Rising Cataract Surgery Rates: Demand and Supply

Abstract

Cataract surgery is the most frequently performed surgical procedure in many developed countries, providing significant, long-term, and cost-effective improvements in the quality of life for patients of all ages. Advances in cataract surgery techniques and technologies over the last decades have led to improved patient safety and better surgical outcomes, resulting in significant changes in the frequency with which cataract surgery is performed. Longitudinal, population-based data on cataract surgery rates in the United States are limited. In this issue, Klein et al provide timely, informative, population-based data on the changing incidence of cataract surgery in Beaver Dam, Wisconsin, during the 20-year period when cataract surgery shifted from planned extracapsular cataract extraction to small-incision phacoemulsification. Klein et al report that the ageand sex-adjusted incidence of cataract surgery increased 6.5-fold between 1988-90 and 2008-10 (1.8% vs. 11.7%) in Beaver Dam residents aged 43 to 86 years. The greatest increases were seen in the most recent 5-year interval (between 2003-05 and 2008-10) in persons older than 65 years of age and in persons with a visual acuity better than 20/40 or without a clinically significant cataract as determined at an examination 5 years before cataract surgery. The strengths of this study include its population basis, 2 decades of cataract surgery incidence, a standardized assessment of cataract status and visual acuity, avoidance of inclusion and recall bias, and adjustment for multiple potential risk factors. Its limitations include a small cohort size (4926 residents), a lack of geographic and racial diversity (99% white), and the interpretation of preoperative cataract status and visual acuity based on measurements performed up to 5 years before cataract surgery. The World Health Organization has set a cataract surgery rate of 3000 per million people per year as the minimum necessary to eliminate cataract blindness. This rate is greatly exceeded in many developed countries (7000e11 000 per million persons), and surgery rates are steadily increasing. Increasing cataract surgery rates have been explained, in part, by an aging demographic structure, reduced thresholds of visual impairment as an indication for surgery, increased frequency of second eye surgery, and increasing expectations by patients for better vision. What can we learn from the Beaver Dam Eye Study? First, the rising cataract surgery rates observed in Beaver Dam also were seen during the same time period in other areas of the United States and in many developed countries, albeit of a significantly lesser magnitude. Across the Mississippi river and 220 miles to the west of Beaver Dam, population-based data from Olmsted County, Minnesota