosion of IOL technology at a pace we have not seen for many years.”
There is also concern about this ruling in that there is already and will continue to be a large stream of ophthalmologists credentialing in these multiple presbyopic-correcting IOLs. It is important to remember that these technologies and there implantation require considerably more specialized pre-operative diagnostic testing and more so, a much greater surgical skill level than associated with routine cataract surgery.
Nicolitz Eye Consultants made a commitment to refractive lens surgery in 1998 well before any of these new developments occurred. That commitment has created in our practice what we feel is the highest level of associated diagnostic technologies and surgical skill level available for patients in Northeast Florida and in fact, in the entire southeastern U.S.
We hope you will consider our unique experience in the field of lens-based refractive surgery as you counsel your patients in this growing area of care. We pledge to you the highest level of care, concern and surgical skill as we work together to make this evolving area of care beneficial to you, your practice and most of all, your patients. Thank you in advance for your trust.
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WINTER 2005
PRACTICE NOTES
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We are proud and honored to introduce to you a new program of Nicolitz Eye Consultants (NEC) and hopefully, a resource for you and your practice. We are calling it the “OD Partners' Letter” which will be a quarterly communication to the optometric physicians in the area with whom we share patients.
We are introducing this program for 3 very specific reasons:
1. NEC is a leading provider of new and innovative eye care procedures and technologies in Northeast FL. By educating and informing you of these services, we feel you will be able to offer state-of-the-art care to your patients as we further solidify our working relationship with your practice.
2. It has always been our personal philosophy that media marketing and advertising is merely a way of competing for “your” patients. We would much rather gain your trust and your support by serving you and your patients rather than competing for them. But to gain that support, we must try to keep NEC in your thinking and considerations when choosing “a partner” in your patients’ care. This Letter will be our way of “marketing” NEC to you directly. And finally…
3. We will be launching some major expansions of our facilities and services over the coming months and years and we want you to be a part of that growth. By sharing with you our plans and asking for your input and suggestions, we truly hope we can make you feel like a partner in our efforts. And that is the goal of this OD Partners’ Letter.
We hope we can achieve our mutual goals by communicating on a regular basis through this “Letter” and your suggestions and by working closely with you in the care of your patients. Thank you in advance for your support.
Ernie,David, Chiel,Jennifer,Lou
CASE OF THE MONTH
Patient: 58 year old female realtor
History:
- Referred by area OD for “3rd opinion”
- OD + 8.50 – 1.00 @ 180; BCVA 20/40 (Refractive amblyope) OS + 6.00 – 2.25 @ 170; BCVA 20/20
- Refractive IOL surgery Feb. 2004
- Post–op BCVA: OD 20/40; OS 20/20 “But blurry”
- OS posterior capsulotomy with no improvement
- Told “no problem” by 1º surgeon and 2 consultants
Examination:
- IOLs clear, centered and in the bag
- OS spec. Rx: + 1.00 – 2.00 @ 170
- Topography OS: 2.00 D asymmetric cyl @ 170
- Wavefront Analysis: 0.9 RMS trefoil (3rd order aberration mostly from cornea)
- (Normal trefoil should be < 0.4 RMS)
- Hard contact lens eliminates OS “blur”
Impression: 3rd order aberration (trefoil) producing OS distortion
Plan: Return patient to referring OD for aspheric back toric contact lens
Take home pearl: Diagnostic value of wavefront analysis (see this month’s “Technology Update”)
The “Case of the Month” in this OD Partners’ Letter is a good example of the value of the wavefront technology as a diagnostic tool. Even though most eye care practitioners think about the technology relative to custom ablation in laser vision correction, it is rapidly becoming an invaluable diagnostic tool in vision care and anterior segment disorders.
There are currently about 8 different types of wavefront technology being used to measure higher order aberrations HOAs. Nicolitz Eye Consultants is working with 4 types clinically and under clinical investigation protocols. They include LadarVision (Shack-Hartmann type) by Alcon for custom ablation; 3-D Wave (dynamic skiascopy type) by Marco for vision, anterior segment and lenticular diagnosis; i-Trace (ray tracing type) by Tracey Instruments for lenticular diagnosis; and Z-View (holographic imaging) by Ophthonix for experimental higher order correcting spectacles and contact lenses.
