“Just the way we always did it”: ophthalmologist perspectives on changing routine anesthesia care for cataract surgery in the United States

BACKGROUND: Cataract surgery is one of the most common elective outpatient surgeries performed among older adults in the United States. Modern surgical technique makes cataract surgery a relatively quick, low-risk, minimally invasive outpatient procedure that can be performed solely under ophthalmologist-directed local or topical anesthesia. However, in the US, the procedure is routinely performed with additional monitoring and intravenous sedation administered by anesthesia-trained personnel. Given the procedure's safety profile, we sought to characterize ophthalmologists' perspectives on barriers preventing the adoption of more individualized approaches to cataract surgery sedation that do not automatically default to employing routine anesthesia care. METHODS: This study was conducted between December 2022 to January 2024. Using a semi-structured interview guide developed with the Consolidated Framework for Implementation Research (CFIR) framework, we completed interviews with ophthalmologists who performed cataract surgery with or without anesthesia care in hospital outpatient departments, ambulatory surgery centers, minor procedure rooms, and/or office-based surgery suites across the United States. Data were analyzed using an inductive thematic analysis approach to uncover descriptive themes. RESULTS: We interviewed 19 ophthalmologists (5 women), including 6 who had experience routinely performing cataract surgery without anesthesia care. Three major themes emerged: (1) inertia, defined as the tendency to continue established practices that serve to maintain the status quo, (2) financial considerations, and (3) the interdependent relationship between ophthalmology and anesthesiology. While some participants supported a more selective approach to the use of anesthesia services, study participants identified multiple barriers to change, including difficulty overcoming the current inertia, decreased reimbursement for office-based surgery, and concerns about implications for patient safety without routine anesthesia involvement. CONCLUSION: Ophthalmologists identified multiple barriers to changing current anesthesia-led sedation models for cataract surgery. Our findings can help inform future efforts to better align anesthesia care with patient and procedural needs in an aging US population.