Though it may be one of the most common surgeries performed worldwide, new research suggests inconsistencies in perioperative cataract care are the norm, including some prevalent and expensive trends that lack scientific backing.

Best Practices in Cataract Comanagement

Dr. Gurwood offers the following tips when comanaging cataract patients: 

  1. When making a referral for cataract surgery, insurances may question the reason and withhold payment without some specific documentation. Dr. Gurwood records these issues as “activities of daily living interruptions” (ADLI). The insurance company may want a comment from the referring doctor that these issues are not correctable by refraction, spectacles or other means. ADLI includes issues such as blur, glare, inability to drive at night, pay bills, recognize faces or do one’s vocation or hobby.

  2. Optometrists should be familiar with the surgeon they refer to. It’s nice to know the surgeon’s overall process so they can prepare the patient on what to expect, Dr. Gurwood explains. This may include a briefing on the surgery itself, its duration, the kind of sedation that is used during the procedure, how long it lasts and when the other eye can be scheduled. Additionally, in the best of circumstances, it’s ideal if the referring OD has observed the surgeon and is familiar with preoperative planning and postoperative drops. “By my experience, optometrists in clinical practice choose surgeons based on several practical criteria including personal relationship, years of observing successful experiences, professional conduct and reputation, observation of mutual respect, a person’s willingness to be mutually helpful, location, ease of use, friendliness of the environment, bedside manner of the surgeon, willingness to accept insurances and ability to take on cases in a timely manner,” Dr. Gurwood says.While an optometrist may have observed the surgeon once—to get to know the person and their techniques, flow and facilities—optometrists are generally not aware of the day-to-day operations of a surgical center, he adds.

  3. It’s always best when ODs and MDs understand what pre- and postoperative data needs to be collected and when, as some surgeons insist on it. The referring optometrist should be familiar with the postoperative routine, general findings, postoperative drops and schedule for recovery. The referring doctor should have some idea about when an emergent referral back to the surgeon is indicated.

  4. The most important thing to the referring optometrist is feedback that indicates their patient’s experience went well. Referring doctors want to find patients in good spirits, following a pleasant, “no hassle” encounter with a good outcome and minimal complications.

“Many evidence-based procedures are unevenly practiced around the world, and some widespread and expensive habits lack solid scientific evidence while consuming enormous amounts of resources both monetary and human,” the researchers wrote in their paper.

The investigators sent an online survey to 240 ophthalmologists across 38 countries, encompassing five continents. The survey queried the doctors on prevailing trends in their institutions that included surgical volume and setting, anesthesia use, preoperative and intraoperative exams and postsurgical care.

A total of 209 ophthalmologists responded. Of these, 38% represented public hospitals, 36% private practices and 26% academic sites. The overall surgical volume was between 241,700 and 410 ,500 cataracts per year.

The investigation found a single surgeon is present in 40% of operating rooms (30% also included a resident), and 27% of MDs cited two ophthalmologists do the extraction.

Additionally, respondents said a dedicated anesthesiologist was present in only 30% of cases, while two nurses were in the operating room 77% of the time.

Another finding: two surgeons, which is mandatory in some countries such as Italy and recommended in others, may increase safety despite also ramping up the cost.

Considering a 20-minute, uncomplicated surgery, medical staff cost per extraction varied from $46 for a single surgeon and available anesthesiologist to $120 for two surgeons and a dedicated anesthesiologist, which translates into $1.2 million physician hours or $132 million dollars in the United States, based on an $110 average cost per hour, which would equate to twice as much in Europe, the investigators said.

The amount of preoperative ocular diagnostics was even more variable, with 40% of responders saying they conduct four or more tests, while 20% only do one.

This difference of cost and healthcare personnel time is striking, the researchers claimed. Assuming an average of $35 per each diagnostic test in the United States, the delta between a single biometry test (mandatory) and the entire panel of six tests would be $175 per surgery or $647 million and twice as much in Europe without even considering medical staff costs.

Considering the findings, there are two ways to approach this issue: one, follow the money. Two, follow the success, says optometrist Andrew Gurwood of Salus University in Philadelphia.

“Since cataract surgery is among the costliest of Medicare expenses, as the population ages and more people require it while becoming eligible for coverage, it will not be a sustainable benefit unless costs are monitored and regulated. Are preoperative drops helpful? How many people should be involved in perioperative care? Should both eyes be done separately or at once? Should postoperative drops be discontinued in favor of an intraoperative intracameral injection?” he says.

Legislating a consistent perioperative process could assist in cost control and provide an evidence-based practice proven to provide success, Dr. Gurwood explains. This evolution is already underway, and many of these questions are currently under investigation, he adds.

Like anything else, cataract surgery is a skill taught in layers, Dr. Gurwood suggests.

A paper that demonstrates differences in the perioperative formula is “neither here nor there” because it points out what should be accepted: there are individual idiosyncrasies which exist among surgeons for numerous reasons, he explains. In other words, take the study’s findings with a grain of salt.

“The paper doesn’t generate a shred of evidence-based data that suggests one way is better than another. The paper attempts to make the point that these inconsistencies have no evidence-based support and have the potential to increase costs; however, the paper does not offer any evidence-based comparison of the different approaches against each other or against a control. Without this information, who is to know that one approach is any better than another?” he says.

Dr. Gurwood suggests that perhaps one method costs more because a certain medication was used, but this approach possibly cut down on office visits, which saved money. For example, an intracameral approach to medication delivery is more costly, but if a patient can’t afford medication, can’t get to the pharmacy to purchase the pharmaceuticals or is unable to give themselves the drops, it may increase the chances of success, he explains.

The “evolution” of the perioperative process of cataract surgery can be defined as the changes that occur to it—steps done before and after the procedure—over the course of time, Dr. Gurwood says. An “evolutionary process” would predict a natural selection of procedures and techniques—things that work stay, things that don’t or that can’t be afforded are dropped.

“Since none of the issues cited by this work have been shown to demonstrate a repeating recipe for failure, I see no reason for the optometrist to be concerned. In the end, if there is a valid reason or need for making perioperative procedures consistent, it will be among ophthalmologists to decide,” Dr. Gurwood says.

Clinically speaking, optometrists can control who they recommend as surgeons. An optometrist who is concerned about surgical “process” can do some reading to familiarize themselves with the overall process. They may ask some surgeons if they can observe their surgical techniques and office flow. With this experience, they can make an informed choice to embrace the platform that makes most sense to them, he adds.

“Different doesn’t mean inferior,” Dr. Gurwood says.

There are rules to “the dance” that is cataract surgery, he adds. These general rules and procedures exist in textbooks, as monographs and position papers in the literature. It is human nature to have likes, dislikes and preferences, he says.

It is likewise human nature to express creativity and control by attempting to improve something by modifying it and rationalizing those changes, he adds.

“We’re a litigious society. If any of the things cited in this paper resulted in consistently deleterious outcomes, legal proceedings and losses would make it prohibitive to continue,” Dr. Gurwood suggests. “The fact that in 2021, almost 70 years after cataract surgery was founded, there is no absolute perioperative checklist, says to me, there must be more than one way to do it. Finally, if one cares that much, they should do their own investigation of the literature and make a conscious choice by finding a surgeon who supports those methods.”

Rossi T, Romano MR, Iannetta D, et al. Cataract surgery practice patterns worldwide: a survey. BMJ Open Ophthalmology. 2021;6:e000464.