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By Roibeard O'hÉineacháin

PARIS - A preference for PRK for moderate myopia and peribulbar anaesthsia for cataract surgery were among the findings of a new survey of French ophthalmologists presented at the annual meeting of the French Implant and Refractive Surgery Society.

In the fifth of his annual surveys of French practises in ophthalmic surgery, Richard Gold MD collected 1,253 responses to an anonymous questionnaire from the membership of the French Society of Ophthalmology.

Of these, he was able to use 1,228, a response rate of 22.52%. The respondents provided details of their surgical habits and opinions on cataract and refractive surgery.
Just over half (54%) of the respondents performed both cataract and refractive surgery, while 14.16% performed only refractive surgery.

The workload of the surgeons involved in the study accounted for 56% of the 450,000 cataract procedures and 43% of the 120,000 refractive procedures performed in France in 2001, according to Dr Gold, former Head of the Department of Ophthalmology at the Cognacq-Jay Hospital, Paris, and now in private practice at Le Raincy, France.

The proportion with a low volume of cataract surgery appears to be decreasing, but at the same time high volume surgeons continue to be in the minority in France. The proportion performing fewer than 100 cataract surgeries per year fell from 22% in 1998 to 15% in 2001.

The proportion performing between 100 and 199 procedures annually remained unchanged at 33%, while the proportion performing 200 to 300 per year rose slightly from 20% to 22%. At the high volume end of the spectrum, those treating 300 to 500 cases per year increased from 15% to 20%, while the proportion treating 500 or more rose from 10% to 12%.

Phacoemulsification is now well established as standard in cataract surgery in France, although a few surgeons continue to perform extracapsular cataract extractions. In 1998, 95% of surgeons used phacoemulsification for most of their cataract extractions, compared to 97% in 2001.

Most respondents (87%) used clear corneal incisions. The size of the incisions used by French ophthalmic surgeons for cataract surgery appears to have decreased over the past few years.
In 1998, 28% of respondents said they used incisions greater than 4 mm compared to only 11% in 2001, while those using incisions 3.2 mm or smaller rose from 1% to 27%. The preferred position of the incision was evenly divided between temporal, 12 o'clock and oblique.

The proportion of respondents who always use sutures during cataract surgery decreased over the past five years from about two-thirds to about half, while the proportion that never used sutures increased from 18% to 31%.

Duovisc has been the most popular viscoelastic during all the years surveyed and its usage among survey respondents increased from 43% to 56%, with the remainder evenly divided between Ophtalin, Amvisc, Viscoat, Healon, and Healon GV.

Outpatient surgery yet to dominate
Ambulatory cataract surgery was only practiced by about half of respondents. Some 14% of respondents kept patients in hospital overnight. Nearly a third of the surgeons kept patients in for two nights, and the remaining respondents kept them in for more than two nights.

About two-thirds of respondents used peribulbar anaesthesia, 12% used topical, 8% used topical plus intracameral lidocaine. Another 8% said they used sub-Tenons anaesthesia, while 5% preferred retrobulbar. Only 2% used general anaesthesia.

The most widely used IOLs were foldable acrylics. Hydrophilic acrylics were still the most popular, being implanted by 57% of respondents. That number is down from 68% in 1998. Nearly as many (56%) were implanting hydrophobic acrylic IOLs, which represents an increase from the 1998 survey, when only 28% were using them.

Over the same period, the usage of PMMA IOLs decreased from 57% to 28% and that of silicone from 31% to 14%.
As with cataract surgery, only a small proportion of respondents performed refractive surgery at a high volume. Only 5% of respondents performed more than 300 refractive procedures per year and about 16% performed 100 to 199 per year. Among the respondents who practiced refractive surgery, 99.25% treated myopia, 89 % treated astigmatism, 69% treated hyperopia, and 7% treated presbyopia.

One surprising finding was that PRK remained the most widely used technique for treating myopia, employed by 84%. By comparison, only 67 % used LASIK for that indication, although it is an increase on Dr Gold's 1998 survey when only 31% of respondents used LASIK for myopia.
"In France, PRK is still number one for myopia because we have non-surgical ophthalmologists practising refractive surgery. In the beginning only surgeons practised refractive surgery but now ophthalmologists who aren't surgeons perform PRK.

"That's because it's not really surgery and is a lot easier to perform than LASIK, and doesn't require the creation of a flap. This is only true for myopia, however; non-surgical ophthalmologists are generally less willing to use PRK for hyperopia and astigmatism," Dr Gold explained.

Clear lensectomy was the second most widely practiced procedure for myopia, its use declining only slightly between 1998 and 2001 from 33% to 29%. The Artisan anterior chamber IOL has had a fairly dramatic rise in popularity over the years surveyed, with 14% implanting the devices in 2001 compared to only 1% in 1998.
The use of rigid anterior chamber IOLs and ICLs remained unchanged at 12% and 7%, respectively. Meanwhile, radial keratotomy was performed by only 5% of respondents in 2001, compared to 19% in 1998.

In contrast with its use in myopia, LASIK has clearly stolen the march on PRK in the treatment of hyperopia in France. Over half (52%) of the respondents used LASIK for treating hyperopia, while only 34% used PRK.

That compared to respective values for the two techniques of 18% and 76% in 1998. Phakic IOLs also appeared to be rising in popularity as a treatment for hyperopia, with 9.32% of respondents implanting them in 2001, compared to only 4.44% in 1998.

LASIK also appeared to have overtaken PRK in the treatment of astigmatism. The procedure was used by 63% of respondents for that indication in 2001, compared to only 27% in 1998.
PRK has had a correspondingly diminished usage, decreasing from 76% to 61%. The proportion using arcuate keratotomy remained fairly stable during the years of Dr Gold's surveys, diminishing only slightly from 14% to 12%.

Only a small proportion of respondents used refractive surgery for the treatment of presbyopia, although such procedures appear to be becoming more widely practiced than they were five years ago.
As with hyperopia and astigmatism, LASIK was the favoured technique in the treatment of presbyopia and was used by 3.8% of respondents in 2001. Presbyopic lens exchange was the next most widely used procedure, being used by 2.28% in 2001.

The use of presbyopic PRK peaked in 1999 at 2.55% but has since diminished to 1.55%. Scleral expansion techniques had a brief surge in popularity and were used by 2.08% in 1999, but by 2001, their usage fell to 0.19%.

Job satisfaction
One of the most telling findings of Dr Gold's survey concerned job satisfaction among ophthalmologists. When asked whether they would have become physicians if they had known what it would be like, 28% said they would not.

Furthermore, even among those who would have been physicians if they could do it all over again, only 39% would advise their children to do so. Moreover, among those who regretted becoming physicians, only 4% would recommend the profession to their children.

"That's because being an ophthalmologist is getting harder and harder due to taxes and insurance fees. We have more and more problems with lawyers without an increase in income.
"Added to that is the fact that we have fewer and fewer ophthalmologists to treat the patients since the number retiring outnumbers those graduating by 10 to one. And all of this is not really new. I've been an ophthalmologist for 20 years and it has worsened every year," Dr Gold concluded.

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