Perhaps you�ve been wondering: How many surgeons are really doing outcomes analysis? How many have made the switch to sutureless procedures? And just how popular is the movement toward phakic intraocular lenses (IOLs)? Answers to questions like these help us to gauge where our profession is headed � and where we stand in relation to our peers.

The most up-to-date research on ophthalmic surgical activity sheds plenty of light on these questions and many other issues. I�ve had the good fortune to conduct surveys on the preferences and surgical styles of anterior segment surgeons for the past 15 years.

Here, I�ll provide insights based on my latest research (response rate: 1,434 of 5,000 surgeons), so that you can compare your approaches to those of your peers and better prepare for the challenges  that will face all of us in the next century.

Surgical options

The growing popularity of laser-assisted in situ keratomileusis (LASIK) has been one of the most obvious trends evidenced in the surveys. The combination of the patient-friendly characteristics of the procedure (minimal pain and recovery time), recent corporation-to-consumer advertising, increased media coverage, better equipment and increased experience among surgeons has caused LASIK�s popularity to grow at a remarkable rate.

It�s worth noting that this growth has taken place at the expense of other refractive procedures. Survey respondents reported doing 43% less radial keratectomy (RK) and 23% less photorefractive keratectomy (PRK) between 1997 and 1998.

Despite this trend, PRK isn�t likely to disappear, because it�s especially helpful when used with epithelial dystrophies or when corneal thickness problems are encountered.

Other surgical options of note include:

• Intracorneal rings. According to the 1998 survey, 30% of respondents plan to offer this option to patients in the future, and 52% are interested in taking a course on this subject. Currently, however, only 4 out of 1,434 survey respondents said they were using them on a regular basis, and the percentage of patients whose refractive errors can be treated with intracorneal rings is smaller than the percentage of patients eligible for LASIK.

• Phakic IOLs. These have also generated a high level of interest, despite most surgeons� lack of experience using them. Forty-six percent of respondents expressed an interest in offering phakic IOLs to patients, and 68% said they�d like to take a course in using them. But only about 1% had actually implanted one.

Given that most ophthalmologists are already comfortable implanting IOLs, phakic IOLs are likely to become more popular (if all safety concerns are addressed).

Cataract surgery shift

One of the most interesting changes uncovered by the 1998 survey was a decrease in total cataract surgery volume since the previous year�s survey. This is the first time in many years that such a drop has occurred.

It�s not hard to guess the reason for the decline: The number of respondents who reported doing LASIK procedures increased from 6% in 1996 to 37% in 1998.

In particular, the surveys indicate that much of this shift has taken place in the workload of higher-volume surgeons. These surgeons are more likely to be doing LASIK than low-volume surgeons, presumably because of greater reimbursement opportunities. (A small number of high-volume surgeons shifting from cataract to LASIK can have a dramatic impact on the percentages.)

Obviously, the number of cataracts occurring in the population hasn�t suddenly diminished, so I believe this decrease in cataract surgery volume will be temporary. The unfilled need for cataract surgery left in the wake of the shift will probably be picked up by lower-volume surgeons.

If these shifts continue in the future, which seems likely, they may have other ramifications as well:

• The shift of cataract surgery to less-experienced, lower-volume surgeons may result in an increase in post-surgical complications. The extent of this effect will depend, in part, upon the growth rate of the refractive surgery market.

• Because LASIK is more consumer-driven, more money will be invested in patient education materials and patient counselors specifically intended for the refractive surgery market.

• Surgeons will adjust hours and availability to make refractive surgery easier for patients.

• As more lower-volume surgeons increase their cataract surgical volume, I expect to see more managed care contracts changing doctors. In general, this could be beneficial for ophthalmology, increasing competition among payers. Hopefully, managed care will be forced to offer better remuneration for our work in taking care of covered patients.

The phaco phenomenon

The trend toward reliance on phacoemulsification continues. All but 3% of respondents now use phaco for cataract extraction. Nearly two-thirds of the respondents say that they no longer use planned extracapsular cataract extraction.

It�s safe to say that the relative safety of the phaco procedure is the main factor behind its popularity. So we�ll see more non-sutured wounds and, when phaco is coupled with capsulorhexus, more foldable lenses, more small incisions and less induced astigmatism.

I expect the trend toward increasing use of phaco to continue, especially if we want a spherical targetable refraction after cataract surgery. This goal will be even more important if multifocal IOLs gain popularity. (Interest in multifocal IOLs has gradually risen since 1994.)

Cataract surgical technique.

