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Cataract surgery projected to rapidly grow in next 10 years in Europe
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The demand for cataract surgery is expected to surge in the coming years, as more baby boomers reach 65 years of age around the world.
“As in other industrialized countries, the percentage and total number of elderly patients will dramatically increase in the years to come. Baby boomers of the ’50s and ’60s are reaching an age over 65 years, while family size has been decreasing ever since,” Rupert Menapace, MD, OSN Europe Edition Editorial Board Member, said. “Europe is aging rapidly.”
Cataract is the leading case of reversible blindness and visual impairment worldwide.
The impending spike in demand for cataract surgery is multifactorial. Aside from a sharp increase in the number of aging patients with cataracts, evolving surgical techniques and improving outcomes promise to boost demand among relatively young, active patients who desire cataract surgery or refractive lens exchange.
 Lucio Buratto, MD, said both the changing needs of patients and improving technologies have added to the increase in cataract surgeries, which should continue as the European population ages. Image: Buratto L
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“The demand for cataract surgery is increasing tremendously, not only because of the expanding aging population, but because the age at which people demand cataract surgery has lowered,” Lucio Buratto, MD, OSN Europe Edition Associate Editor, said. “Cataract surgery is performed earlier, as soon as the first signs of opacification appear, because people ask for it as a way to have a better quality of vision and reduce or avoid the need of glasses.”
In addition, seniors are more physically and socially active than any previous group of seniors. Europeans are living well and living longer. Apart from being a large age cohort, baby boomers — people born between 1946 and 1964 — have higher expectations than previous generations.
“Today, elderly people are more active and await perfect vision. This has already resulted in an increase of the total number of cataract surgeries performed during the last years, and it will much more do so in the years to come,” Dr. Menapace said.
Baby boomers also have greater access to the Internet and expanding technologies and often expect improved outcomes. Ophthalmologists must fully exploit breakthrough technologies and develop innovative practice models to meet increasing demand and rising expectations.
 John A. Hovanesian |
“Seventy is the new 50,” John A. Hovanesian, MD, FACS, OSN U.S. Edition Cornea/External Disease Board Member, said. “The baby boomers who are just beginning to have cataracts are seeking lens replacement surgery for relief of presbyopia and for their own visual disabilities that bother them because they, too, are active.”
Modern life has expanded the need for good to excellent eyesight, with patients needing near, intermediate and distance vision for everyday tasks. Patients use computers, cell phones, notebooks and book readers on a routine basis, requiring a full range of sight, Dr. Buratto said. Everything from satellite navigation systems in vehicles to temperature readings and petrol consumption is automated and requires near and intermediate vision.
“What has changed the scenario in recent years is the widespread use of mobile phones and other mobile electronic devices like the iPad and iPod,” he said. “It’s not like sitting on your armchair and putting on your spectacles to read the newspaper or to make a phone call at home. At all times during the day people are using their near vision and need to be quickly able to see well at near in many occasions, while maintaining a good distance vision because they drive and do many far-sight activities.”
In addition, surgeons will have to be more efficient with their time and technology, Jorge L. Alió, MD, OSN Europe Edition Editorial Board Member, said.
“I think that surgeons need to learn and need to be much more efficient in terms of outcomes. We need shorter number of visits — instead of four, to have only two,” Dr. Alió said. “Better outcomes are mandatory in order to avoid additional visits. Cataract outcomes should be … more efficient in providing the best level of care with a very small number of refractive error dealing with the premium lenses for presbyopia.”
Increasing demand
According to projections by the World Health Organization (WHO), in 10 years, it is estimated that the world’s population will increase by about one-third. At the same time, the number of people older than 65 years will more than double worldwide.
The WHO estimates that by 2020, 32 million cataract operations will be performed, up from 12 million in 2000.
 Jorge L. Alió |
In Europe, each country faces challenges based on the increasing need for cataract surgery, Dr. Alió said.
