A SHARP decline in the use of hydrophilic IOLs and a steep rise in the number of bilateral LASIK procedures were among the more notable findings of the latest survey of French ophthalmologists presented at the annual meeting of the French Implant and Refractive Surgery Association (SAFIR). In the sixth of his annual surveys of French practices in ophthalmic surgery, Richard Gold MD collected 1,119 responses to an anonymous questionnaire sent to over 5,700 French ophthalmologists. The response rate of 19.36% was the lowest since 1999, Dr Gold noted.

"The fact that the response numbers were down is a bit disappointing, but there were still some very interesting findings. I would particularly highlight the decline of hydrophilic IOLs, the rise of bilateral LASIK procedures and the emergence of Orbscan as the most widely used topography system as among the most interesting results," he said. As well as providing valuable insights into trends and developments in clinical practice, Dr Gold’s questionnaire serves as a useful barometer of the current well-being of French ophthalmology in general.

The proportion of French ophthalmologists with a low volume of cataract surgery remained stable, with 15% performing fewer than 100 cataract surgeries per year, down from 22% in 1998. The proportion performing between 100 and 199 procedures annually decreased slightly from 33% to 27%, while the proportion performing 200 to 300 per year rose slightly from 22% to 23%. At the high volume end of the spectrum, those treating 300 to 500 cases per year increased to 22% compared to 15% for 1998, while the proportion treating 500 or more rose from 10% to more than 11%.

Phacoemulsification is now almost universally established as standard in cataract surgery in France, 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. A small percentage of surgeons, however, continue to perform extracapsular cataract extractions. In 1998, 95% of surgeons used phacoemulsification for most of their cataract extractions, compared to more than 98% in 2002.

Most respondents (90%) used clear corneal incisions. The size of the incisions used by French ophthalmic surgeons for cataract surgery has continued to decrease over the past few years. In 1998, 28% of respondents said they used incisions greater than 4.0mm compared to only 8% in 2002, while those using incisions 3.2mm or smaller took a major leap to 34% from 25% in 2001. The preferred position of the incision was evenly divided between temporal, 12 o'clock and oblique, although Dr Gold noted that oblique incisions had become more popular in recent years and now accounted for 27% of incisions compared to 21% in 1999.

The proportion of respondents who always use sutures during cataract surgery decreased over the past six years from about two-thirds to less than half (47%), while the proportion who never used sutures increased from 18% in 1998 to 38% in 2002. Dr Gold reported that the use of injectors for cataract surgery has shown a strong increase in recent years, with 61% of respondents using injectors in 2002 compared to 21% in 1998. Duovisc continues to be the most popular viscoelastic in France, used by 57% of respondents, with the remainder evenly divided between Ophtalin, Amvisc, Viscoat, Healon and Healon GV.

Ambulatory cataract surgery was practised by approximately half of respondents (52%). 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. In terms of anaesthesia, Dr Gold found a slight trend towards greater use of topical anaesthesia, up to 16% for 2002 compared to 12% for the year before. More than half (56%) of respondents used peribulbar anaesthesia, while 10% used topical plus intracameral lidocaine. Another 10% said they used sub-Tenons anaesthesia, while 5% preferred the retrobulbar approach.

Only 2% used general anaesthesia. New questions this year asked whether respondents believed topical anaesthesia to be safer or more comfortable for the patient than other anaesthetic treatments. Some 75% replied that they did not think it was any safer than other forms of anaesthesia, while only 9% considered it more comfortable for the patient. The most widely used IOLs were foldable acrylics. For the first time, however, hydrophobic acrylic IOLs (59%) proved more popular than hydrophilic models (49%, down from 57% in 2001).

The years of Dr Gold’s survey charts the steady decline of PMMA IOLs, down from 57% in 1998 to only 18% in 2002. Silicon implants are also on the wane, from 31% in 1998 to just 9% in 2002. As with cataract surgery, only a small proportion of respondents performed refractive surgery at a high volume. Only 4% of respondents performed more than 300 refractive procedures per year and about 12% performed 100 to 199 per year. Among the respondents who practised refractive surgery, 96% treated myopia, 88% treated astigmatism and 71% treated hyperopia. A total of 8% said they treated presbyopia (up from just 3% in 1998).

The French preference for using PRK to treat myopia was again confirmed, with 83% of respondents expressing a preference for that technique. By comparison, only 66% 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. Clear lensectomy was the third most widely practised procedure for myopia, its use declining only slightly between 1998 and 2002 from 33% to 32%. The Artisan anterior chamber IOL continues to be popular with French ophthalmologists, with 11% implanting the devices in 2002 compared to less than 1% in 1998. The use of rigid anterior chamber IOLs and ICLs was down slightly from previous years, at 7% and 5% respectively.

In contrast with its use in myopia, LASIK continues to outstrip PRK in the treatment of hyperopia in France. More than half (53%) of the respondents used LASIK for treating hyperopia, while only 37% used PRK. That compared to respective values for the two techniques of 18% and 36% in 1998. Phakic IOLs also gained in popularity as a treatment for hyperopia, with 11% of respondents implanting them in 2002, compared to only 4.44% in 1998 and 9% in 2001.

The use of LASIK for the treatment of astigmatism also remained steady. The procedure was used by 62% of respondents for that indication in 2002 (the same as 2001), but still considerably greater than its 1998 figure of 27%. PRK use has diminished slightly for astigmatism, decreasing from 61% to 60% since 2001 and considerably less than its 75% high in 1998.

The proportion using arcuate keratotomy remained fairly stable during the years of Dr Gold's surveys, diminishing only slightly from 14% to 12% in 2002. Only a small proportion of respondents used refractive surgery for the treatment of presbyopia, although such procedures continue to be more widely practised than they were six years ago. As with hyperopia and astigmatism, LASIK was the favoured technique in the treatment of presbyopia and was used by 5.8% of respondents in 2002, up from 3.8% in 2001. Presbyopic lens exchange was the next most widely used procedure, used by 4.32% of respondents in 2002.

Richard Gold MD
Le Raincy, France
Email: rg@ophtalmo.net