Technology to meet the growing demand for cataract surgery

Twenty million cataract surgeries are completed every year, making it the world’s most common procedure. Ageing populations are expected to increase demand further – an additional 2 million Americans will require cataract surgery every year by 2035. Over the same period, the number of practicing ophthalmologists in the US is expected to fall by 12%. These trends predict that 3 in every 10 patients will not be able to access the care they need to restore vision [1].

Healthcare systems will need to complete more procedures with less resource. Significant steps have been made to increase efficiency in cataract surgery – advances in phacoemulsification, folding lenses, and pre-loaded inserters mean that the surgeon’s operating time can be as low as five to ten minutes.  

In the highest throughput clinics, surgeons spend more than 85% of their time performing surgery [2]. Short surgeries, high efficiencies, and downwards cost pressure means innovation can be difficult.  

These challenges create opportunities for medical device and technology companies to build products and services that enable healthcare systems to meet the growing demand for cataracts surgery. This insight explores how technology can improve efficiency in cataract surgery before focusing on some of the opportunities for streamlining diagnostics and surgery. 

A relatively small number of cataract centres have shown that existing workflows can be stretched to enable increased surgical throughput. Initiatives like the NHS’s High-Volume, Low-Complexity Hubs have shown how streamlined surgical lists alongside improved logistics and resource management can dramatically improve capacity. Similar results can be observed in high-volume Ambulatory Surgical Centres (ASCs) in the US. 

There are significant barriers to establishing high-volume surgical centres and it is often dependent on individual practices to develop systems for increasing volume. Products that lower the barrier to entry will raise productivity and provide a win for patients, surgeons, and suppliers. Patients are more likely to get the care they need, surgeons can spend more time treating patients, and the med tech industry can grow the supply of consumables and surgical tools to meet demand. 

These products could address everything from supply chain logistics through to the design of the operating room and surgical lists. In other surgical domains, companies like Theator are already showing how digital tools can enable better scheduling and surgical monitoring. In hospitals, robots are starting to roam the halls to support inventory and logistics management. Automation is transforming workflows in instrument tracking and sterilisation. 

Eyecare has started to adopt technology to connect diagnostics to surgery, which reduces errors and the time absorbed by transcription. However, it has been slower to adopt technology in the wider practice. Companies with product ecosystems that enable surgeons to treat more patients will be well placed to meet future needs in cataract surgery. 

Diagnosis of cataract surgery is completed in primary care facilities through slit lamp examination. An optometrist or ophthalmologist inspects the lens of the eye for opacities or areas of cloudiness. The subjective identification and classification of cataracts is dependent on the experience of the clinician, can be difficult to scale, and requires ophthalmic surgeons to spend more time outside of surgery.  

Once diagnosed, detailed biometry – often based around measures of axial length, corneal curvature, and depth of the anterior chamber – is used for lens selection and surgical planning. Modern tools for biometry are digitally connected to the surgical suite to allow efficient management of data. These tools allow streamlined management of each patient. 

Improving the quality, consistency, and connectivity of grading cataracts offers to improve management across patients. Improved grading can underpin better scheduling and support the design of high throughput surgical lists – nothing undermines efficiency like an unexpectedly complex case in a busy surgical day.  

As an example technology, academic studies using data analytics, deep learning, and other types of AI are already showing how automated systems can match human diagnosis and classification. These tools offer immediate value in designing surgical lists and may ultimately allow for remote screening and diagnosis, therefore reducing the burden on optometrists and ophthalmologists.  

Since the advent of modern cataract surgery, technology and innovation has aimed to improve the efficiency and repeatability of cataract surgery. This has progressed to enable routine cataract surgery to be completed in well under ten minutes.  

Innovation has enabled this by simplifying the procedure – through the development of pre-loaded IOLs, for example – and by optimising processes – such as phacoemulsification. These technical advances have transformed cataract care but are reaching their limits. Alternate approaches are needed to loosen the bottleneck caused by surgeon shortages. 

Femtosecond laser assisted cataract surgery (FLACS) – first approved by the FDA in 2010 – is the most likely candidate to change how routine cataracts is completed. First generation systems, such as Alcon’s LenSx, can create corneal incisions, complete the capsulotomy, and even fragment the lens.  

While these systems are enabling increased precision and consistency, they often only achieve time parity with traditional cataracts surgery and rarely demonstrate increased surgical throughput.  

Next generation systems aim to support more of the surgery – extending lens fragmentation to complete break-up of the lens and removing the need for phacoemulsification. They target multi-spot laser techniques to increase the speed. These systems have the potential to displace phacoemulsification in low-to-moderate grade cataracts. Their use of automated laser systems may enable all but aspiration, polishing and lens placement to be completed by allied healthcare professionals – dramatically increasing surgeon bandwidth. 

Beyond laser systems, there is renewed interest in robotics for cataracts surgery – with public efforts from Foresight Robotics and Horizon Surgical Systems leading the charge. The pathway for commercial adoption remains challenging, but Wright’s Law tells us the cost barrier is likely to fall as robotics continue to penetrate almost every industry. Any company that manages to balance the technical and regulatory complexity alongside the commercial reality of cataracts surgery will be well positioned in a field where demand outstrips supply.  

Ensuring today’s standard of treatment is sustainable will require the development of new products and services for delivering care. The good news is that most of the technology described in this blog exists and leaders are looking at how they can be deployed to meet the unique dynamics of the Eyecare industry. 

With a roadmap becoming clear, the quality and speed of execution will determine who captures the projected growth in the coming decade. Leveraging expertise in ophthalmology with experience of deployment in adjacent markets will be central to delivering surgical capacity within the time frame needed.