CHANGE OF VENUE Will cataract surgery migrate from hospitals and surgery centers to offices?

What will cataract surgery look like 10 or 20 years from now? Hard to say, but the ophthalmic OR is bound to be a lot different than it is today. "If you look back 50 years at what we were doing in cataract surgery, it's night and day compared to now," says George O. Waring IV, MD, FACS, director of refractive surgery and an associate professor of ophthalmology at the Medical University of South Carolina in Charleston. One thing observers are sure of: Case volumes will rise. Here are some possibilities that they see in the busy decades ahead.

1. Office-based cataracts. Office-based surgery is likely to become standard care for routine cataracts and lens replacements, driven largely by their minimally invasive techniques, the successes of LASIK suites and the desire to create a better patient experience, says Dr. Waring. "We'll be looking to our dental and oral surgery colleagues, who do many things well in terms of patient service," he says, adding that ophthalmology's trend toward oral sedation and minimal IV sedation "fits into this paradigm nicely." Offices won't be able to accommodate general anesthesia, special equipment and the complex cases they support, but they could make cataract surgery more approachable for patients, he says.

Medicare doesn't currently reimburse office-based cataracts, but the agency has reportedly considered the subject. Keep in mind, though, that even self-pay cases face roadblocks at present. "The fact that it's technologically feasible, and it is, doesn't mean it's economically feasible yet," says Steve Sheppard, CPA, COE, managing principal of the Medical Consulting Group in Springfield, Mo. Renovating, equipping and staffing a space to meet state-specific requirements and to handle surgery's demands could take several solidly scheduled years to break even, he notes. Additionally, physician-owners might not see a financial incentive to export ASC cases to office suites.

2. Heads-up digital microscopy. Ophthalmic microscopes are paragons of precision, but they're still using traditional optics and they're still less than kind to physicians' necks. Digital optics will offer advances on both fronts, says Daniel S. Durrie, MD, founder of Durrie Vision in Overland Park, Kans., and a clinical professor of ophthalmology at the University of Kansas Medical Center in Kansas City, Mo. Integrating digital visualization into eye surgery could enable 3D imaging, a view of surgery for everyone in the room and the ergonomic advantages of heads-up operations, he says.

While only one manufacturer today makes a digital microscope for the ophthalmic OR, entries into the field from optics and camera makers or from display and image processing experts would enliven the technology and perhaps even convince traditional optics diehards to upgrade, says Dr. Durrie. "It's somewhat of a legacy issue," he says. "Microscopes are $100,000-plus, and we're comfortable with their optics. We get really good results, even though our necks hurt. But young partners definitely don't want the complaints that senior partners have."

3. Virtual reality views from inside the eye. Another way to see ophthalmic surgery is from inside the eye. A virtual-reality display powered by data from non-invasive optical coherence tomography (OCT) imaging could make this happen, says Joel Schuman, MD, FACS, professor and chairman of ophthalmology at NYU Langone Medical Center.

"It'll be a different experience for surgeons, very much immersive," he says. Plus, in a step up over endoscopic cameras, "OCT is like 4D, where time is the fourth dimension, and it'll be possible to see what is happening over time."

These virtual reality views might even escort robotics into eye surgery. Not hulking robotic arms, but nanomachines working under the physician's wireless control. "This could allow physicians to operate closer to delicate tissue, such as the retina, without the risks involved with the human hand doing that surgery," says Dr. Schuman. "You'd have the artisanal aspect of surgery, but also more reproducible."

4. Provider shortage? As ophthalmic case volume climbs, the physician population is expected to remain constant. "The demographics show we're going to have an access-to-care problem," says Mr. Sheppard. Sub-specialization may be the answer, with some physicians forgoing the office to practice in the OR full time, and mid-level providers (or even physician assistants) playing a role. "Does it require a doctor to lock in settings and push a button?" he asks. "Why have an MD doing 20 intravitreal injections per day?"

In Dr. Schuman's view, technology advances technique. "We can already calculate and achieve ideal outcomes for refractive surgery and IOLs by plugging data into our machines," he says. Soon those machines may provide tactile feedback on incision placement and depth, while also decreasing tremors. "My expectation is, any surgeon would be able to operate at the level of a master surgeon, with very little variability," he says.

The drive to deliver quality care efficiently and cost-effectively may even reshape the OR, says Dr. Waring. He imagines the cataract surgeon of the future sitting in the center of a surgical clean room, surrounded by several small, self-contained operating theaters. Each one contains a patient who's prepped and draped for surgery, who the surgeon reaches through a membrane barrier to treat. "That way the surgeon doesn't have to change anything, he just rotates to each consecutive patient around him," he says.

5. Same-day bilateral surgery. Dr. Waring also sees efficiency extending to the choices available to patients, with same-day, sequential, bilateral cataract surgeries becoming the norm when both eyes need treatment. "Bilateral could represent time and cost savings," he says. "Plus, it's a better patient experience. They only need to take one day off, arrange a ride to and from surgery on one day."

While concerns have been raised about the safety of sequential bilateral cataracts, and Medicare will only reimburse half for the second eye if it's done on the same day, there's no proof that the existing standard is better. "There is no data supporting the efficacy or safety" of requirements that the cataracts be removed in separate surgeries on separate days, he maintains. "It's based instead on tradition and dogma. What's best for patients is held up by arbitrary regulation."

Sequential bilateral cataracts have become the standard of care for self-pay patients, he notes, anticipating future studies on the process. "Data will be the driving force that shows this makes sense," he says.

6. Lasers (and phaco machines) here to stay. Experts agree: The femtosecond laser will play a key role in the ophthalmic OR of the future. "Laser cataract surgery will become the standard of care in the U.S. within the next decade," says Dr. Waring. And, once developed, "more compact machines will fit nicely into the office setting."

The advent of lasers in cataract removal has made the procedure safer and its results more reproducible, says Dr. Schuman, and in the future, OCT-guided lasers will let physicians work closer to the pathology with a reduced risk of damage. One thing lasers won't do, however, is eliminate phaco machines from the OR anytime soon.

"Most emulsification of the lens can be done with a femtosecond laser," says Dr. Schuman. "But you will still need to remove the tissue after doing laser softening," and aspiration is still a job for the phaco handpiece, since an independent aspiration/irrigation tool doesn't currently exist.

While cataract surgery incisions have minimized to 1.8 mm, and may someday become even smaller, lasers won't do away with those, either. They'll always be needed for aspiration and intraocular lens insertion.

"Laser can handle a big part of the procedure now," says Dr. Durrie. "But give surgeons a choice of one or the other, and they'll say, 'I love my laser, but I've got to have my phaco machine.'" OSM