There’s no question that cataract surgery—once put off as long as possible and largely reserved for elderly patients—is now being performed on many people who have not even reached retirement age. Here, four experienced surgeons talk about the reasons for this shift, how it has affected their practices and approaches to the patient, and what surgeons can do to most effectively meet the needs of these younger individuals.
Why the Shift?
“I think there are several factors that account for this demographic shift,” says Stephen S. Lane, MD, medical director at Associated Eye Care in St. Paul, Minn., and adjunct professor of ophthalmology at the University of Minnesota. “First, the baby boomer generation that’s now turning 65 has a greater awareness and knowledge of cataract surgery, partly because of the computer and partly because of peer-to-peer interactions spreading awareness of the trend. Second, the surgery is safer and our overall results are better because of improvements in technology, including the IOLs we implant, our measuring technology and the surgical instrumentation we now use. Third, I think we’re now dealing with cataract surgery as a refractive procedure. We’ve given a lot of lip service to this idea in the past, but today we really are able to treat cataract surgery as a refractive procedure. And I think it will continue to get better.”
“There are many reasons for the shift toward younger cataract patients,” says Stephen Slade, MD, FACS, who practices at Slade & Baker Vision Center in Houston. “One is that the surgery has changed. When I started training 25 years ago, people would be in the hospital for two or three days to have a cataract removed; they couldn’t move around and it would take a while to get their vision back. So, they were told to postpone the surgery until the cataracts got really bad. Today, the surgery has gotten much easier; there are far fewer complications and much less fear, and the technology has improved dramatically. The surgery has become much more of a procedure and less of an operation.”
“The technology is better than in the past—and surgical expectations are also higher,” notes Samuel Masket, MD, clinical professor of ophthalmology at the Jules Stein Eye Institute, UCLA School of Medicine. “Together, these factors have helped to increase the volume of surgery in younger-age individuals. But perhaps the most significant factor in this shift is the aging of the baby boomers, who are now turning 65 in large numbers. This is the same group of individuals who sought the technological advances of laser vision correction, attempting to improve their quality of life. Now they’re seeking to take advantage of the latest advances in cataract surgery.”
Dr. Slade points out that the shift has been accompanied by a change in the definition of lens “dysfunction.” “Essentially, you have cataract surgery because the lens stops working,” he says. “In the past, ‘stops working’ was defined as ‘the lens gets cloudy.’ But in reality a healthy lens also focuses the light for both distance and near, and the lens stops doing that around the age of 40.”
A Different Generation
|“Younger patients are accustomed to paying out-of-pocket for health-care related expenses. The more elderly patients are not used to spending disposable income for lifestyle advantages through medical procedures.”
—Samuel Masket, MD
This shift to younger cataract patients is leading to changes in the doctor’s office as well, and much of that is attributable to generational differences. “Baby boomers are not their parents,” notes Dr. Slade. “The previous generation was more complacent—they expected less. I’m a baby boomer myself, so I can say this: There’s nobody as whiny as a baby boomer. One little thing wrong and baby boomers want to have it fixed. And they’re used to having it fixed—whether the ‘fix’ is Botox or Restylane or Viagra or wrinkle cream, or having a hip or knee replaced. Baby boomers are actively looking for solutions, where the previous generation was passively hoping for solutions.”
“People who are in the next generation older typically accept that with age comes loss of opportunity, loss of function,” observes Dr. Masket. “The baby boomers don’t adhere to that philosophy. So, when they sense they have any type of limitation in their vision, they want it fixed. And the fact that we can now come closer to meeting those expectations than we could in the past supports their desire to get this problem addressed earlier.”
“Another difference is in their level of knowledge about the surgery,” adds Dr. Slade. “People go on the Internet now and learn more about cataract surgery in 20 minutes than most first-year ophthalmology residents learned in six months 20 years ago. And, the surgery is now able to address problems like high myopia, hyperopia, astigmatism and even presbyopia. The improvements in cataract surgery fit very well with the baby boomers’ desire to get things fixed as soon as they become an issue.”
Another difference between the generations may be their attitudes regarding spending money for optional procedures. “One part of that is that younger patients are accustomed to paying out-of-pocket for health-care related expenses,” says Dr. Masket. “These are people who have paid out-of-pocket for procedures like LASIK or Botox, to get what they perceive to be a better look or better lifestyle. The more elderly patients are not used to spending disposable income for lifestyle advantages through medical procedures. It’s a little bit foreign to them. In fact, as more young cataract patients come into our offices, it makes increasing sense to offer these options because this group of individuals has already demonstrated their willingness to pay for procedures.”
