To cut or not to cut? Government report suggests alternatives to cataract-removal surgery.

IMAGINE YOU ARE A SALESman who travels throughout the state, spending several nights a week on the road returning home.

During the day, your eyesight is fine -- about 20/30 or 20/40. But with headlights glaring into your eyes at night, you find you can't see as well. In bright sunlight or when you are reading, glare causes similar problems.

Your eye doctor says the problem is a cataract in the back of the eye's lens.

Should you have the cataract removed?

The question of having cataracts removed has raised much debate recently among ophthalmologists and prompted the U.S. Department of Health and Human Services to publish a 14-page booklet outlining patient guidelines on cataracts.

The guidelines were developed by an 18-member committee headed by Dr. Denis O'Day, chairman of ophthalmology at Vanderbilt University Medical Center in Nashville, Tenn.

The committee urges doctors and their patients to consider alternatives to cataract-removal surgery. The booklet, published in April, suggests that a change in glasses, stronger bifocals, the use of magnifying lenses or pupil dilation may be all the treatment needed to improve vision.

"Overall, I believe |the report~ is fine," says Dr. David Nixon of Pine Bluff, president of the Arkansas Ophthalmological Society. "But I hate to get anything into a cookbook where someone can second-guess what you're doing when you feel like you are doing what is best for your particular patient.

"When you start to put medicine down in black and white, that's what you get into."

Dr. Hampton Roy of Little Rock says two national ophthalmological organizations tried to persuade O'Day's committee to include detailed information on two tests.

The first involves potential acuity meters that allow an individual to see around a cataract and predict what the eyesight will be if the cataract is removed. For example, a potential acuity test might indicate that a patient with 20/80 vision could have it improved to 20/40, with eyeglasses, after surgery. Other tests might not reveal this, Roy says.

The second is a glare test. It can reveal how much the removal of a cataract can improve vision if a person's eyesight is impaired by glare.

The O'Day report does mention both the glare test and the potential vision test as examples of exams that may predict one's vision after cataract surgery. It also mentions a contrast sensitivity test, but the report indicates "only a few people need these tests."

(To receive a copy of the booklet issued by Health and Human Services, call [phone].)

Most Common Surgery

Cataracts, cloudy areas in the lens of the eye, are a normal part of aging. About 50 percent of Americans aged 65-74 have cataracts. About 70 percent of those 75 and over have cataracts. Cataracts may develop in people much younger, especially those with a family history of cataracts or those taking large doses of steroids such as prednisone.

There are about 1.5 million cataract surgeries performed annually, making it the most common surgery in the country. The success rate, meaning restoring vision to 20/40 or better with glasses, is 95 percent.

The reason for the government's guidelines on cataracts is that about $3.4 billion in Medicare funds are paid annually for cataract surgery.

In Arkansas, Medicare allows $1,009.95 to physicians for cataract surgery. Medicare would actually pay 80 percent of that, or $807.96. The patient or supplemental insurance would pay the other 20 percent, although in many cases ophthalmologists never receive the additional 20 percent.

Medicare allows $854-$906 in facility fees, often paid to hospitals where the surgery is done or to ophthalmologists who have their own clinics.

Medicare allowed more than $25 million in charges by doctors and facilities in 1992, almost $500,000 less than in 1991.

Critical Media Attention

Recent reports in the media have been critical of some ophthalmologists, known as "big cutters," who perform thousands of cataract surgeries annually. One Illinois ophthalmologist who owns several clinics was featured on a recent segment of ABC's "Prime Time Live."

The report by Sam Donaldson implied that the doctor recommended and performed unnecessary cataract surgeries because of the fees received from Medicare, which with charges for facility use can run as high as $2,400.

Roy indicated that his clinic, the Arkansas Cataract Center, has noticed a significant drop in patients since the critical media reports.

"When the media shows someone who is obviously unscrupulous who is doing cataract surgeries, it concerns people," Roy says. "I tell lots of people I don't think they need to have cataract surgery. They are not having difficulty. I'll tell them to see me again in six months or a year.

"But there is always that element of doubt when |the media~ focuses in on people who are doing inappropriate surgeries."

The O'Day report and the doctors interviewed by Arkansas Business emphasize that cataract removal surgery is almost always elective. Very rarely does the cataract actually cause damage to the eye that requires surgery.

"Except in rare cases, the guideline panel firmly believes that cataract surgery is never justified solely because a cataract is present," O'Day says in the April issue of Review of Optometry. "Cataract surgery is absolutely necessary only in the presence of disease, and it should be considered just one option for treating the condition, not the only one."

Dr. John Shock, chairman of ophthalmology at the University of Arkansas for Medical Sciences, says cataract surgery is "99.9 percent an elective operation."

"There are people who've gone 25 or 30 years with a diagnosis of cataracts who've never needed surgery," Shock says.

The only time surgery is needed is when the cataract interferes with vision, Shock says. Some cataracts don't significantly restrict eyesight. But if the cataract limits vision for activities a person wants to do such as driving, reading or sewing, he may want to consider having the cataract removed.

Cataract surgery removes the eye's clouded natural lens and replaces it with an artificial lens implant. It usually takes less than 45 minutes and is done on an outpatient basis.

Nixon says he interviews his patients and conducts tests to determine the severity of the cataract.

"Most patients are followed for a long time by doctors, and they get to know them," Nixon says. "They see the cataract coming on. What I say is that if you have to stop doing things you want to do or you can't enjoy doing things you enjoyed before, then you should consider cataract surgery. When the cataract gets to the point where I know it's the problem with their vision, then they may want to think about surgery.

"That's part of the art of the whole thing -- doing what is right for the patient."

Shock says the biggest advancement in cataract surgery is the safety of the artificial lens. Another major improvement, he says, is the development of very small, strong sutures that hold the eye together painlessly. Some cataracts now can be removed through a small incision after an ultrasound technique softens the lens, Shock says.

There has been a significant increase in cataract surgeries in recent years because patients do not fear the operation as much and because of extensive advertising by some ophthalmologists, Shock says.

Successful Surgery for Salesman

The salesman with poor night vision was one of Roy's patients.

Even though he did not meet the strict guidelines for cataract surgery, a glare test revealed his night vision was abysmal -- near the point of being legally blind. With cataract surgery, his vision at night could improve significantly.

The salesman chose to have the surgery and was pleased with the results, Roy says.

"I think the O'Day report missed the boat on the test," Roy says.