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Emerging Cataract Surgery Practice Patterns in the Veterans Health Administration
The rates of cataract surgery, the most commonly performed ophthalmic procedure in the U.S., have increased in the past few decades with an estimated rate of 1,100 surgeries per 100,000 people in 2011.1,2 Several emerging practices have the potential to radically impact the efficacy, safety, and cost of cataract surgery.3-5 These practices include femtosecond laser-assisted cataract surgery, intracameral antibiotics, and bilateral same-day cataract surgery.
The femtosecond laser is capable of producing precise incisions in the cornea for access by surgical instruments and reduction of astigmatism. Laser pulses also can create a perfectly round incision of the anterior lens capsule, which surrounds and supports the crystalline lens, and make incisions into the cataractous lens to facilitate disassembly for easy removal of fragments.
[embed:render:related:node:104237]
Placement of antibiotics internally into the anterior chamber, the space between the crystalline lens and the posterior cornea (intracameral space), is a more direct method to prevent bacterial infection within the eye (endophthalmitis), compared with current external methods, including injections under the conjunctiva (subconjunctival) and/or use of antibiotic drops directly onto the eye surface (topical).6
Routine cataract surgery is typically staged, with a period of time between sequential surgeries of 1 week or more to allow for observation of infection (delayed sequential surgery). In view of the very low rate of infection and the impact of staged surgery on patients, including additional visits and copays, some surgeons have begun to perform bilateral surgery (immediate sequential bilateral surgery, using separate patient safety checklists, surgical preps, instruments, and medications) on the same day for patients with significant cataracts in both eyes to promote rapid restoration of binocular vision as well reduce the number of patient visits.
The extent of adaptation of femtosecond laser surgery, intracameral antibiotics, and immediate sequential bilateral surgery in the U.S. is currently unknown.7,8 To provide an updated snapshot of these cataract surgery practices, the authors report on the results of a brief survey administered to ophthalmology section chiefs in the VHA, the largest integrated health care system and the largest provider of health care training in the U.S.
Methods
Following institutional review board approval from the Providence VA Medical Center, the office of the National Program Director of VA Ophthalmology provided a list of all VHA ophthalmology section chiefs and their contact information. The study targeted section chiefs because they are responsible for all eye surgery performed at their respective VAMCs. The survey queried the section chiefs on femtosecond laser-assisted cataract surgery, intracameral antibiotics, immediate sequential bilateral cataract surgery, and resident training at their institutions (Table).
The survey was administered using the web-based Research Electronic Data Capture (REDCap) software.9 The initial survey was e-mailed in April 2015, followed by 2 reminder e-mails 1 week apart and then 2 phone calls 1 week apart to nonresponders.
[embed:render:related:node:75201]
The survey responses were stored anonymously in the REDCap database and analyzed using descriptive statistics.
Results
The original list from the office of the National Program Director included 114 ophthalmology section chiefs (excluding one of the authors). After follow-up phone calls, 9 individuals were identified who were not ophthalmologists (eg, optometrists or nonophthalmic surgeons) or who were incorrectly listed as section chiefs, and 9 were duplicates from institutions that were represented twice on the contact list. These 18 individuals, none of whom had responded to the survey, were removed from the eligible sample. Hence, the analysis included 86% (95/111) of the VAMCs where cataract surgery is performed.10 Sixty-five responses were received for an overall response rate of 68% (65/96), including 1 ophthalmologist who responded to the survey twice.
Most section chiefs (86%, 56/65) trained ophthalmology residents at their respective medical centers (Table). Eleven VAMCs (17%) offered femtosecond laser-assisted cataract surgery; 8 of those 11 (73%) also offered resident training in this surgery. At 12 VAMCs (18%), cataract surgeons used intracameral antibiotics, which included vancomycin (4), cefuroxime (4), moxifloxacin (3), and unspecified (1); at 10 of these VAMCs (83%), surgeons used intracameral and postoperative topical antibiotics concomitantly; 8 VAMCs (67%) compounded the intracameral antibiotics—either in the hospital pharmacy (5) or within the operating room (3). The 2 most common reasons cited for not using intracameral antibiotics were risk of dilution error (28%; 15/53) and a lack of evidence for use (25%; 13/53). Only 2 medical centers (3.1%) offered immediate sequential bilateral cataract surgery.
Discussion
This survey provides updated information on the role of emerging cataract surgery practices in the VHA. These trends may impact future U.S. cataract surgery practice patterns given the large number of ophthalmology residents who receive training in the VHA.
