Eye surgery patients deserve the very best visual outcomes, safety and convenience possible, and the managers of eye surgery facilities are set to purchase the products and services that can make that happen. But there's one caveat: The economics have to make sense.

"Cataract reimbursements are going down, but the costs continue to go up," says a South Carolina ASC administrator.

Our readers are interested in new ideas, but they'll only adopt technology that helps their patients and helps them preserve profits. That's the take from this year's survey on new technology for cataract and other anterior segment procedures. Here's what the 279 facility leaders who responded had to say.

Laser cataract surgery

Once the hottest trend in cataract surgery, laser cataract surgery might be losing some steam. The percentage of facilities offering this service declined from 51% last year to 41% this year. Several facilities that dropped it cited cost, speed, space and tepid surgeon commitment.

"We tried it when it was first implemented, but it was short-lived," says Annquinetta Dansby-Kell, RN, CRNO, clinical coordinator at the Eye Center of the Outpatient Care Center in Birmingham, Ala. "Most surgeons were not interested. It prolonged overall OR time and many felt that they performed a reasonable manual capsulorhexis without the laser."

"We tried it for a year, but it was not a cost-effective option for our patient population and our ASC was not big enough for the process to be efficient," says Laura Picano-Wilson, RN, clinical director of the Livonia (Mich.) Outpatient Surgery Center.

"We have stopped using this modality," says a Philadelphia ophthalmologist. "It increases inflammation, constricts the pupil and, worst of all, creates a capsulotomy that is more prone to radial tears than is a manual capsulorhexis."

Most facilities that don't currently do laser cataracts are not planning to. Three-fourths say it's "not too" or "not at all" likely that they will add it in the next 2 years. They cite expense, limited space and low surgeon interest. Those that do laser cataracts could be doing slightly fewer of them. In our 2017 cataract survey, 46% of facilities that were doing laser cataracts were using the laser for more than one-fourth of their cataracts. In 2018, only 40% of facilities reported doing as much.

That said, the lasers still have devoted fans: 8% of the facilities doing laser cataracts expect laser procedures to grow significantly in the next 2 years, while another 56% of those facilities expect "moderate" growth.

If laser cataracts is experiencing a slowdown, the problem is marketing, not the technology, says Kayla Schneeweiss-Keene, BSN, director of nursing at the Mann Cataract Surgery Center in Houston, Texas. She says her facility is seeing shorter recovery times because of less phaco time in the eye. She says visual outcomes are better because the perfectly centered capsulotomies align with the IOL's optical zone and visual axis. And she praises the accuracy of LRI incisions to correct astigmatism. In her facility, she says, "the outcomes sell this procedure."

Preloaded IOLs

The use of preloaded IOLs is up slightly, and the satisfaction with these systems is up a lot. Well over half of all facility managers say they are "very satisfied" with the devices' efficiency, infection control and ability to satisfy surgeons.

"They are very easy to use for the surgical tech and surgeon," says Ms. Picano-Wilson. "The preloaded lenses help the procedure move a few seconds quicker," says the clinical manager of a Florida ASC. "The fact that misloaded lenses from human error is removed from the equation also helps."

But little less than half say they're "very satisfied" with the cost of these devices. "We have tried several, but the additional cost does not warrant their usage," says a Virginia ASC coordinator. "Surgeons don't care. They just want the case finished."

"IV-free" anesthesia

One in 10 facilities has tried the MKO Melt IV-free anesthesia tablet, where patients put 1 or 2 tablets containing midazolam, ketamine and ondansentron under the tongue and go to sleep. The sublingual sedative dissolves within 2 to 5 minutes.

The drug gets good marks for patient and surgeon satisfaction — 35% each call these "excellent." A nurse administrator of a Texas ASC says, "Patient satisfaction with their surgery experience is better." And Melody Hargrove, BSN, director of nursing at the busy Ophthalmology Surgery Center of Dallas, says the surgeon who's using the drug at her facility likes the "still eye" it produces.

But a lot of facilities (40%) say the drug is not predictable. "Results vary by patient," says a surgical coordinator in Washington State. "Some are so relaxed that they have trouble staying awake for most of the day. Others don't notice any effect."

That may be one reason that anesthesia satisfaction is only "fair" or "poor," say half of all facilities that have tried the drug. "Our director of anesthesia wasn't taken with the idea because there is no way to gauge how much drug would be absorbed and how fast," says Mary Curtin, BSN, RN, director of nursing at Tenaya Surgical Center in Las Vegas, Nev. "Given the demographic, he also thought it was prudent to have an IV, in case of emergency."

Nearly one-third of the facilities (30%) say the drug costs too much. One tablet costs about $15, and "most patients are getting 2 tabs," says a director of a surgery center in Rhode Island, "and I am still keeping the IV in. Patients are spending up to an hour in recovery. So the total cost is higher."

A few facilities say they love the idea of "IV-free" anesthesia, but they're doing it their own way. Amy Thiele, ASN, OR manager at The Eye Surgical Center of Fort Wayne (Ind.), says her facility uses oral Valium and sublingual Versed. "It works very well and our patients are very happy." A couple of facilities offer Versed syrup for patients who don't wish to have an IV.

Of the facilities that haven't tried the MKO Melt, 9% say they will give sublingual sedation a try within the next 2 years. Another 38% are unsure. A piece of good news: Imprimis Pharmaceuticals achieved 503B status for the MKO Melt, so you can obtain supplies of it without individual prescriptions.

