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Same-day bilateral cataract surgery gains ground, but obstacles remain

Issue: February 25, 2015

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Performing immediately sequential bilateral cataract surgery, or ISBCS, as opposed to scheduling two separate surgery days, continues to gain popularity, due mostly to patient convenience and cost savings. However, the safety of same-day surgery is still a lingering concern to some, as are suboptimal visual outcomes. U.S. surgeons also point out unjust compensation: Treating the second eye on the same day is reimbursed at only 50% of the first eye.

The 2011 Preferred Practice Patterns (PPP) from the American Academy of Ophthalmology for cataract in the adult eye notes that most ophthalmologists do not perform same-day surgery but that the “rapid visual recovery and low complication rates associated with small-incision cataract surgery under topical anesthesia has led to increased interest in this approach in some international centers.”

The PPP further says that the pros and cons of such a procedure “must be carefully weighed and discussed by the surgeon and patient.” Although rare, “there have been case reports of bilateral endophthalmitis occurring with simultaneous surgery when these guidelines for strict separation of the two surgical setups were not followed.”

The inability to correct vision in the second eye based on the outcome of the first eye is also a liability of same-day surgery, according to the PPP.

Steve A. Arshinoff, MD, FRCSC, co-president of the International Society of Bilateral Cataract Surgeons, said that the risk for endophthalmitis following immediate sequential bilateral surgery “was extremely low,” according to a survey of members.

Image: Arshinoff SA

“As with most important developments in our field, there exists healthy debate regarding the merits,” Jason P. Brinton, MD, an OSN Refractive Surgery Board Member, said.

Brinton’s conservative practice in Florida adopted same-day surgery only after multiple studies demonstrated its safety. When performing same-day surgery, the vision center follows strict protocols.

“We use primarily disposable instruments and products,” he said. “For the handpiece and a few other reusable instruments, separate sets are maintained and sterilized in separate autoclaves. No instrument opened for the first eye surgery is used in the second eye surgery.”

The center also employs different lot numbers for drapes, solutions, viscoelastics and tubing.

“This requires an additional level of organization in the stockroom but provides assurance that the two surgeries represent statistically separate events,” he said.

Brinton said that since 2011, several HMO, capitated, and integrated payer-provider systems across multiple states in the U.S. have endorsed the practice. Furthermore, recent surveys show that all ophthalmologists belonging to the International Society of Bilateral Cataract Surgeons (iSBCS) and 7% to 9% of those belonging to the International Society of Refractive Surgery and the American Society of Cataract and Refractive Surgery offer same-day bilateral surgery for phacoemulsification with IOL implantation, while nearly 25% of clinicians provide the same for phakic IOL implantation.

Jason P. Brinton

“Practices that provide elective cash-pay refractive surgery services have been among the early adopters of same-day surgery for refractive lens exchange,” Brinton said.

Advantages of same-day surgery include “the prompt restoration of visual function, fewer postoperative visits, simpler postoperative medication regimens, and greater efficiencies for the patient, OR, surgeon and health care system,” Brinton said. The purported risks of same-day surgery as opposed to delayed-interval surgery “have not been substantiated by the literature.”

Concerns about same-day surgery

Andrew P. Schachat, MD, vice chairman for clinical affairs at Cole Eye Institute, Cleveland Clinic, has a different opinion. In a letter to the editor that appeared in American Journal of Ophthalmology in August 2014, Schachat raised concerns about same-day surgery.

“For me, the theoretical risk and anxiety of managing bilateral simultaneous endophthalmitis is worrisome,” he said. “I do not see how the outcomes can be as good as separate surgeries because sometimes the surgeon will choose to adjust the IOL selection based on the results of the first eye.”

Another issue is whether the second eye needs to be treated at all.

Andrew P. Schachat

“I recommend patients consider surgery when their symptoms impact their ability or comfort doing some activity that is important to them, such as reading, driving, sewing or watching TV,” Schachat said. “If there is improvement in the first eye and the symptoms leading to the decision to have surgery are reduced or even eliminated, the need for second-eye surgery will also be reduced and, in some cases, disappear.”