Boomers and Technology
Another difference in the attitudes of baby boomers, noted by many surgeons, is their interest in trying cutting-edge technology. “It’s rare in my practice for anyone over the age of 80 to be interested in premium IOLs,” notes Richard L. Lindstrom, MD, founder and attending surgeon of Minnesota Eye Consultants and adjunct professor emeritus at the University of Minnesota Department of Ophthalmology. “Patients over 80 prefer to wear glasses. The younger patients are more interested in refractive cataract surgery.”
For some surgeons, dealing with an increasing number of younger eyes makes a difference in the operating room as well. “Some younger patients who haven’t undergone surgery are a little more anxious, compared to older patients who have been through more surgery in the course of their lives,” notes Stephen S. Lane, MD, medical director at Associated Eye Care in St. Paul, Minn. “They have more questions than older patients who have often seen multiple doctors over the years. You have to be patient, answer their questions and make sure they’re comfortable with the procedure.
“Intraoperatively, more anti-anxiety medications or anesthesia may be necessary for a younger person than an older person,” he adds. “They tend to be healthier, so it’s usually safer for them to receive a little bit more medication. In general, it takes a little bit more TLC to achieve the same sort of comfort level with a younger, less surgically experienced patient.”
Stephen Slade, MD, FACS, who practices at Slade & Baker Vision Center in Houston, notes that younger eyes are easier to operate on. “The cataracts are softer, there’s less phaco time, they heal better, the corneas are generally clearer and the pupils dilate better,” he points out. “The eyes are usually healthier, and there are fewer other things going on.” (Richard L. Lindstrom, MD, founder and attending surgeon of Minnesota Eye Consultants, notes that the prevalence of softer lenses in these patients causes him to favor supracapsular phaco.)
Samuel Masket, MD, clinical professor of ophthalmology at the Jules Stein Eye Institute, UCLA School of Medicine, says his surgical protocol has shifted in order to meet these heightened baby boomer expectations. “I now incorporate intraoperative aberrometry for all normal eyes, not just the outliers or post-LASIK eyes or eyes in difficult situations,” he says.
“Using intraoperative aberrometry, I end up changing the lens power in 43 percent of cases. As a result, we’re now within 0.5 D of our goal in about 90 percent of eyes. For the younger patients this is probably the most important thing—along with having a non-complicated procedure. Even at this level, we still encounter patients who are disappointed that they’re a half-diopter off.
“Another thing I do now, especially in the younger individual, is remove the subcapsular lens epithelial cells under the anterior capsule to the greatest extent I can,” he adds. “This reduces the fibrotic change and capsule phymosis that is especially common in younger people. There are numerous long-term advantages to doing this, although it does add more time to the chair discussion and in the operating room.”
Despite this trend, Dr. Slade says he doesn’t necessarily recommend presbyopia-correcting IOLs more often to younger cataract patients than older ones. “Whether the patient is 45 or 85, when you take a cataract out you have created absolute presbyopia if you put in a monofocal, regardless of age,” he notes.
Dr. Masket agrees, noting that some people over the age of 75 or 80 may still be open to advanced technology. “You have to individualize,” he says. “There’s no blanket rule to apply here. But when you look at trends, clearly the trend is toward baby boomers spending more on lifestyle enhancement.”
In fact, Dr. Slade believes that advanced technology such as premium IOLs could be of significant benefit to elderly patients. “It’s possible that younger patients who are still in the workforce might be better able to afford them, and they’re probably more active than older patients,” he continues. “However, I think that’s balanced by the fact that the older you get, the smaller your world is—the more you tend to read, watch TV, stay inside. In other words, I don’t think you can argue that having good near and distance vision become less important to you as you age. You’re more dependent on your vision for both safety and entertainment. If you’re young and you stumble, you’ll probably recover and you won’t break anything. If you’re older, it’s a whole different thing to fall and break your hip. And older individuals who are still employed are probably more likely to have a job that depends on their eyesight. So I think your vision becomes more vital to you in just about every way as you get older.”
Dr. Masket notes that the baby boomers’ interest in cutting-edge technology may also extend to femtosecond cataract surgery. “Although it’s not yet clear whether using the femtosecond laser improves optical outcomes, I would say that more of my patients below the age of 65 or 70 opt to pay for femtosecond laser-assisted surgery,” he says. “I happen to practice in a wealthy demographic where some of the older people I care for have far more money than some of the younger people, so I don’t believe it has anything to do with that. I think it’s all about mindset.”
