In the spring, Aetna surprised ophthalmologists by announcing that cataract surgery would, as of July 1, require the insurer’s precertification before surgeons could perform it. In a subsequent message to its providers, Aetna said the move was made because it “helps our members avoid unnecessary surgery.” When pressed on this, the company cited that 4 to 5 percent of cataract surgeries were unnecessary, a number that’s about 2 to 3 percentage points above what ophthalmologists estimate it to be.¹

Aetna’s impressions of ophthalmologists’ approach to surgery doesn’t jibe with the one I’ve formed over the years; instead of avidly performing unnecessary surgeries, ophthalmic surgeons do everything they can to avoid invasive treatments. For examples of this, look no further than this month’s articles. 

In this month’s feature on retina specialists’ approach to epiretinal membranes (p. 48), these physicians are very circumspect when it comes to peeling, and look at the problem from every possible angle before going into the OR. “To me, though, a patient’s symptoms and the impact of ERM on his or her activities of daily living are much more important than a specific visual acuity threshold,” says Houston retina specialist Charles Wykoff. “If patients are bothered by their vision, and I think it’s attributable to an ERM, then I believe it’s reasonable to consider mentioning surgery to them. If they aren’t bothered by the ERM, then I typically leave it alone, even if their vision is decreased. It’s hard to make asymptomatic patients happier.”

Likewise, cornea specialists are actively working on alternatives to performing traditional endothelial transplants, as illustrated by the feature on p. 54. In the technique known as Descemet’s Stripping Only, which is mainly useful in patients with Fuchs’ endothelial corneal dystrophy, the surgeon removes the central diseased area, and the healthy peripheral endothelial cells shift to help clear the cornea. And insurers should be really happy about one particular aspect of the surgery: “It’s also a cost-effective surgery because there’s no expensive corneal tissue involved,” says NYU corneal specialist Kathryn Colby, MD, PhD. 

The other corneal transplant approach, pioneered by Kyoto, Japan’s, Shigeru Kinoshita, MD, PhD, is another minimally-invasive procedure in which cultured human corneal endothelial cells are simply injected into the anterior chamber. The cells then migrate to where they need to be on the cornea. So far, the results are promising.

In the end, let’s hope that Aetna and other insurers take a step back and get to know the specialty of ophthalmology that you and I are familiar with, rather than the one on their balance sheets.

— Walter Bethke
Editor in Chief

^{1. Aetna’s Prior Authorization Plan Spawns Opposition. Review of Ophthalmology Aug 2021;5.}