|Noel A. Alpins,
FRACO, FRCOphth, FACS, said as the number of aging patients increases, a
balance must be struck between new technologies and cost-saving cataract
Image: Alpins NA
The demand for cataract surgery is expected to surge in the coming
years, as more baby boomers reach 65 years of age around the world.
As time passes, you get this gradual encroachment of a higher
percentage of the proportion of people getting older, which obviously impacts
economically the proportion of people paying taxes, which in turn supports the
economy, Noel A. Alpins, FRACO, FRCOphth, FACS, OSN Asia-Pacific Edition
Editorial Board Member, said. You get so many more people 80, 90 and 100
[years old]. This becomes proportionally greater year by year. Its
overwhelming how the need for cataract surgery outpaces the ability to deliver
whats actually required for the community to have its needs
Cataract is the leading cause of reversible blindness and visual
The impending spike in demand for cataract surgery is multifactorial.
Aside from a sharp increase in the number of aging patients with cataracts,
evolving surgical techniques and improving outcomes promise to boost demand
among relatively young, active patients who desire cataract surgery or
refractive lens exchange.
The demand for cataract surgery is increasing tremendously, not
only because of the expanding aging population, but because the age at which
people demand cataract surgery has lowered, Lucio Buratto, MD, OSN Europe
Edition Associate Editor, said. Cataract surgery is performed earlier, as
soon as the first signs of opacification appear, because people ask for it as a
way to have a better quality of vision and reduce or avoid the need of
In addition, seniors are now more physically and socially active than
any previous group of seniors. People are living well and living longer. Apart
from being a large age cohort, baby boomers people born between 1946 and
1964 have higher expectations than previous generations.
According to the World Health Organization (WHO), populations in
developing countries are aging quicker than those in the developed world. In
2000, 248 million of the approximately 418 million people aged 65 and older
were in developing countries.
By 2020, the United Nations estimates the global elderly will total 698
Older people have greater access to the Internet and expanding
technologies and often expect improved outcomes. Ophthalmologists must fully
exploit breakthrough technologies and develop innovative practice models to
meet increasing demand and rising expectations.
Modern life has expanded the need for good to excellent eyesight, with
patients needing near, intermediate and distance vision for everyday tasks.
Patients use computers, cell phones, notebooks and book readers on a routine
basis, requiring a full range of sight, Dr. Buratto said. Everything from
satellite navigation systems in vehicles to temperature readings and petrol
consumption is automated and requires near and intermediate vision.
What has changed the scenario in recent years is the widespread
use of mobile phones and other mobile electronic devices like the iPad and
iPod, he said. Its not like sitting on your armchair and put
on your spectacles to read the newspaper or to make a phone call at home. At
all times during the day people are using their near vision and need to be
quickly able to see well at near in many occasions, while maintaining a good
distance vision because they drive and do many far-sight activities.
According to projections by the WHO, in 10 years, it is estimated that
the worlds population will increase by about one-third. At the same time,
the number of people older than 65 years will more than double worldwide.
The WHO estimates that by 2020, 32 million cataract operations will be
performed, up from 12 million in 2000.
In the Asia-Pacific region, countries will face challenges based on
specific needs and issues. The Global Initiative for the Elimination of
Avoidable Blindness, Vision 2020: The Right to Sight, was launched
in 1999 by the WHO and the International Agency for the Prevention of Blindness
to develop sustained eye health systems in nations around the world.
Interventions against cataract still need to be intensified to
reach affected but so far un-serviced populations, according to a press
release from WHO.
Despite the recent achievements in the prevention and control of
avoidable blindness, the emerging trend is a warning sign against complacency
on the part of governments, WHO and other eye care providers, Ivo Kocur,
MD, the Vision 2020 global coordinator, said in the release. If the
current level of maldistribution of resources is perpetuated, the global
disparity and inequity in the availability of affordable eye health services,
particularly for the elderly in the poorest parts of the world, will be
In Australia and New Zealand, 324 ophthalmologists have graduated and
gone on to fellowships of The Royal Australian and New Zealand College of
Ophthalmologists in the last 10 years, Dr. Alpins said. Of those, 79 were not
locally trained. He said that in the future, numbers similar to these will not
meet the need as more patients need cataract surgery.
I think it really highlights the fact that the number of people
is definitely ahead in cases over and above the number of people
who have been trained locally and also those who have emigrated to Australia to
work, he said.
