Pravin U. Dugel, MD, Phoenix, Ariz.,
Michael A. Romansky, JD, Washington, D.C.

The purpose of this article is to reevaluate the status of ambulatory surgery centers for retina surgeries in light of new regulatory and technical changes in vitreoretinal surgery. In previous articles, we have discussed in detail the reasons to consider vitreoretinal surgery in the ASC, either from the inception of the ASC or as an addition to an existent general ophthalmology-based ASC. We considered the last few years to be particularly opportune because of the combination of major advances in microincisional vitreoretinal surgery, as well as significant changes in the ASC reimbursement system. Since those writings, there have been further developments in microincisional vitreoretinal surgery and new challenges to the ASC reimbursement formula. Should vitreoretinal surgery in an ASC still be considered in the current climate?


Key Technical Advances

A thorough discussion of recent technical ad-vances in vitreoretinal surgery is beyond the scope of this article. However, several highlights will illustrate recent advances. The initial reports of microincisional surgery were very enthusiastic: The surgeon was more efficient and the patient was more comfortable, with a faster recovery of vision. However, the early 25-ga. system exposed its flaws: The flow rate was low, making the core vitrectomy slower; the instruments were flexible, making peripheral vitreous-base dissection difficult. Most disturbing, however, was a retrospective report from the Wills Eye Hospital that showed a 12-fold greater increased risk of endophthalmitis with the 25-ga. system versus the traditional 20-ga. system.1 This report and others that followed gave pause to our initial enthusiasm. Thereafter, a flurry of investigations followed. We learned the importance of wound construction from several investigators using histology and animal models.2 The necessity of conjunctival displacement, globe flattening, and blade angling was demonstrated. Using these wound construction principals, several studies have indicated no increased risk of microincisional vitrectomy surgery with either the 25-ga. or the 20-ga. system.3 However, it must be stressed that a conclusive prospective study has not yet been done. Interestingly, the wound construction evolution in vitreoretinal surgery is very similar to that of cataract surgery in the comparison of clear corneal incision surgery versus scleral tunneling surgery.

New surgical systems have been developed by several companies, designed to address the deficiencies of the original 25-ga. system. For instance, the advances in fluidics allow the vitreoretinal surgeon increased flow when needed (e.g., during fibrous tissue dissection or lensectomy), but an overall low flow rate to assure fluidic stability. A new parameter to change flow rates without changing cut rate or vacuum—duty cycle control—has also been introduced. We have realized that control of the flow rate is paramount: The surgeon should be able to determine when he needs increased instantaneous flow, but should be able to use the lowest possible overall flow during most of the surgery in order to provide maximal fluidic stability and minimize tissue movement. Interestingly, this is a concept that cataract surgeons learned and refined more than a decade ago.

Improvement in material technology has al-lowed companies to expand the inner lumen of cutters and infusion cannulas while increasing stiffness. This, as previously discussed, has improved fluidic control while eliminating the instrument flexibility problem of the older-generation microincisional systems. The understanding and emphasis by industry of the ASC and the migration of vitreoretinal surgery to ASCs is, in our opinion, most underscored by recent advancements in device-initiated procedural efficiencies. For instance, industry has recognized the recurrent cost savings afforded by a vitreoretinal surgical device that is able to make inventory management, billing, dictation and turnover more efficient in ASCs and hospitals. Therefore, significant advances in bar coding, just-in-time inventory control, user-friendly mechanized procedural functions and e-connectivity will be forthcoming. Technical advances make vitreoretinal surgery more suited to ASCs than ever before.



The Medicare reimbursement and regulatory climate continues to favor consideration of vitreoretinal surgery in the ASC. Under the new ASC payment system launched in 2008, the major VR codes double in payment over the four-year transitional period; for example, from 2009 to 2010, CPT 67036 (remove inner eye fluid) increases from $1,077 to $1,351 and CPT 67108 (repair detached retina) from $1,255 to $1,438. Beginning in 2010, all ASC facility fees will receive annual cost-of-living adjustments on the basis of the Consumer Price Index (Urban). And, importantly, the ASC industry has repeatedly and successfully beaten back efforts by the hospital industry to curtail physician ownership of surgery centers.

