Cataract surgery on the couch: What the future holds

By Sean Henahan

WHAT does the future hold for cataract surgery? We asked leading ophthalmologists to contrast the current state of practice with the long-term developments they envisage on the surgical horizon.

The ESCRS finds itself in a similar position to the EU, seeking to define the common cultural elements which unite its members while also learning to understand and appreciate the cultural differences that exist from one country to the next.
European surgeons, for example, are united in support of universal access to health care, but surgeons from individual countries face unique problems with reimbursement and resource allocation.

"It is our responsibility, especially at the ESCRS level, to address governmental, regulatory affairs, providing caretakers and providers and other authorities with well-prepared programmes for teaching, communicating, and research.
"There is an urgent need for a European ophthalmological policy to address the real medical and socio-economical needs of the present," said Director of the Clinique Sourdille, Nantes, France, Philippe Sourdille MD.

One thing that does seem to unite ophthalmologists across Europe is a concern for the demographics of eye surgery. While aging populations guarantee an increasing demand for cataract operations, governments throughout Europe are reducing re-imbursements and increasing workloads for ophthalmic surgeons.

Some countries, such as England, are having a difficult time meeting the current demand and have been forced to try everything from importing surgeons to exporting patients.
Other countries, particularly France, face a manpower crisis, as it appears there are simply not enough ophthalmologists practicing or in training to meet the projected demand.

For some years now, the ESCRS has sponsored the European Cataract Outcomes Study group (ECOSG). That, along with a joint survey project with the ASCRS, provides much insight into how things are changing in Europe.
For example, practice patterns are quite different in the eastern European countries, where inpatient cataract procedures are common and phacoemulsification is still in the early stages of adoption.

Nonetheless, the ECOSG studies show a clear trend towards greater use of outpatient procedures and phacoemulsification across Europe, including the East.
In the near future, European ophthalmology will continue to lead the US in technological development, while relying on FDA clinical trials for large-scale validation.

The majority of our prognosticators predicted that technological improvements would lead to greater use of lenticular approaches to correct refractive errors.
Technologies to watch include small incision cataract surgery, and improved accommodating and multifocal IOLs. One of the most promising new developments is the application of laser to alter the power or cylinder of IOLs after implantation. Also in the pipeline are approaches to substitute the lens with biomaterials that would be flexible enough to allow accommodation.
Phakic intraocular lens technologies which address not only astigmatism but also hyperopia and myopia with presbyopia are going to be formidable competitors to corneal modalities for refractive surgery.

It is faster and easier to adapt to a new implant technology or modify existing implant technology than it is to buy a new large, expensive piece of laser equipment for corneal procedures, noted Burkhard Dick MD Johannes Gutenberg University, Mainz, Germany.
"The turnover rate for both medical knowledge and technology is about 50% every four to five years. Along with economic factors, this might cause a shift toward lenticular refractive surgery rather than corneal surgery in the future.

"The closer we reach the excellence of some of the corneal procedures, lenticular surgery may even overcome and bypass some of the corneal procedures we now think of as state of the art," Dr Dick said.
Ophthalmology pioneer Charles Kelman MD also believes that cataracts will be a rarity 20 years from now. He bases this prediction on the increasing acceptance of prophylactic clear lens extraction.

"There is a revolution coming in eye surgery, involving the ultimate elimination of cataracts in a significant number of patients. It is simply this: remove the presbyopic crystalline lens in 40 to 50- year-olds, before the lens has time to become a cataract, and replace it with either a multifocal or accommodating implant," said Dr Kelman, who is a Professor of Ophthalmology at New York Medical College and past President of the ASCRS.
The next issue of EuroTimes will continue our discussion of the future of ophthalmology, with a look at what is coming in the area of refractive surgery.

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