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Economic Forces Affecting Cataract Surgery

Optometry can help to improve efficiency by participating in perioperative care.

The need for cataract surgery is greater than ever, as patients increasingly wish to improve their fading vision at an earlier age. This demand opens exciting and unique opportunities for optometrists to help their patients achieve unprecedented vision, to collaborate with their colleagues in ophthalmology, and to generate revenue and growth for their practices.


  • With increasing volume of cataract surgery, optometrists must step into the role of primary care eye doctors.
  • ODs must be up to date on all new IOL technologies to help identify patients who are candidates for premium IOLs.
  • ODs can perform elements of pre- and postoperative cataract care to help surgeons improve their efficiency.

It is estimated that, by 2050, the number of people in the United States with cataracts will double to 50 million. At the same time, the number of ophthalmologists is decreasing each year due to aging and retirement.1 The resulting strain on the eye care system puts optometrists in prime position to embrace a bigger role as primary care eye doctors.

This scenario will drive more patients to their trusted optometrists for advice about the many options and technologies available for cataract surgery. Modern lens-based surgical procedures now enable eye care providers to create custom-tailored vision for their patients to match their varied lifestyles.


In the past, eye care providers were taught to defer cataract surgery until a patient’s objective vision had degraded to worse than a minimum threshold, indicating a so-called “ripe” cataract. Improvements in outcomes and modern surgical techniques have changed the cost and the risk-benefit ratio, so that now cataract surgery immediately after a patient becomes symptomatic is thought to be both cost-effective and best for the patient’s quality of life.2

But even with models predicting long-term societal savings from early intervention, the costs of health care in the United States continue to rise. One estimate predicts that, if costs continue to rise at the current rate, 100% of the US budget will go to health care by the year 2040.3

In efforts to curb the increasing costs of US health care, CMS has proposed deep cuts in cataract surgery reimbursement for ophthalmologists in 2020, and even deeper in 2021. In just 2 years, CMS reimbursement for cataract surgery will have decreased from $654 to an estimated $505.84 for 2021, a 22% reduction. These estimated payments, based on a reduced conversion factor, will be reflected in all cataract-related codes.4


These financial changes mean that surgeons will have to perform more cases in the same amount of time to earn the same amount of revenue as in previous years. On top of this, ophthalmology has been one of the medical specialties most severely affected by the COVID-19 pandemic.5 For these reasons, many ophthalmology practices will have to become more efficient in order
to survive.

One way for ophthalmologists to achieve greater efficiency is by collaborating with optometrists to perform pre- and postoperative examinations, while also encouraging patients to choose more private-pay upgrades for IOLs and new surgical technologies.

To lower costs and increase efficiency in the OR, some surgeons have started doing in-office cataract surgery in a clean surgical suite rather than at a surgery center. Companies such as iOR Partners can construct these surgical suites and ensure that they meet relevant regulatory codes. Kaiser Permanente and some Veterans Affairs institutions have also implemented same-day bilateral cataract surgeries in efforts to decrease wait times and number of postoperative visits.


New technologies now allow eye care providers to offer patients a once-in-a-lifetime opportunity to cure their refractive error and presbyopia at the same time. Improved biometry, latest-generation IOL power calculation formulas, and intraoperative aids have all helped to improve the predictability of postoperative refractive results. Most surgeons now achieve refractions within 0.50 D of plano in more than 70% of their cataract patients, and many reach that goal in 90%.6

This improvement in outcomes has led to elevated patient expectations for emmetropia and spectacle independence, and ophthalmologists have adopted new technologies to help achieve results that match these expectations. Presbyopia-correcting IOLs such as the AcrySof PanOptix Trifocal IOL (Alcon) and the extended depth of focus Symfony IOL (Johnson & Johnson Vision) offer reduced dysphotopsia and higher patient satisfaction scores compared with previous generations of IOLs. Today, many surgeons are offering these advanced IOLs to patients, reflecting improved confidence and training. Many surgeons have also started treating lower amounts of astigmatism, either through application of femtosecond laser limbal relaxing incisions or implantation of low-powered toric IOLs. Intraoperative aids such as the ORA System (Alcon) and the Zeiss Callisto eye (Carl Zeiss Meditec) are powerful tools for identifying and efficiently treating astigmatism.

