Article

The Future of Surgical Retina in the Era of Medical Retina

Commentary from a leader in vitreoretinal surgery.

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Vitreoretinal practice has been radically transformed over the past 15 years by the development of intravitreal injections of anti-VEGF agents for wet AMD, diabetic macular edema, retinal vein occlusions, and a variety of other disorders. Success rates are astounding and complications near zero.1 The near-total replacement of angiography by OCT has occurred in parallel with widespread adoption of anti-VEGF therapy. Angiography rarely provides clinically useful information not provided by spectral domain or swept source OCT. Ultimately, OCT angiography may provide enough information so that conventional angiography is no longer needed.

THE RISE OF OFFICE PRACTICE IN RETINA

I believe that micropulse laser, yellow wavelength laser, navigated laser, and widefield angiography-driven targeted laser are largely the agonal throes of the declining laser industry. In my experience, laser retinopexy has clearly shown to be superior to cryopexy, and it is essential for the treatment of retinal breaks/tears/holes, macroaneurysms, and various forms of telangiectasia. Although anti-VEGF agents are probably superior to panretinal photocoagulation for proliferative diabetic retinopathy, many patients present late in the course of the disease, raising questions about compliance; therefore, PRP will continue to play a role in PDR treatment.

Monthly injections of OCT-guided anti-VEGF agent injections dominate retinal office practice and have dramatically driven up patient volumes and helped a multitude of patients; this has truly been a revolution. Overpromising and underdelivering has been the theme to date for drug reservoirs, sustained release anti-VEGF agents, and gene-therapy–mediated intraocular anti-VEGF agent production; injections at 5- to 8-week intervals will probably be with us for many years to come. Endophthalmitis, relatively frequent reservoir refilling, and stochiometric and pharmacokinetic issues haunt the reservoir development prospects. Inflammation, macular hole from subretinal injection, and low efficiency have been serious barriers to gene therapy to produce anti-VEGF agents within the eye.2

Steve Charles, MD, FACS, FICS is with Charles Retina Institute in Germantown, Tennessee. Kevin J. Corcoran, COE, CPC, CPMA, FNAO, is president of Corcoran Consulting Group in San Bernardino, California. Dr. Charles reports consultancy to Alcon.

Most of today’s leading retinal specialists are high-volume clinical trial recruiters who are very knowledgeable about clinical trial design and outcome analysis. The pharmaceutical pass-through cost in most, if not all, clinical practices exceeds physician collections. Pharmaceutical company revenue for Eylea (Regeneron) and Lucentis (Genentech) is greater than medical device company revenue for capital equipment and associated consumables for vitreoretinal surgery. Most vitreoretinal specialists make more money from office practice — office visits, imaging, intravitreal injections, and clinical trials — than they do from surgery. Group retinal practices continue to grow to cover satellite clinics and the high volume of patients seen for anti-VEGF injections. There are many retinal fellowships to meet the demand; far and away most of these fellowships are surgical as well as medical. An unintended consequence is decreased surgical volumes, which creates a concern about quality, especially with difficult cases such as PVR, giant retinal breaks, and diabetic traction retinal detachments.

SURGERY IS NOT DEAD

Laser vitreolysis has recently been highly overpromoted; 25-gauge and 27-gauge pars plana vitrectomy is far more effective and quite safe when appropriate techniques and technologies are utilized.3 Company and physician revenue unfortunately seem to be the prime drivers of laser vitreolysis utilization.

Small-gauge vitreoretinal surgery for retinal detachment, PVR, giant retinal breaks, vitreous hemorrhage, vitreomacular disorders, dislocated lens material, dislocated IOLs, intraocular foreign bodies, and many types of ocular trauma will never be replaced by nonsurgical pharmacologic intervention. The world’s expert in endophthalmitis, Harry Flynn, MD, teaches that there are expanding indications for vitrectomy in these critical cases, although many can be managed by “tap and inject” with intravitreal antibiotics. OCT imaging has driven a marked increase in vitrectomy for vitreomacular disorders; surgeons often repair clinically invisible disorders for the benefit of patients.

Part B Medicare Reimbursement for Retina Specialists

Kevin J. Corcoran, COE, CPC, CPMA, FNAO

CMS data provide some history of the volume of procedures performed by ophthalmologists and optometrists. Although we do not have public data for other third-party payers, we can gain some insights about the trends discussed in the nearby article by Steve Charles, MD, from Medicare Part B, or traditional Medicare, which covers about two-thirds of all Medicare beneficiaries.

Within the most current Part B Medicare Physician and Other Supplier Public Use File, known colloquially as the data dump, we can identify 3,811 ophthalmologists who perform any posterior segment surgeries. Within this group, 1,366 (36%) provide a full spectrum of retina procedures including pars plana vitrectomy (PPV), retinal detachment (RD) repair, laser, and intravitreal injection. The remaining 2,445 (64%) provide medical retina, primarily intravitreal injections and lasers, and 1,309 of those are comprehensive ophthalmologists who also perform anterior segment procedures.

Of the 1,366 full-spectrum retina specialists we identified, they differ in the amount of surgical retina procedures: 122 (9%) concentrate on PPVs and RD repairs with only a few intravitreal injections; 1,154 (85%) concentrate on intravitreal injections with only some PPVs and RD repairs; 90 (7%) concentrate on other types of ophthalmic surgery and perform only a few PPVs and RD repairs.