Schachat does not discount patient convenience and the cost reduction of same-day surgery. Still, he believes most patients who achieve a good outcome in the first eye are “very open to the inconvenience of coming in again for the second procedure,” he said.

Schachat said he also suspects that the No. 1 driver for contemplating same-day surgery is cost.

“If we agree that cost is important, I think we should be more receptive in considering cost reductions elsewhere in our field, for example, in our selection of an anti-VEGF drug or a third- or fourth-generation antibiotic,” he said. “The less costly option is often as good, or if not as good, just slightly less good, and often not worth the incremental cost, in my opinion.”

Schachat noted that the outcomes for same-day surgery are “generally excellent” and that adverse events are becoming increasingly fewer.

“Reliance on Preferred Practice Patterns helps reduce variation and, where evidence-based, improve outcomes and safety,” he said. “In the past, cost was not considered or was rarely considered. I applaud the growing consideration of cost in the decision-making mix. I expect it to have a greater role in how we decide and what we recommend.”

Different mindset today

Steve A. Arshinoff, MD, FRCSC, an OSN Cataract Surgery Board Member, said the resistance to same-day surgery dates back several decades. Arshinoff is also co-president of the iSBCS, which was founded in 2008 to promote education, mutual cooperation and progress in performing bilateral surgery.

“iSBCS does not promote bilateral surgery on every case. Cases of marginal corneal endothelial cell counts, diabetic maculopathy and others are often best performed as [delayed sequential bilateral cataract surgery]. The ‘iSBCS General Principles for Excellence in ISBCS 2009’ is available at www.isbcs.org for general guidance,” Arshinoff said.

“The procedures we do now have such low complication rates that people do bilateral refractive surgery all the time. So why would one not do both eyes at the same time for cataract surgery? In fact, when patients themselves pay for refractive cataract surgery, they often opt to have both eyes done at once, all over the world,” Arshinoff said.

However, there are financial penalties for performing same-day cataract surgery in numerous countries, according to Arshinoff, including Israel and Japan, which pay nothing for the second eye. Therefore, “it is very common in many jurisdictions for surgeons to schedule the second eye on the first day that the payer will allow full payment,” he said. This time frame can vary from 1 day to 1 or 2 months.

Arshinoff, who began routinely performing same-day surgery in 1996, said surgeons with their own surgical centers whose fees are significantly discounted for same-day surgery and still perform bilateral surgery place themselves at risk of going bankrupt. On the other hand, Finland, which has no financial penalty, has “the highest incidence of bilateral simultaneous cataract surgery in the world, about half of all patients,” he said.

Kaiser Permanente in Colorado, an HMO, decided a decade ago that “it was actually less expensive for Kaiser to perform bilateral surgery, even by paying the surgeons and staff the same for the second eye,” Arshinoff said. “Hence, Kaiser offers patients that option, suggesting that the main issue in the United States is money.”

At a presentation at the 2014 ASCRS annual meeting, Kent Stiverson, MD, of Kaiser said that when patients who have bilateral cataracts and equal cost for both methods are given a choice, 80% choose bilateral surgery, according to Arshinoff.

Reasons to delay surgery

“My view is that, for certain patients in certain circumstances, I am sure same-day surgery is absolutely appropriate,” Douglas D. Koch, MD, a professor of ophthalmology at Cullen Eye Institute in Houston, said. “However, for patients who are particular about their vision and about the options for their vision, I still think that separate eye surgery on separate days provides a much higher level of care.” Koch said surgeons should wait at least 1 week and ideally 2 weeks between surgeries.

Waiting between surgeries enables the first lens implant to settle slightly; then, the surgeon can determine the accuracy of the IOL calculations and use this in planning for the second eye.

“Despite improved formulas, we see this commonly. If there is some inaccuracy, you can use that information to make a small adjustment for the second eye,” he said. “There are at least two good papers that show that the results of the first eye, if off significantly, can be used to refine the results of the second eye.”

