664

cases, instruments

and notes

Cataract, intraocular lens, and refractive surgery in 1987 with a

forecast to 1995

MaryAnne Carr

The IOL Market Survey yielded replies from more than 5,000 ophthalmologists during 1987. The follow­ing information is based on these replies.

While cataract surgeries declined during the first half of 1987, a strong second half resulted in 1.365 million cataract surgeries performed during 1987, representing an 8.2% increase over 1986. Intracapsu­lar procedures continued to decline, with extracapsu­lar surgeries accounting for 96% of procedures during the second half of 1987 (Figure 1).

The various methods of extracapsular cataract ex­traction (ECCE) were monitored as part of the IOL Market Survey. Irrigation and aspiration accounted for 60% of these procedures, manual expression, 24%, and phacoemulsification, 16%.

The percentage of physicians performing phaco­emulsification increased slightly since 1986. Twenty­two percent of ECCE surgeons used phacoemulsifica­tion at the end of 1987. Furthermore, there has been a steady increase in the percentage of extracapsular surgeries performed with phacoemulsification -16% in the most current data.

Ninety-eight percent of cataract surgeries resulted in a primary intraocular lens (IOL) implant during the latter half of 1987.

Total IOL implants for 1987 were 1.367 million, up 9.3% from 1986. Anterior chamber lenses comprised 6% of the total, while posterior chamber lenses increased to 94% of the market (Figure 2). Approx­imately 3% or 40,000 lenses were secondary implants.

The use of ultraviolet (UV) absorbing IOLs contin­ued to increase, with 81% of physicians using these lenses (Figure 3). Almost 80% of IOLs implanted during the last half of 1987 had this feature.

Because posterior chamber lenses accounted for 94% of the lenses implanted, I have examined them in more detail to determine style preference, method of fixation, and various features of these lenses.

Presented in part at the Symposium on Cataract, IOL and Refractive Surgery, Los Angeles, March 1988.

Reprint requests to MaryAnne Carr, Health Products Research, Inc., 3.520 U.S. Route 22, po. Box .5178, North Branch, New Jersey 08876-.5178.

J CATARACT REFRACT SURG-VOL 14, NOVEMBER 1988

S U r 9 e r i e 5

0 0 0

70

60

50

40 , , ,

}Z)/'

ALL

, , ~e>

, , , ,

... o ........ /0/ ECCE

oL---~~--_+--~--+_--~-4---+--~--+----

83 84 85 86 Year

87

Fig. 1. (Carr) Extracapsular, intracapsular, and total cataract surgeries performed from 1983 through 1987. Each point on the graph represents six-months' data.

p e

90

80

70

60

r 50 C e n t 40

30

20

10

, (9 --6---e>

, , , ,

% Using

% Lenses

oL---~~~-+--~--~--~~~_+--~--+_---

83 84 85 86 Year

87

Fig. 3. (Carr) Percentage of UV-absorbing IOLs implanted from 1983 through 1987.

The most recent survey results show that modified J-Ioop lenses, while leading the market, have de­creased to 41% of the total; modified C-Ioop lenses increased to 38% during 1987, followed by C-Ioop lenses at 11 %, and capsule or closed loop lenses at 3% (Figure 4).

Thirty-nine percent of posterior chamber lenses were fixated in the ciliary sulcus rather than in the

80

70

60 I 0 L

50

S

0 40

0 0

30 5

20

10

0

.6' ~0/ /0 ........

A' //

, , , (!)

83

(l/ , ,

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85

.6 .6·. '6'

. .... .... 12)

Total .' 12')---e~ . ,

.6 ;' .6' , , ,

~e> .... ,.,,0 ........

Posterior

86 Year

87

Fig. 2. (Carr) Posterior chamber IOLs, anterior chamber IOLs, and total IOLs implanted from 1983 through 1987. Each point on the graph represents six-months' data.

"MODC" 38%

"MODJ" 41%

"J"1%

Fig. 4. (Carr) Styles of posterior chamber IOLs implanted during the second half of 1987.

capsular bag. This represents a reverse trend from 1986 when only 31% of lenses were placed in the sulcus.

While more than 70% of posterior chamber lenses have polypropylene haptics, one-piece polymethyl­methacrylate (PMMA) lenses have increased from 10% in the earlier part of 1987 to 16% in the second half of the year. Two-piece PMMA lenses comprised 11% of the total.

I have defined standard optic size as <6.0 mm with positioning holes on the optics. While more than one­half of posterior chamber lenses fall into this category, nearly one-fourth oflenses are 6.0 mm with no holes or tabs. Seven millimeter lenses have increased to 13% of

J CATARACT REFRACT SURG-VOL 14, NOVEMBER 1988 665

6.0 mm with holes

56%

Fig. 5. (Carr) Optic size of posterior chamber IOLs implanted during the second half of 1987.

the total, while the remaining 8% are 6.5 mm optics (Figure 5).

Lenses are also classified by optic type. About 80% of posterior chamber lenses are plano, 10% biconvex, and 9% meniscus. Within the plano group, 29% with a laser barrier coupled with 9% meniscus yields 38% with some sort oflaser barrier (Figure 6). Last year 40% of lenses had this feature.

Other refractive surgical procedures are monitored as part of the IOL Market Survey. The number of radial keratotomies continued to decline during 1987, with the number of procedures estimated at 28,000 for the year (Figure 7). With a standard error of 13%, this number could be as high as 31 ,000 or as low as 25,000 procedures . The percentage of physicians performing this surgery has remained fairly constant at 10% to 11 %.