The ability to include HOA information in a patient workup has significant value in assessing more subtle vision problems such as:
- Eyes not correctable to 20/20;
- Lower order (sphere/cylinder) correctable eyes with questionable “blurs” and/or distortions (as in our “Case of the Month”); and
- Presbyopic and non-presbyopic near vision, accommodative difficulties.
For anterior segment diagnosis, the list includes (but is certainly not limited to):
- Tear film abnormalities (post blink tear instability, dry eye syndromes, etc.);
- Corneal epithelial disorders (ABMD, keratitis, contact lens related disorders, etc.) with or without visual effects;
- 1º and 2º corneal shape disorders (along with topography) such as the effects of ptosis, chalazia, early keratoconus, etc.; and
- • Pre- and post-operative phakic, aphakic and pseudophakic (IOL) abnormalities affecting vision (in Case of the Month).
Wavefront technology is truly an exciting area in eye care and we are just beginning to scratch the surface of its potential, especially in diagnosis. Please feel free to utilize our wavefront instrumentation and expertise in the care of your patients. We can offer you analysis and data transfer for your interpretation (and billing) or we can provide consultative interpretation as well.
CLINICAL PEARL
When an IOL is inserted into the capsular bag, its haptics often produce a fold in the posterior capsule. This is not considered an intraocular complication, but it can create an interesting post-operative visual reaction.
The fold tends to produce a “Maddox Rod” effect in the patient’s vision. If the effect is horizontal, it generally is of no consequence. However, oblique or vertical Maddox Rod effects are notorious for producing subtle, subjective visual disturbances that the patient usually can’t articulate or describe effectively.
This subtle problem can be dealt with by a skilled lens surgeon during the procedure by rotating the IOL until the haptics create a vertical capsular fold which will result in a horizontal Maddox Rod effect in the patient’s vision. This little “trick” is invaluable in refractive lens surgery.
So the next time a post-op IOL patient (cataract or refractive) gives you that vague complaint of “something just not right” about their vision in one eye or both, measure their Maddox Rod effect. It could be their problem and your answer. A YAG capsulotomy may reduce the effect, but it’s best to avoid it during the primary surgical procedure.
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PRACTICE NOTES
Things are really moving at light speed here at Nicolitz
Eye Consultants. We are particularly excited and proud
of our growing professional staff.
Dr.
Jennifer Henson had to take a leave of absence from the
practice due her husband’s (naval Cmdr.) special assignment
to serve a 4 star Admiral in Europe. Jenn also is pregnant
and we wish her and her new family the very best during
their absence.
But talk
about good fortune! Replacing Jenn is one of our most
respected Jacksonville colleagues, Dr. Mary Rosenbaum.
Mary, who will be NEFOS president next year, will be with us
full-time starting in July.
Meanwhile,
Dr. Lenka Champion continues to develop her surgical
practice as she works closely with Northeast FL medical and
optometric physicians. She greatly appreciates her warm
reception to the ophthalmic community over the past year and
thanks each and every OD for their strong support.
And
now!!!... In September, Nicolitz Eye Consultants (NEC) will
be moving its primary offices to the 3rd
floor of the new Southpoint Surgery Center on Belfort Rd.
The 2nd
floor of this 36,000 sq. ft. facility will be medical
offices and the 1st
floor will be the largest, state-of-the-art, hi-tech
ambulatory surgery center (ASC) in Northeast Florida.
This
facility will give NEC the opportunity to provide the entire
optometric community with a new level of secondary/tertiary
medical-surgical eye care utilizing the latest technologies
and procedures in eye disease care and lens/corneal-based
refractive surgery.
Our
increasing commitment to optometry is a major part of this
exciting venture. We are planning 2 initiatives, one
immediate and one long term, to make our pledge to you a
reality and make NEC a valued resource for you, your
patients and your practice.
In
November, we will conduct the inaugural NEC Optometric
Symposium to be held at the Southpoint Surgery Center (SPSC)
and our clinical offices. The program will include a
closed-circuit TV broadcast of live, lens-based refractive
surgeries utilizing the latest presbyopic IOLs.
