Three surgeons provide a bird’s eye view on the current state of cataract surgery in Australia, including equity and accessibility to the latest advanced intraocular lenses, and how training is adapting to produce more skilled surgeons for tomorrow.
“In the public system, intraocular lens (IOL) selection for cataract patients shouldn’t be seen as a conveyor belt where you can have any colour you want, as long as it’s black.”
This is the view of Dr Ben LaHood, a New Zealand-born cataract and refractive specialist who is outspoken on the inequity between the cataract patient experience in the public versus private system in Australia, where he practises today.
Working across both settings, LaHood is well-placed to highlight what Australia is doing well, and what areas require improvement. But he is not a lone voice in how Australia can provide better cataract surgery outcomes and experiences for patients.
Dr Jacqueline Beltz and Dr Ben Connell, both Melbourne-based, also have opinions on how surgeons’ decision-making can generate better results in 2023, which they share with Insight in this article. LaHood, Beltz and Connell – all leading cataract surgeons in their own right – also share how advanced technology is giving patients greater choice and therefore greater expectations about glasses independence, but more on this later.
First up, does Australia need to address the gap in access to advanced IOLs in public and private systems?
Speaking from his experience in private practice at Adelaide Eye and Laser Centre, LaHood says surgeons, himself included, are unquestionably performing cataract surgery on patients in private practice at an earlier age, and their expectations are higher.
But it’s a different dynamic in public hospitals, something he is familiar with through his role at the Queen Elizabeth Hospital in Adelaide.
“The idea of treating the potentially older, more difficult, denser cataract patient in public differently to the earlier, younger, easier cataract in private, has been quite ageist,” LaHood says.
“We imagine that these older patients come into the public system, have low expectations, and accept average outcomes. But we’re all living longer. The vision we’re giving people is going to dictate how they see for the rest of their life, so it’s vitally important.”
To that end, in his role at the Queen Elizabeth Hospital preparing trainees to work in private practice, LaHood urges cataract surgeons to consider the patient’s refractive outcome in more detail.
“In my public health capacity, part of my job is instilling a refractive-surgeon mentality into cataract surgery – we’re not only removing opacity; we’re giving the patient a once-in-their lifetime opportunity to have the best vision they possibly can, sometimes better than when they were young. Subspecialising in cataract surgery makes you think more and more about the potential outcomes, rather than only the procedure,” LaHood says.
Despite perceived ageism in how cataract patients in the public versus private system are treated, overall LaHood believes Australia is performing well compared to other countries.
He says a patient with private health insurance in Australia can have any IOL they want, regardless of cost.
“In other countries, that would require partial payment – or complete payment for certain IOLs – even as basic as needing to charge for a toric IOL. Whereas, in Australia, I can see a patient, we can discuss all the options, and for an insured patient it doesn’t matter which lens they select, my fee is the same, regardless of which lens I’m implanting,” he says.
Conversely, LaHood adds, it’s difficult to be seen in the public system in a reasonable period of time for cataract assessment – and that’s still a problem.
The delay can result in loss of independence, functional decline, and increase risk of falls. The problem, LaHood says, relates back to training more surgeons, funding more training positions in the public system – and making those public positions more appealing.
“In the New Zealand system, for instance, it is very common to work the majority of your time in public and a minority in private, whereas, in Australia, I work one tenth of my week in public, and even that is seen as basically doing some charity work. This is the system that trained me – I should be giving back more than that, but it’s seen as acceptable. The culture in Australia around how much we give back to the public system is not healthy and I am part of this problem,” he says.
“When you have a choice between a massively overbooked, stressful public clinic where staff feel burnt out and underappreciated, or a calm, controlled private environment where you also earn a lot more, it’s no surprise what the majority of us prefer. I don’t know the exact solution, but if you consider we have an aging population and a growing number of treatments to keep people seeing well for longer, the obvious solution to me would seem to be to increase the workforce. In my opinion this needs to be a combination of more trainees and also delegating tasks such as intravitreal injections to trained nurses. This worked well in New Zealand so I don’t know why we aren’t doing it
in Australia.”
LaHood’s views may seem contentious to some, but he is considered a leader in his field. At 39 years of age, he was Australia’s youngest nominee listed among the top 100 in their field globally in the 2023 Power List, compiled by The Ophthalmologist magazine.
“My views have been seen as controversial, but they shouldn’t be. I believe very strongly that whether a patient has cataract surgery in public or private, they should receive the same level of care. That means they should have a safe surgeon operating in a safe environment, and most importantly, we should be able to implant the same IOL. It shouldn’t be elitist,” LaHood says.
