Reinventing Cataract Surgery for the 21st Century

An avalanche of new technology is upon us. Can practices and patients afford it?

By William F. Wiley, MD

I grew up in an ophthalmology household. My father is a semi-retired ophthalmologist, and I bought his practice seven years ago. Given that I have been observing the evolution of ophthalmology since my teens, I have seen quite a change in the field over the years.

When I was in high school in the mid 1980s, the prime of my father's career, I remember seeing his office party video in which he and his partner got on stage and sang to the whole staff, "We've got to fight… for our right… to phaco" — in tune to the Beastie Boys' hit song at the time, "Fight for Your Right (to Party)."

In those days, a paradigm shift was taking place as the profession moved from in-patient extracapsular cataract surgery to outpatient phacoemulsification. The surgeons who were creating that paradigm were initially considered "cataract cowboys" and were, for a time, shunned by a majority of their peers. It was not necessarily clear to everyone that "phaco" was a better procedure, and surgeons had to work hard through the learning curve and technology development to help standardize and elevate the procedure to where it is today.

The Paradigm Shifts Again

But today's cataract surgery, as safe and predictable as it has become, is not tomorrow's cataract surgery. A veritable avalanche of safer, more effective and more precise technology is in the process of descending upon us. The vanguard of these advances is already here and beginning to incrementally improve outcomes. But progress comes at a cost.

We may be on the verge of being capable of performing perfect cataract surgeries with fantastic results. But we may also be on the verge of separating our patient base into the "haves" who can afford to purchase the best care that we can offer and the "have nots" who will need to accept whatever their insurance sees fit to cover.

In this article, I will examine the onrush of this new paradigm and the costs associated with making it a reality for our patients.

A Historical Perspective

My father caught the LASIK and refractive surgery wave late in his career and was able to help the pioneering effort in elective, self-pay refractive procedures such as RK, PRK and then LASIK. In my first few years of practice, I divided my time relatively equally between two distinct practices: cataract surgery in my general ophthalmology practice, Cleveland Eye Clinic, and LASIK surgery in my self-pay refractive surgery practice, Clear Choice LASIK Center.

Early in my general ophthalmology practice, I was quite content that Medicare and private insurance cataract reimbursement paid for the very best care possible for my cataract surgery patients. This payment covered perioperative pharmaceuticals, phacoemulsification, monofocal IOLs (or, if desired, an Array multifocal or Staar toric). With the exception of co-pays and deductibles, cataract surgery was covered 100% by insurance. This included all surgical techniques, devices and technology. Pharmaceutical coverage for cataract surgery often consisted of a combination steroidantibiotic that could be purchased in a generic form for around two dollars.

Exciting Times — But Also Expensive

Now we are entering a very exciting age of new technology. The major goals for advancement encompass improved safety, precision and efficacy. Physicians, patients and ophthalmic companies are all looking for the same end result — measurably better results with less chance of complications.

We have seen this kind of progress in surgical skills, technology and pharmaceutical advancements. In pharmaceutical care, the standard perioperative coverage for pharma ceuticals for cataract surgery now includes a steroid drop, fourth-generation fluoroquinolone and today's greatly improved NSAIDs, which have come a long way from the days when many cataract surgeons were reluctant to use them at all.

Investment in pharmaceutical development has drastically reduced perioperative infections, postoperative inflammation and swelling, and co-morbid conditions of dry eye and blepharitis. All of which improves the safety and efficacy profile for the patient.

But the classic trio of perioperative drops must now be purchased separately and may cost the patient more than $200 depending on what type of insurance coverage the patient has. In addition, dry eye may be treated with prescription-strength eye drops costing the consumer over $100 per month. Preoperative lid preparation with specific eye drops may cost more than $100.