If the need for cataract surgery is not met, problems will abound, Dr.
First, surgery will become inaccessible to many people because public
system waiting lists will significantly increase and demand for
ophthalmologists will be high, rendering care difficult to find in many areas,
Then, the community at large could be impacted by disabilities,
including from motor vehicle accidents caused by vision impairment.
Many countries have really cut back to the bone as far as what the
reimbursement for cataract surgery is. The government might be thinking
its saving costs, which in the short term it might be, but in the long
term, its creating an increased level of visual disability, which
increases the amount of comorbidities just from the issues created by people
that cant see adequately, Dr. Alpins said.
He said increased life expectancy has contributed to the situation. As
patients age, the life expectancy rate is also increasing, so a person who
reaches 70 years could live to 80 years, while a person who reaches 80 years
could live to 90 years and beyond.
The increase in life expectancy is due to better health, better
food and better lifestyles. At every age, longevity is greater now than in the
past, resulting in greater population in the 50s and 70s and beyond. And anyone
who gets to the age of 90 is going to have some degree of cataract. Its
inevitable, he said.
Meeting the challenge
Surgeons will have to be more efficient with their time and technology
to meet the growing cataract surgery need, Jorge L. Alió, MD, OSN Europe
Edition Editorial Board Member, said.
I think that surgeons need to learn and need to be much more
efficient in terms of outcomes. We need shorter number of visits instead
of four, to have only two, Dr. Alió said. Better outcomes
are mandatory in order to avoid additional visits. Cataract outcomes should be
more efficient in providing the best level of care with a very small
number of refractive error dealing with the premium lenses for
Rupert Menapace, MD, OSN Europe Edition Editorial Board Member, said the
combined situation of an aging population and increased demand for cataract
surgery might not be solved with more surgeons but with more effective surgical
The future challenge is to cope with the projected tremendous
number of surgeries, which will not be paralleled by an increase of the number
of new cataract surgeons. The answer is simple: Surgery must become even more
efficient. In an environment of restraints in costs and reimbursement,
optimizing the organization within cataract facilities and exploiting the
surgical capabilities of the surgeon will be the appropriate answer, he
If surgery does not become more high-volume and efficient around the
world, more patients will pursue private care where it is available, he
This, however, will in turn create political pressure on private
medicine. Reimbursement regulations and incorporation into medical networks
controlled or run by the state may be the result, Dr. Menapace said.
According to Dr. Menapace, the structure and workflow in surgical units
must be significantly altered to provide more procedures at an increased
Cataract surgery providers must make up their minds to improve
their efficiency of both the structure and workflow of the surgical units and
the surgery itself to optimally allocate the financial resources if they want
to successfully cope with the challenges of the future, he said.
Dr. Buratto said the increasing surgical demand should be addressed
through quality and enhanced visual performance. Correcting pre-existing
refractive errors is vital and should be accomplished through the use of
different IOLs that are available, he said.
In addition, the new approach of using femtosecond laser for cataract
surgery could be incorporated for better refractive results and precision.
Other options, such as premium lenses, should be weighed carefully, he
Premium lenses need precise centration, and the ability to do a
precise continuous circular capsulorrhexis, in terms of position, diameter and
centration [with a femtosecond laser], allows the lens to be centered well and
be more stable, he said.
Dr. Alpins said that the increase in surgical efficiency will be vital
in meeting the increasing cataract need as the population ages. However, he
cautioned that cost must be an integral consideration in using some new
With increased knowledge, these new and so-called better
techniques are increasing affordability. This may not apply here because of the
advanced type of implants that you have that often are more expensive, but also
the advanced type of technology that is becoming available such as
laser-assisted cataract surgery, he said.
The problem with that is, do these technologies treat more
patients in less time more affordably? Dr. Alpins asked. And I
think the answer to that, particularly with this generation of lenses and
femtosecond cataract surgery, is that you are going to increase the cost to the
patients in the community of patients who are paying. And it also doesnt
mean a decrease in surgical time; it actually increases duration. So this side
of technology, it might be very attractive superficially to have your cataracts
taken out by laser, and once the patients become savvy to it because
theyre better educated, it actually is counterproductive to the overall
goal of getting more people treated quickly and with less cost.
