Eyedolatry

More Medicare Musings: Why Lucentis is Worth the Price Tag

Macular Degeneration is the leading cause of blindness
in the United States. It can be found during routine eye exams,
but don't wait to get your eye health checked until you
have vision issues! There is no cure of macular degeneration,
and treatments that exist work best when started early in the
disease process!

With Medicare announcing its 2012 payments last month, ophthalmology had a microscope upon them as questions about why $20 million was paid out to a single ophthalmologist in Florida that year. While there is an investigation about whether these charges were fraudulent, the entire world of ophthalmology has been getting lambasted in the press over the expensive use of Lucentis to treat wet macular degeneration.

You see, Lucentis costs Medicare about $2000/injection. But Avastin, a drug made by the same company (Genentech) that is biologically similar, cost only $50/injection.

Lucentis is a "snip" off the larger Avastin molecular, designed to
be specifically used in the eye via

Why aren't ophthalmologists saving Medicare (and taxpayers) an estimated $1 billion by using Avastin? These recent news articles would lead you to believe they are the exact same drug, with the exact same efficacy. And it is true that studies have shown Avastin and Lucentis do have a very similar efficacy when used to treat macular degeneration. But Lucentis has been FDA tested and approved for intravitreal injection to treat macular degeneration, and Avastin has not. Avastin usage in the eye is still considered "off-label" since Genentech has never sought FDA approval for this use of Avastin.

Doctor's use off-label applications of medications very frequently, and using Avastin for macular degeneration does have science to support the doctor's decision to do so. But are we forgetting why so many doctors that were often using Avastin made the switch over to Lucentis in 2012 any way?

via

Unlike Lucentis that comes ready from the parent company Genentech for doctors to inject in their offices, Avastin has to be compounded into formulation for ocular injection. This is the job of a compounding pharmacist, someone that the ophthalmologist or surgery center would contract with to ready their injections. Unfortunately Florida, Tennessee, Texas, and a VA hospital in Los Angeles all had separate instances of contamination during this compounding procedure in 2011. At least 21 people across those instances were infected by the Avastin injection, and in some cases the infection resulted in blindness. One of the patients that lost vision sued for a reported $4 million, with litigation against the ophthalmologist, the pharmacy, and Genentech who manufactured Avastin.

Under this heavy fire, here was Genentech's statement to the New York Times:

“Avastin is not manufactured or approved and to date has not been proven safe for use in the eye,” a spokesman for the company said Tuesday.

So why would any ophthalmologist be willing to risk infection of a patient by using Avastin, if they would not have the support of the company who made that drug? It would be a huge financial and ethical risk if doctors did not disclose to patients this risk of infection (no matter how small), and if both treatments are covered by the patient's insurance, why would the patient choose the off-label treatment with infection risk, versus the FDA-approved treatment?

It has been hard reading the news the last few days as the media has continued to spin against ophthalmology's practices. But the truth is, ophthalmologists were using the FDA-approved treatment they had on the market to treat a condition that is the leading cause of blindness in the United States. Would you want your parent or grandparent to be blinded by macular degeneration, when there is a safe, FDA-approved treatment? Absolutely not. And until ophthalmologists get industry and FDA support for using Avastin safely, why would they make the switch? Doctors have to think about their patients, and not about tax payer dollars, unfortunately. And when you are the patient looking at 2 treatment options: one FDA approved, and one not, which would you pick? You probably aren't thinking about taxpayer dollars at that moment either; just about your vision which is in imminent risk of permanent loss.

Optometrists, ophthalmologists, healthcare practitioners of all branches, and mostly the patients who are getting these treatments need to band together right now for what makes sense. This is not the time for finger pointing, even though the financial burden on our health care system seems so overwhelming, blaming someone is the easiest option to "fix" things. We want the best treatments for ourselves and our families, and doctors want to offer their patients the best standard of care. When we want so much, sometimes it starts to get expensive. And unfortunately, there is just no one that can be blamed for that simple fact.

Share |

Eye Art

Dallas Eye Sculpture 10:40 PM

Share |

The Battle We Won...Did You Know We Fought it?

ABB superior vision 10:21 PM

You don't need me to tell you that health care is changing. In optometry, it sometimes feels like health care is changing every single day. As insurers try to cut their own costs, many new policies are being explored in how insurances reimburse practices for services and goods. Here's an example of a recently proposed plan by Superior Vision that was supposed to go into effect May 1st:

Currently Superior Vision gives member an X dollar amount benefit towards the purchase of "covered" contact lenses. The patient can use their X amount benefit towards purchasing contact lenses through any in-network doctor's office. Beginning May 1st Superior Vision had planned to change this policy so that patients that had their plan would only be able to order their contact lenses through Superior Vision's personal web portal. In essence, the doctor or office would not order or supply the contact lenses. Superior Vision would provide the lenses, and collect the profit on the lenses for themselves. They would pay the doctor's office $5 to process and handle the data collection for them. The patient would lose all ability to price shop, and be forced to use only the web portal for their purchase.

