Understanding ophthalmologists’ perspectives on the risk of cataract surgery

Abstract

Background

Cataract surgery is one of the most common elective surgeries and has been shown to be safe with low adverse event rates. Most cataract patients in the US receive one-to-one intraoperative monitoring and sedation administered by an anesthesiologist or nurse anesthetist, termed “monitored anesthesia care” (MAC). Recent studies have suggested that non-anesthesia-led sedation approaches may safely be used in older adults undergoing cataract surgery. However, it is unknown how individual ophthalmologists perceive the risks of cataract surgery with respect to the need for MAC. We sought to characterize physician beliefs and opinions about the risks of performing cataract surgery when considering potential non-anesthesia-led approaches to cataract surgery sedation.

Methods

Using a semi-structured interview guide developed with the Consolidated Framework for Implementation Research (CFIR) framework, between December 2022 and May 2023, we conducted virtual interviews with ophthalmologists who routinely performed cataract surgeries in the United States with or without anesthesia care in outpatient clinical settings across the continental US. Data were analyzed from June 2023 through January 2024 using an inductive thematic analysis approach.

Results

Interviews of 19 ophthalmologists revealed 2 major themes that formed the foundational understanding of how ophthalmologists perceive cataract surgery risk in the context of non-anesthesia-led models of sedation: (1) overall safety of cataract surgery and (2) concerns about assuming sedation responsibilities. Despite conceding that cataract surgery is a low-risk procedure for the vast majority of patients, participants were hesitant to change their current practice and desired an anesthesia “safety net” at all times in case of an unexpected intraoperative event or emergency. Many ophthalmologists’ responses underscored their aversion to any potential loss of routine anesthesia support without an acceptable alternative present.

Conclusions

Despite acknowledging its low-risk profile, ophthalmologists are wary of making changes to current sedation approaches for routine cataract surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-025-00615-8.

Background

Cataract surgery is a safe and common elective surgical procedure among older adults in the United States (Schein et al. 2000; Sharwood et al. 2008; Perumal et al. 2022; Navaleza et al. 2006). In the US, a majority of cataract surgery patients receive 1-to-1 intraoperative monitoring and sedation administered by an anesthesiologist or nurse anesthetist (monitored anesthesia care or MAC (Ghisi et al. 2005)), which usually entails light intravenous (IV) sedation combined with topical anesthetic (Perumal et al. 2022; Ghisi et al. 2005). General anesthesia is rarely used (Navaleza et al. 2006). Studies in the United States and internationally have suggested that sedation approaches that rely less heavily on anesthesia-led care, such as oral sedation or IV sedation administered by a non-anesthesia provider, may safely be used in older adults undergoing cataract surgery (Sharwood et al. 2008; Ianchulev et al. 2016; Kugler et al. 2023; Zakrzewski et al. 2010, 2005). However, it is unclear whether ophthalmologists practicing in the US would accept a widespread shift towards non-MAC sedation approaches.

At least one US payer previously proposed to stop reimbursing for anesthesia care for routine cataract surgery (Anthem 2018). While ophthalmology and anesthesiology specialty societies opposed this change due to concerns that patient safety and surgical outcomes might be compromised (American Academy of Ophthalmology 2018; Anesthesiologists ASo 2018; Association 2018), professional society position statements may not reflect how individual ophthalmologists feel about these types of proposals. Since ophthalmologists frequently operate on cataract patients with routine anesthesia care, it is important to understand how individual physicians may characterize the risks of cataract surgery before introducing any change in reimbursement guidelines affecting routine anesthesia care for cataract surgery in the US.

To better understand physician perspectives on the overall risks of cataract surgery and how they should inform the routine use of MAC in the future, we conducted semi-structured interviews with ophthalmologists who routinely perform cataract surgery in hospital outpatient departments, ambulatory surgery centers, minor procedure rooms, and/or office-based surgery suites. The goal of this study was to explore and characterize physician beliefs and opinions about the risks of performing cataract surgery and how they may be affected in the face of possible changes to cataract sedation practices.

