Lindstrom reflects on evolution, future of cataract surgery
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In this commentary, I will take a short walk down memory lane, which will amaze some younger ophthalmologists, and then I will share some thoughts on my expectations for the future of cataract surgery.
I began my clinical ophthalmology residency at the University of Minnesota in 1974, 48 years ago. That year, cataract surgery patients were admitted to the University of Minnesota Hospital the afternoon before surgery and received a comprehensive history and physical examination, blood work, an EKG and a chest X-ray. They were visited by an anesthesiologist. They then underwent surgery the following day and remained in the hospital for 7 days of postoperative care with daily examinations. Keratoplasties were admitted for 10 days with daily examinations.
The cataract surgery technique was intracapsular cataract extraction using a Zeiss operating microscope with cryoextraction of the lens and closure with seven to nine 7-0 chromic gut, Vicryl, silk or occasionally 10-0 nylon sutures. No IOLs were implanted. No phacoemulsification was performed. The only extracapsular cataract extractions were in infants and children. Every patient received a retrobulbar block or general anesthesia. Each cataract surgery was scheduled for a 2-hour block of time, and a full day of surgery was four cases. Every patient received subconjunctival antibiotic and steroid at the end of the case and used postoperative antibiotic, steroid and cycloplegic eye drops for 2 to 3 months.
Our busiest anterior segment surgeon operated three mornings a week and performed two cases each morning, six cases a week, plus a few emergencies for a total of 300 surgical cases a year. The same schedule was followed at the outside teaching hospitals, which included St. Paul-Ramsey Hospital, Hennepin County Hospital and the Minneapolis VA Hospital.
I finished my residency and then completed three fellowships, including one in Dallas with William S. Harris, MD, at Mary Shiels Eye Hospital. I worked with Bill Harris, first as a fellow and later as a junior associate, for 2 years between 1978 and 1980. During that time, I was introduced to and trained in phacoemulsification cataract removal and posterior chamber lens implantation. In a small hospital dedicated exclusively to eye surgery, the two busiest surgeons were Harris and Charles Key, MD. At that time, these two surgeons each scheduled cataract surgery cases every 30 minutes, and a full-day caseload was in the mid-teens. After my training in Minnesota, when I joined Harris as a new fellow in 1978, I thought I had landed on a different planet.
In 1980, I returned to Minnesota and joined the full-time faculty at the University of Minnesota and was appointed chief of the ophthalmology section at the Minneapolis VA Hospital. I, like many young surgeons, was bursting with enthusiasm with a new set of skills to share. I found it impossible to change the culture in the university hospital main operating rooms, so I convinced the forward-thinking anesthesiologist director of our minor procedures operating suite, basically an early ASC embedded in a university hospital, to allow me to do my cataract surgery in his facility. We would schedule one cataract surgery by phacoemulsification with a rigid 6-mm optic PMMA posterior chamber lens implant using retrobulbar anesthesia and suture closure with 10-0 nylon every 30 minutes. In the main OR, my colleague surgeons continued to schedule one case every 2 hours.
Soon thereafter, Phillips Eye Institute (PEI) opened, a congressionally designated eye hospital as it had inpatient beds but it was managed like an ASC in the operating rooms. The single-case throughput at PEI was similar to the university-based ASC, but I was given two rooms at PEI compared with only one at the university ASC, and my case output increased to three to four cases per hour.
In 1990, I entered private practice and founded Minnesota Eye Consultants (MEC), which built its own ASCs adjacent to our clinics. MEC and its private equity partner, Unifeye Vision Partners, now own and operate 10 ASC-based operating rooms in Minneapolis, and cataract surgeon case throughput with a single room is 20 cases a day, and with two rooms, 30 or more. We are efficient, patient-friendly and surgeon-friendly, and ASC facility fee reimbursement is an important revenue source. We today perform only one eye of each patient per surgery day, utilize anesthesia standby, start an IV in every case and still use postoperative eye drops.
Looking back, the changes in cataract surgery technique, outcomes and throughput per day represent an amazing transition over a 5-decade career. However, I believe further change enhancing efficiency is on the horizon. Here are a few thoughts on where we go next.
Reimbursement changes and limited surgeon manpower in the face of ever-increasing demand over the next decades will catalyze a trend toward bilateral same-day sequential cataract surgery. This will further enhance efficiency, and as I survey patients, it is also what most would prefer. The use of an IV line with opioid and sedatives delivered by an anesthesiologist or anesthetist will be utilized rarely and only for high-risk or complex cases. Cataract patients are getting younger and healthier, and the young healthy ones will receive oral or sublingual sedation for a relatively short topical anesthesia procedure. Reimbursement changes will also better support so-called office-based surgery suites (OBSS).
If we blindfolded a surgeon today and sat them down behind an operating microscope in a certified ASC and then a certified OBSS, they would not be able to tell the difference. In my opinion, surgeons and patients will be comfortable with either, and outcomes and safety will be equivalent. Over time, our practice environment will look more like that of an oral surgeon and less like that of a cardiovascular surgeon, which is where I started decades ago.
I have personally undergone a dental implant at age 73 by an oral surgeon with no preoperative comprehensive history and physical, no blood work or EKG, no IV, no sedation, significant injected anesthetic and a procedure time of 30 minutes, and hands down it was a much more traumatic experience than any routine cataract surgery patient experiences today with topical anesthesia clear corneal phacoemulsification with posterior chamber lens implantation. If an oral surgeon can do what they do with only a trained assistant in support, and they do it all day every day, we cataract surgeons can as well. As an aside, one dental implant including the OBSS facility fee, surgeon fee, nurse assistant and implant was just more than $4,000 cash in advance, as it was not covered by my dental insurance. If one tooth is worth $4,000, one wonders about the value of a lifetime of restored and in many cases enhanced vision.
Finally, the cataract patient of the future will receive anti-infection, anti-inflammation and antihypertensive medical therapy at the time of surgery, making post-surgical eye drops a rarely needed adjunct. Highly skilled surgeons will perform four to six cases an hour using two rooms, and 30 to 50 case days will be considered routine. When will we see this transition to same-day bilateral sequential cataract surgery with no IV, no postoperative drops, and no preoperative history, physical examination or lab testing performed interchangeably in an ASC or OBSS? Depending on practice environment, surgeon skill and reimbursement environment, we can easily visit a surgeon today who is providing this approach to cataract surgery. I project that by 2040, and perhaps earlier, it will be the norm, not the exception.
The resident cataract surgeon being trained in 2040 will be amazed that we once operated one eye at a time, required a history and physical, blood work, an IV, and an anesthesiologist or anesthetist, made the patients take multiple eye drops for many weeks after surgery, and so rarely utilized adjustable astigmatism and presbyopia-correcting IOLs, which will at that future time be selected by most patients. The surgeon of the future will also be surprised to learn how dependent we were on third-party reimbursement, as cataract surgery will evolve into a cash-pay visual restoration and enhancement procedure that is minimally or non-reimbursed by third-party payers, just like my dental implant last year.
A thought for the younger surgeon: Go visit an oral surgeon colleague and observe them in action, as their practice pattern is likely your future.
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