As a doctor, of course this is immediately offensive. The insurance company would now control sales of contact lenses entirely, forcing small business owner (otherwise known as private practice) optometrists to lose a previous revenue source.

But to a patient, what did Superior Vision's proposed contact lens plan mean to you? Superior was not discounting contact lens prices, and some contact lenses were found to be more expensive through Superior's portal than they were at the current independent doctor's office. Yes, for some lenses you were going to have to pay more for your lenses by purchasing from Superior directly! Additionally, by having the insurance company control how you use your benefits entirely, you would have no ability to shop around or price match with other offers, either at an office or on other websites. You would have to use their service only, and accept their price, no matter how non-competitive. Obviously a major disadvantage for the patients as well!

Luckily, this shockingly bad plan that compromised doctors and patients both was thwarted at the last minute. When they got hit with a letter detailing the change from Superior in late March, private practice doctors immediately started voicing their concerns, and many threatened to stop doing business with ABB (the contact lens supplier that Superior Vision was going to use to fill their orders). Within a very short time, ABB ended their partnership with Superior Vision due to the risk of losing so many private practice accounts, and without a contact lens vendor, Superior was forced to withdraw their new policy plan. But did most of us know we fought this battle and won? It is scary to me that so little press was given to this proposal and its subsequent demise. Optometrists (and people with vision insurance!) please stay vigilant! We can't ban together to collude about pricing, but we can each personally take a stand and refuse to let our career and our patients suffer from insurance monopolies. Please post here, email me, contact your congressman, do whatever you can to fight for patient and optometrist rights, because all of our voices are needed right now. We are so close to losing major battles for pricing fairness to both doctors doing the work and patients trying to use the benefits they paid for, so please don't let your voice go unheard.

Share |

The Patient's Guide to Optic Nerve Drusen

b scan drusen 3:28 PM

Let me start with a picture:

Remember, this (above) is what a normal retina looks like. The red dot in the center of the photograph is the macula, and the yellow circle to the right is the optic nerve. Think of the nerve as a chord that hooks your eye to the brain, a high-speed information highway. The above picture shows a textbook average optic nerve. via

Above, things look slightly different, right? Can you see how the optic nerve looks slightly indistinct, crowded, almost blurry (to the untrained eye)? The above optic nerve is also slightly elevated when you look inside the eye with 3D vision. This is a great example of a crowded optic nerve, crowded because there are deposits buried inside the tissue. This picture depicts Buried Optic Nerve Drusen.

What are Drusen?

Drusen are calcified deposits inside the nerve tissue, thought to be remnants of waste or dead cell matter from the nerve's retinal ganglion cells. Studies suggest drusen can be found in about 1% of the population. Typically drusen are asymptomatic, meaning they don't cause any vision side effects. In younger patients, the drusen bodies tend to be buried within the nerve, making them less visible to the doctor upon examination. The earliest age that doctors may start seeing the signs of drusen in the nerve is typically around 12. With age, the drusen will sometimes be pushed towards the optic nerve surface, revealing their distinct, circular shapes. The patient above is in their twenties, so the obvious drusen bodies are buried beneath the surface. You can only see their side effect -- they are pushing the nerve fibers upward, making the nerve look elevated during the eye examination.

How do we know if there are Drusen if you can't see them distinctly?

The way this nerve appears, slightly elevated, but not actually hazy or swollen is a big tip off. When your doctor sees an elevated optic nerve, they have to decide if it is swollen (papilledema) or not swollen (pseudopapilledema). Blurriness of the nerve is a big indicator of a swollen nerve, but usually a swollen nerve also has bleeding around or nearby making the diagnosis easy. If your doctor is suspicious of a swollen optic nerve, they will likely refer you for an MRI because the big risk of a swollen nerve is a brain tumor.

Optic nerve drusen can be verified a number of ways in your eye doctor's office or at a specialist: OCT, CT scan, but the most common way to verify optic nerve drusen is to use a B Scan. A B Scan is an ultrasound test that is used over top of the patient's closed eyelid, that will show the buried drusen quite distinctly as small reflective particles within the optic nerve.

via

What does Optic Nerve Drusen mean to me?