Only 17% of VAMCs offered femtosecond laser-assisted cataract surgery. Reasons for this low rate may include (a) the high cost of the femtosecond laser units (the lowest average cost of a laser is $400,000, while the average costs of services can be $40,000 or more per year); and (b) the lack of evidence that a femtosecond laser improves cataract surgery outcomes relative to standard phacoemulsification.4,11-15 Another potential barrier to procurement of femtosecond lasers is the emphasis within VHA to increase access to care for the many newly enrolled veterans, which this technology does not address. However, most of the VAMCs with a femtosecond laser unit offered resident training in this technique, confirming early reports on the potential for incorporating femtosecond laser-assisted cataract surgery into ophthalmic graduate medical education.16
In 2007, the multicenter, prospective, randomized European Society of Cataract and Refractive Surgery Endophthalmitis Study demonstrated that intracameral cefuroxime was associated with a 5-fold decrease in the risk of postoperative endophthalmitis.17 In 2011, a statement from the American Society of Cataract and Refractive Surgery (ASCRS) Cataract Clinical Committee noted that the method of antibiotic prophylaxis with the strongest evidence base is “a direct intracameral bolus at the conclusion of surgery.”18 However, surgeons used intracameral antibiotics in only 19% of VAMCs. Although this is a higher rate than those reported in older surveys of VHA ophthalmologists (14%)7 and ASCRS members (15%), it is still significantly lower than the 74% reported in a recent survey of the European Society of Cataract and Refractive Surgeons.3,8
The most common reasons given for not using intracameral antibiotics included risk of a dilution error when preparing the antibiotics and lack of evidence supporting their effectiveness. Less common reasons included risk of contamination, lack of pharmacy approval, and increasing bacterial resistance to commonly used antibiotics. Most of these concerns have been previously cited as barriers to the adoption of intracameral antibiotics.19 The availability of a prepackaged intracameral antibiotic (eg, cefuroxime in Europe) would help address the risks of compounding dilution errors and contamination in the U.S.6 The publication of 3 large observational studies in 2016 has also significantly strengthened the evidence base supporting the use of intracameral antibiotics.20-22
[embed:render:related:node:75783]
Only 2 VAMCs (3%) offered immediate sequential bilateral cataract surgery. The advocates of this practice have touted its potential cost savings, patient convenience, and the opportunity for more rapid visual rehabilitation.23 Recently, several multicenter, randomized clinical trials have reported similar refractive outcomes, complication rates, and patient satisfaction for immediate and delayed bilateral cataract surgery.24,25 Hence, it is possible that rates of immediate sequential bilateral cataract surgery may increase in the VHA over the next few years.
Strengths/Limitations
A strength of this survey is its high response rate (67.7%), which exceeds the 53% and 33% rates reported in previous surveys of cataract surgery practice patterns among VHA ophthalmologistsand ASCRS members, respectively.7,8 Another strength is lack of financial incentive for adaptation of any new practices by VHA surgeons, suggesting that these decisions have been made to improve patient safety, quality of care, and/or resident education. A limitation of this study is that its findings may not be generalizable to ophthalmologists practicing in the private sector or in teaching hospitals outside the VHA.
Conclusion
This study suggests that femtosecond laser-assisted cataract surgery, intracameral antibiotics, and immediate sequential bilateral cataract surgery have limited roles in VHA cataract surgery. More research and clinical experience are needed to understand the barriers to more widespread acceptance and to assess the impact of these emerging practices on cataract surgery in the U.S.
1. Lindstrom R. Thoughts on cataract surgery: 2015. http://www.reviewofophthalmology.com/content/t/surgical_education/c/53422/. Published March 9, 2015. Accessed June 23, 2016.
2. Gollogly HE, Hodge DO, St Sauver JL, Erie JC. Increasing incidence of cataract surgery: population-based study. J Cataract Refract Surg. 2013;39(9):1383-1389.
3. Barry P. Adoption of intracameral antibiotic prophylaxis of endophthalmitis following cataract surgery: update on the ESCRS Endophthalmitis Study. J Cataract Refract Surg. 2014;40(1):138-142.
4. Quiñones A, Gleitsmann K, Freeman M, et al. Benefits and Harms of Femtosecond Laser Assisted Cataract Surgery: A Systematic Review. VA-ESP Project #05-225; 2013. Washington, DC: Department of Veterans Affairs; 2013.
5. Naseri A, McLeod S. Benefits of and barriers to immediate sequential cataract surgery. JAMA Ophthalmol. 2014;132(11):1362-1363.
6. Brage-Mele R, Chang DF, Henderson BA, Mamalis N, Talley-Rostov A, Vasavada A; ASCRS Clinical Cataract Committee. Intracameral antibiotics: safety, efficacy, and preparation. J Cataract Refract Surg. 2014;40(12):2134-2142.