Methods

This study was approved by the Institutional Review Board at the University of California, San Francisco (IRB# 21–35606). All methods were carried out in accordance with the consolidated criteria for reporting qualitative research (COREQ) guidelines and content analysis methodological orientation (Tong et al. 2007; Krippendorff 2018).

Participant eligibility and recruitment

Participants were eligible to sit for an interview with the study investigators if they were ophthalmologists who routinely performed cataract surgeries in the United States.

Participants were recruited from diverse clinical settings and geographic locations across the United States via email invitation to participate in a semi-structured interview. Recruitment relied primarily on purposive sampling from physician professional societies and word of mouth referrals from the professional network of study team members and prior study participants. After using DocuSign to consent to study participation and audio recording, participants filled out a pre-interview REDCap electronic survey with their demographics, training, and current practice characteristics, including practice setting, location, patient volume, and insurances accepted. Verbal consent was re-affirmed at the beginning of each interview.

Data collection

We conducted virtual interviews with study participants using a semi-structured interview guide to assess physician perspectives on non-anesthesia-led sedation during cataract surgery. Guided by the consolidated framework for implementation research (CFIR) framework (Damschroder et al. 2022), interview guides were developed and iteratively refined by the study team (Additional File 1: Semi-structured Interview Guide). All interviews were conducted by the study PI (CLC) while other study staff were present to assist and take analytic notes. Participants received a $200 electronic gift card for completing the interview and brief post-interview survey, with the option to be notified when the study results were published and the opportunity to refer physician colleagues for recruitment as study participants. All interviews were digitally recorded and transcribed. Thematic saturation was reached at 17 interviews, but 2 additional interviews were conducted to ensure there were no additional unique themes to be identified before data collection was deemed complete.

Data analysis

Following best practices for an inductive thematic analysis approach (Braun and Clarke 2006), analysis began and continued iteratively throughout data collection. Using Atlas.ti software (Version 23.3.0), the coding team (CLC, NL, RS) developed and iteratively refined a codebook to align on the most salient themes, with 20% of the data coded and reviewed by a minimum of two coders to ensure rigor. Schemas were reviewed for accuracy and comprehensiveness, with the rest of the transcripts coded by NL. All discrepancies were resolved by consensus through verbal and written discussion.

Independent case summaries were drafted during (NL) and after (CLC) each interview to capture key themes and physician-specific schools of thought. Throughout the process, reflexivity was maintained by discussing interview summaries and reflecting transparently on possible biases during weekly data analysis meetings. The coding team consisted of the female senior author, who, in addition to being a practicing anesthesiologist and health services researcher, holds expertise in finance from a previous career (CLC); the first author, a female clinical research coordinator (NL) pursuing a medical degree; and a female early-career health services researcher and implementation scientist with qualitative expertise (RS). The diversity of the coding team’s professional backgrounds allowed for the integration of different perspectives to further reduce bias.

Results

The self-reported participant demographics of the 19 participants are presented in Table 1. Interviews ranged in length from 31 to 72 min (mean = 51 min). Among the 19 physicians interviewed, 5 (26%) were women, 14 (74%) were in private practice, and 18 (95%) accepted Medicare insurance. Most participants (n = 12; 63%) reported that they had been in clinical practice for 15 years or less. 13 (69%) participants reported that they currently practice in settings that offer routine MAC; among those, 8 reported that they had prior experience performing cataract surgery without MAC (Fig. 1).

Table 1.

Baseline characteristics of study participants

Total ophthalmologists (N = 19)	N (%)
Gender
Male	14 (73.7%)
Female	5 (26.3%)
Age
<35	0 (0%)
36–45	9 (47.4%)
45–55	N = 5 (26.3%)
56–65	3 (15.8%)
66 +	2 (10.5%)
Practice settinga
Academic	8 (42.1%)
Private practice	14 (73.7%)
Other	2 (10.5%)
Current sedation approach
MAC	13 (68.4%)
Non-MAC	6 (31.6%)
Practice duration
0–5 years	1 (5.3%)
6–10 years	7 (36.8%)
11–15 years	4 (21.1%)
16–20 years	2 (10.5%)
21 + years	5 (26.3%)
Current practice region
West	9 (47.4%)
Midwest	2 (10.5%)
South	7 (36.8%)
Northeast	1 (5.3%)

^aDoes not add up to 100% because some physicians practice in multiple settings

Fig. 1.

