LASER CATARACTS About 39% of our 230 survey respondents offer femtosecond laser cataract surgery at their facilities, up slightly from 35.5% in last year's Cataract Technology Survey.

What's hot and what's not in cataract surgery? Our annual Cataract Technology Survey asked 230 managers of ophthalmic surgical facilities to list the most significant innovation or development in cataract surgery in the last couple years. The responses were varied and point to a specialty that's forever finding ways to improve surgical outcomes. Our respondents mentioned patient-pleasing advances like laser cataracts and intraoperative aberrometry, preloaded lenses and premium multifocal and toric IOLs, IV-free sedation and dropless cataracts, microscopes, monitors and more. The buzz over precision laser cataract surgery has yet to subside.

"Refractive cataract surgery has become outcomes-based/lifestyle cataract surgery," says Deb Cochran, administrator of The Surgery Center in Traverse City, Mich. "The doctor and the team's desire to deliver great outcomes for the patient is key. The technology is impressive. Combine education with high-level surgeon skill and a supportive and skilled team, and you'll deliver and have a happier patient."

As you'll see in this rundown of 10 recent cataract innovations, the one factor that can temper the enthusiasm of ophthalmic administrators is cost. If it's going to increase case costs, the innovation had better be something, many say.

1. Femtosecond laser. About 39% of respondents offer femtosecond laser cataract surgery at their facilities, up slightly from 35.5% in last year's Cataract Technology Survey. Of those, most (45.5%) own the laser, 27.3% lease it, 16.9% outsource it and 10.4% lease it via a "bundling arrangement," meaning they pay for the use of the laser by agreeing to buy IOLs and supplies from the vendor.

One respondent says her facility took out a 12-month lease from the femto manufacturer with the option to buy after 1 year. "If we buy, then the lease payment goes toward the purchase price," she says.

Eye centers that have a femto laser are getting a lot out of it, using it in 27.1% of their cataract cases. More facilities are planning to add laser cataract surgery. Nearly one-third (31.7%) of respondents say it's likely that they'll add femto within the next 2 years. For those respondents who say it's unlikely (57.8%), the reasons were many and varied: space, cost, time, patient benefit and surgeon interest.

"Our main ophthalmologist is an excellent surgeon and does not need the laser to make the cuts," says one respondent.

COST CONSCIOUS If a new product is going to increase case costs, it had better improve outcomes or efficiency, says our survey.

"Our doctors are not convinced that the femtosecond laser leads to a better outcome," says Jackie Dayton, RN, the supervisor of the Surgery Center of Ophthalmology Consultants in Fort Wayne, Ind. "The outcome is the true, ethical thing to measure. Not speed or newest technology — just patient satisfaction."

2. "Combination" femto lasers. You can now use at least 3 femtosecond cataract laser machines for either cataract surgery or LASIK. We asked our panel how attractive a "combination" femtosecond laser machine would be as compared to a machine that can only do cataract surgery. The reviews were mixed: 13.1% say it's very attractive, 31.3% say it's somewhat attractive, 30% say it's not too attractive and 25.6% say it's not attractive at all. Many respondents say their surgeons either don't perform LASIK or, if they do, they perform it in their offices. Some also cited a diverse patient mix: LASIK patients tend to be younger and cataract patients tend to be older.

"We do a limited number of LASIK procedures, but our LASIK laser is near the end of its life," says the director of surgical services at an ophthalmic ASC. "If cost were not prohibitive, we would consider a combination laser."

EYE ON ERGONOMICS Microscopes with adjustable oculars and "heads up" surgery where the surgeon looks at a flat TV screen instead of through a microscope help prevent repetitive stress injuries of the neck and back.

3. Refractive cataract surgery. Our respondents are making good use of a variety of refractive cataract surgery technologies, including toric intraocular lenses (90%), multifocal intraocular lenses (80.6%), arcuate corneal incisions (41.3%), intraocular lenses available in .25D steps (27.5%), digital marking for toric IOL alignment and arcuate incisions through the operating microscope (25%) and intraoperative wavefront aberrometry (16.3%).