“For instance, in England, it’s clear that they don’t have the number of surgeons that will be necessary in the coming years. Because actually in this very moment, cataract surgeries in England are on demand and they can’t meet the number that they need. They will not be ready for the future,” he said.
According to the European Union of Medical Specialists (UEMS), there are approximately 40,000 ophthalmologists for a population of about 500 million people in Europe. The ophthalmologist-per-patient ratio varies from country to country. In the U.K., the ophthalmologist-per-patient rate is the lowest at 2.51 per 100,000. The U.K. is followed by the Netherlands at a rate of 3.13 per 100,000 and Ireland at a rate of 3.99 per 100,000.
Greece has the highest ophthalmologist-per-patient ratio at 14.34 per 100,000. Italy also has a high ratio at 12.27 per 100,000, with Spain approximately the same. Germany and France are both at 8.72 per 100,000, according to the UEMS.
“In other countries, like in Germany, there they have a demand for doctors, and many doctors in Germany are coming from Poland or from previously the Eastern European countries just to work [there] because of the better conditions for labor and also because of the demand of surgery,” Dr. Alió said.
Public, private sector
The health systems in European countries typically run in a public or private sector fashion, with either public or private surgeries. If the public sector cannot offer quick and appropriate responses to the increased need for cataract surgery, more patients will seek private care, Dr. Buratto said.
Surgery is free in the public sector, but only standard phacoemulsification with implantation of monofocal IOLs is offered.
“Only private clinics offer more innovative techniques and technologies, like [microincision cataract surgery] with premium lenses,” Dr. Buratto said. “But the patient must pay the entire cost of surgery, and no reimbursement is provided.”
The possibility of patients being insured under the National Health System for a standard option while being allowed to pay extra for an option such as a premium IOL in a co-payment method is being accepted in some European countries, including France, Denmark and the Netherlands. The idea has not yet been introduced in Italy, Dr. Buratto said.
Meeting the challenge
In Western Europe, 11,000 cataract surgeons perform about 3 million cataract surgeries per year, according to Market Scope. However, with the surgeon population aging alongside the patient population and countries facing different difficulties concerning ophthalmic education and training, introducing new ophthalmologists to the work force throughout Europe might be challenging.
“It is true that baby boomer ophthalmic surgeons are coming into their 60s and will be retiring in some years, and this will create some gaps between the need of surgeries and the providers,” Dr. Alió said.
Italy has a specific issue with training more ophthalmologists to enter the work force, Dr. Buratto said.
“In Italy, we have a problem with meeting the demand of medical students who want to become surgeons. There are few fellowships offered to ophthalmic surgeons, and the candidates are many. Quite a number of them have to give up,” he said.
 Rupert Menapace |
Dr. Menapace said the combined situation of an aging population and increased demand for cataract surgery might not be solved with more surgeons but with more effective surgical practices.
“The future challenge is to cope with the projected tremendous number of surgeries, which will not be paralleled by an increase of the number of new cataract surgeons. The answer is simple: Surgery must become even more efficient. In an environment of restraints in costs and reimbursement, optimizing the organization within cataract facilities and exploiting the surgical capabilities of the surgeon will be the appropriate answer,” he said.
If surgery does not become more high-volume and efficient in the public health care sector, more patients will pursue private care, he said.
“This, however, will in turn create political pressure on private medicine. Reimbursement regulations and incorporation into medical networks controlled or run by the state may be the result,” Dr. Menapace said.
According to Dr. Menapace, the structure and workflow in surgical units must be significantly altered across Europe to provide more procedures at an increased rate.
“Cataract surgery providers must make up their minds to improve their efficiency of both the structure and workflow of the surgical units and the surgery itself to optimally allocate the financial resources if they want to successfully cope with the challenges of the future,” he said.
Dr. Buratto said the increasing surgical demand should be addressed through quality and enhanced visual performance. Correcting pre-existing refractive errors is vital and should be accomplished through the use of different IOLs that are available, he said.
