Popular Post-Surgery Practice Can Backfire, Cause Blindness

An eye procedure that has commonly been used as follow-up care after cataract surgery significantly raises the risk of developing retinal problems that could lead to blindness, according to a major new study of Medicare recipients.

A team of researchers from Georgetown University and the Johns Hopkins Medical Institutions studied more than 57,000 Medicare patients who underwent cataract surgery.

They then followed nearly 14,000 of these patients who later underwent the commonly used laser surgery, known as YAG laser capsulotomy, following removal of their cataracts.

The procedure has long been considered a nearly risk-free operation and was designed to treat vision problems that can follow cataract surgery. Today, doctors are increasingly using it as a preventive measure.

The study found, however, that detachment of the retina--a complication that impairs vision and can lead to permanent blindness if not treated promptly--affects 2% of patients who had laser surgery, an estimated 13,000 Americans a year. That puts the risk of retinal detachment in patients who had the procedure at four times the risk of those who did not.

These results suggest that patients who are not experiencing any decline in vision after cataract surgery should avoid undergoing the laser procedure as a preventive measure.

“The question that patients need to ask themselves is, ‘Has my vision deteriorated to the point where assuming this small level of risk is worth it?’ ” said Jonathan C. Javitt, director of the Worthen Center for Eye Care Research at Georgetown University and lead author of the study.

Results of the study were published in the journal Ophthalmology this month.

Eye surgeons, responding to the study, noted that the capsulotomy is still an important treatment option for people who have vision problems after cataract surgery.

They said the new information will make doctors and patients aware of the risk of detached retinas so they can watch for any problems and move to remedy them quickly.

But experts also said the study underscores why the procedure should no longer be considered an automatic follow-up to cataract surgery.

“There are doctors who do this routinely,” said Richard Bensinger, an ophthalmologist in Seattle and a spokesman for the American Academy of Ophthalmology. “I don’t agree with that. This gives support to that position.”

But Bensinger and others also stressed that the risks of complications for the laser surgery are still small and should not deter patients whose vision has been impaired from undergoing the procedure.

“To my way of thinking, it heightens the fact that all procedures, all medicines, all surgeries have side effects,” said Frederick Ferris, chief of clinical trials at the National Eye Institute, which helped fund the study.

Cataract surgery is one of the operations most commonly performed on Medicare beneficiaries, according to the Health Care Financing Administration, which spent nearly $2 billion on cataract surgery in 1991.

Each year, an estimated 1.3 million Americans undergo the surgery to improve vision impaired when the lens in the eye becomes clouded. Largely an outpatient procedure, cataract surgery costs roughly $2,500.

It is not the cataract surgery itself that is the focus of the study but the follow-up laser procedure that was performed 770,000 times in 1991 on Medicare beneficiaries at a cost of $375 million, according to HCFA.

Within three years of cataract surgery, 20% to 25% of the patients experience vision problems when their lens re-clouds for reasons still not understood, according to Javitt.

YAG laser capsulotomy quickly restores their vision by using a brief pulse of the laser light to punch a hole through the back of the lens capsule. The hole enables light to again reach the retina unimpeded.

Before the introduction of YAG laser capsulotomy about 10 years ago, surgeons had to go back to the operating room to cut a tiny slit in the back of the lens capsule when it clouded.

Capsulotomy quickly gained wide appeal because it was fast, painless and could be performed in a doctor’s office. The procedure requires no anesthesia, does not pose a risk of infection and costs $500 to $1,000.

The number of YAG capsulotomy procedures performed jumped 20% from 1990 to 1991, according to HCFA statistics, in part because the procedure is increasingly used as a preventive measure to keep vision from deteriorating after cataract surgery.

The study found that in some areas of the country, as many as 50% of cataract patients routinely undergo capsulotomy.

The research examining YAG laser capsulotomy is part of an ongoing federal effort to evaluate practice patterns of physicians in the United States and to standardize care for patients.

This is the latest in a series of reports, sponsored by the Agency for Health Care Policy and Research, which are examining treatments for such wide-ranging conditions as heart disease, back pain and incontinence.