7. Greenberg PB, Havnaer A, Oetting TA, Garcia-Ferrer FJ. Cataract surgery practice patterns in the United States Veterans Health Administration. J Cataract Refract Surg. 2012;38(4):705-709.
8. Chang DF, Braga-Mele R, Mamalis N, et al; ASCRS Clinical Cataract Committee. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey. J Cataract Refract Surg. 2007;33(10):1801-1805.
9. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381.
10. French DD, Margo CE, Campbell RR. Do ophthalmology training programs affect corrective procedure rates after cataract surgery? Am J Med Qual. 2013;28(3):250-255.
11. Donaldson KE, Braga-Mele R, Cabot F, et al; ASCRS Refractive Cataract Surgery Subcommittee. Femtosecond laser-assisted cataract surgery. J Cataract Refract Surg. 2013;39(11):1753-1763.
12. Abouzeid H, Ferrini W. Femtosecond-laser assisted cataract surgery: a review. Acta Ophthalmol. 2014;92(7):597-603.
13. Chen H, Hyatt T, Afshari N. Visual and refractive outcomes of laser cataract surgery. Curr Opin Ophthalmol. 2014;25(1):49-53.
14. Yu Y, Chen X, Hua H, Wu M, Lai K, Yao K. Comparative outcomes of femtosecond laser-assisted cataract surgery and manual phacoemusification: a six-month follow-up. Clin Experiment Ophthalmol. 2016;44(6):472-480.
15. Ewe SY, Abell RG, Oakley CL, et al. A comparative cohort study of visual outcomes in femtosecond laser-assisted versus phacoemulsification cataract surgery. Ophthalmology. 2016;123(1):178-182.
16. Cohen MN, Intili A, Ni N, Blecher MH. Femtosecond laser-assisted cataract surgery in residency training. Curr Opin Ophthalmol. 2015;26(1):56-60.
17. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33(6):978-988.
18. Packer M, Chang DF, Dewey SH, et al; ASCRS Cataract Clinical Committee. Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis. J Cataract Refract Surg. 2011;37(9):1699-1714.
19. Schimel AM, Alfonso EC, Flynn HW Jr. Endophthalmitis prophylaxis for cataract surgery: are intracameral antibiotics necessary? JAMA Ophthalmol. 2014;132(11):1269-1270.
20. Herrinton LJ, Shorstein NH, Paschal JF, et al. Comparative effectiveness of antibiotic prophylaxis in cataract surgery. Ophthalmology. 2016;123(2):287-294.
21. Haripriya A, Chang DF, Namburar S, Smita A, Ravindran RD. Efficacy of intracameral moxifloxacin endophthalmitis prophylaxis at Aravind Eye Hospital. Ophthalmology. 2016;123(2):302-308.
22. Jabbarvand M, Hashemian H, Khodaparast M, Jouhari M, Tabatabaei A, Rezaei S. Endophthalmitis occurring after cataract surgery: outcomes of more than 480 000 cataract surgeries, epidemiologic features, and risk factors. Ophthalmology. 2016;123(2):295-301.
23. Neel ST. A cost and policy analysis comparing immediate sequential cataract surgery and delayed sequential cataract surgery from the physician perspective in the United States. JAMA Ophthalmol. 2014;132(11):1359-1362.
24. Sarikkola AU, Uusitalo RJ, Hellstedt T, Ess SL, Leivo T, Kivelä T. Simultaneous bilateral versus sequential bilateral cataract surgery: Helsinki Simultaneous Bilateral Cataract Surgery Study Report 1. J Cataract Refract Surg. 2011;37(6):992-1002.
25. Serrano-Aguilar P, Ramallo-Fariña Y, Cabrera-Hernández JM, et al. Immediately sequential versus delayed sequential bilateral cataract surgery: safety and effectiveness. J Cataract Refract Surg. 2012;38(10):1734-1742.
The rates of cataract surgery, the most commonly performed ophthalmic procedure in the U.S., have increased in the past few decades with an estimated rate of 1,100 surgeries per 100,000 people in 2011.1,2 Several emerging practices have the potential to radically impact the efficacy, safety, and cost of cataract surgery.3-5 These practices include femtosecond laser-assisted cataract surgery, intracameral antibiotics, and bilateral same-day cataract surgery.
The femtosecond laser is capable of producing precise incisions in the cornea for access by surgical instruments and reduction of astigmatism. Laser pulses also can create a perfectly round incision of the anterior lens capsule, which surrounds and supports the crystalline lens, and make incisions into the cataractous lens to facilitate disassembly for easy removal of fragments.