A second reason to delay surgery on the second eye is that it allows the patient to experience vision in the first eye alone.

Douglas D. Koch

“The patient can determine if he or she wants the same, more distance or more near in the second eye,” Koch said. “If a multifocal IOL was implanted, this delay allows the patient and surgeon to ensure that a multifocal IOL is optimal for the fellow eye.”

IOLs can also cause unwanted visual symptoms such as negative or positive dysphotopsia.

“Even though these dysphotopsias typically subside, there are lenses and techniques that are much less prone to inducing dysphotopsia, so you have the option of implanting a different lens or using anterior optic capture in the second eye,” Koch said.

Koch noted that patients have become increasingly sophisticated and discerning about their vision.

“They are willing to come in a couple of times, if it affords them the opportunity of a better overall outcome,” he said.

From a safety standpoint, “you need at least 1 week after surgery to rule out most occurrences of endophthalmitis,” Koch said.

Perhaps more alarming, though, is if the first eye develops cystoid macular edema.

“You will know 2 weeks postoperatively by a decrease in vision,” he said. “It would be devastating to the patient to develop bilateral cystoid macular edema. Some eyes have subtle epiretinal membranes that might not be detected, and those can predispose to cystoid macular edema.”

Koch does not discount the benefits of same-day surgery but also does not see a reason to have two eyes at risk at the same time.

“And why would you give up the opportunity to refine the visual outcome in the second eye?” he said.

However, Koch said more surgeons appear receptive to performing same-day surgery.

“Still, I suspect that less than 1% of surgeons in the U.S. currently do so,” he said. “I think it could eventually increase up to 3% to 5%.”

Willingness to consider sequential surgery

Ophthalmic Mutual Insurance Company (OMIC) “is open to same-day surgery, and there may be extenuating circumstances that make it appropriate for individual patients,” OSN Cataract Surgery Section Editor John A. Hovanesian, MD, FACS, said. “In other words, it is at the physician’s discretion.”

The AAO is also receptive; however, the organization “prefers not to get too involved in specific recommendations,” he said.

Hovanesian believes limitations in the payment structure are a barrier for same-day surgery.

“I do not know if it is going to change. It may change if physicians push for a change,” he said.

John A. Hovanesian

Hovanesian said he can envision a scenario in which surgeons transfer much of their cataract surgery from surgery centers and hospitals to the office, with the routine being same-day surgery with no or minimal sedation.

“All of it would be paid out of a patient’s pocket, either because it is a premium surgery or because health insurance plans begin to allow physicians and patients to do that,” he said.

In addition, “the refractive outcomes of the second eye are not meaningfully altered by the results of the first eye,” Hovanesian said. “We now have methods of measuring refraction intraoperatively with wavefront aberrometry, so we do not have to wait 2 weeks to know the correct lens implant. Those fears were very legitimate in their day but really have been disproven by experience. In fact, just a few years ago, same-day surgery was considered by many to be malpractice.”

Hovanesian said there are now surgeons who have performed thousands of same-day cases.

“They swear by it, and their patients swear by it,” he said.

Furthermore, the growing practice of same-day surgery in countries outside the U.S. without regulatory restrictions “indicates it is valid,” Hovanesian said. He also mentioned how Kaiser Permanente’s practice of allowing surgeons in the U.S. to perform same-day surgery greatly increases the efficiency of the process and positively affects the lifestyle of a patient “who just wants to see better.”

Recent articles and studies

Arshinoff was the author of a 2012 article in Survey of Ophthalmology that said from the perspective of the patient, who may be older and have other medical problems, it places a burden on family members to bring the patient back on a different day for the second eye surgery and the other additional visits.

“Also, studies from the 1990s show that patients gained visually much more when they had their second eye done as opposed to their first eye,” Arshinoff said. “The reason is because our brains see by summation of the images from two eyes. When you treat only one eye, you affect the patient’s perception beyond Snellen acuity. But by treating both eyes on the same day, patients are really pleased with how much better they see immediately, restoring binocularity, normal stereopsis, color vision and other visual parameters. There is a huge ‘wow factor’ in ISBCS.”

