How do Advanced Technologies Affect the Practice of Cataract Surgery?

It is no secret that ophthalmology has become an incredibly diversified specialty. As surgeons shift their focus from providing patients with adequate visual acuity to striving for quality of vision postoperatively, so is the technology shifting. Surgeons now have more means to not only to correct patients' vision, but also to address more cosmetic concerns, thanks to advanced technologies, such as the excimer and femtosecond lasers and refractive IOLs.

Ophthalmology is experiencing surgical subspecialization, creating a highly fragmented marketplace that requires advanced training in areas including cataract surgery and laser vision correction. According to the American Academy of Ophthalmology, approximately 33% and 13.6% of ophthalmologists consider themselves subspecialists in cataract surgery and laser vision correction, respectively, with 42% working in group practice. But with the lines between cataract and refractive surgery blurring, surgeons are also finding the need to expand their own armamentariums.

Many surgeons are beginning to incorporate products including refractive IOLs and procedures such as refractive lens exchange into their practices in the hopes of offering patients excellent quality of vision postoperatively. To this end, refractive cataract surgery is becoming more mainstream. One reason for this shift is the level of technology available to cataract and refractive surgeons today.

Patients are also increasing their knowledge base, frequently educating themselves on their own visual complaint or disease and available surgical options before visiting their ophthalmologist. Many patients have high expectations and demand better correction than eyeglasses or contact lenses can provide. As the population continues to age and the number of people with presbyopia increases, demands from patients will only become more commanding. As a result, surgeons and industry alike are striving to improve upon existing approaches to correction and develop new approaches that may better answer these rising patient expectations.

MEDICAL DEVICES
This article reviews results from a MedMarket Diligence report on the products, technologies, markets, and opportunities in ophthalmology.¹ Within the realm of medical devices used in ophthalmology, three categories are referenced: diagnostics, including office-based diagnostic equipment; cataract surgery products, including IOLs, ophthalmic viscosurgical devices, and phacoemulsifiers; and refractive surgery products, including excimer lasers, femtosecond lasers, microkeratomes, and usage-based procedure cards. Combined, these categories accounted for $17 billion in 2006, according to the MedMarket report. The report also suggests that the four areas that will experience significant growth are refractive surgery, cataract surgery, glaucoma, and management of retinal disorders.

Diagnostic equipment. Previously, diagnostic equipment was mostly used to identify diseases and conditions of the cornea and macula; this technology is now also being used to select vision-correction treatments on an individual basis, according to MedMarket. Now, surgeons can customize treatment depending on the patient's own eye as well as his requirements and lifestyle habits. Thus, there is a trend toward using diagnostics as a tool for preoperative clinical assessment, and many surgeons now integrate diagnostic findings with therapeutics. According to the MedMarket Diligence report, the sophistication of diagnostic instruments and therapeutic approaches go hand-in-hand, with manufacturers combining diagnostic tests for better therapies. For example, it has recently become popular for autorefractors and keratometers to be offered as a combination device, and surgeons performing laser vision correction are now requiring accurate corneal thickness and aberration measurements.

Cataract surgery products. Cataract surgery accounts for 11% of total ophthalmic products (Figure 1).¹ Surgeons are faced with the challenge of wading through the options for IOL implantation, including monofocal, multifocal, accommodating, aspheric, toric, and phakic IOLs. Phakic IOLs are increasingly used in patients who are contraindicated for laser vision correction. With so many options, IOLs signify a major area of technology that influences the surgeon's practice. Surgeons will continue to have to choose the best IOL as more are introduced into the market and revisions are made to existing designs. Additionally, the popularity of refractive cataract surgery will influence this surge of IOL options, as surgeons will continue incorporating refractive IOL designs into their practices.

Phaco technology is another consideration, and most phacoemulsification systems have been recently updated to include better fluidics and other features. More than 2,000 units are sold each year, and surgeons upgrade their equipment on average once every 4 years.¹

Refractive surgery products. Although refractive surgery does not account for as much of the total ophthalmic market as cataract surgery (7%; Figure 1), more than $4 billion is spent annually on refractive surgery globally.¹ A portion of this revenue is due to manufacturers' per-procedure fee for laser systems. Laser systems provide ophthalmologists with the means to not only correct their patients' refractive errors but also enhance outcomes after IOL implantation. Once again, the blurring lines between cataract and refractive surgery are evident in today's practice of ophthalmology.

The market for laser vision correction is still healthy; however, several factors will affect the evolution of refractive surgery, including clinical outcomes, physician education, access, patient education, cost, and reimbursement. According to the MedMarket report, refractive procedures that cater to a niche set of patients may likely falter, whereas faster-growing techniques, such as all-laser LASIK, will continue to develop the broad range of treatment options for patients. The more techniques the surgeon incorporates into his practice, the more chance for patient loyalty and word-of-mouth referrals.

One drawback to all the advancements in refractive surgery is the associated costs. Not only are refractive procedures expensive, but many times they are not covered by insurance plans.

DEMAND FOR SERVICES
The patient population is aging—and, as has been said before, with age comes experience. Patients know more about medicine now than they ever have, taking the time to educate themselves before they seek treatment. Their awareness of surgical options and their eagerness to make educated decisions about their eyes is fueling the fire for industry to develop new and exciting technologies to treat conditions including hyperopia, myopia, astigmatism, and presbyopia. Some of these technologies combine treatments with pharmaceutical therapies, further transitioning cataract and refractive surgery onto a level playing field.

Cataract and refractive surgeons will continue to see technological advances that will aid in providing better quality of vision to patients. Although many surgeons do not perform both cataract and refractive surgery, this trend will likely change in the future with the penetration of new technologies. Surgeons who already offer a combination of cataract and refractive options will pave the way for the future success of refractive cataract surgery.

1. MedMarket Diligence Report. Products, technologies, markets and opportunities on ophthalmology surgical, device and drug markets worldwide, 2007. MedMarket Diligence, LLC; Report G125; Foothill Ranch, California; 2007.