While the Medicare database is flawed because it omits hospital-based ophthalmologists and very low-volume physicians, the ratio of medical to surgical retina specialists, 2.2:1, is interesting and suggestive. The future of surgical retina is in a few hands while the volume of intravitreal injections, 2.96 million in CY 2015, consumes the most time and resources.

Figure 1 shows the growth of intravitreal injections within Part B Medicare. There is no evidence that the rate of growth of intravitreal injections is slowing.

Figure 1. Medicare utilization of intravitreal injection.

In comparison, there is no growth during the same time interval for vitrectomies and RD repairs, and there is a decline in retinal laser procedures (Figure 2).

Figure 2. Medicare utilization of major retinal surgery.

At present, implantable drug delivery devices including Ozurdex (Allergan), Retisert (Bausch + Lomb), and Vitrasert (Bausch + Lomb), represent a very tiny part of vitreoretinal surgery.

The imaging tests that support evaluation and management decisions of retina specialists include fundus photography, scanning computerized ophthalmic diagnostic imaging of the retina (SCODI-R), fluorescein angiography (FA), and indocyanine green (ICG) angiography. Figure 3 shows the growth of the volume of those procedures for all ophthalmologists, not just retina specialists. Without doubt, SCODI-R dominates all other imaging tests and will likely continue to do so.

Figure 3. Medicare utilization of retinal imaging.

Overall Part B Medicare expenditures for the professional services of ophthalmologists and optometrists in calendar year 2015, the most recent year for which data are available, are described in Table 1.

Table 1: Medicare Payments for Eye Care
OPHTHALMOLOGY OPTOMETRY
Eye exams $2.2 B $0.9 B
Tests $1.0 B $0.2 B
Surgery $2.3 B $0
Supplies $3.0 B $0
Total $8.5 B $1.1 B

The elephant in the room is the cost of drugs. Just 2 anti-VEGF agents, ranibizumab (Lucentis; Genentech) and aflibercept (Eylea; Regeneron), represent 93% of the ophthalmic supplies in Table 1. The Medicare Part B payments for these in CY 2015 were $1.1 billion and $1.7 billion, respectively. All other supplies, including bevacizumab (Avastin; Genentech) ($48 million), were inconsequential by comparison. Presidential and Congressional action on payments for prescription medications can be expected in the future, and perhaps very soon if extraordinary price increases continue to make headlines in the news media. Unlimited pricing flexibility for pharmaceutical manufacturers is unlikely to continue. We only have to look to Canada, Europe, and Japan for examples of price containment policies on drugs.

Dr. Charles observed that, “Although medical retinal practice volume, efficacy, and revenue have dramatically increased because of anti-VEGF agents and OCT, vitreoretinal surgery is not going away.” Training programs for full-spectrum retina specialists with surgical skills are still needed, but training for medical retina specialists serves a wider physician audience and will satisfy a larger patient need. Young ophthalmologists considering fellowship training would be wise to weigh the relative demand for surgical retina vs medical retina.

Surgery for retinal detachment for ROP is rarely indicated and rarely successful in stage 4 or 5 cases. This disease is best managed by NICU process, timely retinal clinical examination or telemedicine, and treatment with intravitreal anti-VEGF agents. Laser will be utilized less and less, and patients requiring surgery represent process failure, for the most part.

Although medical retinal practice volume, efficacy, and revenue have dramatically increased because of anti-VEGF agents and OCT, vitreoretinal surgery is not going away. Small-gauge 25-gauge and 27-gauge vitrectomy has low complication rates and high patient satisfaction. It has, fortunately, largely supplanted scleral buckling, which causes refractive error, increased phorias and tropias, ptosis, pain, ocular surface disorders, difficulty for glaucoma surgeons, and buckle extrusion.4

In the highly detailed analysis that accompanies this article, Kevin Corcoran, COE, illuminates vitreoretinal surgery trends in the Medicare market. Access to this information informs and confirms our view of the state of medical and surgical retina. Also, according to industry sources, an estimated 300,000 surgeries are being performed yearly, approximately 3 times the number that can be accounted for with Medicare data.

SYNERGY BETWEEN MEDICAL AND SURGICAL RETINA

Vitreoretinal surgery improves the vision and lives of most patients, is enjoyable to the surgeon in most instances, and is a welcome break from reading OCTs and injecting. And although some vitreoretinal specialists may experience burnout from the repeated “OCT and inject” cycle in office practice, I think it well to remember the incredible outcomes achievable with anti-VEGF agents and the rich diagnostic capability of OCT and OCT angiography.

REFERENCES

  1. Brand CS. Management of retinal vascular diseases: a patient-centric approach. Eye (Lond). 2012;26(Suppl 2):S1-S16.
  2. Grob SR, Finn A, Papakostas TD, Eliott D. Clinical trials in retinal dystrophies. Middle East Afr J Ophthalmol. 2016;23(1):49-59.
  3. Milston R, Madigan MC, Sebag J. Vitreous floaters: etiology, diagnostics, and management. Surv Ophthalmol. 2016;61(2):211-227.
  4. Kinori M, Moisseiev E, Shoshany N, et al. Comparison of pars plana vitrectomy with and without scleral buckle for the repair of primary rhegmatogenous retinal detachment. Am J Ophthalmol. 2011;152(2):291-297.