Annual volume of cataract surgeries

Interview content was classified into 2 major themes that formed the foundational understanding of physician perspectives on the overall risks of cataract surgery: (1) the perceived safety of cataract surgery (Table 2); and (2) concerns about assuming sedation responsibilities (Table 3).

Table 2.

Illustrative quotes regarding the perceived safety of cataract surgery (Theme 1)^a

Low procedural risk	O3: Their chance of having a fatal car accident far exceeds their chance of any need for hospital transfer, not even close…I’ve never in my career transferred anyone to a hospital from any eye procedure ever, even at the VA, when they were really sick patients
	INT: In terms of true emergencies, how often have you experienced that when you're operating, either with or without MAC? O5: Define true emergency INT: I guess emergencies that were life-threatening to the patient O5: Zero
	O15: I don’t think there’s evidence that eye surgery [increases morbidity/mortality for the patient]. If we’re doing some other surgery well sure… but we’re a bloodless surgery, there’s no hemorrhage risk. Or there’s no embolism risk. It’s the same as laying in bed
Fear of unexpected, non-emergent events	O4: The problem is that it’s unpredictable, and then those cases that you’ll need it, you’ll be in a pickle…there are so many cases where you feel those patients are going to be fine and you go in and that the patient is not fine after doing a few steps, and then you’re stuck
	O6: The surgery doesn’t take very long, but even if the patient moves a little bit, there’s high stakes and like millimeters of margin for error inside the eye
	O10: The ones that we had to convert [to GA] were not predictable… you just had to pray that it didn’t happen while your hands were in the eye, and they zig when you should have zagged
	O19: I feel like my patients who have worn contact lenses, who are just calm, don’t need [as much sedation]. I could do local [anesthesia]…I mean, probably most patients are like that, but then there are some subjects who are very anxious for whatever reason or just like don’t like anything around the eye who starts squeezing and fidgeting
Risk of oversedation	O10: [Having an oversedated patient] was usually when the anesthesiologist was in the room who hadn’t really done a whole lot of cataracts…we’d be twiddling our thumbs and waiting and saying, yeah, we could have finished by now before we started, because I wouldn’t start until the patient was responsive…
	O13: I think you get sort of used to patients under light anesthesia doing verbal anesthesia… it works very well and you don’t have over-sedated patients. Over-sedated patients, I think, is bad or maybe even worse than under-sedated patients when it comes to eye surgery because they can’t control themselves. They’re moving around…
	O16: “…it does seem almost overkill now when I go to the ASC [n.b. ambulatory surgery center] and…we’re giving Versed and watching the patients fall asleep.”

^aO ophthalmologist, INT interviewer

Table 3.

Illustrative quotes regarding concerns about assuming sedation responsibilities (Theme 2)^a

