Health policy regulations pertaining to advanced surgical devices—their socio-economic effects on ophthalmology practice

Abstract The Israel Ministry of Health enacted regulations that aim to reduce private expenditure on healthcare services and mitigate social inequality. According to the modified rules, which went into effect in the second half of 2016, patients who undergo surgery in a private hospital and are covered by their healthcare provider’s supplemental insurance (SI) make only a basic co-payment. The modified regulations limited the option of self-payment for advanced devices not covered by national health basket, meaning that patients for whom such devices are indicated had to pay privately for the entire procedure. These regulations applied to all medical and surgical devices not covered by national health insurance (NHI). Toric intraocular lenses (IOLs) are a case in point. These advanced lenses are implanted during cataract surgery to correct corneal astigmatism and, in indicated cases, obviate the need for complex eyeglasses postoperatively. Toric IOL implantation has been shown to be highly cost-effective in both economic and quality-of-life terms. Limitations of the use of these advanced IOLs threatened to increase social inequality. In 2017, further adjustments of the regulations were made which enabled supplemental charges for these advanced IOLs, performed through the SI programs of the healthcare medical organizations (HMOs). Allowing additional payment for these lenses at a fixed pre-set price made it possible to apply a supplemental part of the insurance package to the surgery itself. In mid 2018 these IOLs were included without budget in the national health basket, allowing for self-payment for the additional cost in addition to the basic coverage for all patients with NHI. This case study suggests that, in their efforts to enhance health care equity, policymakers may benefit if exercising due caution when limiting the extent to which SI programs can charge co-payments. This is because, when a service or product is not available via the basic NHI benefits package, limiting SI co-payments can sometimes result in a boomerang effect - leading to an increase in inequality rather than the sought-after decrease in inequality

Bilateral Sequential NAION following Cataract Extraction: Case Report and Review of the Literature

We report a 64-year-old patient who developed nonarteritic ischemic optic neuropathy (NAION) in both eyes following cataract extraction. The cataract surgeries in both eyes were uneventful and performed within a year, and NAION occurred a few months postoperatively in both eyes. A review of the literature on this rare complication is provided. This case report serves to raise awareness among cataract surgeons about this potential complication associated with irreversible visual loss, and especially about its high risk of bilaterality

Bilateral Sequential NAION following Cataract Extraction: Case Report and Review of the Literature

We report a 64-year-old patient who developed nonarteritic ischemic optic neuropathy (NAION) in both eyes following cataract extraction. The cataract surgeries in both eyes were uneventful and performed within a year, and NAION occurred a few months postoperatively in both eyes. A review of the literature on this rare complication is provided. This case report serves to raise awareness among cataract surgeons about this potential complication associated with irreversible visual loss, and especially about its high risk of bilaterality

Femtosecond LASER-Assisted Double Intraocular Lens Exchange in Nanophthalmic Eyes

Introduction: Though patients with nanophthalmos frequently endure decreased quality of vision with contact lenses or spectacles, refractive surgery is generally an inadequate alternative due to the associated high refractive error. A refractive lens exchange (RLE) is an alternative option but is technically challenging, requiring accuracy in biometry measurements and procedures. Case Presentation: This case discusses a 27-year-old female with nanophthalmos (axial lengths 17.6 mm and 17.4 mm, right and left eyes, respectively) who underwent a femtosecond laser-assisted (FLA) RLE with simultaneous implantation of a monofocal and a Sulcoflex trifocal (Rayner, Britain) lens in each eye. Preoperative cycloplegic refraction was +11.50/−0.75 × 145 and +12.00/−1.00 × 35 in the RE and LE, respectively. Best-corrected visual acuity (BCVA) at distance and near in the RE and LE was 6/7.5 and J1, 6/8.5 and J2, respectively. Uncorrected visual acuity (UCVA) was >6/120 and >J14 for each eye. FLA RLE was performed in the RE, then in the LE 2 weeks later. In each eye, a monofocal (44.0 D, RE, and LE) and a Sulcoflex trifocal lens (both implants, Rayner, Britain) were implanted in one procedure. Distance and near UCVA measured 6 weeks post-op RE and 1-month post-op LE at 6/8.5 and J1 in the RE, 6/10 and J1 in the LE. The RE and LE refraction and BCVA were +0.50/−1.00 × 115, 6/7.5, and plano/−1.00 × 55, 6/8.5, respectively. The post-op outcomes were uneventful. Conclusion: A single procedure concurrently implanting a monofocal and Sulcoflex trifocal intraocular lens in nanophthalmic eyes resulted in an excellent UCVA. This procedure can be considered esthetic and reconstructive as it significantly improves patient appearance and function

Carotid Artery Endarterectomy Effect on Choroidal Thickness: One-Year Follow-Up

Purpose. To evaluate the change in choroidal thickness after carotid artery endarterectomy (CEA) in patients without retinal pathology. Methods. A prospective series of patients who underwent CEA at the Tel Aviv Medical Center. Spectral domain optical coherence tomography (SD-OCT) was performed one day before the CEA and at least 6 months after. Data included medical history, smoking history, percentage of carotid stenosis before and after CEA, best-corrected visual acuity (BCVA), central macular thickness (CMT), and choroidal thickness (subfoveal, 500 µm, 1000 µm, and 1500 µm nasal and temporal). Results. Eight patients (seven male and one female) with a mean age of 70.5 ± 6.1 years were included in the study. The mean internal carotid artery (ICA) stenosis was 89.8% ± 5.1 in the operated side, 33.7% ± 10.9 in the nonoperated side (p<0.0001), and 0% after CEA (p<0.0001). Operated side BCVA was 0.35 ± 0.66 compared to 0.61 ± 0.83 in the nonoperated side (p=0.51). The mean subfoveal choroidal thickness (SFChT) of the operated side was 277 ± 67 µm compared to 268 ± 71 µm in the nonoperated side (p=0.81). SFChT and CMT after CEA were 275 ± 64 µm (p=0.96) and 268 ± 29 µm (p=0.98), respectively. Conclusions. SFChT and CMT in patients without retinal or choroidal pathology and significant ICA stenosis can be normal and may not change after successful ipsilateral CEA