In addition, the new approach of using femtosecond laser for cataract surgery could be incorporated for better refractive results and precision. Other options, such as premium lenses, should be weighed carefully, he said.
“Premium lenses need precise centration, and the ability to do a precise continuous circular capsulorrhexis, in terms of position, diameter and centration [with a femtosecond laser], allows the lens to be centered well and be more stable,” he said.
Patient education
Educating patients about realistic options will most likely be a vital part of meeting the future need for cataract surgeries, Dr. Menapace said. He said patients learn from sources such as the Internet about different surgical options and IOL technologies. Sometimes they decide on IOLs and commercial platforms that cannot meet their needs before discussing their options with their surgeons. This scenario will likely occur more often in the future, he said.
“Evidence-based noncommercial education in Internet platforms should be provided for patients to allow them to appropriately shape their demands,” he said.
Dr. Buratto also said that older patients are increasingly knowledgeable about surgery and expect to be part of the surgical process from the start. Patients need to know what they will experience in cataract surgery, he said.
“The time of unconditioned trust is over, and now, no matter how good your reputation is, you need to provide your patients with detailed information on the type of lens you are using, on the technique, etc. When you see your patients for a visit, this is already the second stage. Normally patients want to be well-informed before they come to your office. They want to be able to compare what different private clinics offer and decide what’s best for them,” Dr. Buratto said.
Technology
Improving technology could increase efficiency and productivity and enable surgeons to meet burgeoning demand, Dr. Hovanesian said. He urged practitioners to embrace new technology, particularly femtosecond lasers, as a way to improve outcomes and increase efficiency. Many surgeons believe femtosecond lasers decrease efficiency and do not significantly improve safety, he said.
“This is the very first generation of these lasers,” Dr. Hovanesian said. “Despite all those woes, the reason we’re excited about technology is because we know what it is capable of. We need to allow it to continue to evolve. We need to support it and use it. We should reward the innovation of those companies that bring these lasers to market so that they will make further developments that will benefit us and our patients. Let’s not be afraid of the future. Let’s shape it to be better for everyone and to move forward this great specialty that we’re all a part of.”
Dr. Alió said technology is the way forward in meeting the surging cataract surgery need around the world.
“Technology is improving. Femtosecond cataract surgery is taking better control of the anatomy of eye during the surgery and after the surgery probably as well. We’ll make the patient happy sooner,” he said. “Technology is going to play a role because it will make cataract surgery faster, probably more controllable and probably will be more systematic in terms of approach. And all of this is of benefit to the patients.” – by Erin L. Boyle, Michela Cimberle and Matt Hasson
References:
- Brian G, Taylor H. Cataract blindness – challenges for the 21st century. Bull World Health Organ. 2001;79(3):249-256.
- Roodhooft JM. Leading causes of blindness worldwide. Bull Soc Belge Ophtalmol. 2002;(283):19-25.
- Jorge L. Alió, MD, PhD, can be reached at Vissum Corporation, Avenida de Denia, s/n, 03016 Alicante, Spain; +34-965150025; fax: +34-965151501; email: jlalio@vissum.com.
- Lucio Buratto, MD, can be reached at Centro Ambrosiano Oftalmico, Piazza Repubblica 21, 20124 Milano, Italy; +39-02-6361191; fax: +39-02-6598875; email: office@buratto.com.
- John A. Hovanesian, MD, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653, U.S.A.; +1-949-951-2020; fax: +1-949-380-7856; email: drhovanesian@harvardeye.com.
- Rupert Menapace, MD, can be reached at the Medical University of Vienna, Vienna General Hospital, Department of Ophthalmology, Waehringer Guertel 18-20, A-1090 Vienna, Austria; +43-1-404007941; fax: +43-1-404006630; email: rupert.menapace@meduniwien.ac.at.
- Disclosures: No products or companies are mentioned that would require financial disclosure.