[embed:render:related:node:104237]
Placement of antibiotics internally into the anterior chamber, the space between the crystalline lens and the posterior cornea (intracameral space), is a more direct method to prevent bacterial infection within the eye (endophthalmitis), compared with current external methods, including injections under the conjunctiva (subconjunctival) and/or use of antibiotic drops directly onto the eye surface (topical).6
Routine cataract surgery is typically staged, with a period of time between sequential surgeries of 1 week or more to allow for observation of infection (delayed sequential surgery). In view of the very low rate of infection and the impact of staged surgery on patients, including additional visits and copays, some surgeons have begun to perform bilateral surgery (immediate sequential bilateral surgery, using separate patient safety checklists, surgical preps, instruments, and medications) on the same day for patients with significant cataracts in both eyes to promote rapid restoration of binocular vision as well reduce the number of patient visits.
The extent of adaptation of femtosecond laser surgery, intracameral antibiotics, and immediate sequential bilateral surgery in the U.S. is currently unknown.7,8 To provide an updated snapshot of these cataract surgery practices, the authors report on the results of a brief survey administered to ophthalmology section chiefs in the VHA, the largest integrated health care system and the largest provider of health care training in the U.S.
Methods
Following institutional review board approval from the Providence VA Medical Center, the office of the National Program Director of VA Ophthalmology provided a list of all VHA ophthalmology section chiefs and their contact information. The study targeted section chiefs because they are responsible for all eye surgery performed at their respective VAMCs. The survey queried the section chiefs on femtosecond laser-assisted cataract surgery, intracameral antibiotics, immediate sequential bilateral cataract surgery, and resident training at their institutions (Table).
The survey was administered using the web-based Research Electronic Data Capture (REDCap) software.9 The initial survey was e-mailed in April 2015, followed by 2 reminder e-mails 1 week apart and then 2 phone calls 1 week apart to nonresponders.
[embed:render:related:node:75201]
The survey responses were stored anonymously in the REDCap database and analyzed using descriptive statistics.
Results
The original list from the office of the National Program Director included 114 ophthalmology section chiefs (excluding one of the authors). After follow-up phone calls, 9 individuals were identified who were not ophthalmologists (eg, optometrists or nonophthalmic surgeons) or who were incorrectly listed as section chiefs, and 9 were duplicates from institutions that were represented twice on the contact list. These 18 individuals, none of whom had responded to the survey, were removed from the eligible sample. Hence, the analysis included 86% (95/111) of the VAMCs where cataract surgery is performed.10 Sixty-five responses were received for an overall response rate of 68% (65/96), including 1 ophthalmologist who responded to the survey twice.
Most section chiefs (86%, 56/65) trained ophthalmology residents at their respective medical centers (Table). Eleven VAMCs (17%) offered femtosecond laser-assisted cataract surgery; 8 of those 11 (73%) also offered resident training in this surgery. At 12 VAMCs (18%), cataract surgeons used intracameral antibiotics, which included vancomycin (4), cefuroxime (4), moxifloxacin (3), and unspecified (1); at 10 of these VAMCs (83%), surgeons used intracameral and postoperative topical antibiotics concomitantly; 8 VAMCs (67%) compounded the intracameral antibiotics—either in the hospital pharmacy (5) or within the operating room (3). The 2 most common reasons cited for not using intracameral antibiotics were risk of dilution error (28%; 15/53) and a lack of evidence for use (25%; 13/53). Only 2 medical centers (3.1%) offered immediate sequential bilateral cataract surgery.
Discussion
This survey provides updated information on the role of emerging cataract surgery practices in the VHA. These trends may impact future U.S. cataract surgery practice patterns given the large number of ophthalmology residents who receive training in the VHA.
