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Bill Prentice: 0:37
Hello, and welcome to the Advancing Surgical Care Podcast. My name is Bill Prentice, and I'm CEO of the Ambulatory Surgery Center Association, or ASCA. I'll be joined on today's podcast by Dr. David George, a board-certified ophthalmologist in Marietta, Ohio, and Parkersburg, West Virginia, and medical director of Physicians Outpatient Surgery Center in Belpre, Ohio. Dr. George specializes in outpatient eye surgery, laser-assisted cataract surgery and refractive surgery. And I've asked Dr. George to join today for a brief discussion about elective eye surgeries, including why and when eye surgery becomes necessary and what patients should know and expect from eye surgery, both before, during and after a procedure. His most common therapeutic procedure is cataract surgery. Dr. George graduated from Ohio State University with distinction. He completed medical school at the Ohio State University College of Medicine, interned at Riverside Hospital and completed his residency in eye surgery at Ohio State University. Dr. George also received a master's in healthcare management from Harvard University. As I mentioned a moment ago, Dr. George is board certified by the American Board of Ophthalmology. He's a member of the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery. He's a past board member of ASCA and is a current leader in the Outpatient Ophthalmic Surgery Society. His special interests include laser-assisted cataract surgery, advanced technology intraocular implants to reduce dependency on glasses, refractive surgery, such as LASIK and PRK, and surgical procedures for glaucoma. With that lengthy introduction, let me welcome David.
David George: 2:19
Thanks for having me, Bill.
Bill Prentice: 2:21
Great, happy to have you. So, David, let's start with a discussion about cataracts. As you know, more than 3 million Americans undergo cataract surgery each year. And by the time any of us reaches the age of 80, more than half of us will have had or need to have this surgery. Can you explain to our listeners why someone would need cataract surgery and also what that surgery entails?
David George: 2:43
Well, cataracts are basically a clouding of the human lens, the natural lens of the eye; it happens to everyone eventually. The time to really think about cataract surgery is when that cloudiness impairs the vision enough to where it starts affecting the patient's activities of daily living, like trouble driving, trouble reading, glare. The patient really needs to have a problem to really undergo the surgery. It's not meant to be an elective refractive procedure in general. So, when patients are impaired, they can come to us and we can evaluate them to see if they're a candidate for the surgery. The surgery itself is done as an outpatient procedure. It's probably the most common outpatient procedure done in the country. So basically a patient would go to the hospital or surgery center, in my case surgery center, and the patients go home after the procedure. It usually takes about 10 minutes depending on the technique. Some newer technology actually increases the time a little bit; laser-assisted cataract surgery has an extra step that takes a few extra minutes for the case, but in general, patients go home. Vision starts out a little blurry, a little scratchy, patients slowly get better over a week or two, generally go back to their normal activities the next day. So, it doesn't set people back like it used to years ago.
Bill Prentice: 4:01
Speak to that, because my understanding is that if someone got cataract surgery a generation or so ago it was a much different experience. Can you contrast what it was like to get cataract surgery 20–30 years ago versus the experience now?
David George: 4:18
Years ago, we would use a much larger incision and take the entire cataract out in one big piece. So the incision was about 13 millimeters long and would take several sutures to close it. That long incision took a long time to heal. Patients couldn't bend or lift, you have to worry about the incision coming open and the incision wasn't stable over time as the years go on. The incisions induced a lot of astigmatism that drifted considerably, and that astigmatism has to do with the shape of the cornea. It's essentially not round like a ball but more like a spoon, and that shape changes with those large incisions. Today's incisions are about an eighth of an inch. We don't even use sutures to close most of them, they self seal. Patients can bend and lift, they can recover quicker, there's not a lot of activity restrictions. We simply just ask patients to keep the incision clean. So, the incisions are much sturdier and safer and the refractive outcomes, as far as astigmatism production, are much more predictable.
Bill Prentice: 5:21
So, it's safe to say if somebody recalls maybe their parent or grandparent getting a cataract procedure and what they may have gone through, it's far different today— much simpler procedure from the patient's perspective and their recovery time is much easier than it used to be.
David George: 5:39
Yes, that's correct. Patients generally feel almost no discomfort having it done, maybe a little pressure at most. They go home the same day, it's a little scratchy. But most patients say it's not as bad as what they would envision, and they really do get a pretty quick recovery in most cases.
Bill Prentice: 5:55
Before moving on from cataracts, what about the technology for the lenses for intraocular lenses? How has that changed over time and how does that impact the patient experience?
David George: 6:06
Yes, there have been a lot of advances with the implants for surgery. For decades, we've used simply monofocal implants which are set for the distance—they don't change focus, they don't correct astigmatism. So more of these patients would really required glasses to be functional; in fact, most of them did. Today, we have options where we have lenses that can correct astigmatism, or at least reduce it, to where patients can get pretty good distance vision. On top of that, we have other implants that correct presbyopia, or that difficulty seeing at near, so that after surgery, patients can get a full range of vision from distance to near without wearing glasses. And that's something they probably didn't have most of their life or at least since their 50s. So some of these options, they're expensive, it's expensive technology, but we do have options that are available for patients to get to choose pretty much what their outcome is going to be like. If patients can afford the presbyopia correcting lenses, they can be free of glasses, if that's something they desire.
Bill Prentice: 7:11
That's fascinating. Listen, I want to talk to you about a couple other procedures, but if you don't mind, I'd like to pause now for a message from our podcast sponsor.