Surface Refractive Surgery Outcomes in Israeli Combat Pilots

Photorefractive keratectomy (PRK) has long been the method of choice for refractive surgery in pilots, and was FDA approved for U.S. Air Force aviators in 2000. We retrospectively reviewed the medical records of 16 male combat pilots (mean age 25.0 ± 5.5 years) who had undergone bilateral laser refractive surgery with surface ablation (alcohol-assisted PRK: 81.25%, transepithelial-PRK: 18.75%), and who had a mean baseline spherical equivalent (SE) of −2.1 ± 0.7 D in the right eye, and −2.0 ± 0.7 D in the left. The mean follow-up was 8.4 ± 6.6 months. On the last visit, the uncorrected visual acuity (UCVA) had improved from 0.75 ± 0.33 logMar to −0.02 ± 0.03 logMar (p p < 0.001), for the right and left eyes, respectively. The percentages of participants with a right eye UCVA of at least 0.0, −0.08, and −0.18 logMAR (6/6, 6/5, and 6/4 Snellen in meters) were 100%, 37.5%, and 6.2%, respectively, and for the left eye, 93.7%, 43.75%, and 6.2%, respectively. No complications occurred. This is the first study to assess refractive surgery outcomes in a cohort of Israeli combat pilots. Surface refractive surgery effectively improved UCVA and reduced spectacle reliance for the members of this visually demanding profession

Surface Refractive Surgery Outcomes in Israeli Combat Pilots

Photorefractive keratectomy (PRK) has long been the method of choice for refractive surgery in pilots, and was FDA approved for U.S. Air Force aviators in 2000. We retrospectively reviewed the medical records of 16 male combat pilots (mean age 25.0 &plusmn; 5.5 years) who had undergone bilateral laser refractive surgery with surface ablation (alcohol-assisted PRK: 81.25%, transepithelial-PRK: 18.75%), and who had a mean baseline spherical equivalent (SE) of &minus;2.1 &plusmn; 0.7 D in the right eye, and &minus;2.0 &plusmn; 0.7 D in the left. The mean follow-up was 8.4 &plusmn; 6.6 months. On the last visit, the uncorrected visual acuity (UCVA) had improved from 0.75 &plusmn; 0.33 logMar to &minus;0.02 &plusmn; 0.03 logMar (p &lt; 0.001), and from 0.72 &plusmn; 0.36 logMar to &minus;0.02 &plusmn; 0.05 logMar (p &lt; 0.001), for the right and left eyes, respectively. The percentages of participants with a right eye UCVA of at least 0.0, &minus;0.08, and &minus;0.18 logMAR (6/6, 6/5, and 6/4 Snellen in meters) were 100%, 37.5%, and 6.2%, respectively, and for the left eye, 93.7%, 43.75%, and 6.2%, respectively. No complications occurred. This is the first study to assess refractive surgery outcomes in a cohort of Israeli combat pilots. Surface refractive surgery effectively improved UCVA and reduced spectacle reliance for the members of this visually demanding profession

Epiretinal Membrane in Patients with Diabetic Macular Edema

PURPOSETo compare anatomical and functional outcomes of pars plana vitrectomy (PPV) with epiretinal membrane (ERM) peeling in diabetes retinopathy (DR) patients with and without diabetic macular edema (DME). METHODSA retrospective interventional case series of consecutive patients who underwent PPV with ERM peeling. Patients were divided into two groups: With and without preoperative DME. Visual acuity (VA) and optical coherence tomography (OCT) parameters were evaluated before surgery and during 12 months follow-up. RESULTSA total of 354 patients underwent PPV with ERM peeling, of which 51 met the inclusion criteria. Twenty-three were diagnosed with DME and were younger (66.3±9.6 vs 73.1±8.2years, p=0.001), had longer diabetes mellitus (DM) duration (18.9±7.1 vs 14.3±10.9 years, p=0.04) and higher HbA1C% (7.6±1.4 vs. 7.1±1.3, p=0.04). VA improved from 20/105 to 20/60 Snellen (p=0.004) and central macular thickness (CMT) decreased from 469.3±64.9μm to 331.1±92.2μm (p<0.001) in the DME group and from 20/87 to 20/44 Snellen (p<0.001) and from 463.1±53.5μm to 341.3±49.5 μm (p=0.01) in the non DME group. Yearly intravitreal injections rate decreased from 5.9±2.5 to 2.9±3.0 (p<0.001) injections in the DME group. CONCLUSIONSDME patients with ERM, experience significant improvement in VA, macular thickness and yearly intravitreal injections after PPV with ERM peeling. DME patients are younger, with longer duration of DM and higher HbA1C% levels at presentation in comparison to diabetic ERM patients without DME