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

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. Compensation is also an issue in some cases: Treating the second eye on the same day is not reimbursed or only partially reimbursed in some countries.

Steve A. Arshinoff, MD, FRCSC, an OSN U.S. Edition Cataract Surgery Board Member, is co-president of the International Society of Bilateral Cataract Surgeons (iSBCS), which was founded in 2008 to promote education, mutual cooperation and progress in performing bilateral surgery. He said that the resistance to same-day surgery dates back several decades.

“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.

“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,” he said.

Advantages for patients, providers, society

Cyres K. Mehta, MS, FASCRS, an OSN APAO Edition Board Member and a member of the iSBCS, believes that bilateral surgery holds many advantages for the patient.

Image: Mehta CK

“Patient comfort is significantly enhanced when both eyes regain vision simultaneously, without having to cope with the troublesome symptoms of anisometropia. For instance, a patient who is –9 D in both eyes is significantly handicapped with monocular vision when the eyes are operated at a gap of 1 month,” he said.

Simultaneous implantation of multifocal IOLs also leads to faster adaptation, better and quicker near vision gain, and higher patient satisfaction.

“If you do one eye at a time, in case of a slight IOL power miscalculation with multifocal lenses, patients will instantly compare the unoperated with the operated eye and keep complaining. They may go for second opinions where your choice of lens implant may be questioned,” Mehta said.

Reduced times and costs may be additional arguments in favor of same-day surgery.

“The preparation is done only once for both eyes, the patient occupies a bed only once, and between the two eyes, it takes just 2 minutes to wheel the second trolley into place. The standby anesthetist gets reimbursed only for one procedure, and if sedation has to be used, it is used only once. When you are operating 20 or 30 cases in a row, all this adds up to significantly less time and significant savings. Also, the cost of postoperative medications is half what it would be with two separate procedures,” Mehta said.

Related personal and social costs are also diminished. Active patients or accompanying family members need only half the number of days off work, as well as half of the expenses for transportation, food and accommodations when the operating center is far from home, which is not an uncommon situation in India and other Asian countries, he said.

Concerns about bilateral complications

In a letter to the editor that appeared in American Journal of Ophthalmology in August 2014, Andrew P. Schachat, MD, vice chairman for clinical affairs at Cole Eye Institute, Cleveland Clinic, USA, expressed concerns about same-day surgery. He commented on an article by Li and colleagues who, in consideration of the growing financial burden of cataract and low risk of endophthalmitis, advocated widespread introduction of bilateral surgery.

“I am not sure I want to explain to the unfortunate bilaterally blind patient my risk/benefit and cost/convenience thinking that leads to the collaborative decision to undertake bilateral simultaneous surgery,” Schachat wrote.

“For me, the theoretical risk and anxiety of managing bilateral simultaneous endophthalmitis is worrisome,” he said in an interview with OSN.

According to Oliver Findl, MD, chair and associate professor of ophthalmology at Hanusch Hospital in Vienna, Austria, even more worrisome is the potential risk of having toxic anterior segment syndrome (TASS) in both eyes.

“When a [TASS] outbreak occurs on one day and in the same operating theater, typically several eyes are affected. It can be very severe, and you can end up blind as a consequence of severe glaucoma, corneal decompensation, uveitis or toxicity to the retina. I never had an outbreak yet in my institution, but the chance can never be excluded. Sources are many: It can be the irrigating solution, the surgical instruments, residuals from the cleaning process, the viscoelastic, even the IOL and IOL cartridge,” he said.

In his clinic, same-day bilateral cataract surgery is only performed in patients who require general anesthesia, and a strict, dedicated protocol is applied.

“Before we operate on the second eye, everything is cleaned again, a new eye drape is applied, and everyone changes gowns and gloves. We have to ensure that from one eye to the other eye no product is used from the same lot and even the same company. An electronic system tells us where the tray was washed, and we never use trays that were washed in the same machine or had undergone the same sterilization procedure. Pre-packed instruments must be from either a different lot or a different manufacturer, and the same applies to irrigating solution and viscoelastic. Cefuroxime is administered in one eye and not in the other eye, just in case the formulation may be incorrect,” Findl explained.

“Such a stringent and logistically challenging protocol is fine for one or two patients a week, but if we did it on a regular basis, it would be a logistical nightmare,” he said. “It would cost at least as much time as to change from one patient to another, and it would be neither time saving nor cheaper.”

Power adjustment and visual outcomes

According to Douglas D. Koch, MD, a professor of ophthalmology at Cullen Eye Institute in Houston, USA, separate surgeries on separate days provide a much higher level of care. 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.

“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.”