Only 17% of VAMCs offered femtosecond laser-assisted cataract surgery. Reasons for this low rate may include (a) the high cost of the femtosecond laser units (the lowest average cost of a laser is $400,000, while the average costs of services can be $40,000 or more per year); and (b) the lack of evidence that a femtosecond laser improves cataract surgery outcomes relative to standard phacoemulsification.4,11-15 Another potential barrier to procurement of femtosecond lasers is the emphasis within VHA to increase access to care for the many newly enrolled veterans, which this technology does not address. However, most of the VAMCs with a femtosecond laser unit offered resident training in this technique, confirming early reports on the potential for incorporating femtosecond laser-assisted cataract surgery into ophthalmic graduate medical education.16
In 2007, the multicenter, prospective, randomized European Society of Cataract and Refractive Surgery Endophthalmitis Study demonstrated that intracameral cefuroxime was associated with a 5-fold decrease in the risk of postoperative endophthalmitis.17 In 2011, a statement from the American Society of Cataract and Refractive Surgery (ASCRS) Cataract Clinical Committee noted that the method of antibiotic prophylaxis with the strongest evidence base is “a direct intracameral bolus at the conclusion of surgery.”18 However, surgeons used intracameral antibiotics in only 19% of VAMCs. Although this is a higher rate than those reported in older surveys of VHA ophthalmologists (14%)7 and ASCRS members (15%), it is still significantly lower than the 74% reported in a recent survey of the European Society of Cataract and Refractive Surgeons.3,8
The most common reasons given for not using intracameral antibiotics included risk of a dilution error when preparing the antibiotics and lack of evidence supporting their effectiveness. Less common reasons included risk of contamination, lack of pharmacy approval, and increasing bacterial resistance to commonly used antibiotics. Most of these concerns have been previously cited as barriers to the adoption of intracameral antibiotics.19 The availability of a prepackaged intracameral antibiotic (eg, cefuroxime in Europe) would help address the risks of compounding dilution errors and contamination in the U.S.6 The publication of 3 large observational studies in 2016 has also significantly strengthened the evidence base supporting the use of intracameral antibiotics.20-22
[embed:render:related:node:75783]
Only 2 VAMCs (3%) offered immediate sequential bilateral cataract surgery. The advocates of this practice have touted its potential cost savings, patient convenience, and the opportunity for more rapid visual rehabilitation.23 Recently, several multicenter, randomized clinical trials have reported similar refractive outcomes, complication rates, and patient satisfaction for immediate and delayed bilateral cataract surgery.24,25 Hence, it is possible that rates of immediate sequential bilateral cataract surgery may increase in the VHA over the next few years.
Strengths/Limitations
A strength of this survey is its high response rate (67.7%), which exceeds the 53% and 33% rates reported in previous surveys of cataract surgery practice patterns among VHA ophthalmologistsand ASCRS members, respectively.7,8 Another strength is lack of financial incentive for adaptation of any new practices by VHA surgeons, suggesting that these decisions have been made to improve patient safety, quality of care, and/or resident education. A limitation of this study is that its findings may not be generalizable to ophthalmologists practicing in the private sector or in teaching hospitals outside the VHA.
Conclusion
This study suggests that femtosecond laser-assisted cataract surgery, intracameral antibiotics, and immediate sequential bilateral cataract surgery have limited roles in VHA cataract surgery. More research and clinical experience are needed to understand the barriers to more widespread acceptance and to assess the impact of these emerging practices on cataract surgery in the U.S.
The rates of cataract surgery, the most commonly performed ophthalmic procedure in the U.S., have increased in the past few decades with an estimated rate of 1,100 surgeries per 100,000 people in 2011.1,2 Several emerging practices have the potential to radically impact the efficacy, safety, and cost of cataract surgery.3-5 These practices include femtosecond laser-assisted cataract surgery, intracameral antibiotics, and bilateral same-day cataract surgery.
The femtosecond laser is capable of producing precise incisions in the cornea for access by surgical instruments and reduction of astigmatism. Laser pulses also can create a perfectly round incision of the anterior lens capsule, which surrounds and supports the crystalline lens, and make incisions into the cataractous lens to facilitate disassembly for easy removal of fragments.
[embed:render:related:node:104237]
Placement of antibiotics internally into the anterior chamber, the space between the crystalline lens and the posterior cornea (intracameral space), is a more direct method to prevent bacterial infection within the eye (endophthalmitis), compared with current external methods, including injections under the conjunctiva (subconjunctival) and/or use of antibiotic drops directly onto the eye surface (topical).6
Routine cataract surgery is typically staged, with a period of time between sequential surgeries of 1 week or more to allow for observation of infection (delayed sequential surgery). In view of the very low rate of infection and the impact of staged surgery on patients, including additional visits and copays, some surgeons have begun to perform bilateral surgery (immediate sequential bilateral surgery, using separate patient safety checklists, surgical preps, instruments, and medications) on the same day for patients with significant cataracts in both eyes to promote rapid restoration of binocular vision as well reduce the number of patient visits.
The extent of adaptation of femtosecond laser surgery, intracameral antibiotics, and immediate sequential bilateral surgery in the U.S. is currently unknown.7,8 To provide an updated snapshot of these cataract surgery practices, the authors report on the results of a brief survey administered to ophthalmology section chiefs in the VHA, the largest integrated health care system and the largest provider of health care training in the U.S.
Methods
Following institutional review board approval from the Providence VA Medical Center, the office of the National Program Director of VA Ophthalmology provided a list of all VHA ophthalmology section chiefs and their contact information. The study targeted section chiefs because they are responsible for all eye surgery performed at their respective VAMCs. The survey queried the section chiefs on femtosecond laser-assisted cataract surgery, intracameral antibiotics, immediate sequential bilateral cataract surgery, and resident training at their institutions (Table).
