Adoption of refractive cataract surgery essential for anterior segment surgeons

Issue: December 10, 2011

ByRichard L. Lindstrom, MD

Richard L. Lindstrom

More than 8,000 ophthalmic surgeons perform about 3.2 million cataract/lens implant operations per year in the United States. That is about 400 procedures per cataract surgeon on average. Of course, some surgeons do less than 100 and others well more than 1,000, but the well-trained cataract surgeon should be able to build a practice that includes 400 surgeries per year, or eight to 10 per week typically done on a single surgery day.

The volume of cataract surgery has been growing about 3% per year for some time, and the growth rate is expected to accelerate to 4% as the population ages. The compounding rule of 72 tells us that at that rate, the volume of cataract surgery should double in 18 to 24 years. Thus, the typical 30-year-old ophthalmologist of today can expect to perform about 800 cataract surgeries a year at age 50 years and more than 1,000 a year in their 60s.

Of concern to all, the reimbursement rate per procedure for third-party pay procedures seems to be under never-ending downward pressure, but the projected volume growth is certainly bullish for ophthalmology. Considering the downward pressure on fees paid directly to surgeons, the prudent young ophthalmologist will be well served if he or she arranges to participate as an owner in an ASC. At 600 procedures per year, a single OR ASC works well economically, and as volume grows to more than 1,000 cases per year, an ASC becomes a very helpful revenue source for the owner-ophthalmologist.

Even more exciting is the growth in patients who seek lifestyle-enhancing refractive outcome goals, and patients are confirming a willingness to share in the costs of this refractive cataract surgery. The same 78 million baby boomers in America who drove the growth in refractive corneal surgery are now turning 65 years old at the rate of 10,000 per day, and they are accustomed to sharing in the cost of their care, especially when quality of life is enhanced. Today, about 8% of patients choose to enhance their spectacle-free vision through the surgical management of astigmatism with custom corneal relaxing incisions and/or a toric IOL. Another 7% choose an accommodating or multifocal IOL, targeting reduced dependence on glasses at far, intermediate and near. Together, these two elective patient-pay lifestyle-enhancing refractive cataract surgery options total nearly 15% of patients.

While a lower market penetration than many had hoped for in 2011, refractive cataract surgery is clearly crossing the chasm from innovator/early adopter surgeons to the mainstream middle adopter ophthalmologist, the so-called silent majority that quietly does most of the work in America. The annual American Society of Cataract and Refractive Surgery survey suggests that more than 70% of cataract surgeons have treated at least one patient with a toric, accommodating or multifocal IOL. Market Scope reports that this patient-pay channel is growing at 20% per year. Again, using the compounding rule of 72, this growth rate suggests that the number of patients undergoing some form of refractive cataract surgery will grow to 30% in 3 to 4 years and 60% to 70% before 2020.

Of course, there is a limit to the number of patients who want, can afford and are candidates for refractive cataract surgery, but if one includes the management of astigmatism with a target of 0.5 D or less residual cylinder after surgery and reasonable fees, I can foresee well more than 50% of patients selecting a lifestyle-enhancing refractive outcome goal and sharing in the cost of achieving it by 2020. This leads me to believe that the upcoming decade is the decade in which refractive surgery for the cataract patient becomes mainstream and routine, just as refractive corneal surgery did over the past 10 years. If I am correct, it behooves every ophthalmologist who intends to practice the art and science of cataract surgery for 5 years or more to embrace refractive cataract surgery, as it will be at the core of the successful cataract practice in only a few years.

While IOL technology will continue to improve, the greatest challenge, in my opinion, is generating refractive outcomes for our refractive cataract patients similar to those obtained by our refractive corneal patients who undergo LASIK or excimer laser surface ablation. Interesting to me is the probability that the application of lasers to refractive cataract surgery may affect outcomes as positively as they did when we transitioned from manual incisional refractive corneal surgery to our current sophisticated computer-assisted custom laser corneal refractive surgery. In addition, other tools of value in refractive corneal surgery, including wavefront aberrometry applied before, during and even after cataract surgery as adjustable IOLs become available, look to be helpful. And of course, excimer laser corneal refractive surgery remains one of the best enhancement tools for residual refractive error after refractive cataract surgery.

While there is much to make the ophthalmic surgeon of today anxious about his or her future, the projected growth in cataract surgery and the tremendous opportunity afforded the ophthalmologist who embraces refractive cataract surgery are nothing short of transformative for our specialty. In my opinion, in this decade, adoption of refractive cataract skills is no longer optional for the anterior segment surgeon but mandatory.