Wanting a safety net	O4: …if something happens or if the patient is uncomfortable, I would prefer MAC rather than nurse sedation because I think it would make my comfort level so much more if I know that there’s somebody else who can take care of things, then I don’t need to worry about other things while I’m operating
	O7: …all of the guys running high volume ASCs all know perfectly well that they don’t need an anesthesiologist for every case…They also worry about, I’m no good at medicine. I’m no good at codes. What happens in ASC if somebody crashes? Essentially, a lot of this money is being poured into this as a backup
	O14: I mean I would say that for 99.9 percent of my cases they probably could go without MAC. But I mean for me the real thing is that if something does go wrong, that kind of is the main benefit for me, if something does go wrong, if we suddenly need to deepen the level of sedation…
	O17: My understanding in other surgical and anesthetic settings there’s always the ability to have the backup… So then the question is…what’s the backup [when oral sedation fails]?
Discomfort with managing systemic medical issues	O6: I still feel a mild level of discomfort even assessing [the airway] because I still don’t feel like in the patient’s best interest for me to perform that assessment fairly because I’m not going to be the one, taking care of it or accessing it or using it should the need arise
	O10: I mean, I’m in the middle of doing intraocular surgery, my hands are in the eye, my feet are on the pedals, I’m looking through the microscope. I can’t stop and look at a monitor. I can’t process a nurse telling me ‘The blood pressure is this and that, what do you want more of?’…the anesthesiologist would just handle it, or the anesthesiologist would say blood pressure is spiking, I’m giving them a little duh-duh-duh
	O14: I don’t know that I would be comfortable with [managing medical emergencies]… If I’m the only one who has to take care of it then obviously I have to say, ‘All right listen, let’s try and save their life, but we might lose this eye’…but then I would sit down and at the end of the day, I would be like, ‘Well why didn’t I have a second person there who could have worked on saving the life while I closed this wound and saved the eye?’
Risk aversion	O1: You, of course, have read all the headlines and of those dental procedures gone wrong, where it is a one-in-a-million chance, but do you want to be that one-in-a-million?
	O13: I think they’re always worried that something could happen, even though the risk of these things is really small. But I think there’s always a possibility and they may remember the one case where…they had the anesthesiologist that helped them…
	O16: I think part of the, the skepticism is you’re taking on, it’s almost like a complete transfer of the risk and the responsibility onto you, which I obviously felt okay and comfortable with but I could see how other people would not feel that way
	O18: …having [administered sedation as an ophthalmologist] for many years, we’re still like ‘I can’t remember.’ Like we just go into fear mode. Like I cannot be the one running a code. Do not tell me I’m going to be– I’m an ophthalmologist. So it’s hilarious

^aO ophthalmologist, INT interviewer

OBS office-based cataract surgery

Theme 1: perceived safety of cataract surgery

Low procedural risk

Most participants perceived the overall risk of cataract surgery to be extremely low. They highlighted the safety of cataract surgery, noting that “the intraocular portion” is “absolutely safer than it has [ever] been….” Several commented that the duration of surgery is “really short,” thus reducing the risk of systemic medical events occurring intraoperatively. As one participant explained, the overall frequency of emergent events “where you truly didn’t anticipate that this would be a problem” occurred “at most three to five times a year.”

Fear of unexpected, non-emergent events

The fear of unexpected, non-emergent events—including sudden, unanticipated intraoperative patient movement—was raised by multiple participants, since “any movement under the microscope is like an earthquake.” They acknowledged how difficult it is for some patients to “keep still, focus straight ahead, and, you know, not move,” going as far as taping the head or performing more invasive blocks in elderly patients with a “tough cataract” to decrease unexpected eye movement during surgery. It was also difficult for participants to anticipate which patients might require escalation of intraoperative sedation or conversion to general anesthesia (GA). Despite conceding that most patients would probably do well without routine anesthesia care, participants expressed anxiety about the possible consequences of having unexpected events arise during surgery without the ability to deepen sedation or convert to GA: “I would say 99% of the patients probably you can predict, but then that 1% whom you cannot, it’s going to be very tough.”

Risk of oversedation

While the main solution for addressing unexpected events was to rely on anesthesia staff to titrate intraoperative sedation, multiple ophthalmologists also worried about the risk of oversedation, which would lead to “a semi-cooperative or an unaware patient.” Some participants wondered whether they were “overdoing it” in terms of sedation to begin with: “We’re giving patients significant anesthesia for a simple surgery. So the question is, is it too much?”.

Theme 2: concerns about assuming sedation responsibilities

Wanting a safety net

Multiple participants strongly expressed that having anesthesia staff immediately available served as an important safety net and were wary of abandoning the current model of sedation. They described anesthesiologists as clinicians who are “fully attentive to the monitoring and the [intraoperative] care—the anesthetic needs of the patient” and who can offer “an independent assessment” as well as “take care of unusual, rare circumstances that may require higher-level expertise.” One ophthalmologist shared that their group had successfully made the transition to cataract surgery without MAC years ago, but said that they personally still “really want” anesthesia personnel to staff their cataract cases. However, some participants conceded that, in a scenario where routine anesthesia care was no longer the norm for cataract surgery, the medically complex patients with higher potential for unexpected events where “…oh my gosh, the patient’s crashing. We need an anesthesiologist here right now!” would probably already be identified as needing anesthesia care to begin with, which would potentially reduce the need for a safety net for all cataract cases.