Brinton and colleagues recently analyzed refractive outcomes for 212 IOL surgeries performed by Brinton, primarily same day, during several months in 2013.

“We then looked at the database of 83 other surgeons using intraoperative aberrometry with a surgeon-specific constant for 2,260 IOL cases performed in delayed fashion during that same period,” Brinton said. “Our data showed that 89% of eyes were 0.5 D or lower with a mean absolute value of the prediction error of 0.27 D ± 0.2 D, whereas for the multicenter delayed-interval data, 87% of eyes were 0.5 D or lower with a mean absolute value of the prediction error of 0.26 D ± 0.21 D. There was no difference between the two groups, which we would have expected if waiting for refractive stability following IOL surgery on the first eye conferred a significant refractive benefit for the second eye in our patient population.”

Moreover, Brinton said that the value of fellow eye data in the calculation of IOL power for the second eye continues to decrease, due to newer formulas and enhanced surgical instrumentation and procedures.

Arshinoff added that the study by Olsen in Ophthalmology in 2011 demonstrated that as biometric methods continue to improve, the benefit gained from second eye IOL power adjustment based upon the result in the first eye becomes “vanishingly small.”

Arshinoff was the lead author of a 2011 article in the Journal of Cataract and Refractive Surgery that found that the incidence of postoperative endophthalmitis after immediate sequential bilateral cataract surgery in a survey of iSBCS members “was extremely low,” he said.

“Actually, it was the lowest infection rate reported by anyone in any series. Even without administering prophylactic intracameral antibiotics, the infection rate was only one in 2,000 eyes (0.05%),” he said. With intracameral antibiotics, the infection rate fell to one in 16,800 eyes (0.006%).

More impressive, “the risk of having a bilateral infection in a bilateral simultaneous procedure, even if one assumes increased risk by a threefold linkage factor, was about one in 100 million,” Arshinoff said. “And postoperative endophthalmitis rates are continuing to decline globally with the acceptance of intracameral antibiotic prophylaxis.”

A third study, also co-authored by Arshinoff, determined potential cost saving at an Ontario hospital by performing same-day vs. delayed surgery. The 2010 article in the Canadian Journal of Ophthalmology found same-day surgery costs 32.4% less than two separate unilateral cataract surgeries: $1,059 Canadian dollars vs. $1,566 Canadian dollars.

“If we perform all unilateral surgeries because of fear of bilateral simultaneous endophthalmitis, we can combine the results of the Arshinoff and Bastianelli ISBCS endophthalmitis study with the Arshinoff and Leivo cost-savings studies of ISBCS to calculate that such action results in spending about $100 billion U.S. dollars to prevent one case of bilateral endophthalmitis. Rarely performing bilateral surgery and preferring only unilateral surgeries to prevent bilateral simultaneous infection is an unbelievably expensive method to avoid one case,” Arshinoff said.

Brinton believes the sentiment about performing same-day surgery has gradually changed over the years.

“OMIC’s new coverage of bilateral LASIK, PRK and phakic IOL procedures is a tremendous milestone and one which should not be underestimated,” he said. The Centers for Medicare and Medicaid Services and regional Medicare carriers are also “showing increased interest in sequential bilateral cataract surgery.”

“In every country, there are obstacles, which for any other procedure would be viewed as sort of ridiculous because they have no relationship to the procedure,” Arshinoff said. “In the U.S., for example, the government pays only half for the second eye, a completely illogical approach which results in the expenditure of huge amounts of money because surgeons and facilities cannot afford to forego income, despite the benefits of ISBCS.”

“For governments, it is far cheaper to treat someone’s eyes than it is to take care of that person as an invalid,” Arshinoff said. “I think once governments finally figure out they will increase efficiency and save money, they will embrace bilateral cataract surgery because it immediately rehabilitates the visual system, never results in uncomfortable anisometropia while waiting for second eye surgery, is often the only real choice for debilitated patients (Down syndrome and many others), and every study has shown that the cost is less and it requires fewer medical visits. Sharing some of the cost savings of ISBCS with surgeons by not penalizing them for undertaking ISBCS is a logical way to encourage better surgery for the patient and cost savings for the health care system.”