Can retinal surgeons feel comfortable about the legislative, regulatory, and reimbursement prospects of ASCs going forward? ASCs are an indelible component of the health-care delivery system; there are now more ASCs in the nation than there are hospitals. Even under the most pernicious health-care reform proposals that emanated from Congress, ASCs were not adversely impacted; policymakers recognize ASCs—with lower costs, improved beneficiary access and exceptional quality—as part of the solution, not the problem.

There have been major recent changes in regard to vitreoretinal surgery in ASCs. Our original premise to consider vitreoretinal surgery in ASCs remains valid: the combination of technical advances and reimbursement changes. As this article describes, companies have made significant commitments to the advancement of microincisional vitrectomy surgery, which is particularly suited to the ASC. Industry clearly sees the movement of vitreoretinal surgery to ASCs as inevitable, as evidenced by its research and development investments.

Although challenges remain, the recent developments and outcomes in ASC reimbursement policies described in this article make two critical points: First, ASCs are part of the solution, not the problem for current health-care policy reform; and, second, political lobbying organizations, such as the Outpatient Ophthalmic Surgery Society are vital in order for ophthalmologists to protect patient access to ASCs and maintain fair reimbursement. Everyone agrees that the migration of vitreoretinal surgery to ASCs is inevitable. However, we must support political lobbying organizations, such as OOSS, to insure that patient access, superior quality and fair physician reimbursement will be protected during this migration.

The practical bottom line question is: Should the general cataract surgeon who owns an ASC consider adding vitreoretinal surgery to his portfolio of surgical cases given the above-described technological and political changes? The answer is not simple at all. As technology advances, so does cost. The minimum investment to equip a retina room is at least $350,000. Although the migration, in our opinion, may be inevitable, many superb vitreoretinal surgeons are still most comfortable in a hospital setting, perhaps with general anesthesia, and abhor concepts of costs and procedural efficiency. Although technically superb, such surgeons would not, at present, thrive in an ASC setting.

On the other hand, a vitreoretinal surgeon who embraces such efficiency concepts and is technically sound would be a valuable addition. We know of no other surgery that, because of massive recent technological changes, is as surgeon-driven. The risk and rewards for the ASC rest squarely on the chosen surgeon or surgeons. Although we think that in the near future, all surgeons will have to be aware of cost and procedural efficiencies, the trend is not yet complete.

Further, although ASCs are a part of the solution of the current health-care reform, undoubtedly, further governmental economic pressures will be brought to bear on ASC reimbursements. The question, or the risk for the ASC owner, is how we as a subspecialty will handle such pressure. Will we support and foster ASC lobbying groups or will we be fragmented and vulnerable? Ultimately, bringing vitreoretinal surgery is, like any other investment, a risk and reward proposition based mainly on surgeon selection.
If you find the appropriate vitreoretinal surgeon, your investment in vitreoretinal surgery will be rewarding for you, the vitreoretinal surgeon and your patients. If you do not, exercise patience … the trend is inevitable.

Dr. Dugel is managing partner at Retinal Consultants of Arizona and founding partner of Spectra Eye Institute, Sun City, Ariz. Mr. Romansky is Washington counsel and vice president for corporate development for the Outpatient Ophthalmic Surgery Society.


1. Kunimoto DY, Kaiser RS, for the Wills Eye Retina Service. Incidence of endophthalmitis after 20- and 25-gauge vitrectomy. Ophthalmology 2007;114:2133-2137.

2. Singh A, Chen JA, Stewart JM. Ocular surface fluid contamination of sutureless 25-gauge vitrectomy incisions. Retina 2008;28:553–557.

3. Mason JO III, Yunker JJ, Vail RS, White MF Jr, et al. Incidence of endophthalmitis following 20-gauge and 25-gauge vitrectomy. Retina 2008;28:1352-4.