Picture this: It’s 4:30 pm on a Friday and your patient presents with a macula-on retinal detachment (RD). You have the diagnosis; you know the surgical plan; the patient is consented and anxiously awaiting their vision-saving surgery. What don’t you have? An operating room (OR).
For vitreoretinal surgeons, this scenario is growing increasingly familiar. The decision to operate is often measured not in weeks to months, but in hours to days. Yet across the country, it is growing harder to obtain the OR time needed to perform surgery. The irony is striking: As the volume and complexity of vitreoretinal surgery continue to increase, access to the infrastructure needed to perform these procedures is becoming more limited.
The OR cannot simply be viewed as a physical room; rather it must be considered a complex organization of resources including surgeons, anesthesiologists, nurses, technical staff, and equipment. On paper, these resources translate into fiscal numbers. When cases grouped within the same ambulatory payment classifications (APCs) vary in surgical complexity, variability in OR time can have substantial financial implications. Across ambulatory surgery centers (ASCs), community hospitals, and academia, these financial pressures can shape how OR time is allocated, creating a dilemma that extends beyond economics into patient access and timely care.
A 2025 survey of American Society of Retina Specialists (ASRS) members showed that this concern is more than theoretical.1 Of 276 respondents, approximately 90% noted increasing difficulty in obtaining sufficient OR time. More than half reported difficulty accessing hospital OR time during weekdays, and just under half reported difficulty after hours, including nights and weekends. Similar ratios of accessibility difficulty were found in both academic and private practice settings.1 Most remarkably, 99% of respondents were concerned about continued loss of OR access in the future.1
Barriers to OR accessibility were multifactorial and commonly included limited block time, anesthesia availability, staffing shortages, and relatively lower reimbursement for vitreoretinal surgery compared with other procedures. This matters because 94% of respondents felt that limited OR availability adversely affects their patients.1 More specifically, surgeons reported delays in urgent RD repair (77%), increased travel burden (62%), longer wait times for elective cases (53%), and worse patient outcomes (41%).1 Together, these findings suggest that limited OR access is no longer solely an operational challenge—it has become an impediment to timely retinal care.
Time Is Money
The economics of retinal surgery help explain why time is the most expensive resource. A recent time-driven analysis conducted by the University of Michigan demonstrated the financial discrepancy between standard and complex RD repairs. Complex pars plana vitrectomies (PPVs) were associated with significantly higher anesthesia time, OR time, surgery time, and postoperative care.2
This analysis estimated total day-of-surgery costs for standard vs complex RD repairs with PPV at approximately $5,200 vs $7,900, respectively.2 After accounting for institutional facility payments and postoperative visits, standard and complex RD repairs with PPV resulted in estimated net losses of approximately $980 and $3,300, respectively.2 This highlights how cases that more heavily consume OR resources may be among the least financially attractive for a facility.
The paradox of time and reimbursement in vitreoretinal surgery becomes even clearer when we consider surgical minutes as currency. Busquets et al demonstrated, using time-driven activity-based costing, that although retina surgery generates greater facility reimbursement per case than cataract surgery in the ASC setting, this advantage disappears when analyzed on a per-unit-time basis.3 Among all current procedural terminology (CPT) codes assessed, no vitreoretinal surgery surpassed the financial efficiency of cataract surgery, and this should not be mistaken for surgical efficiency or inefficiency. Cataract surgery generated nearly 3 times the profit per minute of retinal surgery ($23.35 vs $8.40, respectively).3 When considered over average intraservice time, retinal surgery is estimated to be approximately 71% less financially efficient than cataract surgery.3
Reimbursement Inequity
Mismatched reimbursement and economic inflation are not new topics in the vitreoretinal community. An analysis of Medicare reimbursement for common vitreoretinal procedures from 2011 through 2020 found that, although unadjusted reimbursement changed variably across procedures, inflation-adjusted reimbursement declined for all procedures studied by an average of 19.5%. Reimbursement for some CPT codes declined by more than 30% over the 9-year period.4
Compounding the burden of reduced reimbursement, the costs associated with providing surgery have continued to rise. OR personnel, anesthesia, supplies, equipment, facility overhead, postoperative care, and administrative infrastructure all contribute to the growing cost of delivering vitreoretinal surgery. After adjusting for inflation, the American Medical Association (AMA) and US Bureau of Labor Statistics estimate physician payment declined by 33% between 2001 and 2025.5 This widening gap between the cost of providing care and the payment received creates financial strain for physicians and the facilities in which they operate.