While the data is from small study groups, a reported 60-70% of patients with optic nerve drusen will have changes in their peripheral visual fields throughout the course of their lives. The most common anomaly is an enlarged blind spot. Everyone has a natural blind spot in each eye's vision where the nerve leaves the back of the eye. In people with optic nerve drusen, this spot is usually larger. In most cases the enlargement of the blind spot does not result in symptomatic vision issues, since the brain is programmed to "not see" or not process the blind spot information any way (but it can be fooled into doing so -- click this link if you want to fool yours.) People with exposed drusen have a higher risk of visual field changes than people with buried drusen -- because the deposits are buried deeper in the nerve, they are having less impact on vision. While this high percentage of people with changes on their visual field testing may be scary, keep in mind that this is just changes found on a test. In most cases, patients with optic nerve drusen have no noticeable vision changes in their day to day life.

As an eye doctor, when I have a patient with optic nerve drusen there are 2 things that I need to look for closely every year:

1) Is the patient's eye pressure within a normal range? People with nerve drusen are more susceptible to damage from high internal ocular pressure (commonly a cause of Glaucoma or optic nerve death). Think of the connection this way: you already have deposits pushing against your nerve tissue inside the eye. If high fluid pressure is pounding against the nerve in the other direction, your nerve fibers are at an even greater risk of suffering damage!

2) Is there any bleeding inside the eye? In rare cases, optic nerve drusen can be associated with bleeding in the eye called a choroidal neovascular membrane. Inject-able treatment of Avastin or Lucentis can be used to stop this bleeding, so if you have been diagnosed with optic nerve drusen, regular eye exams are extremely important even if you have perfect vision. With the eye, most damage to nerve or retinal tissue is irreversible, so if you wait to get treatment after vision loss has occurred, there may be no way to get your vision back. Please see your eye doctor yearly if you have been diagnosed with drusen, so any malicious findings can be found, no matter how rare they may be.

Share |

Fashion in Focus: Two-Tones for Spring!

how to wear two-tone glasses 1:22 PM

Share |

Air Optix Multifocal Fitting Guide -- do you really know the recommendations for best fit?

air optix multifocal fitting guide 8:47 PM

Fitting contact lenses can be such a routine after awhile, it's easy to forget about that little fitting guide the reps give you the first time a lens launches. We all know how to do it any way, right? Pick the right lens, the right add, and over refract. But with the new launch of Ciba's Dailies Aqua Comfort Plus Multifocal which is utilizing the exact same multifocal design as their original monthly Air Optix Multifocal lens, let's take another look at the fitting guide because what's inside may surprise you.

Here's the link to Ciba's Version

1) Start with your vertexed distance power and select your add based on this traditional scale. Start with the same add in both eyes.

via

2) Over-refract at a distance with +0.25/-0.25 trial lenses or flippers. Make sure both eyes are open (do NOT do monocular over-refractions). Change power of lens accordingly -- try to push as much plus as possible at this stage without hurting distance vision.

STOP. If vision is acceptable distance and near with binocular vision and good lighting, dispense the trial lenses.

Having trouble with distance or near? Time to take advantage of ocular dominance. To determine dominance I like to use the +2.00 blur out method. Hold up +2.00 or +1.50 over each eye at a distance binocularly. Which option looks better? The eye that can't take the plus is your dominant eye.

If Issues with Distance:

If over-refraction can't solve distance complaints, it is time to use that dominant eye to our advantage and split adds. This may seem obvious, but check out that last line of the table. For Hi adds, you should drop to medium add power on the NON-dominant eye. Yes, you read that right. Shocked? I was. I can't say it makes sense, but apparently it should work.

If Issues with Near:

1) Add +0.50 to the Non-Dominant eye. That's right, before you start messing with add, try pushing a little more plus. At this point, you are committing to sacrificing a little distance in the name of near.

If you still can't get good enough near vision, then from here, split the add as described:

2) Split the Add:

Yes, again the Hi add power is counter-intuitive. You drop the non-dominant add to medium.

I haven't been able to get a good scientific explanation as to why this strange add adjustment on the Hi adds works, but the blended zones of multifocal contact lenses can yield crazy results. I am guessing if there are vision issues, then we are assuming the eye is not being able to take advantage of a certain add power's blend, so we are trying to utilize a different power blend to increase visual function. As we all know, the power of the multifocal contact lens is just a starting place, and many times the final contact lens Rx doesn't match that well with a person's glasses prescription because multifocal contact lenses are so variable in the vision they provide. It is all about how a patient's eye and brain can utilize the blended zone information it is being given. That's why vision may take a week or two to even reach it's true potential; the eye and brain have to learn how to interpret the lens.

So if you are wanting to achieve even better multifocal results, try revisiting the fitting guides of your lenses. You may be surprised by the suggestions inside!

Share |