The popularity of clear cornea incisions has increased steadily throughout this decade. The approach was preferred by 1.5% of survey respondents in 1992, but by 36% in 1998. Changing attitudes toward sutureless surgery have followed a similar track, preferred by 1.2% of respondents in 1990, but 81% in the most recent survey.

Preference for both methods seems to parallel surgical volume. Only 29% of surgeons doing less than 25 cataracts each month prefer clear cornea; in contrast, more than half of the surgeons doing 50 or more surgeries prefer clear cornea. Likewise, only 55% of surgeons doing less than 6 cataracts per month prefer sutureless surgery, whereas 93% of high-volume surgeons prefer it.

As long as clear cornea incision continues to be a safe, sutureless, astigmatism-neutral procedure, it�s likely to remain a player for many years to come.

Other trends uncovered in the surveys:

�        Choice of anesthesia. Reported usage of topical anesthesia has climbed steadily from 8% in 1995 to 37% in 1998. Topical anesthesia has grown on the backs of sutureless surgery, small incision surgery and foldable IOLs. It has the advantage of �instant visual improvement� without having to use a patch or risk needle perforation.
To a large extent, use of topical anesthesia parallels surgical volume. Only 22% of surgeons who performed fewer than six cataract removals per month preferred topical anesthesia. On the other hand, 63% of surgeons doing more than 51 cataracts per month preferred to use topical anesthesia.

�        Incision technique. The most recent survey indicated that, for the first time, a temporal incision is preferred over a 12 o�clock incision. The preference for a temporal incision rose from 33% to 43%, while preference for a 12 o�clock incision dropped from 49% to 35%.
The temporal approach simply mirrors the trend toward clear cornea surgery. If clear cornea continues to grow, the move toward temporal incision will continue as well.
As I noted, high-volume surgeons prefer clear cornea, sutureless incision and topical anesthesia more than low-volume surgeons, and � not surprisingly � the preference for a temporal incision follows the same pattern.

�        Nuclearfractis technique. Surgeons haven�t reported much change in nuclearfractis technique during the last 5 years. By far the most popular technique in 1998 was the four quadrant split, which 60% of respondents favored (a drop of 7% from the 1997 survey).

Preference for other techniques was as follows:

�        18% favored stop and chop (a 7% increase over 1997)

�        9% preferred the two-section divide and conquer

�        7% used the sculpt-and-nibble-until-gone technique

�        5% reported using other techniques.

Ultimately, I believe whichever technique has the fewest complications will prevail.

�        Secondary IOLs. Respondents reported using an anterior chamber IOL 87% of the time. However, 28% of high-volume surgeons � those doing more than 75 cataracts per month � said they use a sutured posterior chamber lens.

�        Outcome analysis. There hasn�t been much of a change in the use of outcome analysis recently; the percentage of respondents who say they track outcomes has remained in the mid-teens for several years.
It�s worth noting, however, that higher-volume surgeons are far more likely to go to the trouble. Thirty-five percent of surgeons doing more than 75 cataracts per month reported using an outcome program.
Only 5% of surgeons doing less than six per month reported tracking outcomes.

Intraocular lens trends

Where IOL preferences go in the future will be determined by many factors, including corporation-to-patient advertising of the different IOLs (toric, multifocal, and so forth). In the meantime, several trends are clear:

�        Choice of material. For the first time since I began surveying surgeons in 1985, Acrylic surpassed polymethyl methacrylate (PMMA) as the most popular IOL material. (The majority of respondents felt that acrylic is the most promising lens material for small incision cataract surgery.) Silicone also continued to increase in popularity.
Surgeons doing more than 50 cataracts per month preferred silicone 37% of the time. These surgeons have more experience with silicone than many of their peers, and they�re comfortable with its characteristics. In contrast, lower-volume surgeons often opted for acrylic, which unfolds in a more controlled manner and has a lower capsular opacification rate. (Surgeons doing fewer than six cataracts a month reported using silicone lenses only 11% of the time.)
How well PMMA fares in the coming years will probably be determined by how astigmatically-neutral we�re able to make the incision, especially as we drift toward refractive cataract surgery.

�        Choice of lens type. As you might expect, foldable lenses received a very favorable rating from the vast majority of respondents (85%). Other observations:

�        Interest in multifocal lenses has remained fairly low throughout this decade, but has gradually risen in recent years. In the 1998 survey, 17% expressed a high level of interest in these IOLs.
Eleven percent of respondents expressed high interest in toric IOLs.

�        As mentioned earlier, phakic IOLs have generated a fair amount of interest � roughly half of the respondents plan to offer this option to patients in the future. Almost none currently offer it.

