Emerging Cataract Surgery Practice Patterns in the Veterans Health Administration

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

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.