4. Preloaded IOLs. About one-fourth (26.7%) of our respondents use preloaded IOL injection systems. Those who do are generally very satisfied from efficiency and infection control standpoints, but 15.1% were "not too satisfied" with the cost. One respondent complains that her system adds to the surgery time because it's slower to unfold.

5. IV-free anesthesia. Cataract patients can bypass the discomfort of the IV start by placing a lozenge containing midazolam, ketamine and an antiemetic under their tongue. We asked our panel to rate the potential attractiveness of this concept at their facility. It's very attractive for 9.4%, somewhat attractive for 32.1%, not too attractive for 18.9% and not at all attractive for 20.8%.

"We've already used this melt with success," says Cassie Diehl, BA, LHRM, COA, administrator of the Same Day Surgery Center in Zephyrhills, Fla.

"This would be very interesting to consider. It's something I believe patients would like," says Matt Umbehant, BSN, the surgical services manager at Stephens County Hospital in Toccoa, Ga.

Ms. Dayton says IV-free anesthesia is on her next meeting agenda. "IV supplies are expensive and IV starts are painful. I know patients would be all for it," she says.

IV-free is not for everybody, like those who give local anesthetic or prefer IV sedation (many in our panel insist on IV access in case of an emergency). Some prefer not to put patients to sleep because physicians like them responsive during surgery. Some worry it'll overly sedate patients, increasing recovery time and leaving patients groggy. "We have a high elderly population and the best practice is a small dose of Ativan with a local," says a hospital administrator. Another respondent says she's already IV-free: "We use oral midazolam with great results." Others balk at the cost, $25 for 2 tablets, compared to IV drugs.

6. Dropless. In so-called "dropless" cataract surgery, the ophthalmologist injects an antibiotic-steroid combination before closing so that the patient doesn't have to instill drops post-operatively. "Hopefully, Medicare will realize that they will save money by using this option instead of eye drops. I love dropless!" says Denise Carpenter, RN, BSN, director of nursing at the Surgery Center of Northern California in Redding, Calif., among the 28.8% of respondents who say some of their surgeons have gone dropless. "It's good for non-compliant patients, but it's an added expense," says a respondent.

7. Optical coherence tomography. OCT, a technology that lets surgeons visualize clear tissue intraoperatively, is available on several ophthalmic microscopes, but only 3% of our panel say OCT is available on their facilities' microscopes.

8. Surgical glue. About one-fifth (21.7%) of our respondents use ReSure Sealant, an ocular sealant that seals and protects clear corneal incisions in the immediate post-operative period when wounds are most vulnerable. "Only on some complex cases — not for every patient," says Amy Wiatt, RN, director of surgical services at MidAmerica Surgery Center in Chesterfield, Mo. Another respondent says one of her surgeons wants to use ReSure Sealant, but she's reluctant because it costs twice as much as suture and has a 1-year expiration date.

9. Ergonomics. Some research suggests that cataract surgeons are particularly vulnerable to repetitive stress injuries of the neck and back because of the position they must assume at the operating microscope. Our respondents are mindful of their surgeons' comfort, widely offering ergonomic accommodations such as microscopes with adjustable oculars that allow a more natural posture (85.2%) and "heads up" surgery (61.2%), where the surgeon looks at a flat TV screen instead of through a microscope.

10. Outsourcing. Only 9.3% of our respondents use a cataract outsourcing service where the company brings the equipment, supplies and technician for the surgery for a fixed fee per case. Those that do, however, are unanimously satisfied. "Very time-saving for us," says Linda Winkelman, RN, surgical director of Community Medical Center in Falls City, Neb. The administrator of an ophthalmic ASC says her facility used an outsourcing service for the LenSx laser before acquiring its own. "It was a good way to ease into the femtosecond world without a huge financial commitment," she says. OSM