�        Sixty-eight percent of responding surgeons preferred an assembled lens rather than a plate lens.

In terms of the future, high-tech lenses still have to prove their merit, as their predecessors did. And again, as we move toward refractive cataract surgery, lens material and incision size will become ever more important factors in determining the successful use of these lenses.

Into the future

It�s clear that a number of factors will shape surgical trends in the coming years. The economics of managed care will certainly influence our choices, and technological advances will eventually cause today�s techniques and instruments to become replaced by more efficient and effective options.

Perhaps the most profound influence in the coming years will be the trend toward consumer-oriented surgery. As new, ever more patient-friendly technologies and techniques become available, the push to advertise directly to patients

will bring more of them into our practices � and make their desires and preferences an increasingly important factor in the choices we make.

Whatever the future holds, one thing is certain: Advancing technology will continue to improve the options and outcomes we offer to our patients. With luck, both we and our patients will reap the rewards.

Looking at Tools and Adjuncts

A number of trends concerning surgical procedure and technique are evident from the Dr. Leaming surveys:

•  Choice of blade. Factors such as the cost of acquisition and the cost of repair keep the metal blade a top player. The number of respondents using diamond blades to make clear corneal or anterior limbal incisions dropped from 38% to 34% in the most recent survey. In contrast, preference for a metal blade grew from 46% to 52%. (13% reported using both types.)
  One interesting note: Surgeons who own or control their own surgicenter are more likely to invest in a diamond blade. Presumably this is because they can hold personnel more accountable and have more control over the blade�s use.

• Use of a miotic. There has been a steady move away from use of an intraocular miotic during cataract surgery. Seventy-five percent of survey respondents said they routinely used a miotic in 1991; by last year the number had dwindled to 42%.
  This appears to be the result of a decline in use among high-volume surgeons. Only 30% of those doing more than 75 cataracts per month in the most recent survey said they routinely use an intraocular miotic. In contrast, 65% of surgeons doing fewer than 6 cataracts a month still use a miotic. I believe this is the result of the economics of high-volume surgery.

• Choice of viscoelastic. In my experience, this is predominantly a question of the surgeon�s personal preference. Many surgeons I know have no problem using whichever viscoelastic is bundled with the pack/lens.
  The most recent survey results indicated that 71% of surgeons use one specific type of viscoelastic, 21% use a variety of types, and 8% use whatever viscoelastic is supplied. These numbers haven�t changed significantly since 1996. (Note: Only 1% of the survey respondents don�t routinely use a viscoelastic with cataract surgery.)

• Use of disposable tools. The number of respondents using disposable tools only once before disposal increased in 1998, to 61%. The most notable trend here is that surgeons doing a large number of cataracts each month were much more likely to reuse disposal tools. Sixty-four percent of those doing more than 75 cataracts per month reused disposable instruments; in contrast, only 31% of doctors doing 5 or less cataracts reused them.
  Similarly, 39% of the high-volume group reused disposable phaco tubing; only 18% of the low-volume group did.
  As with miotics, the number one driving force behind this trend is probably economics.

•  Location of surgery. In 1998, 41% of survey respondents did cataract surgery exclusively in the hospital; 26% used an ambulatory surgery center (ASC) exclusively.

Two factors notably affected choice of location:

• High-volume surgeons were more likely to use an ASC than low-volume surgeons. (It�s worth noting, however, that the number of high-volume surgeons using an ASC exclusively has dropped since 1996.)

• Sixty-one percent of respondents reported that insurers determined the location of surgery at least some of the time. Thirty-nine percent said insurers never determined the location.

Factors determining the location of surgery have remained fairly stable over recent years, and I see no reason to expect a change in the near future.

The Surgical Volume Factor

One thing that�s become clear from the survey results is that high-volume surgeons � usually categorized in past surveys as those doing more than 75 cataracts per month � responded quite differently to many questions than low-volume surgeons (those doing five or less cataracts a month).

Here are a few of the differences that have emerged: 

Factors that might be causing these differences in preference probably include:

�        the difference in experience levels accumulated over time

�        differences in volume-related cost-management concerns

�        the increased likelihood that a high-volume surgeon will be working in an ambulatory surgery center.

Besides managing a busy general ophthalmology practice in Palm Springs, Calif. (since 1978), Dr. Leaming has been conducting surveys on the practice styles and preferences of the American Society of Cataract and Refractive Surgeons since 1985. His 1999 survey results will be published next summer in the Journal of Cataract and Refractive Surgery.