Retinal Surgery Is Not Created Equal
Retina practices must be prepared for the unpredictable. Unlike many elective surgical procedures, urgent conditions such as RDs, endophthalmitis, and ocular trauma carry a sense of surgical urgency, and therefore unpredictability, when considering OR schedules.
Furthermore, even seemingly routine cases can be difficult to predict. A retinal detachment that appears relatively straightforward preoperatively may prove more complex during surgery because of unanticipated proliferative vitreoretinopathy (PVR), membrane pathology, or other findings. Even non-PVR detachments vary based on the number, location, and type of breaks. Intraoperative findings may require the surgeon to deviate from the anticipated plan to perform more time-intensive procedures, such as retinectomy, scleral buckling, or silicone oil tamponade, the latter necessitating subsequent surgery. Although preoperative examinations help predict surgical complexity, intraoperative findings ultimately dictate the interventions required and, consequently, the OR time needed.
This variability creates a challenge for facilities that prioritize predictable case duration and financial return. Standardized procedures that reliably fit predetermined scheduling blueprints may be more appealing. For vitreoretinal surgeons, however, longer cases, variable complexity, and urgent procedures make surgical time more difficult to forecast—and therefore more difficult to secure. When OR allocation is driven primarily by fiscal efficiency, the system may fail to account for the unfavorable clinical consequences.
The Misconception of “Local Care”
What happens when local surgical capabilities cannot sustain community demand? Patients are often asked to travel for referrals or transferred elsewhere. Unfortunately, this may disproportionately affect patients in lower socioeconomic regions.
The 2025 ASRS survey found that 40% of respondents had clinical offices in lower socioeconomic regions.1 This cohort more often referred patients to academic centers because of OR inaccessibility, commonly secondary to insurance requirements.1 When comparing areas of lower vs higher socioeconomic status, the median distance from an office to an ASC was 19 vs 9 miles and the median distance to a hospital was 17 vs 9 miles.1
For some patients, 10 miles may be inconsequential; for others, it may be a significant barrier. A retina specialist may be able to provide appropriate care, but if that care cannot be performed because of OR restrictions and requires travel to another city or academic center, the practical definition of “access” becomes very different. The loss of local surgical capacity can therefore compound existing disparities in care accessibility.
What Needs to Happen?
Inaccessibility to vitreoretinal ORs is a multifactorial issue. Changes are needed at multiple levels, including how surgical time is allocated and measured, where certain procedures are safely performed, and how surgery is reimbursed. Each is instrumental in optimizing OR accessibility.
Understanding Policy
APCs are Medicare’s system for grouping hospital outpatient services into categories with similar resource utilization and corresponding facility reimbursement. Despite the greater time, staffing, equipment, and resource requirements of vitreoretinal surgery compared with many ophthalmic procedures, retinal surgeries may be assigned to lower-paying APC groups, creating a reimbursement disparity that can discourage centers from accommodating these longer, resource-intensive cases. Aligning APC assignments and reimbursement with the true resource intensity and clinical urgency of retinal surgery could provide a meaningful financial incentive for centers to preserve access to urgent, vision-saving cases.
The proposed Ophthalmic Emergency Activation (OEA) payment policy is based on Medicare’s trauma activation approach and is intended to provide additional reimbursement to facilities that maintain the resources needed to provide urgent ophthalmic surgery. The policy has not yet been adopted by the Centers for Medicare and Medicaid Services. ASRS and other ophthalmic organizations continue to advocate for its implementation through the Outpatient Prospective Payment System (OPPS) and ASC payment system or Physician Fee Schedule. Its adoption would signify meaningful progress toward improving patient access to urgent retinal surgeries.
Redefine Vitreoretinal Surgical Efficiency
Metrics used by other services, including those used by our anterior-segment colleagues, may not adequately capture the inherent value of retinal surgery for our patients. When OR success is measured primarily by case volume, turnover, or revenue per minute, the time required for increased surgical complexity, case unpredictability, and visual benefit should not be misconstrued as inefficiency. Hospitals and ASCs should consider protected retina access models that account for surgical complexity and clinical urgency when measuring OR productivity. These models should be accompanied by commensurate policy adjustments. Reallocating urgent retinal surgeries to higher APC groups and providing solutions such as implementation of the OEA could reduce the financial burden for centers that accommodate these cases.
