Looking at the Latest Trends in Cataract Surgery

Ophthalmology

By: Joe Paone

Published: 8/10/2020

Share:

Our annual reader survey reveals ophthalmic facilities continue to embrace new technologies even as COVID-19 impacts case volumes and patient confidence.


It's certainly been a challenging year for eye surgery centers, many of which were forced to close for several weeks during the initial stages of the COVID-19 pandemic. The adoption of new tools, technologies and medications for enhancing surgical outcomes continues unabated, however, according to results of our 2020 cataract technology reader survey. Let's take a closer look at what the responses reveal.

  • Femtosecond laser. Use of femtosecond lasers is now reported by a majority of respondents ?— up from 40% in our 2018 survey to 60% this year. In terms of the percentage of cases for which surgery centers use the laser, almost 40% said they are in the 26% to 50% range, while 45% said they use it on less than a quarter of their patients. More than 60% of respondents expect laser cataract procedures to grow "moderately" at their centers over the next two years. Interestingly, however, more than 80% of centers that aren't using femto lasers say it's unlikely they'll be performing laser cataract surgery in the next two years, which indicates a leveling out of the market.

"We've been performing femtosecond cataract surgery for eight years, and our volume and percentages have been steady over time," says one respondent. Another predicts laser cataract procedures will grow significantly in their facility because "patients are more informed and want the best outcomes." A nurse manager at a Michigan surgery center cited laser's virtues as "ease of use, less trauma to the eye and better outcomes," and adds their surgeons love it.

However, a significant minority has yet to embrace the technology. "We did perform femto laser-assisted cataract surgery for a year and found our results were just as good without it," says Susan Marks, MS, BS, administrator at Augusta (Ga.) Eye Surgery. Dianna Reed, BA, administrator at Sani Eye Surgery Center in Templeton, Calif., says it's "faster for my doctors to perform surgery without the laser." An administrator at a New York City surgery center says they simply don't have room for the platform.

COMMON COMBINATION Microinvasive glaucoma surgery (MIGS) is performed simultaneously with cataract procedures at about 70% of surgery centers.

Still others are on the fence. Kathy Young, RN, BS, director of nursing and administrator at the Colorado Eye Institute's Peak Surgery Center in Colorado Springs, says she expects the volume of laser procedures to grow only moderately at her facility because of the extra cost associated with the procedure.

  • IV-free surgery. Usage of "under the tongue" anesthesia as an alternative to starting an IV remains relatively minimal, although centers reporting adoption rose from 9% in 2018 to 16% this year. All told, 63% of respondents who aren't using IV-free anesthesia said they don't expect to adopt it over the next two years.

Kim Nordby, RN, MSN, CNOR, administrator at NovaMed Surgery Center Chicago Northshore, says "99% of our cases are IV-free."

Most respondents, however, brought up several reasons why they don't use it, and they go beyond the higher per-case cost. "With the older population, you never know the effect after discharge," says Nancy Haskell, RN, CNOR, CRNO, director of nursing at Capitol City Surgery Center in Sacramento, Calif.

"We did use it, but the timing of onset is hard to manage with such fast cases," says Carson McCafferty, MSN, clinical director at Eye 35 Ambulatory Surgery Center in Schertz, Texas. "We've gone back to using IV midazolam and fentanyl."

A nurse manager at a Florida surgery center reports, "We currently prefer to start an IV via saline lock for emergency access due to the age and health status of our patients." Another respondent who's considering shifting cataract cases to an office-based setting says oral sedation might be a safe alternative to IV sedation in healthy, younger patients.

  • Dropless surgery. Post-op drop compliance is a perennial problem with cataract patients, meaning so-called "dropless" cataract surgeries are an attractive option. Use of dropless techniques rose from 31% in our 2018 survey to 45% this year. One respondent reports performing "less-drops surgery," which involves injecting medications intracamerally, and still having patients use drops post-operatively.

Russell Snook, MD, of Eye Surgery Center of North Dallas in Carrollton, Texas, reports that he doesn't use dropless techniques yet because of both the higher cost and the lack of an available FDA-approved product.

  • Intracameral antibiotics. Nearly 45% of respondents say their surgeons are using intracameral antibiotics during surgery. At 60%, moxifloxacin is the most frequently used agent among centers that have embraced the approach.
  • MIGS. Micro-invasive glaucoma surgeries remain popular, with 71% of respondents saying their centers perform the procedure. Among those centers, stent implantation was the most common method (92%), followed by goniotomy/trabeculotomy (67%).

The impact of the pandemic

Facility administrators say the COVID-19 pandemic has resulted in decreased case volumes, temporary closures and protocol changes. Numerous respondents said their surgery centers had closed for six weeks or more.

Some reported case volumes had returned to normal, or were approaching normal, as of mid-July. "Since we were able to restart cases, we have seen our numbers reach pre-COVID levels," says Ms. Reed. "The time required to clean ORs between cases has increased 20%, but we added additional staff to help with the turnovers."

Lisa White, RN, LHRM, administrator at Tomoka Surgery Center in Ormand Beach, Fla., says patient volume at her facility is "mostly back to normal," although she's starting to see patient cancellations and staff call-outs due to COVID-19 exposure and the need to isolate as her state deals with a major rise in cases. "Patient feedback has been good about the precautions we're taking," says Ms. White. "They feel safe with the guidelines we're following."

Several other respondents say many patients who were scheduled for cataract surgery have canceled their procedures as COVID-19 cases continue to increase. Others report patients accept having to wear masks and abide by visitor restrictions, and appreciate all the protocols put in place to protect them. The survey shows staff members are worried about exposing family members to the virus, have concerns about dealing with a colleague or patient who tests positive and dread having to shut down their ORs again if local coronavirus cases continue to increase.

GET INSIDE Almost half of the survey's respondents embrace the use of intracameral antibiotics.

An administrator at an Ohio surgery center says communicating with patients about the safety precautions you've implemented can be powerful. Discussions of the risks associated with undergoing surgery during a pandemic should start with the pre-op phone call, suggests the administrator, who says patients are more comfortable with undergoing surgery if they're informed about the precautions you have in place.

Many patients are still hesitant to show up for scheduled procedures. "We were temporarily shut down for six weeks when COVID-19 hit our city hard," says Ms. Nordby. "We're currently at about 75% of our typical case volume. We've seen more late cancellations and no-shows from patients who are nervous about having surgery when the day gets closer."

Another respondent says their facility postponed 700 cataract procedures, adding, "We did not extend operating hours, so our numbers will be down in 2020." An administrator in New York City reports substantial financial loss, saying, "We're at 25% patient volume — having to complete screening tests within five days is a burden. All of our staff members returned, but they're anxious about the COVID situation. Although we provide them with PPE and ask if there are any safety issues, they're still worried."

Respondents discussed safety measures they've implemented such as increased in-depth cleaning in waiting areas, mask-wearing requirements, prescreening for all patients and more restrictive visitor policies for those accompanying patients to their centers. A few mentioned the need to assign or hire dedicated staffers to perform temperature checks and screen patients for COVID-19. Other issues mentioned included not letting surgeons push to hurry up turnover times, as well as staffing issues due to childcare concerns.

It's clear COVID-19 has impacted cataract surgery, but facilities are still interested in innovations that will continue to advance patient care long after the pandemic eventually ends. OSM

Related Articles