What's hot and what's not in the ever-evolving field of ophthalmic surgery? We surveyed 126 facility administrators and physician-owners to gauge their interest in five technologies and procedures that have emerged on the scene in recent years. Here are the results, plus analysis and commentary from Wayne Bizer, DO, FAOCO, medical director of the Foundation for Advanced Eye Care Ambulatory Surgery Center and chairman of the ophthalmology department at Nova Southeastern University in Fort Lauderdale, Fla.

1. Smaller phaco incisions
Nearly one-fourth (23.9 percent) of respondents said the smallest incision used for phacoemulsification at their facilities is 2.75mm. A combined 55.6 percent of respondents said the smallest incision size used at their facilities is even smaller. "Smaller than 2.8 or so is getting to ultra-small incisions," remarks Dr. Bizer, who was somewhat surprised by the findings. He notes that this technique has its advantages, such as faster healing and less risk of induced astigmatism, but is more challenging for the surgeon. Micro-incision phaco requires widening the incision to accommodate the intraocular lens, since no IOLs currently approved for use in the U.S. will fit through a 1.8mm incision. "Perhaps we are dealing with a subset of highly skilled surgeons in the United States," suggests Dr. Bizer of the survey sample. More than half of respondents who said their smallest phaco incisions were 2mm or less described their facilities as "very aggressive" about adopting new technologies and procedures (see "Who's on the Cutting Edge?" on page 60). About 17 percent of respondents were in hospitals, with most of the remaining pool operating in ambulatory surgery centers.

2. Topical anesthesia
Half the sample said their physicians are using topical anesthesia more than they were three years ago for ophthalmic cases, citing a number of reasons including a growing preference for and comfort with the technique among both newer and more seasoned surgeons.

"We've found that the topical anesthesia along with a small amount of sedation gives the patients a pain-free surgery and a quicker recovery," says Mary Wilhide, RN, clinical director of the Carroll County Eye Surgery Center in Westminster, Md. "It is also very efficient and easy to manage during the pre-op period."

But while some have found success with topical anesthesia, others noted that the decision depends on the comfort level of the surgeon and the patient. Dr. Bizer says he tried using topical as the primary method of anesthesia for a while, but eventually went back to peribulbar injections with MAC anesthesia because his patients didn't like topical. Several of the 8.9 percent of respondents who said they're using topical anesthesia less now than they were three years ago expressed a preference for blocks.

3. Premium IOLs
About three-fourths of respondents said they implant three types of premium IOLs — multifocal, aspheric lenses and toric lenses — at their facilities. Fifty-three percent also said accommodating IOLs are implanted at their facilities, while only 24 percent currently implant phakic lenses. Large majorities (60 percent or more) of respondents said they were very likely to begin implanting most of the different types of premium lenses over the next five years. But only 43 percent said they were very likely to add phakic lenses, and 31 percent said they weren't likely to add them at all. Dr. Bizer notes that "many surgeons are concerned about the possibility of cataract development" with these lenses. He also says there's a "limited population of patients who have refractive errors that require" phakic IOLs.

Premium IOLs are expensive, and patients must pay a significant portion of the bill out of pocket, so economic and demographic conditions in different areas may impact your decision to start implanting them. "We are in a very rural area in Polk County [Fla.], and I personally think [the physicians] don't feel there is much of a market here," says Emily Duncan, RN, BS, CASC, executive director of the Lakeland Surgical & Diagnostic Center. Ms. Duncan's facility doesn't implant any of the premium lenses listed, but she says they are "somewhat likely" to in the next five years. "All the physicians have been to the training???. They keep talking about wanting to start."

4. Retinal procedures
Although a 48 percent plurality of respondents said they don't do vitreoretinal procedures at their facilities, some retinal procedures are gathering steam. Pars plana vitrectomies are performed at 41 percent of the facilities that responded; retinal laser procedures are performed at 35 percent of facilities; and membrane peels, retinal detachment repair and intravitreal injections are performed at roughly 30 percent of facilities. Among those facilities that haven't adopted retinal procedures as part of their case mixes, there appears to be some reticence to do so, even though changes to the Medicare payment system have made these procedures more lucrative for ASCs. For example, the ASC reimbursement for CPT code 67107 (repair detached retina) went from $717 in 2007 to $922.86 in 2008 and is on track to reach $1,540.44 when the rate changes are fully implemented in 2011. Sixty to 65 percent of facilities said they aren't likely to add any of the retinal procedures listed.

Still, about one-fourth of respondents said they're "very likely" to add some or all of the retinal procedures. The Capital City Surgery Center in Sacramento, Calif., isn't doing any vitreoretinal procedures at the moment, but ASC Manager Kim Russell says they'd like to add retina to their case mix. "The difficulty is attracting a retina surgeon," she says. Dr. Bizer sees an opportunity here for ASCs. "Most of the retina guys I talk to would like to get out of the hospitals because the turnaround times are so slow," he says.

5. Safety blades
Everyone can agree that safeguarding surgeons, staff and patients from sharps injuries is of the utmost importance, but survey respondents were divided over whether technology — specifically, ophthalmic surgical knives that come with a retractable shield for the blade — is the best way to achieve that goal. A plurality of respondents (41.6 percent) said they never use ophthalmic safety knives, while a combined 43.4 percent said they use them very or somewhat frequently.

The Madison Street Surgery Center in Denver, Colo., uses safety blades very frequently because they're "safer for staff" and "meet OSHA requirements," explains Director of Nursing Donna White, RN, MSN, MHA. Many respondents indicated that surgeon preference is the main driver behind their decision whether to implement safety blades. "Our surgeons have not felt the need with our current safety techniques," says Steven D. Williams, MD, FACS, medical director of the Riverside Ambulatory Surgery Center in Bourbonnais, Ill. Dr. Bizer agrees that good communication and a consistently safe method of passing instruments are the real keys to avoiding sharps injuries. Still, more than half of respondents said they were very or somewhat likely to adopt ophthalmic safety knives sometime in the next five years.