The survey was administered using the web-based Research Electronic Data Capture (REDCap) software.9 The initial survey was e-mailed in April 2015, followed by 2 reminder e-mails 1 week apart and then 2 phone calls 1 week apart to nonresponders.
[embed:render:related:node:75201]
The survey responses were stored anonymously in the REDCap database and analyzed using descriptive statistics.
Results
The original list from the office of the National Program Director included 114 ophthalmology section chiefs (excluding one of the authors). After follow-up phone calls, 9 individuals were identified who were not ophthalmologists (eg, optometrists or nonophthalmic surgeons) or who were incorrectly listed as section chiefs, and 9 were duplicates from institutions that were represented twice on the contact list. These 18 individuals, none of whom had responded to the survey, were removed from the eligible sample. Hence, the analysis included 86% (95/111) of the VAMCs where cataract surgery is performed.10 Sixty-five responses were received for an overall response rate of 68% (65/96), including 1 ophthalmologist who responded to the survey twice.
Most section chiefs (86%, 56/65) trained ophthalmology residents at their respective medical centers (Table). Eleven VAMCs (17%) offered femtosecond laser-assisted cataract surgery; 8 of those 11 (73%) also offered resident training in this surgery. At 12 VAMCs (18%), cataract surgeons used intracameral antibiotics, which included vancomycin (4), cefuroxime (4), moxifloxacin (3), and unspecified (1); at 10 of these VAMCs (83%), surgeons used intracameral and postoperative topical antibiotics concomitantly; 8 VAMCs (67%) compounded the intracameral antibiotics—either in the hospital pharmacy (5) or within the operating room (3). The 2 most common reasons cited for not using intracameral antibiotics were risk of dilution error (28%; 15/53) and a lack of evidence for use (25%; 13/53). Only 2 medical centers (3.1%) offered immediate sequential bilateral cataract surgery.
Discussion
This survey provides updated information on the role of emerging cataract surgery practices in the VHA. These trends may impact future U.S. cataract surgery practice patterns given the large number of ophthalmology residents who receive training in the VHA.
Only 17% of VAMCs offered femtosecond laser-assisted cataract surgery. Reasons for this low rate may include (a) the high cost of the femtosecond laser units (the lowest average cost of a laser is $400,000, while the average costs of services can be $40,000 or more per year); and (b) the lack of evidence that a femtosecond laser improves cataract surgery outcomes relative to standard phacoemulsification.4,11-15 Another potential barrier to procurement of femtosecond lasers is the emphasis within VHA to increase access to care for the many newly enrolled veterans, which this technology does not address. However, most of the VAMCs with a femtosecond laser unit offered resident training in this technique, confirming early reports on the potential for incorporating femtosecond laser-assisted cataract surgery into ophthalmic graduate medical education.16
In 2007, the multicenter, prospective, randomized European Society of Cataract and Refractive Surgery Endophthalmitis Study demonstrated that intracameral cefuroxime was associated with a 5-fold decrease in the risk of postoperative endophthalmitis.17 In 2011, a statement from the American Society of Cataract and Refractive Surgery (ASCRS) Cataract Clinical Committee noted that the method of antibiotic prophylaxis with the strongest evidence base is “a direct intracameral bolus at the conclusion of surgery.”18 However, surgeons used intracameral antibiotics in only 19% of VAMCs. Although this is a higher rate than those reported in older surveys of VHA ophthalmologists (14%)7 and ASCRS members (15%), it is still significantly lower than the 74% reported in a recent survey of the European Society of Cataract and Refractive Surgeons.3,8
The most common reasons given for not using intracameral antibiotics included risk of a dilution error when preparing the antibiotics and lack of evidence supporting their effectiveness. Less common reasons included risk of contamination, lack of pharmacy approval, and increasing bacterial resistance to commonly used antibiotics. Most of these concerns have been previously cited as barriers to the adoption of intracameral antibiotics.19 The availability of a prepackaged intracameral antibiotic (eg, cefuroxime in Europe) would help address the risks of compounding dilution errors and contamination in the U.S.6 The publication of 3 large observational studies in 2016 has also significantly strengthened the evidence base supporting the use of intracameral antibiotics.20-22
[embed:render:related:node:75783]
Only 2 VAMCs (3%) offered immediate sequential bilateral cataract surgery. The advocates of this practice have touted its potential cost savings, patient convenience, and the opportunity for more rapid visual rehabilitation.23 Recently, several multicenter, randomized clinical trials have reported similar refractive outcomes, complication rates, and patient satisfaction for immediate and delayed bilateral cataract surgery.24,25 Hence, it is possible that rates of immediate sequential bilateral cataract surgery may increase in the VHA over the next few years.