“I don’t know how much of that mentality stems from being brought up to treat the CEO the same as the cleaner, but I think it’s as simple as that. If we stop and look at the benefits of the latest advanced technology lenses – multifocal, extended depth of focus lenses – the arguments against implanting them in public patients are not valid.”
One of the main arguments against it is cost, but as LaHood points out, the cost of advanced IOL implants compared to other prostheses like a hip or a knee joint replacement, is minimal.
“If we performed a proper cost analysis and factor in ongoing need for glasses, ongoing trips to an optometrist, potential loss of independence, time out of work for family members to take patients to appointments, it would be overwhelmingly in favour of properly correcting a patient’s vision fairly. Admittedly, advanced technology lenses aren’t for everyone, but we should be able to offer it to them,” LaHood says.
“Another [invalid] argument is we must have a point of difference to incentivise patients to use the private system to take some burden off the public system, but there’s still enough incentive in the private system with patients getting to choose their surgeon and surgery date more precisely. I don’t think that would stop a patient having surgery in private because they felt that they were getting the same IOL as in public.”
Multifocal and toric IOLs offer a greater range and quality of vision. However, that may come with a trade off in terms of visual side effects or risks. Patient selection and counselling are crucial to match the right patient and IOL option. Concerns that clinics will be overrun with unhappy patients who inappropriately received a more premium IOL option in the public system are also unwarranted, LaHood says.
“At the moment, toric lenses are considered advanced, but they should be considered the most basic device we have. I’m often asked about toric lenses and the low threshold in the public system because surgeons are worried their clinic will be inundated with unhappy patients who need a lens rotation,” he says.
“We’ve been implanting toric lenses and multifocal IOLs for years at Queen Elizabeth Hospital in Adelaide and we’re not seeing a tidal wave of unhappy patients. I’m standing on the shoulders of giants like Dr Michael Goggin who drove this with ZEISS and Bausch + Lomb and really pushed this program along. Unhappy patients are super rare, as long as the preoperative counselling is appropriate, and the surgery is executed well – as it should be with every patient.”
Train trainees to become capable, adaptive, innovative
Like LaHood, ophthalmologist Dr Jacqueline Beltz splits her time between public (75%) and private (25%) practice, which equates to about four days a week at the Royal Victorian Eye and Ear Hospital and one to one-and-a-half days private at Eye Surgery Associates in Melbourne.
Among several leadership roles, she directs the Advanced Cataract Fellowship at the Eye and Ear, a role she says allows her to directly supervise and execute complex cataract surgeries for public patients.
She was also recently appointed co-president of Australasian Society for Cataract and Refractive Surgeons (AUSCRS) with Professor Gerrard Sutton, a position that recognises her preeminent standing in cataract surgery in Australia.
“We are very fortunate in Australia to have access to such a high level of surgical training and excellence as well as the technologies, particularly resources for pre-operative measurements and conversations as well as IOL technology and instrumentation that it takes to achieve excellent results,” she says.
“We are one of few countries that can provide toric IOLs to many of our patients without additional cost. The fact that we can provide astigmatism correction without having to justify or consent patients to additional cost really leads us to the very best results.”
Furthermore, she adds, surgeons in Australia can also provide presbyopia correcting IOLs for many of their patients without additional cost.
“Working patients up for these technologies takes additional time and resources and sometimes extra visits that we are often able to provide.”
Beltz points out that recently, in Victoria, a team of ophthalmologists, orthoptists, executives and industry representatives collaborated to reduce the cut off for astigmatism correcting IOLs.
“This means more patients can be free of spectacles, at least for distance vision, after cataract surgery. The same team have also been successful in gaining access to some IOLs with a small degree of extended depth of focus,” she says.
“We have also been able to introduce presbyopia correction at the time of cataract surgery as a structured surgical training program for third-and fourth-year ophthalmology trainees. The hope is that this program will help to close the gap between private and public cataract surgery in Victoria.”
Beltz agrees with LaHood that there still exists a gap between what surgeons can offer their patients in public versus private.
“There is no lower limit to astigmatism correction in private and so I can strive to correct as much as possible of the pre-existing astigmatism for my patients in private practice,” she says
“In public, at least in Victoria, many patients unfortunately still fall below the threshold for astigmatism correction, and this might lead them to needing glasses for all distances after cataract surgery.”
She continues: “Similarly, despite our new program [for third- and fourth-year ophthalmology trainees], there still remains better access to presbyopia correction at the time of cataract surgery, meaning the reduction of glasses also for near work after cataract surgery, between private and public patients.”
Beltz recently completed six years as director of training for ophthalmology in Victoria, and through that role, plus her involvement with trainees at the Eye and Ear Hospital and utilising her Masters of Surgical Education, has been heavily involved in restructuring the microsurgical training program, particularly for cataract surgery in Victoria.