The number of epikeratophakia procedures peaked during the first half of 1987 but decreased during the last half of the year. The number of surgeries per­formed in 1987 was estimated to be 5,700, with upper and lower bounds of6,500 and 5,000, respectively. The 10% of ophthalmologists performing this procedure has remained fairly constant.

Table 1. Forecast for cataract surgery through 1995.

Total Cataracts

Plano 510/0

~----~:--===::::::JUnsp. 1%

Plano VI Laser Barrier

29%

Fig. 6. (Carr) Optic type of posterior chamber IOLs implanted during the second half of 1987.

s u r 9 e r i e 5

o o o 5

15

10

5

o

Fig. 7.

84

III " , \ , \ , \ , \ , \ , \ , \ , \ , \

\

86

Year

/ /

/ /

/

)2]

, '/ '\. [!] ........... t!J , / , /

87

(Carr) Radial keratotomy procedures performed from 1984 through 1987. For 1985, 1986, and 1987, each point on the graph represents six months' data. Bars at the bottom of the graph represent number of physicians performing RKs .

Total IOLs IOLs

Year Number (OOOs) Percentage Change Number (OOOs) Percentage Change Primary Secondary

1987

1988

1989

1990

1991

1992

1993

1994

1995

666

1,365

1,382

1,389

1,385

1,355

1,350

1,332

1,352

1,267

1,367

+ 1.8 1,396 1.7

+0.5 1,401 0.4

-0.3 1,397 -0.3

-2.2 1,368 -2.1

-0.4 1,363 -0.4

-1.3 1,344 -1.4

+ 1.5 1,362 + 1.3

-6.3 1,279 -6.0

J CATARACT REFRACT SURG-VOL 14, NOVEMBER 1988

1,327 40

1,355 41

1,361 40

1,357 40

1,329 39

1,324 39

1,306 38

1,325 37

1,241 38

How many cataract surgeries will be performed during 1988 and in future years?

A computer model created by Health Products Research forecasts cataract surgeries and IOL implan­tations using population dynamics, cataract preva­lence, treatment rates, and other factors affecting the incidence of cataract surgery. Assumptions can be varied, thereby producing different forecasts.

A forecast presented in 1987 projected the number of cataract surgeries for 1987 at 1.31 million, 50,000 less than the actual 1.36 million.

The model has been calibrated to 1987 data, and it has been assumed the current treatment rate will continue. The resulting forecast for cataract surgeries through 1995 is shown in Table 1.

A 1.8% increase in cataract procedures in 1988 should yield 1.382 million surgeries. The peak is reached in 1989 with 1.389 million procedures, fol­lowed by decreasing numbers through the 1990s. A slight blip is found in 1994.

Higher numbers of surgeries have been proposed by others citing the percentage increases demonstrated during the past years. I have no documented rationale for changing cataract prevalence, current data result­ing from the Framingham study and published by the government. However, these data are regionally biased; should there be an increase in the inci­dence of cataracts in sunbelt states, prevalence may be understated.

Other factors may affect the future number of cataract surgeries. There are nearly 30 million people 65 years or older in the U.S. It is estimated that 15% (or 4.5 million) have never seen an ophthalmologist. Referrals within the National Eyecare Project have resulted in diagnosis and/or treatment of cataracts for almost 33,000 additional patients since 1986.

Spontaneous enlargement of neodymium: YAG posterior capsulotomy in aphakic and pseudophakic patients

Henry M. Clayman, M.D. Norman S. Jaffe, M.D.

AB TRA T Tv 0 ca e ' of spontaneou enlar ement of a

neod mium:YA po terior cap ulotom invol ing an aphakic and a p eudophakic patient are pre­ented. Con equence and po ible cau alit al-e

di eus ed.

Ke \VOI-d intraocular I n., n odvmium:Y la. 1', post rior cap. u]otc;my

A posterior caps ulotomy is the predominate indica­tion for the Nd:YAG laser and the introduction of this modality coincided with the trend toward extracapsu­lar surgery. A laser capsulotomy provides an expedient and successful treatment for the opacifying posterior capsule, though one not entirely free of complication. 1

This paper presents an aphakic and a pseudophakic patient, each with spontaneous enlargement of the posterior capsule subsequent to an Nd:YAG posterior capsulotomy. It is the first report of this complication.

Case 1 The patient was first seen in 1974 at age 69 with a

history of a retinal detachment in the right eye, successfully operated on in 1971 with a 360-degree scleral buckling procedure. Nuclear sclerotic cataracts were noted at this initial visit and these slowly progressed, culminating in a planned extracapsular cataract extraction on the right eye without an intra­ocular lens (IOL), performed on March 10, 1980. The patient had a similar operation on the left eye on May 29, 1980, and by July 16, 1980, both eyes corrected to 20/25 with an aphakic refraction.

On February 9, 1983, the patient presented with complaints of decreased vision in the right eye in which

From the Bascom Palmer Eye Institute, University of Miami School of Medicine, and the Miami Eye Foundation , Inc.

Presented at the Symposium on Cataract, IOL and Refmctive Surgery, Orlando , April 1987.

Reprint requests to Henry M. Clayman, M.D., St. Fmncis Hospital, 250 West 63rd Street, Miami Beach, Flodda 33141.

J CATARACT REFRACT SURG-VOL 14, NOVEMBER 1988 667