According to Findl, no matter how good a surgeon is with biometry and IOL power calculation, deviations from target refraction occur, as shown by numerous studies.

“In spite of our best efforts, there are patients whose refractive outcome is not as good as we would like it to be. So when the patient comes for second eye surgery, we can adapt the lens power accordingly to try to get closer to our goal,” Findl said.

“This is something I don’t want to lose. I don’t want to lose the possibility to make the second eye better,” he said.

A very low risk

Arshinoff said that a 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.”

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.”

As one of the members of iSBCS, Mehta said that with the use of separate machines, separate sets and separate intracameral moxifloxacin for each eye, he has not had a single case of endophthalmitis at his center in the last 10 years.

“And we operate more than 1,500 patients bilaterally each year,” he said.

Reimbursement issues

Recent surveys show that all ophthalmologists belonging to the 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.

According to Mehta, the procedure is still performed by a minority of surgeons in India, probably no more than 5%. According to the 2013 survey of the European Society of Cataract and Refractive Surgeons, 9% of European surgeons offer this option, with little growth over the past 3 years.

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. 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.

According to Findl, however, financial issues may not weigh a great deal on the choice.

“Reimbursement may be an issue in some health systems, but in my country, there is only a small deduction for the second eye. This is not one of my arguments, but it is that of poorer outcomes that make me refrain from bilateral surgery, with the exception of the few that require general anesthesia,” he said.

In India, most insurance providers pay for bilateral surgery, Mehta said.

“If ISBCS is not widespread in India, this is mainly because not all operating theaters here are well equipped with multiple machines, multiple sets of instruments and high-speed flash autoclaves to meet the extra requirements of this surgery,” he said. “Also, the mindset of patients and surgeons needs to change.” – by Michela Cimberle and Bob Kronemyer

• References:
• Arshinoff SA. Surv Ophthalmol. 2012;doi:10.1016/j.survophthal.2012.05.002.
• Arshinoff SA, et al. Curr Opin Ophthalmol. 2009;doi:10.1097/ICU.0b013e32831b6daf.
• Arshinoff SA, et al. J Cataract Refract Surg. 2003;doi:10.1016/S0886-3350(03)00052-X.
• Arshinoff SA, et al. J Cataract Refract Surg. 2011;doi:10.1016/j.jcrs.2011.06.036.
• Chang DF. Br J Ophthalmol. 2003;doi:10.1136/bjo.87.3.253.
• Filkorn T, et al. J Refract Surg. 2012;doi:10.3928/1081597X-20120703-04.
• Henderson BA, et al. Surv Ophthalmol. 2012;doi:10.1016/j.survophthal.2012.05.001.
• Ing MR. Ophthalmic Surg. 1991;22(1):41-43.
• iSBCS General Principles for Excellence in ISBCS 2009. isbcs.org/wp-content/uploads/2011/03/2010-07-20-FINAL-ISBCS-SBCS-suggestions-from-ESCRS-Barcelona.pdf. Accessed Jan. 7, 2015.
• Knobloch R, et al. Klin Monatsbl Augenheilkd. 1962;141:348-353.
• Lam FC, et al. Eye (Lond). 2012;doi:10.1038/eye.2012.91.
• Leivo T, et al. J Cataract Refract Surg. 2011;doi:10.1016/j.jcrs.2010.12.050.
• Li O, et al. Am J Ophthalmol. 2014;doi:10.1016/j.ajo.2014.01.002.
• Lundström M, et al. J Cataract Refract Surg. 2006;doi:10.1016/j.jcrs.2006.01.075.
• Nassiri N, et al. Eye (Lond). 2009;doi:10.1038/sj.eye.6702989.
• O’Brien JJ, et al. Can J Ophthalmol. 2010;doi:10.3129/i10-094.
• Olsen T. Ophthalmology. 2011;doi:10.1016/j.ophtha.2011.04.030.
• Recchia FM, et al. Arch Ophthalmol. 2000;doi:10-1001/pubs.Ophthalmol.-ISSN-0003-9950-118-7-ecs90231.
• Schachat AP. Am J Ophthalmol. 2014;doi:10.1016/j.ajo.2014.05.008.
• Seguridad, efectividad y coste-efectividad de la cirugía de cataratas bilateral y simultánea frente a la cirugía bilateral de cataratas en dos tiempos. aunets.isciii.es/ficherosproductos/sinproyecto/534_SESCS-2006_05.pdf. Accessed Jan. 7, 2015.
• Tatham A, et al. Eye (Lond). 2012;doi:10.1038/eye.2012.92.