“In 2017 I introduced structured virtual reality and lab-based microsurgical training as an essential pre-requisite to starting live surgery in Victoria. Mind-training with high performance psychologists also became a part of that training program in 2019,” Beltz explains.
Having seen the program’s success, RANZCO introduced mandatory virtual reality training for all ophthalmology trainees in Australia and New Zealand in 2023.
Her wealth of experience in training makes her well-placed to provide insight into how advanced lenses fit into the IOL landscape.
“Advanced IOLs are a relatively new category within cataract surgery and so far, it has mainly been up to consultant ophthalmologists to seek out training and experience of their own accord,” she says.
“This has led to quite a variation in comfort with these technologies as well as results. I believe the time is right now for all trainee ophthalmologists to be training with these technologies.”
While training programs use current technologies, Beltz says they’re focusing on the skills and mindset that it takes to safely and expertly pick up new techniques and technologies.
“Hopefully, in this way, we can help our current trainees to become capable, adaptive, and innovative experts who are ready to develop the next generation of technologies and become much better ophthalmologists than we are today.”
Beltz says the profession is working to improve training in advanced IOL use – meaning patient selection, optimisation, conversations, IOL calculations, surgical techniques, post operative assessments and audit, and dealing with problems or complications or the need for refractive enhancements.
“Third- and fourth-year trainees in Victoria now all have access to this program that includes structured training across all of those areas as well as access to a certain number of IOLs to use throughout their training,” she says.
It was important to Beltz, when developing this program, that it did more than merely provide trainees with premium IOLs to use.
“There is a lot more to achieving excellent refractive outcomes than just access to lenses. Our program, run through the GENEYE platform, which is a part of Eye and Ear education, will help us to close the gap between private and public refractive outcomes over the next few years,” she says.
“While training in presbyopia correction has become essential and is likely to continue to be an important part of our training program, removing a threshold for astigmatism correction would make the greatest difference to our patient outcomes, in my opinion.”
Great expectations
Cataract, refractive and corneal surgeon Dr Ben Connell believes strongly in the value of data, specifically in the outcomes of cataract surgery. He says reflecting on his own results guides him to give subsequent patients better information on how they’re going to go
with surgery.
“I think it’s important as doctors that we look at our results, we reflect on them, and we make adjustments for future practice. As a cyclist who uses Strava, I find it amazing that we can have detailed data about our leisure activities, but with professional activities, we don’t get that same thorough feedback.”
Connell, who, similarly to Beltz, splits his time 20% in public practice at the Eye and Ear Hospital, 80% in private at Eye Surgery Associates, says lens technology has improved to such a degree over the past 15 to 20 years, there are now increased options where patients can have their glasses dependence significantly reduced.
“When patients come to see me, they are a lot more aware of their options, and I think as an ophthalmologist, we have to consider them. There are limitations, but the newer types of advanced lenses do have great outcomes in the appropriate patient. Patients are a lot more aware of those outcomes, and we need to think a lot more about them,” Connell says.
“Ten years ago, the only option for patients wanting to reduce their glasses dependence was multifocal lenses but patients would often experience issues with night vision where they would see rings around lights and halos. Now, the extended depth of focus and monofocal-plus lenses offers patients a lot more glasses independence at the intermediate vision range – used in 80% of their day – with fewer night vision symptoms; that’s a great outcome.”
But improved lens technology and more options has given rise to a new challenge for Connell.
“The biggest challenge for me – and this is where my practice has changed a lot – is managing patients’ expectations. When discussing newer lens options, I prefer to use the term ‘reduced glasses dependence’ instead of ‘spectacle free’ because there may be some circumstances where the patient might still need glasses. It’s important to manage their expectations in that respect,” he says.
As well as regularly reviewing his cataract surgery results, Connell sees immense value in patient reported outcomes.
“There’s often an overlap between what surgeons consider important and what the patient does; accurate refractive outcomes and reduced glasses dependence to name two. But there are other factors where there’s room for improvement,” he explains.
“I don’t think our profession systematically looks at patient reported outcomes pre and post-surgery. We tend to look at short term refractive outcomes but there’s a range of other outcomes that are equally important, such as reducing the patient’s risk of having a fall and improving their quality-of-life – those are outcomes we don’t really look at.”
Connell sums up: “I think there’s a lot of technology that’s underutilised. There should be more surgeons using toric lenses because it gives patient’s better vision without glasses, and it reduces their astigmatism. Surgeons need to increase their use of newer lenses and familiarise themselves and become more confident with them. I think that’s where there’s room for improvement.
“Overall, surgical techniques are improving, our complication rates are getting lower, we’re accurate with predicting to what degree a patient will require glasses after surgery, and generally speaking, patient satisfaction levels are incredibly high.”
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