Worldwide survey highlights current cataract surgery practice trends

CLINICAL practice patterns of European and US cataract surgeons are becoming more similar, although some interesting and important differences continue to distinguish the two groups, according to David Leaming MD. Dr Leaming will present a comparison study of practice styles of European and American surgeons at the XXII Congress of the ESCRS in Paris. He will compare the responses of 964 US surgeons surveyed by mail with those of 500 European surgeons who responded to an on site survey conducted at last year’s ESCRS Congress in Munich. The surveys showed similar practice patterns in terms of the use of anaesthesia. Topical anaesthesia was the favourite among 58% of the US respondents and 47% of the EU respondents, with retrobulbar second in US (24%) and peribulbar second in EU (24%). US surgeons appeared more likely to use intracameral lidocaine than their European colleagues. Surgeons from both regions are more likely to use temporal, clear corneal, and sutureless incisions.A majority of both groups said they used Alcon phaco machines. Both groups also expressed a preference for acrylic as an optic material. Following the US trend where virtually all cataract surgeries are performed on an outpatient basis, 76% of cataract procedures in Europe now reportedly take place in the outpatient setting. “While there is much more variety in practice styles in Europe between individual countries, both societies as a whole seem to following a similar path,” he said. Regional differences among European respondents were particularly notable regarding extracapsular cataract extraction (ECCE).While 80% of US respondents said they perform no ECCE, only 37% of the Europeans said they did not perform the procedure at all.While respondents from Finland, Belgium, the UK and Switzerland rarely if ever perform ECCE; the procedure is still used in countries as diverse as Greece, Hungary, Italy, and Spain. Dr Leaming began surveying US eye surgeons in 1984, and has done so annually ever since. He presented the results of a 2003 survey of nearly 1000 ASCRS members at the annual meeting of the ASCRS earlier this year.The results subsequently appeared in the April 2004 issue of the Journal of Cataract and Refractive Surgery. The survey respondents came from all regions in the US and ranged in age from 25 to more than 60 years old.The majority of respondents, 59%, were members of group practices. Some 32% of respondents were in solo practice with the remainder reporting that they were part of multispeciality practices. An analysis of monthly surgical volume responses indicated that overall cataract surgery volume continued to increase from the year before. Dr. Leaming estimated that US cataract surgery volume in 2003 exceeded 2.7 million procedures, well above the 2002 estimate of 2.4 million procedures. A look back at previous survey years shows that cataract surgery volume decreased slightly in 1997 and 1998, but rebounded in 2000.This apparently coincides with the rapid growth of interest in LASIK and subsequent flattening of that market during the same period, he noted. Ninety-seven percent of ASCRS respondents performed phacoemulsification in their cataract patients, a number that was echoed by European respondents. Phaco volume varied widely with 27% of US surgeons and 19% of Europeans performing 16-25 phaco procedures per month, 32% of both groups performing up to 50 procedures per month and 17% and 22% of US and European surgeons, respectively, performing more than 50 procedures. Bimanual phaco appears to be catching on in the US, with 16.5% reporting they were now using the technique.Another 20% said they planned to switch to bimanual phaco within 12 months.The European survey also revealed a high level of interest in bimanual small incision surgery. The US respondents expressed enthusiasm for new machines, with 44% saying the AMO Sovereign Whitestar held the greatest promise for bimanual small incision surgery. Another 28% expressed support for the Alcon Legacy, and 18% for the Alcon Infiniti Aqualase system. European respondents similarly showed strong interest in the Alcon Infiniti and the AMO Sovereign machines. In patients with bilateral cataract, almost half of US respondents said they perform cataract surgery in the second eye within three weeks. Most said they perform the second surgery within a month of the first. Less than one percent of surgeons said they performed bilateral same-day surgery. In contrast, 12% of the European surgeons reported that they did perform bilateral, same-day surgery on occasion. The surveys also yielded interesting clues regarding IOL choice. Some 70% of those surveyed in the US felt that acrylic is the best optic material.A majority, 87%, said the Alcon Acrysof was their preferred acrylic lens, followed by the AMO Sensar, preferred by 12%.Among Europeans, the Acrysof and Sensar IOLs were the most popular. The AMO SI-40 was the silicone lens most US surgeons used, followed by the Solfles/L161U,AMO Clariflex, and the recently approved AMO Tecnis lens. Europeans favoured the AMO SI-40, the Ceeon, Clariflex and Tecnis lenses. Staar’s Collamer lens was the hydrogel most mentioned by US respondents, accounting for 70% of the total, with 15% citing the B&L Hydroview and another 15% choosing the Ciba/Novartis Memory Lens. The Hydroview and MemoryLens were most cited by the Europeans surveyed. There was little agreement among the respondents when they were asked which IOL material appeared most promising for small incision surgery.There were advocates for foldable acrylics, silicone foldables, hydrogels and even injectable lens materials. Most US surgeons (93%) are not implanting the as yet unapproved phakic IOLs.A few pioneers are implanting a few phakic IOLs each month. However, the survey did show a high degree of interest in phakic IOLs among respondents and the number of implants is likely to jump after approval. Both the AMO Verisyse and the Staar ICL are close to approval in the US. Perhaps waiting for more clinical study results, the US surgeons reported only moderate interest in multifocal IOLs, toric IOLs, and thin optic diffractive IOLs.They showed considerably more enthusiasm for aspheric IOLs and accommodating IOLs. Interestingly, the European respondents expressed a higher degree of interest in multifocal IOLs than their US colleagues. Contact applanation continues to be the primary method chosen for A-scans, preferred by 60% in the US survey.Another 29% use partial coherence interferometry and the remainder use the non-contact immersion method. However, partial coherence interferometry gained a few percentage points from the year before, while contact applanation appears to have declined slightly in recent years, he noted. Prednisolone was by far the most preferred anti-inflammatory used in the US postoperatively, while Europeans opted for dexamethasone. Preferred prophylactic antibiotics included: tobramycin (Tobrex, Alcon), gatifloxacin (Zymar Allergan); moxifloxacin (Vigamox,Alcon); Ofloxacin (Ocuflox,Allergan); and Levofloxacin (Quixin, Santen). The survey also provides some clues to the current level of job satisfaction among US eye surgeons.While half of the respondents reported being as satisfied with work as they had been one year previously, another 27% said they were ‘somewhat less satisfied” or ‘much less satisfied’ with the job. Money worries could be a factor in job satisfaction.The survey saw many reporting that their offices had significant suffered fraud or embezzlement in the past three years. Some 28% of surgeons reported losing between $5,000 and $25,000, with another 17% reporting losing more than $25,000. Dr Leaming’s surveys provide some of the only national and international data on cataract and refractive surgery practice patterns. However, he cautions that the surveys have a number of weaknesses. For example, the US survey was presented in multiple-choice format, increasing the chances for bias to enter in. Other caveats are the limited sample sizes and the fact that the surveys query ASCRS members and ESCRS conference attendees, rather than all ophthalmologists who perform cataract and refractive surgery in the respective regions.