Worldwide need for cataract surgery projected to rapidly grow in next 10 years

Noel A. Alpins, FRACO, FRCOphth, FACS, said as the number of aging patients increases, a balance must be struck between new technologies and cost-saving cataract surgical practices. Image: Alpins NA

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 time passes, you get this gradual encroachment of a higher percentage of the proportion of people getting older, which obviously impacts economically the proportion of people paying taxes, which in turn supports the economy,” Noel A. Alpins, FRACO, FRCOphth, FACS, OSN Asia-Pacific Edition Editorial Board Member, said. “You get so many more people 80, 90 and 100 [years old]. This becomes proportionally greater year by year. It’s overwhelming how the need for cataract surgery outpaces the ability to deliver what’s actually required for the community to have its needs satisfied.”

Cataract is the leading cause 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.

“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 now more physically and socially active than any previous group of seniors. People 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.

According to the World Health Organization (WHO), populations in developing countries are aging quicker than those in the developed world. In 2000, 248 million of the approximately 418 million people aged 65 and older were in developing countries.

By 2020, the United Nations estimates the global elderly will total 698 million.

Changing needs

Older people 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.

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 put 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.”

Increasing demand

According to projections by the 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.

In the Asia-Pacific region, countries will face challenges based on specific needs and issues. The Global Initiative for the Elimination of Avoidable Blindness, “Vision 2020: The Right to Sight,” was launched in 1999 by the WHO and the International Agency for the Prevention of Blindness to develop sustained eye health systems in nations around the world.

“Interventions against cataract still need to be intensified to reach affected but so far un-serviced populations,” according to a press release from WHO.

“Despite the recent achievements in the prevention and control of avoidable blindness, the emerging trend is a warning sign against complacency on the part of governments, WHO and other eye care providers,” Ivo Kocur, MD, the Vision 2020 global coordinator, said in the release. “If the current level of maldistribution of resources is perpetuated, the global disparity and inequity in the availability of affordable eye health services, particularly for the elderly in the poorest parts of the world, will be compounded.”

In Australia and New Zealand, 324 ophthalmologists have graduated and gone on to fellowships of The Royal Australian and New Zealand College of Ophthalmologists in the last 10 years, Dr. Alpins said. Of those, 79 were not locally trained. He said that in the future, numbers similar to these will not meet the need as more patients need cataract surgery.

“I think it really highlights the fact that the number of people over 50 … is definitely ahead in cases over and above the number of people who have been trained locally and also those who have emigrated to Australia to work,” he said.

Cataract impact

If the need for cataract surgery is not met, problems will abound, Dr. Alpins said.

First, surgery will become inaccessible to many people because public system waiting lists will significantly increase and demand for ophthalmologists will be high, rendering care difficult to find in many areas, he said.

Then, the community at large could be impacted by disabilities, including from motor vehicle accidents caused by vision impairment.

“Many countries have really cut back to the bone as far as what the reimbursement for cataract surgery is. The government might be thinking it’s saving costs, which in the short term it might be, but in the long term, it’s creating an increased level of visual disability, which increases the amount of comorbidities just from the issues created by people that can’t see adequately,” Dr. Alpins said.

He said increased life expectancy has contributed to the situation. As patients age, the life expectancy rate is also increasing, so a person who reaches 70 years could live to 80 years, while a person who reaches 80 years could live to 90 years and beyond.

“The increase in life expectancy is due to better health, better food and better lifestyles. At every age, longevity is greater now than in the past, resulting in greater population in the 50s and 70s and beyond. And anyone who gets to the age of 90 is going to have some degree of cataract. It’s inevitable,” he said.

Meeting the challenge

Surgeons will have to be more efficient with their time and technology to meet the growing cataract surgery need, 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.”

Rupert Menapace

Rupert Menapace, MD, OSN Europe Edition Editorial Board Member, 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 around the world, more patients will pursue private care where it is available, 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 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.

Dr. Alpins said that the increase in surgical efficiency will be vital in meeting the increasing cataract need as the population ages. However, he cautioned that cost must be an integral consideration in using some new technologies.

“With increased knowledge, these new and so-called better techniques are increasing affordability. This may not apply here because of the advanced type of implants that you have that often are more expensive, but also the advanced type of technology that is becoming available such as laser-assisted cataract surgery,” he said.

“The problem with that is, do these technologies treat more patients in less time more affordably?” Dr. Alpins asked. “And I think the answer to that, particularly with this generation of lenses and femtosecond cataract surgery, is that you are going to increase the cost to the patients in the community of patients who are paying. And it also doesn’t mean a decrease in surgical time; it actually increases duration. So this side of technology, it might be very attractive superficially to have your cataracts taken out by laser, and once the patients become savvy to it because they’re better educated, it actually is counterproductive to the overall goal of getting more people treated quickly and with less cost.”

He said reducing the number of cataracts in the community is the most important goal, which should not be forgotten in the pursuit of new technologies.

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,” he said.

According to Dr. Alpins, the use of the Internet and other ways of accessing information could be another way that costs could increase.

“As younger people get older, the older people are becoming [aware of] the knowledge base that you can find out there. It allows them to thoroughly research what their options are. This might mean an increase in the amount of patients who actually want the best technology available to them,” he said. “Which once again adds a cost factor to it, because these advanced lenses are much more expensive than the standard monofocal aspheric implants.”

Technology

Improving technology could increase efficiency and productivity and enable surgeons to meet burgeoning demand, John A. Hovanesian, MD, FACS, OSN U.S. Edition Cornea/External Disease Board Member, 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

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References:

• Brian G, Taylor H. Cataract blindness – challenges for the 21st century. Bull World Health Organ. 2001;79(3):249-256.
• Global pattern of blindness changes with success in tackling infectious disease and as population ages. World Health Organization website. http://www.who.int/mediacentre/news/notes/2004/np27/en/index.html. Dec. 16, 2004.
• 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.
• Noel A. Alpins, FRACO, FRCOphth, FACS, can be reached at 7 Chesterville Road, Cheltenham, Victoria 3192 Australia; +61-3-9584-6122; fax: +61-3-9585-0995; email: alpins@newvisionclinics.com.au.
• 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.