Original Research

Emerging Cataract Surgery Practice Patterns in the Veterans Health Administration

A survey finds low rates for femtosecond laser-assisted cataract surgery, intracameral antibiotics, and immediate sequential bilateral cataract surgery.

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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.

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.


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.

The survey responses were stored anonymously in the REDCap database and analyzed using descriptive statistics.


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.


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.


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