Thus, for one basic cataract surgery, the patient may be personally responsible for more than $400 in pharmaceuticals alone. Now that surgeons have the ability to charge patients for "premium" surgery, this $400 in out-of-pocket pharmaceutical charge also competes with the self-pay upgrade options available to the patient. With physicians competing against the drug companies in the out-of-pocket costs, we may see ophthalmologists exploring other options for perioperative antibiotic coverage that may include intraocular injections at the time of surgery and/or greater acceptance of generic pharmaceuticals.

With the rising cost of healthcare and the increasing political pressure to control costs, Medicare no longer has the ability to pay for the "best technology available." So, in an ironic twist, we are seeing these compelling new technology advances arriving at just the time when we are questioning the ability of insurance to pay for the most advanced care. Thus, for patients to now receive "the best" care available, they are forced to — or have the opportunity to — pay outside of insurance to achieve more advanced care and technology.

Because ophthalmology has had previous experience with a thriving private market in the form of corneal refractive surgery, the template is already in place to provide the same sort of services as add-ons to insurance-reimbursed care. We are seeing a merger of traditional self-pay refractive surgery with insurance-reimbursable cataract surgery, such that the margin between both services are blurring.

The New Cataract Technology

With regard to technology, the largest areas of recent improvement in safety and efficacy include advancements in IOL biometric diagnostics, IOL technology and cataract removal technology. Innovation — and innovators — now abound in cataract surgery. Signs of innovation are everywhere, from Hoya's pre-loaded and highly efficient iSert IOL inserter, to light-adjustable IOLs, to dual-optic accommodative lenses, even extending to new devices to deal with complications. One quick example: When intraoperative floppy iris syndrome (IFIS) was first identified about five years ago, innovators quickly swung into action to combat this complication. One result was the Malyugin Ring, which has proven to be an effective response to IFIS.

In everyday practice, we now have available an advanced tool in IOL biometry. Our practice has had success integrating the ORange intraoperative aberrometer from WaveTec. This is a device that takes aphakic and pseudophakic images to help predict the correct IOL power prior to implantation and then reconfirm that the correct IOL has been placed in the appropriate position after implantation. Through the use of this device, we have the ability to increase the success for astigmatism correction through toric IOLs and limbal relaxing incisions (LRIs).

With the ability to meet patients' increasing demands on expectations, we are able to charge a premium price to patients who are demanding a premium outcome. But there is an increased cost to the practice to use a high-ticket instrument like the ORange. So one has to ask the question: Is it worth the investment for such new technology?

In regard to the ORange system, we have found our premium IOLs and astigmatism-correction results have significantly improved. Thus, we have more confidence in charging the patient for the improved outcomes. In addition, we have seen a reduction in the need to perform enhancement surgeries for these patients, which allows for significant cost savings for our practice, happier patients who provide referrals, and an elevated reputation for our practice in the community.

A Whole New World of IOLs

In my father's day, the primary goals of cataract surgery were simply to remove a media opacity and allow for unobstructed view with the need for aphakic spectacles. Today, the goal of first-rate cataract surgery is having the ability to successfully implant advanced presbyopia-correcting IOLs that can provide for both uncorrected distance and near vision.

Additionally, we have developed advanced surgical techniques and IOLs that can correct astigmatism through toric IOLs and LRIs. This increase in efficacy allows physicians to charge above and beyond insurance for the extra services associated with the premium technology, thus resulting in additional cost to the patient of up to $2,000 to $3,000.

The technology for presbyopia correction is constantly improving. The current state of lens technology may only be appropriate to a certain segment of the patient population. The current accommodative lenses provide some ability to "focus" but are limited in the amount of near vision they can provide. The current multifocal lenses provide good near vision but often have associated side effects that are sometimes not tolerated. In addition, there are no presbyopic lenses that can correct for astigmatism available in the US (Alcon, however, just launched the Restor toric in Europe). Thus, if a patient has significant astigmatism, he or she may not be a candidate for presbyopic correction.