Strengths/Limitations
A strength of this survey is its high response rate (67.7%), which exceeds the 53% and 33% rates reported in previous surveys of cataract surgery practice patterns among VHA ophthalmologistsand ASCRS members, respectively.7,8 Another strength is lack of financial incentive for adaptation of any new practices by VHA surgeons, suggesting that these decisions have been made to improve patient safety, quality of care, and/or resident education. A limitation of this study is that its findings may not be generalizable to ophthalmologists practicing in the private sector or in teaching hospitals outside the VHA.
Conclusion
This study suggests that femtosecond laser-assisted cataract surgery, intracameral antibiotics, and immediate sequential bilateral cataract surgery have limited roles in VHA cataract surgery. More research and clinical experience are needed to understand the barriers to more widespread acceptance and to assess the impact of these emerging practices on cataract surgery in the U.S.
1. Lindstrom R. Thoughts on cataract surgery: 2015. http://www.reviewofophthalmology.com/content/t/surgical_education/c/53422/. Published March 9, 2015. Accessed June 23, 2016.
2. Gollogly HE, Hodge DO, St Sauver JL, Erie JC. Increasing incidence of cataract surgery: population-based study. J Cataract Refract Surg. 2013;39(9):1383-1389.
3. Barry P. Adoption of intracameral antibiotic prophylaxis of endophthalmitis following cataract surgery: update on the ESCRS Endophthalmitis Study. J Cataract Refract Surg. 2014;40(1):138-142.
4. Quiñones A, Gleitsmann K, Freeman M, et al. Benefits and Harms of Femtosecond Laser Assisted Cataract Surgery: A Systematic Review. VA-ESP Project #05-225; 2013. Washington, DC: Department of Veterans Affairs; 2013.
5. Naseri A, McLeod S. Benefits of and barriers to immediate sequential cataract surgery. JAMA Ophthalmol. 2014;132(11):1362-1363.
6. Brage-Mele R, Chang DF, Henderson BA, Mamalis N, Talley-Rostov A, Vasavada A; ASCRS Clinical Cataract Committee. Intracameral antibiotics: safety, efficacy, and preparation. J Cataract Refract Surg. 2014;40(12):2134-2142.
7. Greenberg PB, Havnaer A, Oetting TA, Garcia-Ferrer FJ. Cataract surgery practice patterns in the United States Veterans Health Administration. J Cataract Refract Surg. 2012;38(4):705-709.
8. Chang DF, Braga-Mele R, Mamalis N, et al; ASCRS Clinical Cataract Committee. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey. J Cataract Refract Surg. 2007;33(10):1801-1805.
9. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381.
10. French DD, Margo CE, Campbell RR. Do ophthalmology training programs affect corrective procedure rates after cataract surgery? Am J Med Qual. 2013;28(3):250-255.
11. Donaldson KE, Braga-Mele R, Cabot F, et al; ASCRS Refractive Cataract Surgery Subcommittee. Femtosecond laser-assisted cataract surgery. J Cataract Refract Surg. 2013;39(11):1753-1763.
12. Abouzeid H, Ferrini W. Femtosecond-laser assisted cataract surgery: a review. Acta Ophthalmol. 2014;92(7):597-603.
13. Chen H, Hyatt T, Afshari N. Visual and refractive outcomes of laser cataract surgery. Curr Opin Ophthalmol. 2014;25(1):49-53.
14. Yu Y, Chen X, Hua H, Wu M, Lai K, Yao K. Comparative outcomes of femtosecond laser-assisted cataract surgery and manual phacoemusification: a six-month follow-up. Clin Experiment Ophthalmol. 2016;44(6):472-480.
15. Ewe SY, Abell RG, Oakley CL, et al. A comparative cohort study of visual outcomes in femtosecond laser-assisted versus phacoemulsification cataract surgery. Ophthalmology. 2016;123(1):178-182.
16. Cohen MN, Intili A, Ni N, Blecher MH. Femtosecond laser-assisted cataract surgery in residency training. Curr Opin Ophthalmol. 2015;26(1):56-60.
17. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33(6):978-988.
18. Packer M, Chang DF, Dewey SH, et al; ASCRS Cataract Clinical Committee. Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis. J Cataract Refract Surg. 2011;37(9):1699-1714.
19. Schimel AM, Alfonso EC, Flynn HW Jr. Endophthalmitis prophylaxis for cataract surgery: are intracameral antibiotics necessary? JAMA Ophthalmol. 2014;132(11):1269-1270.
20. Herrinton LJ, Shorstein NH, Paschal JF, et al. Comparative effectiveness of antibiotic prophylaxis in cataract surgery. Ophthalmology. 2016;123(2):287-294.
