Disclosures: Lindstrom reports relevant financial disclosures for AcuFocus, Alcon, Bausch + Lomb, Foresight Vision 6, Johnson & Johnson Vision, LayerBio, Lensar, Melt, Ocular Therapeutix, RxSight, Surface Ophthalmics and Zeiss.
February 01, 2021
3 min read
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Future of cataract surgery seems promising

Disclosures: Lindstrom reports relevant financial disclosures for AcuFocus, Alcon, Bausch + Lomb, Foresight Vision 6, Johnson & Johnson Vision, LayerBio, Lensar, Melt, Ocular Therapeutix, RxSight, Surface Ophthalmics and Zeiss.
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We now have three excellent FDA-approved laser methods to treat myopia, hyperopia and astigmatism in PRK, LASIK and SMILE.

A significant number of surgeons still use corneal or limbal relaxing incisions generated by a blade or femtosecond laser to treat astigmatism, often in combination with cataract surgery. Femtosecond laser application to the corneal stroma, which can change the cornea’s refractive index, is being evaluated by several companies, including Clerio, and first-in-human treatments have been promising.

Richard L. Lindstrom
Richard L. Lindstrom

All of these procedures together fall into the category of refractive corneal surgery. Together they account for about 1 million procedures a year in the United States and perhaps 3 million a year globally. The impact of refractive corneal surgery on ophthalmology and its patients, while significant, pales in comparison to the impact of its sibling, refractive cataract surgery. For that reason, I will focus my commentary on a few facts and thoughts on the current state of cataract surgery and offer a few predictions for the future.

Cataract surgery is a modern-day miracle. Since 1995, more than 500 million cataract procedures have been performed worldwide, and about 130 million living people are benefiting from this miracle procedure today. At present, approximately 4 million cataract procedures are performed every year in the U.S. and nearly 28 million worldwide. About 60,000 cataract procedures are performed every day globally.

The aging of our population and increased life expectancy project a compound annual growth rate of 3% to 4% per year for cataract surgery in the next 30+ years. That means that in 24 years or less, we will be performing 8 million cataract surgeries a year in the U.S. and more than 60 million in the world. If the 8 to 11 cataract procedures a year per 1,000 population done in the advanced countries is the correct number, and resources allow it, volume could approach 100 million procedures a year by 2050.

In the United States, advanced technology/premium IOLs are at approximately 16% as we exit 2020 and may grow past 20% in 2021. Refractive cataract surgery followed by implantation of a premium IOL, with or without the use of femtosecond laser-assisted cataract surgery (FLACS), is today a lucrative procedure for both the ophthalmologist and the ophthalmic industry. For this reason, the field continues to attract significant investment, resulting in a continuous flow of new products.

Advances and innovations in IOLs, cataract removal technology, IOL injectors, FLACS, heads-up visualization systems, diagnostics and perioperative medical therapy are accelerating. We have moved the site of cataract surgery for most patients from the hospital to the ASC and are currently investigating office-based surgery.

Now for the hard part, looking into the future. A few personal projections for 2030, just 9 years away. In 2021, 10,000 U.S. cataract surgeons will perform approximately 4 million procedures, for an average of 400 per year per surgeon. In 2030, a slightly smaller group of surgeons will perform 6 million procedures with an average annual volume of just more than 600 per year. The mean age of the patient undergoing cataract surgery will decline 5 years, from 73 today to 68 in 2030. The cataracts removed will be softer or softened by FLACS, other devices or medications, and phaco aspiration will replace phacoemulsification for most cases, making surgery safer and faster.

The majority of patients will undergo immediate (same-day) bilateral sequential cataract surgery. This trend will be largely patient driven, and reimbursement will be modified to not only allow it, but actually incent it. Advanced technology/premium IOLs will be used in more than a third of cases. The vast majority of cataract will be removed in an ASC or office-based surgery suite using a cataract workstation that integrates phacoemulsification, phaco aspiration and FLACS. Heads-up visualization systems will dominate with younger cataract surgeons, as that is how they will be trained, just like the transition from loupes to microscopes that occurred with my generation. Eye drops will be a historical footnote for perioperative care of the cataract patient, and concerns about patient adherence will be a thing of the past.

The top-of-the-line procedure will be an adjustable accommodating IOL that reduces posterior capsule opacification implanted with a preloaded single-use injector after FLACS-assisted phaco aspiration using a surgical workstation, heads-up visualization, and surgeon-administered extended-release infection, pain and inflammation prophylaxis in an ASC or office-based surgical suite with no IV. Reimbursement for the surgeon will sadly continue to decline, but reimbursement for the facility will likely increase at the same rate. The increased use of advanced technology/premium IOLs, enhanced surgeon and operating suite efficiency with increased case numbers performed per hour, and continued growth of patient pay will compensate the well-trained refractive cataract surgeon and support industry well, probably better than today.

The past and future of ophthalmology are closely tied to cataract surgery, and my vision of the future for this field is bright indeed.