ASCRS News: EyeWorld Journal Club
July 2023
by Luke (Jin Kyun) Oh, MD
Columbia University Irving Medical Center ophthalmology resident
Residency Program Director
Edward S. Harkness Eye Institute
Columbia University Irving
Medical Center
New York, New York
Surveys of cataract and refractive surgeons are used globally to evaluate the current practice patterns and preferences of surgeons in comparison with constantly evolving evidence-based standard of care and technological advancements. This practice was started as early as 1975 by the American Intra-Ocular Implant Society, now known as the American Society of Cataract and Refractive Surgery, and has been adopted as an annual practice by various organizations worldwide including in Europe, South Korea, Japan, Canada, and New Zealand.1,2 These surveys typically assess surgeon preferences as they pertain to IOL choice, surgical technique, use of diagnostic imaging or tools, and perioperative examination. The results of these surveys can then be used longitudinally to not only inform societies on developing trends and areas for educational emphasis, but also as a comparison for how preferences may vary across different societies around the world. In this study by Kohnen et al., a retrospective analysis of the European Society of Cataract and Refractive Surgeons (ESCRS) Clinical Trends Surveys was performed between the years of 2016–2021 to highlight practice preferences among delegates.
Ophthalmology Resident
Columbia University Irving
Medical Center New York, New York
Methods
The authors conducted a longitudinal retrospective analysis of the ESCRS Clinical Trends Surveys obtained during the annual ESCRS congresses between the years of 2016 and 2021. Surveys were available to all delegates both in person and online regardless of attendance. The number of questions varied across years; however, many questions were repeated to analyze change over time. Broad categories of questions included those pertaining to cataract surgery, use of evolving IOL technology, ocular surface disease, and glaucoma. For survey questions involving a numerical range, the midpoint of the range was used for calculation of means. For survey questions using a rating scale (i.e., very confident, confident, neutral), multipliers were assigned to each response in order to determine a mean. Cross-tabulation analysis was performed across four categories, Practice Location, Years in Practice, Primary Surgery Location, and Average Annual Volume of Cataract Surgery, for additional segmentation and analysis of the survey responses.
Results
Survey response rates were stable across the study period except for a lower response rate of 13.9% seen in 2020, which was attributed to the COVID-19 pandemic and a strictly online- only survey. Most responses were from delegates practicing in Western Europe followed by Eastern Europe and Africa/Middle East. Cataract surgery trends have demonstrated fluctuating but overall stable volumes with an average of 360 surgeries in 2021. The rate of presbyopia-correcting IOLs, especially trifocal/multifocal IOLs, increased significantly (p<0.01) over the study period, although persistent concerns remained about decrease in quality of night vision and increased costs. Similarly, the use of presbyopia-correcting and toric IOLs for astigmatism nearly doubled from 7.4% to 15.5%, with delegates suggesting use would be even higher if not for the cost. Methods for correction of astigmatism have remained consistent and dependent on cylinder, with surgeons preferring on-axis incision for 0.75 D and toric IOLs for greater than 1.25 D. Greater than 75% of respondents preferred biometry for preoperative measurements; however, an increase in the use of Scheimpflug tomography (p<0.01) was seen, coinciding with a decrease in the use of manual keratometry (p<0.01). The use of digital image registration has also increased for axis alignment of toric IOLs (p<0.01), while manual ink marking has decreased (p=0.01). Only 61% and 45% of respondents reported evaluating the ocular surface prior to refractive and cataract surgery, respectively. Finally, the percentage of delegates performing glaucoma surgery, including MIGS or lasers, has decreased significantly over the study duration alongside a significant increase in the number of respondents stating they only have a medical glaucoma practice (p<0.01 for both).
