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Government Raises Caution Flag on Cataract Surgery

February 25, 1993

WASHINGTON (AP) _ Government-backed guidelines issued today tell eye doctors not to be so quick to perform cataract surgery, and call into question some oft-used tests for prospective elderly candidates for the operation.

A panel of leading ophthalmologists and other eye experts recommended that doctors and their patients try stronger glasses, magnifying lenses and other steps before resorting to surgery.

″Cataract surgery is never justified solely because a cataract is present,″ the agency said.

Dr. Denis O’Day, a Vanderbilt University professor who chaired the Cataract Guideline Panel, said patients and surgeons should weigh the risks and benefits of surgery and discuss how much the cataract interferes with daily activities.

″Ultimately, the decision must be made by the patient,″ he said.

The guidelines issued by the Public Health Service’s Agency for Health Care Policy and Research came with endorsements from the American Academy of Ophthalmology and the American College of Surgeons.

But they drew immediate fire from other groups of eye surgeons who claimed the government was really looking for ways to cut the $3.4 billion in spends on cataract surgery for 1.35 million Medicare patients each year.

A cataract is a cloudy area in the lens of an eye that normally occurs as people grow old. Some 400,000 Americans develop cataracts each year; half of those ages 65-74 and 70 percent of those 75 or older have them.

It can lead to fuzzy vision and create problems driving at night because of the glare of headlights.

Cataract removal and insertion of an artificial lens is usually performed as an outpatient procedure in less than an hour. Medicare has sharply reduced the fees paid to cataract surgeons, from $1,850 five years ago to about $1,150 now.

There is no medical way to stop a cataract from forming or getting worse. And there is currently no objective way to measure when functional impairment makes surgery necessary.

The panel said there was inadequate evidence that glare testing or contrast sensitivity testing provides useful information beyond that the physician gets from a complete patient history and eye exam.

Dr. David McIntyre, a Seattle ophthalmologist and past president of the Outpatient Ophthalmic Surgery Society, charged that if Medicare funding were tied to the guidelines, ″one-third of all Medicare beneficiaries would be unable to obtain needed surgery.″

″Patients would have to give up their driving license before they would qualify for surgery,″ he charged. The guidelines ″turn out to be a system of rationing care.″

At a news conference, Dr. James S. Todd, executive vice president of the American Medical Association, commended the guidelines and said, ″The goal is not to ration care. The goal is to make more rational the care that we give based on the best medical science available.″

Officials declined to estimate how many cataract surgeries would not be performed under the guidelines but said there are wide variations now in how often the surgery is performed in different parts of the country.

McIntyre’s group along with the American College of Eye Surgeons and two others issued their own guidelines taking a more favorable view of preoperative tests.

Dr. B. Thomas Hutchinson of Boston, president of the American Academy of Ophthalmology, said he did not believe the federal guidelines would discourage cataract surgeries. With an aging population, ″there’s more people to be taken care of,″ he said.

″It’s an imperfect world. The guidelines have been done in the right fashion,″ he said. ″The methodology is sound.″

The government panel of experts reviewed nearly 8,000 studies in preparing the guidelines.

It said surgeons ″cannot abrogate (their) responsibility for the patient’s postoperative care,″ which in some cases is left in the hands of optometrists or other providers.

Serious complications are rare and the operation has a 95 percent success rate in people with otherwise healthy eyes.

The federal agency has previously issued clinical practice guidelines on treatment of pain, urinary incontinence and ulcers, and it is preparing 16 more on depression, HIV infection, otitis media, low-back problems and other maladies.

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