The
surgeries will be followed by live (recent and long term)
post-op presbyopic IOL patients for examination by attendees
in the 3rd
floor NEC offices. There will also be a presentation by a
nationally recognized optometric practitioner on ASCs and
new concepts in optometric coding and comanagement.
Due to the
hands-on nature of this program, there will be limited
attendance, by invitation only. Please let us know (tel.
904 398-2720; ask for Pat) if you would like an invitation
to this special meeting.
The second
(long term) initiative NEC will be conducting with the
optometric community starting in 2007 regards your active
participation in the intra-operative and post-operative care
of your patients treated at SPSC. We will be outlining this
unique clinical program in our next newsletter.
These
initiatives are only the beginning of a stronger
relationship we hope to build with Northeast FL optometric
physicians. We will be working hard to expand educational,
clinical and economic opportunities to our referring ODs as
NEC advances as the leading ophthalmic surgery practice in
NE FL.
TECHNOLOGY UPDATE
For the past few years we have
been talking extensively about PRELEX, refractive
lens exchange, lens-based refractive surgery and the
numerous other synonyms being applied to cataract and clear
lens refractive surgery. Nicolitz Eye Consultants
(NEC) has led this field in Northeast FL since 1998.
Over the past year, two landmark developments
have moved this evolving area of eye care to a new level.
The first is the FDA’s approval in March, 2005 of 2 new
multifocal IOLs; and the second and most significant is the
Center for Medicare Services’ (CMS) new ruling regarding
shared billing for presbyopic correcting IOLs in cataract
surgery.
The 2 new multifocal IOLs approved by the FDA
for use in clear or cataract lens surgery, bring the number
of approved specialized IOLs to 4. Each of these
technologies has their own strengths and weaknesses, but
collectively, they represent a set of options which can fit
an increasing range of patient needs and desires in
post-operative intraocular lenses and presbyopic correction.
The major features and strengths (+) and
weaknesses (–) of each include:
1.
ReStor by Alcon (Diffractive multifocal, acrylic)
+ Near dominant, apodized optics
– Distance and near vision only
2.
ReZOOM by AMO (Zonal, multifocal, acrylic)
+ Reduced halos thru blended optics
– Cortical adaptation (up to 3 mos.)
3.
Aspherics by multiple companies
+ 40% reduction in spherical aberration
– Monofocal optics (no near vision)
4.
Crystalens
by Eyeonics (Accommod., silicone)
+ Distance, intermediate and near
– Limited near vision (~ + 1.50 max.)
The second major development regards the CMS
ruling issued May 3, 2005 that gives Medicare beneficiaries
the choice to pay out of pocket for presbyopic-correcting
IOLs. This is an unprecedented advance for CMS which has
always disallowed any form of shared billing.
The fact that Medicare will now allow surgeons
and facilities to be paid for the differential material
costs ($750/lens) of these new presbyopic-correcting
technologies and the additional services (>$1,300/eye)
associated with them is sure to fuel expanded research and
development in this evolving area of vision care. It was
stated during the CMS hearings on this ruling that “…The net
result will be an explosion of IOL technology at a pace we
have not seen for many years.”
There is also concern about this ruling in that there is
already and will continue to be a large stream of
ophthalmologists credentialing in these multiple
presbyopic-correcting IOLs. It is important to remember
that these technologies and there implantation require
considerably more specialized, pre-operative diagnostic
testing, optics considerations and a much greater surgical
skill and experience level than is associated with routine
cataract surgery.
Nicolitz Eye Consultants made a commitment to refractive
lens surgery in 1998 well before any of these new
developments occurred. That commitment has created in our
practice what we feel is the highest level of associated
diagnostic technologies, wavefront optics skills and a level
of surgical skill and experience unsurpassed in Northeast
Florida and in fact, in the entire southeastern U.S.
We hope you will consider our unique experience
in the field of lens-based refractive surgery as you counsel
your patients in this growing area of care. We pledge to
you the highest level of surgical care and appropriate,
equitable comanagement fees for your patients’ presbyopic
IOL care as we work together to make this evolving area
beneficial to you, your practice and most of all, your
patients. Thank you in advance for your
trust.
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WINTER 2007
This will be completed in
the near future.
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