One important difference in the baby-boomer generation noted by surgeons is higher expectations than previous generations. “If you tell a baby boomer he has to wait five minutes, he’ll try to figure out a way to cut it to three minutes,” notes Dr. Slade. “If you tell him to sit in row eight, he’ll try to sit in row four. Boomers have high expectations for eye surgery, and right now we’re really not able to meet all
of those expectations.
“The other problem,” he adds, “is that these patients often have no expectation of a negative result. If a younger, clearer-lens patient has a significant complication such as an infection or vitreous loss, it’s hard for him to accept it, no matter how well he’s counseled before surgery.”
Dr. Slade says you have to see this problem coming and deal with it up front. “It’s important to make sure you really get in the patient’s face and emphasize that although this is a very low-risk surgery, it is surgery, and there are risks,” he says. “Sometimes you emphasize this to patients and they say, ‘I know that will never happen to me.’ Or, ‘That’s why I came to you—I know you’re the world’s greatest doctor. You never have a complication.’ In that situation you have to say, ‘Thank you, but that’s not correct.’ And sometimes you have to be willing to say, ‘I just don’t think this is a good option for you right now because of your expectations.’
“It has a lot to do with the risk/benefit ratio,” he adds. “One of the scariest phone calls I ever had was from a surgeon who had done bilateral ICLs on a 7- or 8-D myopic patient, both on the same day. The patient came back a few days later with infections in both eyes. If something does go wrong with an early cataract patient, you have a serious problem; you weren’t saving his vision, you were removing an inconvenience. You have to be prepared to deal with that possibility and make the patient understand at the outset that his expectations really need to be realistic.”
Dr. Lane agrees. “On average, the younger population is more demanding and they won’t be satisfied with their vision unless it meets their expectations,” he says, “so I think it’s really important to clearly define what those expectations should be.
“To help convey the risks associated with these procedures our practice uses visual aids, and we have these patients spend time with counselors that we’ve trained,” he adds. “Still, it’s one thing to say something to the patient; it’s another thing for the patient to grasp what you’re saying. You have to make sure your patients understand that complications can happen to anybody—including them.”
The Previous-LASIK Factor
Dr. Lane notes that many of the current, younger cataract patients have previously had refractive surgery such as LASIK or PRK. “They know the kind of results they can get,” he points out. “Now, as they turn a little bit older, they start to develop early cataracts. Ten years ago we might have said, ‘Come back in a year or two and we’ll see how that cataract is coming along.’
“That level of vision isn’t satisfactory to these patients,” he continues. “Today’s younger cataract patients are more likely to say, ‘No, this is really bothering me. I can’t live with this for another year or two. And I know you can get good results with today’s lenses and technology because I’ve been reading about it. I’m going to need cataract surgery in several years anyway, so let’s do it now.’ I also think this generation is less afraid of surgery than their parents were—and for good reason. The surgery is safer and complications are fewer.”
|“Patients who have previously had LASIK have become used to a certain level of vision. When that becomes impaired they want it fixed, and back to the level it was at before it got broken. So if they had a good LASIK result and now have to wear reading glasses and are getting a cataract, they’re going to want lenses that can correct for both distance and near.”
—Stephen Lane, MD
Dr. Slade agrees that previous LASIK is an issue. “If they’ve had it and it turned out well, you have a problem because you don’t have anything quite as dramatic to offer them—unless they have a true cataract,” he says. “If you take them from cloudy to clear vision, that’s something.”
“Patients who have previously had LASIK have become used to a certain level of vision,” adds Dr. Lane. “When that becomes impaired they want it fixed, and back to the level it was at before it got broken. So if they had a good LASIK result and now have to wear reading glasses and are getting a cataract, they’re going to want lenses that can correct for both distance and near. It’s a progression: going from glasses to contact lenses to LASIK to refractive cataract surgery. So I spend more time talking with the younger patients about the options that allow them to remain free of glasses—especially LASIK patients who come to see me with early cataracts.”
Dr. Masket agrees that expectations are elevated when patients have previously had LASIK. “We know from published studies that typically 93 percent of the LASIK population will come within 0.5 D of their optical goal,” he points out. “Whereas, looking at the cataract literature, using the National Health System in the U.K. as an example, their published rates for cataract surgery are 55 percent within 0.5 D of the optical goal and 85 percent within 1 D. The problem is that the younger patients are expecting the level of optical result achievable with LASIK. In addition, they expect the surgery to be painless, nearly instantaneous and cosmetically nonblemishing. LASIK has really changed the way people think about eyes and eye surgery. This is this mindset we have to deal with.”
