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US cataract surgeons are concerned about dropping reimbursement rates, but are growing more interested in recent innovations such as accommodative IOLs, phakic IOLs and clear lens extraction, according to the latest ASCRS survey on practice styles and preferences of its members. As in past years, David Leaming MD provided the latest information on cataract practice trends in the US in a presentation at the annual ASCRS symposium on Cataract, IOL and Refractive surgery. The data come from the responses of more than one thousand members who completed a mail-in survey. "One of the reasons for doing the surveys is to find out what people are really doing. We want to try and separate the hype that you encounter at conferences from the reality of what is being done here and in Europe as well," Dr Leaming commented. Some 16.4% of respondents fell in the higher volume category, performing more than 50 phaco cataract procedures per month. Another 57% perform between 15 and 50 procedures per month. The majority of respondents, 94%, reported that they rarely if ever did extracapsular cataract extractions. Previous surveys indicated that many surgeons were migrating from cataract surgery to refractive laser surgery. This transition was particularly dramatic in 1998. The current survey, in contrast, showed that the percentage of surgeons performing refractive laser procedures and the total number of LASIK procedures had actually declined slightly, while the number of cataract surgeries was increasing. Nearly 40% of those surveyed said they perform all surgeries in an ambulatory surgery centre setting, while another 20% said they performed ‘most’ surgeries at such centres. Interestingly, 32% reported that they perform all surgeries in the hospital setting, while another nine percent said they performed ‘most’ procedures in hospital. None of the surgeons did simultaneous bilateral procedures. "Some of the surgeons are working in rural areas where ambulatory surgical facilities are nonexistent but they are doing their surgeries at the hospital on an outpatient basis. We think this accounts for this particular finding. The survey also tells us that almost all surgeries are being done on an outpatient basis by our members," Dr Leaming told EuroTimes. The current survey reflects broader trends in anaesthesia use. Topical anaesthesia with intracameral lidocaine was by far the most common type of anaesthesia, employed by 45% of respondents. Another 13% said they preferred topical anaesthesia alone. Nearly 20% said they use the periocular injection route. A significant number, nearly 20%, continue to use retrobulbar injection with or without facial block. Only two percent said they use the sub-Tenon’s blunt cannula method. In 1993 virtually all surgeons surveyed said they performed the cataract incision at the 12 o’clock position. By 1998, two thirds of surgeons had switched to the temporal approach. This figure remained unchanged in the current survey. Newer techniques adopted The last decade has also seen a remarkable evolution in the choice of suturing technique. In 1990, nearly 99% of surgeons were still using sutures. In 2002, 92% preferred to use the sutureless approach. The remaining surgeons surveyed said they used either the interrupted or running radial suturing techniques. The survey revealed a diversity of approaches to breaking up the nucleus. A little more than half of the respondents expressed a preference for the four-quadrant divide approach, while 24% used a chopping technique. Other techniques included the two-section divide and the phaco flip. Some 62% of those surveyed said they used an Alcon machine for phaco. Another 17% used Bausch and Lomb phaco equipment, 16% used AMO equipment, while the remainder used equipment by Staar, Nidek and other manufacturers. The survey also revealed contrasting attitudes towards re-using equipment. Some 59% of respondents admitted to re-using phaco tips, while 24% said they also re-use the phaco tubing. Clear corneal cataract incisions, reported by 57%, follow the trend set by the rise in temporal incisions and topical anaesthesia. However, 25% continue to make a limbal incision, while other respondents said they made an incision 1.0 mm or more back. Acrylic and PMMA were the favourite optic materials of two-thirds of those surveyed. Silicone maintained its position in second place, a favourite of 25% of the doctors. The Acrysof was the favourite acrylic IOL of 88% of respondents. The AMO S140 was the favourite silicone lens (48%), while the Memory lens was the favourite hydrogel IOL for 75% of those polled. Innovations attracting interest When queried about their level of interest in emerging innovations, the surgeons expressed the highest levels of interest in accommodative IOLs, limbal relaxing incisions and aspheric IOLs. Asked to choose between an accommodative IOL or a multifocal IOL 87% of respondents choose accommodative IOLs over the 13% who were more interested in multifocal IOLs. The surgeons also expressed interest in toric IOLs. Clear lens extraction with IOL implantation is gaining adherents. Although nearly 75% of respondents said they still do not do the procedure, the remainder said they now performed anywhere from one to 25 such procedures per month. This is a slight increase from the previous year. Elsewhere on the presbyopia front, four percent of surgeons said they now performed phakic IOL implants, although it continues to be considered an experimental procedure in the US. Interestingly, 17% of respondents said they had taken a course on phakic IOLs, while another 53% said they would like to take a course to learn about the lenses. The vast majority of cataract operations performed in the US are reimbursed by the federal healthcare system. The rates of reimbursement have dropped steadily in recent years. Some 43% of respondents said they would stop performing cataract surgery when and if the rate dropped to $500 per procedure. Another 18% would draw the line at $600, while 20% said $400 would be the point of no return. Finally, the survey asked how satisfied the surgeons were in the field of ophthalmology. Approximately half of the respondents report being neither more nor less satisfied than they were one year before. Another 24% said they were ‘somewhat’ or ‘much more’ satisfied than previously. However, 22% said they were ‘somewhat less’ or ‘much less’ satisfied than in the previous year. " I look forward to surveying the attendees at the upcoming ESCRS meeting in Munich and sharing the information with them on the website, www.leamingsurveys.com," Dr Leaming added. David Leaming MD |