Less energy to remove the cataract

What about new technology to fragment the lens without phaco? Iantech's miLoop recently won FDA approval. It employs a thin filament loop that the surgeon uses to quarter the nucleus. Soft lenses may then be extracted via aspiration; harder ones still require phaco. Of those respondents who've already tried this technology, 9% rate it "very attractive" and another 40% think it's "somewhat attractive."

Many say the device has a real niche with mature cataracts. "There's nothing wrong with phaco for most cases," says our Philadelphia ophthalmologist, "but for the densest cataracts, the addition (not substitution) of miLoop is a godsend." An Iowa nurse anesthetist likes the simplicity. "One less instrument to fail," he says. A Tennessee ASC administrator who finds the concept "very attractive" echoes that sentiment: "Cost is the main reason. Phaco machines are extremely expensive and technology changes."

The problem is that although the miLoop may reduce the amount of phaco energy in the eye, phaco is typically still required, says a Minnesota director of surgical services. It's better for the patient, but it ends up cutting into profits because reimbursement is fixed. Some facility managers also question the need for a phaco replacement. "If it isn't broken, don't fix it," says Daniel Hauer, CASC, administrator of the Valley Ambulatory Surgery Center in St. Charles, Ill.

"Dropless" cataract surgery

Post-op shots are hot. Drops are not. We asked our survey respondents to rate 2 single injections that surgeons administer at the end of surgery that treat post-op inflammation and dispense with post-op eye drops. So-called "dropless" cataract surgery eliminates noncompliance and dosing errors associated with relying on the patient to dispense frequent drops following cataract surgery. There are 2 kinds:

• Antibiotic-steroid. One-third of our survey respondents say their physicians inject an antibiotic-steroid combination into the posterior chamber before discharging the patient. That's about the same as last year. Facilities that use it love it.

"Patients love the convenience and the reduced expense," says an Indiana ASC executive director. It "decreases patient noncompliance with drops and the negative outcomes that this can have," says an Oklahoma ASC administrator.

Others are not as pleased, though. Donald Lenz, ASN, clinical director of the Eye Surgery Center of New Albany (Ind.), says his facility "identified an increase in rebound inflammation post-operatively" with the dropless approach and discontinued it. Our Philadelphia surgeon worries that it's too invasive. "It involves either shoving a cannula through the zonule or adding a pars plana injection."

And there's the ever-present element of cost. While patients make out because they don't have to buy drops, the injections are expensive for facilities and there's no reimbursement, says Ellen Lopez, RN, the director of the Arizona Ophthalmic Outpatient Surgery facility in Phoenix.

• Extended-release steroid. In February, the FDA approved Dexycu, an extended-release dexamethasone for injection into the posterior chamber following cataract surgery. A single injection of Dexycu administered at the conclusion of surgery treats post-op inflammation and dispenses with eye drops after cataract surgery, says EyePoint Pharmaceutical, maker of the corticosteroid. More than half of our respondents like the concept, 13% finding it "very" attractive and 41% finding it "somewhat" attractive. "I would love to eliminate post-op drops for the patient anyway I can," says Ms. Picano-Wilson. "Anything to reduce drops is a win-win for all of us," adds John Kraves, BSN, ASC manager at Northwest Eye Surgeons in Renton, Wash.

Two worries, however. First and most important, the cost.

"Cost is the biggest issue here," says a Missouri ASC administrator. What will be the tab for the new drug and will insurers reimburse it? Failing that, will patients be allowed to pay? Second, clinical concerns. Ms. Schneeweiss-Keene asks, What about patients who are steroid responders? And is it dangerous to inject drugs into the posterior chamber? "Our retina surgeon is opposed to the routine installation of medications into the posterior chamber and our anterior surgeons cooperate with his suggestions," says Mr. Lenz.

Pupillary dilation and maintenance

How are facilities handling floppy iris syndrome and miotic pupils? Our survey found that 48% say their surgeons typically use a mechanical pupil expansion device and 16% use a compounded pharmaceutical like Shugarcaine. Meanwhile, 5% use the FDA-approved ketorolac phenylephrine compound Omidria. That drug might be more popular, but its pass-through status expired at the beginning of 2018. "Omidria will be widely used once again as of Oct.1, 2018, due to the approval of a new 2-year approval pass through," opines a clinical supervisor at a North Carolina ASC. Elsewhere, 7% use intracameral phenylephrine alone, 7% use high-viscosity viscoelastic and 17% of facilities say there is no one prevailing technique.

Micro-invasive glaucoma surgery

Micro-invasive glaucoma procedures, often called MIGS, are hot: 71% of facilities host them. Within that group, 77% host stent procedures like iStent, Cypass and the Xen gel stent, 42% host goniotomy/trabeculectomy procedures like the Trabectome, Trab 360 and the Kahook Dual Blade and 20% host canaloplasty/viscodilation procedures like the iTrack and Visco 360.

We asked our survey subjects how satisfied they were with the pressure-lowering ability of these devices, the complication rate and the patient satisfaction. Most expressed satisfaction with all 3, although some commented that they were not in a position to know what happened post-operatively.

It's perhaps no surprise that what they're not consistently happy with is the reimbursement. Our respondents are divided evenly, with about half saying the reimbursement is "excellent" or "good" and the other half calling it "fair" or "poor." "These products are so highly priced that when reimbursement is lower than the cost of the product, it doesn't make it very appealing to the consumer," says a Missouri facility manager. OSM