This episode of the Advancing Surgical Care Podcast is brought to you by Somnia Anesthesia, a national perioperative anesthesia management company, bringing advanced anesthesia and pain management techniques to surgery centers for 27 years. Somnia’s anesthesiologists and nurse anesthetists integrate fully with ASC clinical teams to deliver safe, high-quality care. Learn how they do it at somniainc.com.
Bill Prentice: 7:52
David, you're also a specialist in refractive surgeries that are commonly performed to correct vision errors like nearsightedness, farsightedness and astigmatism. Can you tell us who may want or need to undergo a refractive surgery, and what it involves and what the expectations for a patient should be about improving their vision using one of these technologies?
David George: 8:14
Well, refractive surgery, surgery to decrease dependency on glasses or contacts, is totally elective; it's not medically indicated, hence it's really not covered by insurance in general. So, the people that want to be free of glasses and are willing to pay for the procedure really need to have healthy eyes—you can't have a cataract, you can't have macular degeneration or a pathology. So in general, it's a younger patient population, generally over 21. There's many options for the procedure—the ones I'm most familiar with are LASIK or Advanced Surface Treatment or PRK. The LASIK offers the quickest recovery because you make a flap and you reshape the eye and replace the flap. Patients generally see pretty good the next day. With PRK you resurface the whole eye without the flap and it takes longer to heal. And you may say, why do one versus the other? Well, it comes down to how thick the cornea is and how much correction there is. Not everybody is a LASIK candidate; more people may be a PRK candidate. But patients generally want LASIK. They want the quick recovery, they want to be able to do both eyes the same day, you don't have to but almost all of them do. So, it's the young, healthy eye—generally patients between 21 and 40 or 45.
Bill Prentice: 9:32
If a patient were interested in finding out whether or not they'd be a good candidate for either of those procedures, what's the starting point? How do they go about finding out if that's an option for them?
David George: 9:43
Well, generally they can talk to their optometrist or they can make an appointment to see a LASIK surgeon. What it comes down to is, is there any pathology, as we discussed. Number two is, what is the refractive errors, is it something that's within the treatment limitations—we could treat quite a bit. And number three, how thick is their cornea, and we'd have to do measurements to determine that. So, we can very quickly tell if someone's a candidate when we have them in the office, but you can't really do it over the phone.
Bill Prentice: 10:13
Sure. So out of, say, 100 patients that come to you seeking one of those procedures, about how many of them couldn't have it because of one of those pathologies you mentioned?
David George: 10:24
Probably five, maybe 10.
Bill Prentice: 10:27
David George: 10:28
So, most patients are candidates. The biggest ones that I end up turning away are patients that are 55 years old or 60 years old, and they can't see up close but they see great in the distance. Well, LASIK is to provide good distance vision. Their problem is they can't accommodate anymore due to age. LASIK doesn't fix that. So, we turn a lot of those patients away because they have a misconception of what LASIK does.
Bill Prentice: 10:51
Right. They're stuck with their reading glasses.
David George: 10:53
Bill Prentice: 10:54
Got it. So, in addition to the millions of people who have experienced this substantial improvement in their quality of life as a result of either a cataract or refractive surgery, there are also millions who are afflicted with other serious conditions and diseases of the eye, like glaucoma. Why is it so essential that patients with a disease such as that are seen regularly and what can you do to help a patient with something like glaucoma?
David George: 11:19
Glaucoma is something that most patients don't know they have until it's really severe and there has been a lot of damage done. It slowly robs your side vision and it's something you would not notice as a patient. We can check it in the office by checking the visual field. So, in general glaucoma happens, it can run in families, but it generally happens more frequently when patients get older. So, we recommend routine eye exams and the frequency of exams gets greater when you're 65 or older because there's a greater chance you're going to get glaucoma. One in 50 patients will have glaucoma, and over time it really can cause a lot of visual loss if it's left untreated. So, this is why we recommend yearly checks in the office. Most glaucoma patients can be treated with a laser procedure or with eye drops to get the pressure down, and that protects from further vision loss by simply lowering the eye pressure. And there's some new technology now, there's some things we do surgically that we call minimally invasive glaucoma surgeries, or MIGS. One that we do is called the iStent, it's something you put in at the time of the cataract surgery. It's FDA approved only for implantation during the surgery, but you put a couple of drains into the drainage system where the fluid drains out of the eye and helps lower the pressure. It's kind of a second procedure you can do, just takes a few minutes more in the operating room. And there's other ones that can be done without cataract surgery, such as a XEN procedure or Hydrus procedure. I'm not mentioning all of them, but there are new devices that can be used surgically to decrease the eye pressure and treat the glaucoma.
Bill Prentice: 13:04
That's fascinating. And I think obviously the larger lesson here is, don't wait until you have a problem, particularly as you're getting older, to make sure that you're visiting your ophthalmologist and getting those checks to prevent those types of problems from ever starting.
David George: 13:18
Exactly. Yes, it's important to have routine eye exams, especially when you're over 65.
Bill Prentice: 13:23
Well, that's great. Well, David this has been fascinating. I've learned a lot, I hope our listeners have as well. And I want to appreciate you taking a few minutes out of your busy day to talk with me.
David George: 13:34
I appreciate you having me, Bill. It's good to see you again.
Bill Prentice: 13:37
Before closing this podcast, I would like again to acknowledge the support of our ASCA affiliate Somnia Anesthesia, a national anesthesia management company bringing advanced anesthesia and pain management techniques to surgery centers for over 27 years. Learn more at somniainc.com. So until next time, thanks for listening and please continue to follow your local public health guidance.