• For more information:
• Steve A. Arshinoff, MD, FRCSC, can be reached at York Finch Eye Associates, 2115 Finch Ave. W, No. 316, Toronto, ON, Canada M3N 2V6; email: ifix2is@gmail.com.
• Oliver Findl, MD, can be reached at Department of Ophthalmology, Hanusch Hospital, Vienna; email: oliver@findl.at.
• Douglas D. Koch, MD, can be reached at Cullen Eye Institute, Baylor College of Medicine, 6565 Fannin, NC205, Houston, TX 77030, USA; email: dkoch@bcm.tmc.edu.
• Cyres K. Mehta, MS, FASCRS, can be reached at Cyres K. Mehta’s International Eye Centre, Ram Nimi Building, Mandlik Road, Mumbai 400001, India; email: cyresmehta@yahoo.com.
• Andrew P. Schachat, MD, can be reached at Cole Eye Institute, i-30, 9500 Euclid Ave., Cleveland, OH 44195, USA; email: schacha@ccf.org.

Disclosures: Arshinoff, Findl, Koch and Mehta report no relevant financial disclosures. Schachat reports he is a paid consultant to AnGes MG, Bausch + Lomb and Allergan.

 

 

Is same-day bilateral cataract surgery a good option in pediatric patients?

Same-day surgery avoids amblyopia development, repeat anesthesia

There are many good reasons for operating infantile bilateral cataracts early and simultaneously. In a child’s developing visual system, a bilateral vision impairment results in sensory deprivation and nystagmus, while unilateral obstruction of the visual axis from a dense cataract results in deprivation amblyopia. Rehabilitation becomes easy and rapid when bilateral cataract surgery is done. Needless to say, strict preoperative sterile precautions, as well as the use of intraoperative subconjunctival antibiotics and postoperative antibiotic drops, are mandatory to prevent the risk of infections.

Existing literature data suggest that early or repeated exposure to general anesthesia may affect a child’s development and may be the cause of long-term cognition deficits. With simultaneous surgery, the risk of anesthetic exposure is reduced and so are the complications related to the anesthetic drugs and intubation. Even more important is to avoid repeated exposure to anesthesia in children with mental disabilities and structural abnormalities, as well as in premature infants.

When bilateral cataract surgery is performed on the same day, the cost spent by the patient’s family for the entire procedure, including hospital stay and treatment, is reduced as compared with separate surgeries on different days. Simultaneous bilateral cataract surgery for infants with congenital cataracts is associated with a 21.9% reduction in medical expenses. Patients who travel long distances or come from abroad also save considerably on the indirect costs related to commuting for surgery and follow-up visits.

Last but not least, the reduced emotional stress is another great advantage of same-day surgery. Facing the doctor and going through the entire series of tests again will induce more emotional trauma to the child as compared with a one-time process.

 

Dhivya Ashok Kumar, MD, is of Dr. Agarwal’s Eye Hospital, Chennai, India. Disclosure: Kumar reports no relevant financial disclosures.

Potential advantages do not outweigh risk of bilateral infection

If there were absolutely no risk of postoperative infection, I would do all my bilateral infantile cataracts on the same day simultaneously. It makes good sense to have one anesthesia to complete a task, which currently in my hands takes at least two visits to the operating room.

One may argue until one is blue in the face that the risk of endophthalmitis is very low and it is worth the risk of same-day bilateral cataract surgery. The proponents of same-day bilateral surgery will say morbidity and mortality risk is higher in children having anesthesia, and no one yet knows the long-term consequences of general anesthesia on a child’s neurological development. Hence, the argument that having anesthesia once is safer than having it twice. One can also say that cataract surgery is theoretically less prone to amblyopia if there is no gap between the two eyes, and needless to say, one operation is cheaper than two.

Despite all these points, the risk of bilateral endophthalmitis due to cross infection from one eye to the fellow eye cannot be excluded. Completing one eye’s surgery and waiting until there is no risk of infection before doing the second eye ensures better safety. Our anesthetists can deliver low-risk anesthesia in this age group, and with the help of dedicated parents, we can effectively manage amblyopia and apply good spectacle correction or contact lenses.

Some uncooperative children will need a second operation even if both eyes are operated on the same day. They might need an examination under anesthesia for testing IOP and refraction. In cases in which the two eyes are operated on different days, the surgeon can check the first operated eye at the time of the second eye’s operation to work out the possible refractive need for both eyes by assuming that the second eye would be similar.

 

Geoffrey Lam, MD, is of University of Western Australia, School of Paediatrics and Child Health, Centre for Ophthalmology and Visual Science, Crawley, Australia. Disclosure: Lam reports no relevant financial disclosures.