What does 2017 have in store for ophthalmology?

In preparing for the new year, Editorial Advisory Board members of Ophthalmology Times weighed in on a few questions about their predictions for how 2017 will impact ophthalmology as a specialty. A special thanks goes out to Samuel Masket, MD, Michael Snyder, MD, Sharon Fekrat, MD, FACS, Robert K. Maloney, MD, MA(Oxon), Richard S. Hoffman, MD, Andrew G. Lee, MD, and Randall J. Olson, MD, and Ernest W. Kornmehl, MD, FACS.

What most surprised/excited you in ophthalmology during this past year?

Dr. Masket: To my sense as an anterior segment surgeon the most exciting developments in 2016 were the release of the Kamra corneal inlay (AcuFocus), the Symfony IOL (Abbott), and the FDA approval of the “SMILE” procedure as all of these represent 3 new areas of technology. 

Dr. Snyder: This year, I was most excited by the release of the Hill-RBF artificial intelligence based IOL calculation program. This platform has already provided us with superior results within .5 D of target and as data is added, it will continue to become increasingly accurate. It is also great to have a program that will tell us a priori when the case fits within the highest confidence intervals of the program. In the rare cases where the Hill-RBF does not have enough data to as accurately extrapolate, it will issue an “out of bounds” notice to identify the outlier.

Dr. Fekrat: That we still have to give intravitreal injections every month for retinal diabetic neuropathy. 

Dr. Maloney: I was surprised at how good our results were with the new Symfony IOL. We are finding excellent distance vision and surprisingly good near vision. 

Dr. Hoffman: I started performing bavacizumab (Avastin, Genentech) injections for macular edema from diabetic retinopathy and AMD. I have found treating these patients to be quite rewarding and look forward to performing more of these procedures in the future.

Dr. Lee: Stem cell initial successes

Dr. Olson: Intratissue Refractive Index Shaping (IRIS)! This has now worked in rabbits and could rapidly make it to patients due to the novel nature of the technology. I see this as a real game changer!

Where do you see the most growth in the field of ophthalmology?

Dr. Masket: I believe that ocular imaging has shown and will continue to show the greatest expansion. In the foreseeable future I believe that OCT imaging may replace tractional slit lamp exam and ophthalmoscopy.

Dr. Snyder: I believe that angle-based glaucoma surgery will be a high growth area for 2017.

Dr. Fekrat: Gene therapy, visual cortical prosthesis Robotic Retinal Dissection Device (R2D2), preventing vitreous liquefaction.

Dr. Maloney: I think we will see significant growth in intracorneal inlays as a treatment for presbyopia.

Dr. Hoffman: I still feel that the refractive surgery market including LASIK and Refractive Lens Exchange (RLE) is being underpromoted. There is a huge potential market for RLE which, unfortunately, is currently dependent on our economy and patient’s ability to cover the costs of these procedures.

Dr. Lee: Laser technology, stem cell, gene therapy, OCT angiography

Dr. Olson: IRIS could be more important than cataract surgery as far as profitability but could really hammer a lot of the present technology. My prediction is it will be huge for ophthalmology.

Dr. Kornmehl: Inlays for presbyopia will become increasingly popular. It will be important for surgeons to offer both the Raindrop and KAMRA Inlays since they are most effective in different patient populations.

What are you looking forward to in 2017?

Dr. Masket: Perhaps not in 2017, but soon enough I am anticipating improved IOL designs with regard to accommodation and reduced incidence of undesirable side effects, including the dysphotopsias.

Dr. Snyder: The FDA study on the custom-matched, flexible artificial iris has completed enrollment of its PMA arm. I am hopeful that 2017 will usher in a PMA approval for this special device. [Disclosure: I am medical monitor for the study and a consultant for Humanoptics, the manufacturer of the device.]

Dr. Fekrat: Recently, the FDA approved prefilled ranibizumab (Lucentis, Genentech) syringes. Watson Health cognitive imaging tool for ophthalmology.

Dr. Maloney: I am hoping for FDA approval of the Light Adjustable IOL.

Dr. Hoffman: I am looking forward to future advancements in IOL technology including trifocal IOLs and increasing utilization of increased depth-of-focus IOLs.

Dr. Lee: Argus II

Dr. Kornmehl: Femto cataract surgery will continue to gain in popularity and will soon be the standard of care in some communities. Ophthalmic imaging will continue to play and expanding role in ophthalmology, particularly corneal surgery. Anterior segment OCT will be crucial in performing inlays in patient who have already had LASIK and PRK. We will soon have technology to measure the central cornea directly and distorted corneas, which will revolutionize our ability to determine implant powers in post refractive surgery patients and quickly fit patients with scleral lenses.

Where do you think the ophthalmic community will stand a year from now?

Dr. Masket: The political climate remains uncertain at this time with regard to reimbursements and regulations as restructured payment programs loom ahead. Furthermore, there is much political “noise” regarding the Affordable Care Act (Obamacare) and what might potentially replace it. At this time, “uncertainty” is the key word.

Dr. Snyder: I remain convinced that the ophthalmology workforce is well positioned to tackle the eye care needs of the population, recognizing a growth in the demographic that we serve. I do not see any major short-term changes in the field over the next year.

Dr. Hoffman: I do not believe there will be much change in ophthalmology one year from now. Hopefully, a lot of the government requirements for reporting etc. will disappear since they do nothing for cost savings or improving the quality of care.

Dr. Lee: Probably more move to hospital employment.

Dr. Olson: Much better off, but the presidential change and unknown as to legislation is a big unknown. Right now I am optimistic that ophthalmology will come out okay.

What do you see as the major hurdles ophthalmology will be confronting? 

Dr. Masket: The major hurdles remain the same as always; regulation and reimbursement.

Dr. Snyder:  I think the greatest threat to our ability to provide needed care is from potential disincentives within the health care systems and regulatory environments to provide care efficiently and pleasantly. Many outstanding providers who ordinarily might have practiced for many more years or decades are choosing to and thinking about retiring earlier, given the increasing regulatory administrative demands being placed between doctors and their patients. The most obvious of these hurdles is the electronic record mandates, though there are many other regulatory and government barriers in play, including PQRS and MACRA, which create perverse incentives and disincentives.

Dr. Fekrat: Physician burnout due to EMR and increased documentation, rules, regulations, and coding.

Dr. Hoffman: Additional government regulations and encroachment into the world of medicine which adds little to care except increasing practice cost and physician frustration. There will be a serious physician shortage 5-10 years from now from early physician retirement and fewer MD graduates. 

Dr. Lee: New regulations post Obamacare 

Dr. Olson: Even less pay for the same unit of insured activity. That is why the IRIS technology, as a refractive option, will be so important.