Dr. Lane points out that, ironically, previous LASIK can undermine the advantages of current presbyopia-correcting technology. “Previous LASIK makes the outcome less predictable,” he notes. “So this becomes part of the expectation issue. Patients who have had LASIK need to understand that sharpness of vision after cataract surgery may not be as good as it would have been if they had not had LASIK 20 years earlier. That’s especially true if the LASIK was done with one of the older lasers.”
Making the Best of It
Treating younger cataract patients means new challenges and opportunities. “These patients are more demanding,” notes Dr. Lindstrom. “They want a high tech/high touch experience. They will check out the surgeon and share their experience widely, including on social media.” Surgeons offer the following suggestions to increase the likelihood of a positive experience for you and your younger cataract patients.
• Think long-term. Dr. Masket notes that when operating on a younger cataract patient the post-surgery lifespan is considerably greater. “When we do a procedure, there’s more at stake than how the patient will see over the next three months,” he points out. “With younger people, we have a long-term obligation.
“At one time I was doing a relatively large number of pediatric cataracts,” he says. “It was daunting to realize that the quality of my work had to last for 90 years. Now, as we operate on cataract patients who are getting younger, our work may have to last for 40 or 50 years. So it’s a significant decision regarding which lens might serve the patient best over the course of a lifetime. That means, for example, that if we’re considering implanting multifocals, we need to consider whether there’s a strong family history of macular degeneration or other condition that may limit quality of vision as the patient ages.
“We really need to do our best-case procedure with young individuals,” he adds, “because our responsibility goes up as the patient’s age goes down.”
• Keep your website up-to-date. “Your website needs to be excellent and informative, and ranked high so that it comes up when patients Google your name,” notes Dr. Slade.
• Provide work-friendly time slots. “It’s important to deliver the kind of patient experience that will meet the busy, active lifestyles of this group of patients,” says Dr. Lane. “They’re not going to patiently sit in your waiting room for an hour and a half waiting for their appointment.
“This is a generation that’s used to having things done simply, quickly and exactly,” he continues. “You might want to set aside specific times in your schedule for these patients. For example, you could make earlier time slots available so they can come in, get done and get to their office at the start of the day, or make slots available at the end of the day after work.”
• Allow more chair time. “I like to say that it used to be very easy to do cataract surgery,” says Dr. Masket. “We had very few lenses to choose among, in terms of their function—just materials and design. We didn’t have toric lenses or presbyopic lenses. We didn’t have lasers or aberrometry. The fact that we have so much more technology to offer translates to increased chair time. Patients must be cognizant of the benefits and drawbacks of all of these new lenses and devices.
“To accommodate this, we try to schedule cataract consult time when we are primarily seeing only these patients, rather than mixing them in with other case types—for example, blepharitis, conjunctivitis or glaucoma management patients,” he says. “In these blocks we’re scheduling fewer patients and giving them more time, but the economics pan out because many of the patients choose shared-expense options.”
• Make sure your office looks modern. “The practice needs to look good cosmetically,” notes Dr. Slade. “People used to expect a tiny waiting room with a glass window that slid open when you rang the little bell. Now they have more modern ideas of how a practice is supposed to look.”
• Consider having designated technical staff or check-in staff for these patients. “Make sure your counselors understand that these patients have higher expectations and are likely to want in-depth education about the procedure,” suggests Dr. Slade.
• Make the waiting area fit their lifestyle. “Think about the choice of magazines you have in the waiting room and the type of coffee you serve,” says Dr. Lane. “You can provide iPads and other high-tech devices for them while they’re waiting. We have Internet service in our office so patients can access the Internet on their iPads or smartphones. Those inds of things are all geared to this younger cataract population.”
• Take cosmesis into account. “Many younger patients are concerned about the cosmetic aspects of the surgery,” advises Dr. Masket. “Certain lenses generate increased Purkinje images. We try to be sensitive to this, and if the patient is concerned about it, we may choose a lens that’s less likely to create Purkinje images.”
• Offer financing for out-of-pocket options. “Younger patients are likely to have more disposable income,” notes Dr. Lane. “They’re used to reaching into their pocket and paying for things. They aren’t nearly as conscious, for example, about what insurance does and doesn’t cover. They have many work years left ahead of them, and that seems to make them feel that they can afford to spend money.