He said reducing the number of cataracts in the community is the most
important goal, which should not be forgotten in the pursuit of new
Educating patients about realistic options will most likely be a vital
part of meeting the future need for cataract surgeries, Dr. Menapace said. He
said patients learn from sources such as the Internet about different surgical
options and IOL technologies. Sometimes they decide on IOLs and commercial
platforms that cannot meet their needs before discussing their options with
their surgeons. This scenario will likely occur more often in the future, he
Evidence-based noncommercial education in Internet platforms
should be provided for patients to allow them to appropriately shape their
demands, he said.
Dr. Buratto also said that older patients are increasingly knowledgeable
about surgery and expect to be part of the surgical process from the start.
Patients need to know what they will experience in cataract surgery, he
The time of unconditioned trust is over, and now, no matter how
good your reputation is, you need to provide your patients with detailed
information on the type of lens you are using, on the technique, etc. When you
see your patients for a visit, this is already the second stage. Normally
patients want to be well-informed before they come to your office. They want to
be able to compare what different private clinics offer and decide whats
best for them, he said.
According to Dr. Alpins, the use of the Internet and other ways of
accessing information could be another way that costs could increase.
As younger people get older, the older people are becoming [aware
of] the knowledge base that you can find out there. It allows them to
thoroughly research what their options are. This might mean an increase in the
amount of patients who actually want the best technology available to
them, he said. Which once again adds a cost factor to it, because
these advanced lenses are much more expensive than the standard monofocal
Improving technology could increase efficiency and productivity and
enable surgeons to meet burgeoning demand, John A. Hovanesian, MD, FACS, OSN
U.S. Edition Cornea/External Disease Board Member, said. He urged practitioners
to embrace new technology, particularly femtosecond lasers, as a way to improve
outcomes and increase efficiency. Many surgeons believe femtosecond lasers
decrease efficiency and do not significantly improve safety, he said.
This is the very first generation of these lasers, Dr.
Hovanesian said. Despite all those woes, the reason were excited
about technology is because we know what it is capable of. We need to allow it
to continue to evolve. We need to support it and use it. We should reward the
innovation of those companies that bring these lasers to market so that they
will make further developments that will benefit us and our patients.
Lets not be afraid of the future. Lets shape it to be better for
everyone and to move forward this great specialty that were all a part
Dr. Alió said technology is the way forward in meeting the
surging cataract surgery need around the world.
Technology is improving. Femtosecond cataract surgery is taking
better control of the anatomy of eye during the surgery and after the surgery
probably as well. Well make the patient happy sooner, he said.
Technology is going to play a role because it will make cataract surgery
faster, probably more controllable and probably will be more systematic in
terms of approach. And all of this is of benefit to the patients.
by Erin L. Boyle, Michela Cimberle and Matt Hasson
better to use co-management with optometrists or hire ancillary personnel to
reduce practice demands?
- Brian G, Taylor H. Cataract blindness challenges for the
21st century. Bull World Health Organ. 2001;79(3):249-256.
- Global pattern of blindness changes with success in tackling
infectious disease and as population ages. World Health Organization website.
Dec. 16, 2004.
- Roodhooft JM. Leading causes of blindness worldwide. Bull Soc
Belge Ophtalmol. 2002;(283):19-25.
- Jorge L. Alió, MD, PhD, can be reached at Vissum
Corporation, Avenida de Denia, s/n, 03016 Alicante, Spain; +34-965150025; fax:
+34-965151501; email: email@example.com.
- Noel A. Alpins, FRACO, FRCOphth, FACS, can be reached at 7
Chesterville Road, Cheltenham, Victoria 3192 Australia; +61-3-9584-6122; fax:
+61-3-9585-0995; email: firstname.lastname@example.org.
- Lucio Buratto, MD, can be reached at Centro Ambrosiano Oftalmico,
Piazza Repubblica 21, 20124 Milano, Italy; +39-02-6361191; fax: +39-02-6598875;
- John A. Hovanesian, MD, can be reached at Harvard Eye Associates,
24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653, U.S.A.;
+1-949-951-2020; fax: +1-949-380-7856; email:
- Rupert Menapace, MD, can be reached at the Medical University of
Vienna, Vienna General Hospital, Department of Ophthalmology, Waehringer
Guertel 18-20, A-1090 Vienna, Austria; +43-1-404007941; fax: +43-1-404006630;
- Disclosures: No products or companies are mentioned that would
require financial disclosure.