July 2016




Cataract surgery varies by race, state, even latitude

by Matt Young and Gloria Gamat EyeWorld Contributing Writers

Man carries home

What new research means for how cataract surgery may be carried out in your town

In a report about geographic variation of cataract surgery in the United States, published in JAMA Ophthalmology, Courtney Kauh, MD, Madison, Wisconsin, and colleagues noted how different cataract surgery practices are between the north and south regions, and also compared the practices to 30 years ago.1

Previous studies using data from the 1980s found relatively little geographic variation in cataract surgery rates across the United States, Dr. Kauh reported. Things have changed, to say the least.

Major findings

The report had diverse findings, including: Median patient age was 59.960.1 years old in Lansing, Michigan as well as in Aurora, Illinois. But it was 77.079.6 years old in Marquette, Michigan; Rochester, New York; and Binghamton, New York. The median time from diagnosis to surgery was 17 days in Victoria, Texas, while it was 367 days in Yakima, Washington. There were significant racial differences. Black patients had a 15% decreased hazard of surgery compared to white patients (the term hazard here is derived from hazard ratios and does not refer to cataract surgery complications). Latino and Asian patients, meanwhile, had an increased hazard of surgery compared to whites. In this study, multivariable regression modeling generated hazard ratios (HRs) with 95% CIs identifying factors associated with patients likelihood of undergoing cataract surgery. For every 1 degree higher latitude, the hazard of surgery decreased by 1%. For every additional optometrist per 100,000 patients, the hazard of surgery increased 0.1%. The lowest age-standardized cataract surgery rate was 7.5%, in Honolulu, Hawaii, and the highest was 37.3% in Lake Charles, Louisiana.

The study obtained records from beneficiaries of a nationwide managed care network, accessing all eyecare recipients from 2001 to 2011. Researchers identified patients older than 40 who had at least 1 cataract.

Of note

Lake Charles, Louisiana came up as particularly noteworthy in this study. It had the countrys highest cataract surgery rate in both [the Kauh and earlier Javitt2] studies despite the studies use of different data and an approximately 20-year difference in observation periods, Dr. Kauh reported. Although it is unclear why this particular community has such high surgery rates, possible reasons include patient-related factors (e.g., increased patient motivation for surgery), health care professional-related factors (e.g., differences in health care professionals aggressiveness in recommending surgery), or factors specific to that particular community (e.g., environmental exposures). Lake Charles is a major center for petrochemical refining, and chronic exposure to naphthalene and other pollutants involved in the refinery process increase the risk for cataracts. Meanwhile, focus groups found that older black patients named lack of transportation and ability to reach an ophthalmologists office as a hurdle to achieving appropriate eyecare, the authors noted. Trust, communication, social support, and cost may be additional factors at play, the researchers reported. Given that cataracts are a leading cause of blindness among black people, and yet racial disparities in receipt of cataract surgery persist, additional work is needed to better identify and to eliminate black patients barriers to surgery, Dr. Kauh reported. In another line of inquiry, Dr. Kauh and colleagues suggested that surgical differences related to latitude may, in fact, be linked to UV light. The hazard of surgery was reduced for persons living in communities farther away from the equator (higher latitude), they wrote. This highlights the importance that UV light exposure can have on the development and progression of cataracts. Further, the authors theorized that there is an impact of optometrists on cataract surgery rates for good reason. It may be easier for patients who are struggling with their eyesight to access eyecare services in communities with more optometrists. With increased access, more patients are receiving cataract diagnoses and referrals for surgery, they reported.

Timing from diagnosis to surgery

Of all the factors analyzed, differences in timing from diagnosis to surgery may be the least well understood.

More work is required to understand the factors contributing to the large differences in timing observed, Dr. Kauh and colleagues reported. Communities differ with respect to the characteristics of the patients residing in them, eyecare professional availability, how assertive the ophthalmologists are at recommending surgery, and different environmental and lifestyle factors that can affect the timing of surgery. Visual demands may also vary among persons residing in one community vs. another. For example, some communities have better public transportation systems, so there may be less of a need to see well enough to operate a motor vehicle to drive to work.

Another view

While scientific analysis has been pursued in analyzing such broad trends, 1 skeptic is John Sheppard, MD, professor of ophthalmology, microbiology and molecular biology, and clinical director, Thomas R. Lee Center for Ocular Pharmacology, Eastern Virginia Medical School, Norfolk, Virginia.

There are too many variables here [for a meaningful analysis], Dr. Sheppard said. Latitude [for example] may be too general to draw conclusions. The researchers acknowledged study limitations, suggesting that some community-level variation in median age and rate of surgery could be due to chance alone.


1. Kauh CY, et al. Geographic variation in the rate and timing of cataract surgery among US communities. JAMA Ophthalmol. 2016;134:26776.

2. Javitt JC, et al. Geographic variation in utilization of cataract surgery. Med Care. 1995;33:90105.

Editors note: The physicians have no financial interests related to their comments.

Contact information

: webmaster@ophth.wisc.edu
Sheppard: jsheppard@vec2020.com

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Double trouble: Diplopia following cataract or refractive surgery by Maxine Lipner Senior EyeWorld Contributing Editor

Cataract surgery on what could be “the most myopic eye ever operated on” by Liz Hillman EyeWorld Staff Writer

Considerations for cataract surgery in short eyes by Liz Hillman EyeWorld Staff Writer

ASA classifications correlate with cataract surgery outcomes by Vanessa Caceres EyeWorld Contributing Writer

How are we performing nucleus division during cataract surgery? by Mitchell Gossman, MD

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