“Older patients, even if they have disposable income, seem to be more concerned about whether they have enough money,” he continues. “They’re not working, so their savings are slowly dwindling. Some feel that they’re broke even though they have hundreds of thousands of dollars in the bank. Meanwhile, the younger generation is borrowing money to buy the latest car without any money in the bank.
“These are generalizations, of course, but I think older patients are generally more concerned about finances,” he adds. “The younger generation is also more accustomed to borrowing money. They’ll often finance a procedure such as LASIK, which is much less common in the older generation of patients. So I think it’s important to offer financing options for premium alternatives. I think you need to treat these younger cataract patients as if they were LASIK patients.”
• Maintain the vision the patient is accustomed to. “We don’t want to convert people who have had laser vision and are free from glasses to people who are dependent on glasses,” notes Dr. Masket. “So if they’ve had a strategy that has worked well for them, I try to do the same thing in the selection of IOLs. If they’re accustomed to monovision, we’ll continue them in monovision. If they’ve worn contact lenses that correct for astigmatism, we’ll try to match that. Above all, spectacle independence is a very important consideration when dealing with the younger age group. As a group they’ve demonstrated their desire to be spectacle-free.”
|“We have some things to accomplish before we can offer lens-based surgery as a refractive tool to everybody. We really need to control the fate of the capsular bag and the subcapsular lens epithelial cells; we need to have a greater degree of accuracy in our optical outcomes; and we need to address the issue of true and adequate accommodation.”
—Samuel Masket, MD
How Far Might This Go?
Given the trend toward cataract surgery at an earlier age, what is the logical endpoint? “As the outcomes of cataract surgery improve, I think the age of patients who will want to have this is going to continue to go down,” says Dr. Lane. “Cataract surgery, regardless of the density of the cataract and the disability involved, is still an elective procedure. So the better the results and the faster the rehabilitation, the more people are going to demand this, and the earlier they’ll want it. Fifteen years ago we never dreamed of doing cataract surgery on a patient with 20/25 vision. Now it’s not uncommon.”
“It’s very disabling to lose your near vision,” notes Dr. Slade. “Ideally, people would like to treat that. At this point, I think the surgery is almost ready to meet that need, but the lenses aren’t quite there yet for everyone.
“The presbyopia-correcting IOLs are way better than anything we had 10 years ago, but they’re not perfect,” he adds. “However, if the lenses get better, then I think it will really become the norm. People are willing to have a face lift for saggy skin and botulinum toxin injected into their faces, so I think people will be willing to have a very safe procedure to get their full range of vision back.”
Dr. Masket notes that obstacles to early surgery for presbyopia remain. “We have some things to accomplish before we can offer lens-based surgery as a refractive tool to everybody,” he says. “We really need to control the fate of the capsular bag and the subcapsular lens epithelial cells; we need to have a greater degree of accuracy in our optical outcomes; and we need to address the issue of true and adequate accommodation. In the absence of those considerations, I don’t see this trend toward younger cataract patients going much further at this point.
“Of course, those issues will eventually be addressed,” he continues. “I’m often amazed that despite the constraints of the marketplace, the constraints of the Centers for Medicare & Medicaid Services and the constraints of the FDA, manufacturers keep investing in R&D. We continue to have more products available to us. Technology will improve, and as it improves, utilization will go up. That’s been demonstrated many times.
“Presbyopia is one of the most unpleasant conditions for people to accept,” he adds. “It comes right around the time a lot of people are dealing with midlife crisis, so there surely is an emotional component to it; it’s more than just an annoyance. Presbyopia reminds us of our mortality and interferes with our lifestyle. So when we have better presbyopia solutions, from the standpoint of lens-based surgery, there’s no question that they will be adopted at any early age.”
“Surgery will keep getting done earlier for many more decades,” agrees Dr. Lindstrom. “ ‘Dysfunctional lens syndrome’ is the cataract of the future. Presbyopia and reduced contrast sensitivity will be the indication someday.”
“All things considered, I could easily see the day when 90 percent of people get their lenses swapped out between the ages of 40 and 45,” adds Dr. Slade. “If the surgery is that safe and effective, why wouldn’t they?”
Drs. Masket, Lane, Lindstrom and Slade consult for Alcon and Bausch + Lomb; Drs. Lane and Lindstrom also consult for Abbott Medical Optics; and Dr. Slade also consults for IntraLase.