Femto-Phaco Arrives on the Scene

In the near future, we will have access to even newer technology in the area of cataract extraction technology. Femto-phaco will be the newest frontier. This technology again seems destined to improve safety and efficacy through safer lens removal, better quality corneal incisions and more precise capsulorhexis.

The major potential advantage of femto-phaco technology is to decrease intraoperative complications through precision-made laser cuts — with less energy placed into the eye for removal of the cataract and fewer capsule-related intraoperative complications. In addition, the femto should allow for more stable and predictable postop refractions and fewer wound-related complications in the postop course.

It has been shown that capsulorhexis size can affect the ultimate refraction by up to one diopter. Having more consistency in the size of the capsulorhexis will allow for better lens centration and tighter postop refractions. It is unclear how much this technology will cost the patient, but it could be perhaps $500 or more per eye — again, a fairly large cost that we must justify to the practice and to our patients if we are to adopt this technology.

Multiple Advances Create Synergies

Twenty-some years ago, my father was involved in the 3M multifocal lens trials. At that time, the lens was considered to be a failure. I had the opportunity to study the results from his patient enrollment. The lens was a diffractive multifocal IOL very similar to what our current lenses look like. However, it was made of PMMA and required a large incision.

Cataract complications of cystoid macular edema were more common then, and adequate therapeutics to treat and/ or prevent these complications were not available. In addition, the biometry and phaco techniques of the time resulted in variable postoperative results. Many of his patients were 1 to 2 diopters off target with 1 to 3 diopters of residual cylinder. This was an age before LASIK/PRK, and at that time there was no easy way to correct residual refractions.

In hindsight, it is easy to see that the 3M lens may not have been that much of a failure in itself. The main issue was that our concept of cataract surgery was not quite advanced enough at that time, resulting in overall failure of the final product.

With multiple new technologies coming into the marketplace at about the same time, we are beginning to see synergies and co-dependence on these technologies. This will result in ultimate improvement of the entire process from beginning to end, resulting in the sum being greater than the individual pieces.

However, such an avalanche of progress may prove cost-prohibitive to physicians who feel pressure from peers and patients to adopt the ORange, femto and expensive IOLs. We may see a contraction in providers in the super-premium field because not everyone will have the necessary technology to provide premium care.

The ORange technology requires very demanding control of surgical variables; incisions have to be perfect and the cataract must be removed in an efficient manner to control and prevent corneal edema. A tool like femto-phaco may allow for better control of variables, allowing improved ORange readings and thus better results for both cataract removal and intraoperative aberrometry. In addition, future IOL technologies, like multifocal toric IOLs, may require very precise positioning for ultimate results. We may need an instrument like ORange to achieve these results. New accommodating IOLs — fluid-filled or dual optic — may require the precision of aphakic or pseudophakic readings to allow for precise refractive fit.

Where Cataract Surgery is Headed

In summary, with new technology we as surgeons will have the ability to emulsify the cataract with laser assistance, enter the eye in a blade-free manner and choose the perfect lens for the patient that will correct both near and distance vision. Technology will be able to predict, check and adjust the lens on the table to allow for near perfection. Our ability to meet and exceed the patients' expectations for safety and efficacy will truly be a miracle.

This ability and opportunity will require a co-pay of perhaps $3,000 to $5,000 above the patient's insurance coverage. When the added costs begin to dwarf insurance reimbursements, our field may see physicians opting out of traditional private or governmental insurance. With the upgraded options now becoming available, surgeons will have the opportunity to put their services at a price determined by the free market, which may allow surgeons to receive a higher fee for the advanced care they will provide.

Some consumers will have the opportunity to buy and receive the best possible care. However, this care will come with a cost that not all consumers may afford. This is both the blessing and the curse of the coming new paradigm in cataract surgery. OM

William F. Wiley, MD, is Medical Director of Cleveland Eye Clinic and Clear Choice LASIK Center. He can be reached via e-mail at drwiley@clevelandeyeclinic.com.