Maximizing Support
The physical OR is not the only factor contributing to the bottleneck. In the ASRS survey, anesthesia and staffing were commonly reported barriers to OR access.1 The number of physical ORs may not be the sole issue, but rather the availability of required personnel for each institutional OR. Collaboration among retinal surgeons, anesthesia and nursing teams, and hospital administrators may support staffing models that accommodate the unpredictable nature of vitreoretinal surgery.
Restructured Reimbursement
Medicare reimbursement continues to decline across medicine, with vitreoretinal surgery disproportionately affected by procedural complexity, timing, and resource intensity.4,5 When payment fails to sufficiently represent the resources required to deliver vitreoretinal surgery, facilities will continue to face fiscal disincentives when considering longer cases. These economics work against the patients who need our care the most. Addressing this incongruity will require policy and reimbursement reform at the federal level. The American Academy of Ophthalmology and state ophthalmologic societies provide key pipelines for ophthalmologists to communicate these challenges directly with lawmakers. Participating in the AAO Mid-Year Forum offers an opportunity to collaborate with colleagues across the country while educating elected representatives about the barriers we and, ultimately, our patients face.
Moving Beyond the OR?
The retina community continues to explore alternative surgical environments. Mahajan et al recently reported outcomes from 173 vitreoretinal procedures performed in a Joint Commission–accredited office-based surgical suite.6 Patients were limited to American Society of Anesthesiologists physical status I or II and underwent surgery with minimal oral sedation and local anesthesia. Treatments included rhegmatogenous RD repair, macular hole repair, epiretinal membrane peeling, and subretinal gene therapy. Although careful patient selection is required, these findings may open the door for future expansion. Office-based surgery will not replace standard OR time for cases requiring general anesthesia, medically complicated patients, complex RDs, or pediatric cases, yet it offers an opportunity to expand surgical capacity while preserving OR resources for more complicated cases. Enhanced training of OR personnel at existing facilities may also help bridge this gap.
Conclusion
Ultimately, addressing the OR access problem requires us to rethink how we value surgical time. The procedures that are most urgent may also be among those that consume the most minutes. The procedures that are most complex may generate the least favorable profit. And patients who require specialized surgical care may often be the least able to obtain distant transportation when local access disappears.
None of this means that other, more financially favorable procedures or specialties are undeserving of OR access. It also does not mean that financial sustainability should be ignored—hospitals and ASCs must remain economically viable. But we must remember that clinical value and financial value are not synonymous. Addressing this problem will require collaboration among retinal surgeons, hospitals, ASCs, anesthesia teams, health care administrators, professional societies, and policymakers. It will also require reimbursement reform, more flexible block allocation, improved staffing models, and dedicated emergency capacity.
For retina specialists, the question is no longer whether we have enough surgeons to meet the demand for surgery, but rather, do we have the resources to perform it? When the surgeon and patient are ready, but the OR is not, an economic constraint can become a clinical consequence—measured not in dollars or minutes, but in vision lost. RP
REFERENCES
1. Leung EH, Blim J, Ghorayeb G, et al. Operating room access: survey of the American Society of Retina Specialists. J Vitreoretin Dis. Published online June 11, 2026. doi:10.1177/24741264261453055
2. Pan WW, Portney DS, Mian SI, Rao RC. The cost of standard and complex pars plana vitrectomy for retinal detachment repair exceeds its reimbursement. Ophthalmol Retina. 2023;7(11):948-953. doi:10.1016/j.oret.2023.06.021
3. Busquets MA, Al-Khersan H, Finn A, et al. A comparative time-based profit analysis of retinal and cataract surgery in ambulatory surgery centers. J Vitreoretin Dis. Published online July 26, 2026. doi:10.1177/24741264261469011
4. DeRuyter NP, Patel S, Chen Q, et al. Trends in Medicare reimbursement for common vitreoretinal procedures: 2011 to 2020. Ophthalmology. 2022;129(7):829-831. doi:10.1016/j.ophtha.2022.01.019
5. Henry TA. Medicare physician pay has plummeted since 2001. Find out why. American Medical Association. April 21, 2025. Accessed September 8, 2026. https://www.ama-assn.org/practice-management/medicare-medicaid/medicare-physician-pay-has-plummeted-2001-find-out-why
6. Mahajan VB, Kadmiel M, Almeida DRP. Safety and efficacy of vitreoretinal office-based surgery: a case series of 173 procedures in an office-based suite. J Vitreoretin Dis. Published online April 27, 2026. doi:10.1177/24741264261440768