Discomfort with managing systemic medical issues

When contemplating taking on sedation responsibilities, multiple participants felt uncomfortable with the possibility of managing the patient’s systemic medical issues, considering it beyond their scope of practice. They explained that “it would be pretty unnerving and stressful for the surgeon to have to moderate all that” and they would “worry a little bit about practicing in that kind of a scenario” since “most ophthalmologists don’t feel really comfortable handling complex medical issues.” Ophthalmologists also worried about multitasking, expressing unease regarding the cognitive load it would take to manage sedation and surgery simultaneously in a complex patient. One ophthalmologist recounted an instance during cataract surgery where a patient “…had a new onset Afib in the middle of some irregular rhythm… I was just like, ‘I’m in the eye. I can’t think about this. Go find somebody.’”.

Risk aversion

Multiple ophthalmologists characterized themselves and their peers as having a low threshold for risk while simultaneously acknowledging the low likelihood and acuity of unplanned events. One participant explained that their clinical training had “drilled into all of us” the importance of being “conservative in your approach” and “to have layers and layers of safety.” Ophthalmologists were also sensitive to the fact that vision is a critical aspect of patients’ quality of life, which strengthened their risk aversion, as one explained: “…I think everyone who is an ophthalmologist is very aware that eyesight is very precious and you do your best to do the best for the patients.”

Discussion

The goal of this study was to understand ophthalmologists’ perspectives regarding the use of monitored anesthesia care during routine cataract surgery sedation, with interviews yielding two major themes. The first major theme described how ophthalmologists view the overall safety of cataract surgery, which encompassed the subthemes of low procedural risk, fear of unexpected nonemergent events, and risk of oversedation. The second theme, where ophthalmologists expressed concerns about assuming sedation responsibilities, included the subthemes of wanting a safety net, discomfort with managing systemic medical issues, and risk aversion, which lay at the core of many physicians’ statements across all themes.

In the modern era of cataract surgery, the evidence suggests that cataract surgery is a safe and effective procedure regardless of the sedation approach (Schein et al. 2000; Sharwood et al. 2008; Perumal et al. 2022; Navaleza et al. 2006; Ianchulev et al. 2016; Kugler et al. 2023; Zakrzewski et al. 2010, 2005; Lee et al. 2016; Norregaard 2007; Stein et al. 2011). Our study participants generally agreed that cataract surgery is objectively a very low-risk procedure, and comments on the risks of the procedure itself centered on non-life threatening concerns such as unexpected patient movement, undersedation, or oversedation. However, despite the safety of cataract surgery, ophthalmologists still felt that there was value in having anesthesia personnel present during cataract surgery. Multiple ophthalmologists expressed appreciation for the “safety net” of a licensed anesthesia provider being immediately available in usual cataract surgery care settings such as ASCs and hospital outpatient departments, which allows ophthalmologists to focus exclusively on their surgical performance. While some ophthalmologists may be exercising defensive medicine with medicolegal risks in mind, this preference is more likely a reflection of the low risk tolerance afforded to a specialty that operates on a delicate and important part of the body (Kessler and McClellan 1996; Studdert 2005). These venues also have the necessary equipment and staffing to manage untoward events compared to other less-resourced settings such as office-based surgery suites.

Participants who were already employing other models of sedation for cataract surgery were generally enthusiastic about the approach. However, those who had not yet done so were averse to the idea of transferring intraoperative care to non-anesthesia trained personnel. Many participants, including at least one ophthalmologist whose group had already fully transitioned to this type of sedation approach, expressed personal discomfort with taking on roles traditionally performed by anesthesia-trained clinicians, citing a lack of confidence in their sedation or airway skills and in their ability to manage systemic medical comorbidities. However, most participants also conceded that there was a mismatch between procedural risk and the expectation that every patient should receive one-to-one anesthesia care during their procedure.