Discussion
Analysis of annual survey trends by large ophthalmologic societies highlights the practice patterns, rate of evolution, and potential patient care and public health needs across populations. In this retrospective review of 6 years’ worth of survey data, Kohnen et al. provided perspective on the current state of cataract and refractive surgeons practicing predominantly in Europe. ESCRS members reported relatively lower cataract and corneal refractive surgical volume compared to ASCRS members but similar to those reported by the Korean Society of Cataract and Refractive Surgery (KSCRS).2,3,4 Interestingly, both ESCRS and ASCRS members endorsed increasing use of presbyopia-correcting and toric IOLs as well as preoperative Scheimpflug tomography; however, the use of toric IOLs and tomography in ESCRS members has lagged behind that of ASCRS members, suggesting a higher threshold for or slower adoption of change among ESCRS members.2,3
Perhaps most notably, the ESCRS survey trend demonstrates a significant decrease in members performing glaucoma surgery, including MIGS and laser procedures, with fewer than 30% of ESCRS members performing glaucoma procedures compared to 49% of ASCRS members.2 The differences in use of MIGS may be attributable to increased availability and confidence among U.S. respondents; however, the absolute difference in glaucoma practice demonstrates that a significantly higher proportion of ESCRS members maintain a medical glaucoma only practice compared to their ASCRS counterparts. Literature on procedural glaucoma management in Europe is divided with several country-based studies suggesting that rates of glaucoma procedures have increased over the last decade whereas another study evaluating first glaucoma surgical referrals across Europe suggests that up to 50% of glaucoma surgical referrals may occur late and require earlier attention.5,6,7 While the underlying cause of this trend is unclear, the results of this survey may reflect a developing need for surgeons comfortable with glaucoma procedures among the ESCRS community.
ESCRS Clinical Trends Survey 2016–2021: 6-year assessment of practice patterns among society delegates
Kohnen T, et al. J Cataract Refract Surg. 2023;49:133–141
- Purpose: To evaluate clinical opinions and practice patterns of delegates to the European Society of Cataract and Refractive Surgeons (ESCRS).
- Setting: Clinical Trends Surveys were administered during annual ESCRS congresses held from 2016 to 2021, and data was collected online and in person.
- Design: Survey questions addressed several specialty areas, including cataract surgery, presbyopia-correcting and toric intraocular lenses (IOLs), ocular surface disease, and glaucoma.
- Methods: Survey results were compared and analyzed across 6 years. Four main profile questions were used for cross-tabulation analyses of questions pertaining to refractive surgery: practice location, years in practice, primary surgery setting, and average annual volume of cataract surgery.
- Results: The highest number of responses (3,019) was collected in 2019, with the lowest (569) received in 2020. The use of presbyopia-correcting and toric IOLs has increased significantly from 2016 to 2021, with certain respondent segments using them more frequently than others. While optical biometry remains the preferred method for obtaining preoperative measurements, the use of tomography (Scheimpflug) has significantly increased. In 2021, 61.1% and 44.9% of respondents always performed preoperative checks of the ocular surface before refractive and cataract surgery, respectively. The proportion of respondents who perform glaucoma surgery has significantly decreased over the years, with an increasing number of delegates reporting having only a medical glaucoma practice. On average, 5.4% of patients with cataract and glaucoma underwent combined MIGS and cataract procedures in 2021.
- Conclusion: Evaluation of the Clinical Trends Survey data provides valuable insights into the shifting practice patterns and clinical opinions of ESCRS delegates.
References
- Hoffer KJ. Survey on the use of intraocular lenses. Ophthalmology. 1978;85:400–407.
- 2018 ASCRS Clinical Survey. EyeWorld. Available at: https://supplements. eyeworld.org/eyeworld-supplements/december-2018-clinical-survey. Accessed May 15, 2023.
- 2019 ASCRS Clinical Survey. EyeWorld. Available at: https://supplements. eyeworld.org/eyeworld-supplements/ascrs-clinical-survey-2019. Accessed May 15, 2023.
- Rho CR, et al. Cataract surgery practice in the Republic of Korea: a survey of the Korean Society of Cataract and Refractive Surgery 2020. Korean J Ophthalmol. 2021;35:272–279.
- Bron AM, et al. Trends in operating room-based glaucoma procedures in France from 2005 to 2014: a nationwide study. Br J Ophthalmol. 2017;101:1500–1504.
- Murphy C, et al. Recent trends in glaucoma surgery in Scotland, England and Wales. Br J Ophthalmol. 2015;99:308–312.
- Holló G, et al. Referral for first glaucoma surgery in Europe, the ReF-GS study. Eur J Ophthalmol. 2019;29:406–416.