21. Haripriya A, Chang DF, Namburar S, Smita A, Ravindran RD. Efficacy of intracameral moxifloxacin endophthalmitis prophylaxis at Aravind Eye Hospital. Ophthalmology. 2016;123(2):302-308.
22. Jabbarvand M, Hashemian H, Khodaparast M, Jouhari M, Tabatabaei A, Rezaei S. Endophthalmitis occurring after cataract surgery: outcomes of more than 480 000 cataract surgeries, epidemiologic features, and risk factors. Ophthalmology. 2016;123(2):295-301.
23. Neel ST. A cost and policy analysis comparing immediate sequential cataract surgery and delayed sequential cataract surgery from the physician perspective in the United States. JAMA Ophthalmol. 2014;132(11):1359-1362.
24. Sarikkola AU, Uusitalo RJ, Hellstedt T, Ess SL, Leivo T, Kivelä T. Simultaneous bilateral versus sequential bilateral cataract surgery: Helsinki Simultaneous Bilateral Cataract Surgery Study Report 1. J Cataract Refract Surg. 2011;37(6):992-1002.
25. Serrano-Aguilar P, Ramallo-Fariña Y, Cabrera-Hernández JM, et al. Immediately sequential versus delayed sequential bilateral cataract surgery: safety and effectiveness. J Cataract Refract Surg. 2012;38(10):1734-1742.
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8. Chang DF, Braga-Mele R, Mamalis N, et al; ASCRS Clinical Cataract Committee. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey. J Cataract Refract Surg. 2007;33(10):1801-1805.
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11. Donaldson KE, Braga-Mele R, Cabot F, et al; ASCRS Refractive Cataract Surgery Subcommittee. Femtosecond laser-assisted cataract surgery. J Cataract Refract Surg. 2013;39(11):1753-1763.
12. Abouzeid H, Ferrini W. Femtosecond-laser assisted cataract surgery: a review. Acta Ophthalmol. 2014;92(7):597-603.
13. Chen H, Hyatt T, Afshari N. Visual and refractive outcomes of laser cataract surgery. Curr Opin Ophthalmol. 2014;25(1):49-53.
14. Yu Y, Chen X, Hua H, Wu M, Lai K, Yao K. Comparative outcomes of femtosecond laser-assisted cataract surgery and manual phacoemusification: a six-month follow-up. Clin Experiment Ophthalmol. 2016;44(6):472-480.
15. Ewe SY, Abell RG, Oakley CL, et al. A comparative cohort study of visual outcomes in femtosecond laser-assisted versus phacoemulsification cataract surgery. Ophthalmology. 2016;123(1):178-182.
16. Cohen MN, Intili A, Ni N, Blecher MH. Femtosecond laser-assisted cataract surgery in residency training. Curr Opin Ophthalmol. 2015;26(1):56-60.
17. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33(6):978-988.
18. Packer M, Chang DF, Dewey SH, et al; ASCRS Cataract Clinical Committee. Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis. J Cataract Refract Surg. 2011;37(9):1699-1714.
19. Schimel AM, Alfonso EC, Flynn HW Jr. Endophthalmitis prophylaxis for cataract surgery: are intracameral antibiotics necessary? JAMA Ophthalmol. 2014;132(11):1269-1270.
20. Herrinton LJ, Shorstein NH, Paschal JF, et al. Comparative effectiveness of antibiotic prophylaxis in cataract surgery. Ophthalmology. 2016;123(2):287-294.
21. Haripriya A, Chang DF, Namburar S, Smita A, Ravindran RD. Efficacy of intracameral moxifloxacin endophthalmitis prophylaxis at Aravind Eye Hospital. Ophthalmology. 2016;123(2):302-308.
22. Jabbarvand M, Hashemian H, Khodaparast M, Jouhari M, Tabatabaei A, Rezaei S. Endophthalmitis occurring after cataract surgery: outcomes of more than 480 000 cataract surgeries, epidemiologic features, and risk factors. Ophthalmology. 2016;123(2):295-301.
23. Neel ST. A cost and policy analysis comparing immediate sequential cataract surgery and delayed sequential cataract surgery from the physician perspective in the United States. JAMA Ophthalmol. 2014;132(11):1359-1362.
24. Sarikkola AU, Uusitalo RJ, Hellstedt T, Ess SL, Leivo T, Kivelä T. Simultaneous bilateral versus sequential bilateral cataract surgery: Helsinki Simultaneous Bilateral Cataract Surgery Study Report 1. J Cataract Refract Surg. 2011;37(6):992-1002.
25. Serrano-Aguilar P, Ramallo-Fariña Y, Cabrera-Hernández JM, et al. Immediately sequential versus delayed sequential bilateral cataract surgery: safety and effectiveness. J Cataract Refract Surg. 2012;38(10):1734-1742.