The desire for predictability in a controlled intraoperative environment highlights the importance of risk aversion—the tendency to prefer certainty over uncertainty—when considering any major change in medicine (Kahneman and Tversky 2000; Tversky and Kahneman 1981). Along with loss aversion—the cognitive bias wherein individuals exhibit a stronger preference for avoiding losses compared to acquiring gains of equivalent value — risk aversion seemed to be an important driver for ophthalmologists favoring the continuation of anesthesia care for cataract sedation (Tversky and Kahneman 1991; Kahneman et al. 1991). The societal importance placed on vision appeared to further reinforce ophthalmologists’ anxieties since visual impairment is associated with detrimental effects on quality of life and mental health (Owsley et al. 2002; Evans et al. 2007; Senra et al. 2015; Tseng et al. 2012). The heightened risk attributed by ophthalmologists to unexpected events, despite their low incidence, is a significant barrier that needs to be addressed before any widespread change in sedation practices can be implemented in the US. In light of current and projected anesthesia staffing shortages and the rapidly increasing elderly population who will require cataract surgery in the near future, there is an imperative to develop a thoughtful action plan for cataract surgery that considers the societal impact of continuing routine anesthesia care while addressing the specific concerns expressed by ophthalmologists about any change in sedation practice.

Limitations

The purpose of this study was to inductively generate hypotheses regarding ophthalmologist risk assessment and provide an understanding of physician experiences that may not be adequately explored with traditional quantitative investigations. However, our study is not without limitations. While the literature suggests that thematic saturation can be achieved with a sample size of nine participants (Crouch and McKenzie 2006; Hennink and Kaiser 2022), our sample size of nineteen may not reflect the perspective of all ophthalmologists. The use of purposive sampling may have further prevented us from capturing all ophthalmologists’ sentiments, thus limiting generalizability. Subjective bias may also be present among the ophthalmologists who consented to be interviewed. In addition, while we sampled across multiple practice settings such as HOPD, ASC, minor procedure rooms, and office-based surgery suites, we may not have captured the full range of profile variation within each practice setting, and we were unable to analyze differences in sentiment between practice settings due to the modest sample size. Demographics such as ethnicity were collected but not included in this manuscript due to the risk of re-identification given the relative dearth of minority physicians within ophthalmology. Despite these limitations, this study deepens our understanding of physician sentiments around cataract surgery risk and changing routine sedation practices for this procedure.

Conclusions

To the best of our knowledge, this is the first qualitative study exploring ophthalmologists’ perspectives regarding the risks of cataract surgery and their opinions regarding the potential transition away from anesthesia care. While ophthalmologists felt that cataract surgery was overall a safe procedure, they did not feel comfortable expanding their scope of practice to take on sedation tasks currently performed by anesthesia staff. Our study provides important insights about ophthalmologists that will help inform the development of a cost-effective, evidence-based approach to cataract surgery sedation that is also acceptable to ophthalmologists.

Abbreviations

MAC

Monitored anesthesia care

IV

Intravenous

US

United States

COREQ

Consolidated criteria for reporting qualitative research

CFIR

Consolidated framework for implementation research

GA

General anesthesia

ASC

Ambulatory surgery center

HOPD

Hospital outpatient department

OBS

Office-based surgery

Authors’ contributions

CLC and NL had full access to all data in the study and take responsibility for the integrity of the data and accuracy of data analysis. CLC, NL, MLF, and DD took part in interview guide creation and design. CLC and NL carried out data collection, manuscript drafting, and figure creation. CLC, NL, RS, SR, NP, MLF, and DD partook in data analysis, data interpretation, and critical review of the manuscript.

Funding

This work was supported by a K23 AG072035 (PI: Chen) and K07 AG066814 (PI: Dohan) from the NIH National Institute on Aging, the Patricia Sander Award, and UCSF Anesthesia Research.

Data availability

Datasets generated and analyzed during this study are not publicly available to preserve the privacy and anonymity of study participants. Redacted versions may be available upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board at the University of California, San Francisco (IRB# 21-35606). All study participants electronically signed an informed consent to participate and be recorded. All methods were carried out in accordance with the consolidated criteria for reporting qualitative research (COREQ) guidelines and content analysis methodological orientation.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.