“As we look at the growing aging population in the U.S. and the shrinking number of ophthalmologists, it is a no-brainer that our most commonly performed procedure should move toward a more efficient mode,” Hovanesian said. “Bilateral same-day surgery creates a great deal of efficiency.” – by Bob Kronemyer

For more information:

What are the special considerations for and against performing same-day bilateral cataract surgery in pediatric patients in the US?

Same-day surgery has advantages

Rudolph S. Wagner

Simultaneous surgery for bilateral cataracts is not commonly performed in children in the U.S. The primary concern is the possibility of a vision-threatening complication occurring, such as bilateral endophthalmitis. The incidence of endophthalmitis after pediatric cataract is minute, and I am not aware of any bilateral cases after surgery.

The published literature on this subject supports my observation. In an infant born with dense cataracts, bilateral simultaneous cataract removal reduces anesthetic risk, hospital stay and cost. Most importantly, however, same-day bilateral cataract surgery allows earlier optical correction. It is well established that there is a critical period of visual development at approximately 6 to 8 weeks after birth during which time the foveas of both eyes must receive clear images.

Bilateral visual deprivation results in sensory deprivation nystagmus, while unilateral obstruction of the visual axis from a dense cataract results in deprivation amblyopia. It is easy to recognize that the timely removal of dense cataracts and bilateral optical correction are the key factors in obtaining the best possible vision in both eyes. Same-day bilateral cataract surgery may be the most expeditious way to achieve this result. Avoiding a second general anesthesia in certain high-risk infants is another significant benefit.

Keep in mind, however, that many children will develop progressive bilateral cataracts after the 8-week critical period of development. If they had a clear visual axis in both eyes before developing cataracts that require surgery, the interval between surgical removal and optical correction of the two eyes is not as great an issue as it is in infants. In these cases, the two main considerations for a two-in-one procedure are avoiding a second anesthesia and, as I have learned from my colleagues in different countries, a significant cost reduction.

Rudolph S. Wagner, MD, is an OSN Pediatrics/Strabismus Board Member. Disclosure: Wagner has no relevant financial disclosures.

Self-inflicted trauma is a concern

M. Edward Wilson

Immediately sequential bilateral cataract surgery (ISBCS) for children remains controversial. The risks of serious sight-threatening complications affecting both eyes must be carefully considered. The risk of endophthalmitis is increased in children undergoing planned posterior capsulectomy and vitrectomy. Bilateral toxic anterior segment syndrome is also more likely with ISBCS compared with separate surgeries a few days or a week apart. For me, the risk of bilateral self-inflicted trauma to the fresh cataract incisions persuades me not to put both eyes of children in the toddler age range and older at risk simultaneously. An example was a patient of mine, an older child, whose parents requested that I implant secondary IOLs bilaterally on the same day. I refused. The child, while being supervised by a nanny, swam in a lake on the second postoperative day, resulting in wound disruption, endophthalmitis and loss of the eye. The second eye was implanted 1 month later and still sees well.

I consider ISBCS only for infants who are at a higher-than-normal risk for anesthesia-related complications. The ISBCS approach is also often used in infancy when frequent illnesses or travel difficulties make it more likely that delays in surgery for the second eye could lead to deprivation amblyopia. Infants are not independently mobile, and the risk of bilateral self-imposed trauma is much less. When ISBCS is performed in infancy, each eye is treated with a separate set of instruments and a separate sterile preparation, as if the second eye were a different patient from the first. Intracameral moxifloxacin is also used in every case.

In my view, ISBCS is an acceptable alternative but must be undertaken with great care and decided upon only after a full and frank discussion with the parents.

M. Edward Wilson, MD, is an OSN Pediatrics/Strabismus Board Member. Disclosure: Wilson has no relevant financial disclosures.