Additional IOL technologies are also on the horizon, such as postoperatively adjustable lenses (Light Adjustable Lens, RxSight) and adaptable fluid-driven presbyopia-correcting lenses (Juvene, LensGen).

There are also outside-the-box opportunities in postoperative eye medications, and many eye care providers are now using intracameral or intracanalicular steroids rather than burdening patients with complex drop regimens. Optometrists can also sell some compounded postoperative drops in their offices.


Depending on state licensure, some of these new options and offerings can be performed by optometrists as they prepare their patients for cataract surgery. There will continue to be greater emphasis on collaboration between optometrists and ophthalmologists as the entire health care system is being pushed to reduce costs and increase efficiencies. The primary care eye doctor and the surgeon must have excellent communication and unified protocols, which can be made easier with shared electronic health records and provider portals.

As the quarterback of the cataract experience, the optometrist has an opportunity to help his or her patients maximize their surgical outcomes. Optometrists must become more active in screening and preparing patients for cataract surgery. They must be up to date on the intricacies of every new technology in order to properly counsel their patients.

These new roles will require optometrists to perform more preoperative medical visits to identify and treat preexisting diseases such as dry eye, glaucoma, or macular degeneration. The presence of any of these conditions can have implications regarding which types of IOL a patient is eligible for. Pretesting to identify irregular topographies or a less-than-perfect macular OCT can help optometrists flag and treat subclinical disease before referring a patient for a surgical consultation.

Embracing new technologies and educating patients about their potential benefits can help deepen the OD-patient relationship, while also reducing chair time for the MD and increasing the conversion rate for upgrades in the patients we comanage. To achieve these synergies it is important for the optometrist to find a like-minded progressive cataract surgery partner with whom to collaborate. By helping patients to achieve their best vision, we can strive to retain happy patients and create increased revenue for both optometrist and ophthalmologist.

1. Cataract Data and Statistics. National Eye Institute. www.nei.nih.gov/learn-about-eye-health/resources-for-health-educators/eye-health-data-and-statistics/cataract-data-and-statistics. Accessed September 2, 2020.

2. UK National Institute for Health and Care Excellence. Cataracts in adults: management. London: National Institute for Health and Care Excellence; 2017. NICE Guideline No. 77. Appendix J, Health economics. www.ncbi.nlm.nih.gov/books/NBK536591/. Accessed September 22, 2020.

3. Pinto JB, Lindstrom RL. Change is inevitable: Prepare for a challenging future in ophthalmology. Ocular Surgery News. April 16. 2019.

4. Ophthalmology at risk for significant cuts from 2021 E/M changes. EyeWorld. April 2020. www.eyeworld.org/ophthalmology-risk-significant-cuts-2021-em-changes. Accessed September 22, 2020.

5. The national patient and procedure volume tracker. Strata Decision Technology. www.stratadecision.com/National-Patient-and-Procedure-Volume-Tracker/. Accessed September 22, 2020.

6. Behndig A, Montan P, Stenevi U, Kugelberg M, Zetterström C, Lundström M. Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study. J Cataract Refract Surg. 2012;38(7):1181-1186.

Richard Chu, DO
  • Medical Director, Chu Eye Associates, Fort Worth, Texas
  • drrichard@chueye.com
  • Financial disclosure: Principal Investigator (Alcon, Bausch + Lomb)
Robert Chu, OD
  • Managing Director, Eyeworks Group, Fort Worth, Texas
  • Member, Modern Optometry Editorial Advisory Board
  • drrobert@eyeworksgroup.com
  • Financial disclosure: None disclosed