What are the barriers to bilateral sequential cataract surgery?
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Safety
A small percentage of surgeons are performing same-day bilateral sequential cataract surgery in the U.S., but there is still a lot of concern in our local community about infection risk.
In order to confidently recommend and perform same-day sequential surgery, we would need to develop enhanced sterile protocols that would lower surgeon stress about this uncommon but serious complication.
As with any surgery, there is a risk for endophthalmitis. When there is an infection or toxic anterior segment syndrome, we do not always know where that contamination came from. Was it the instruments? Was it something with the sterile preparation before surgery? Was it related to an early postoperative event such as eye rubbing or a wound with microleaks? If you are performing surgery on both eyes using the same equipment on the same day, there is a risk for having issues in both eyes. Having an infection develop in any eye is of major concern, so one can imagine the devastation if infections were to develop in both eyes. To perform sequential cataract surgery, a number of surgeons recommend using separate equipment for each eye. You would want to prep one eye and then have completely different sterilized equipment and disposables for the second eye so you do not have any cross contamination in the rare chance that there was a contaminated instrument.
Having a seamless set of protocols and getting down to the nuts and bolts for every aspect of the surgery would go a long way. In a lot of cases, there is some pushback from the staff in the operating room. Sterile guidelines would aid in the training of staff to be better prepared for these situations. We have some experience in this, at least in other non-intraocular surgeries. While the risks and consequences for infection are not as high in these cases, having a protocol to follow has been a huge benefit.
There are certain situations in which bilateral sequential cataract surgery would be beneficial, such as in patients who require general anesthesia. One expects that in the future, same-day bilateral sequential cataract surgery will be mainstream. Having better protocols in place will be part of the process that allows for wider adoption.
Jennifer M. Loh, MD, is an OSN Technology Board Member.
Reimbursement
The biggest impasse we face in terms of bilateral sequential cataract surgery is not safety or even outcomes. It is reimbursement. We have already been hit so hard when it comes to reimbursement for cataract surgery that only 50% of that money for the second eye is not viable.
In the days when our biometry and preoperative measurements were not as consistent or exemplary as they are today, we often waited to see what the refractive outcome was on the first eye to make any changes to the calculations for the second surgery. Except in unusual cases, such as in patients with corneal ectasia or with unusual anatomic characteristics, that wait is not necessary. In typical low-risk cases, we can be pretty confident to do both eyes on the same day and achieve good refractive outcomes.
The other issue used to argue against bilateral cataract surgery is the low risk for endophthalmitis. If it did happen, you would want to avoid it in the fellow eye. However, if you start the second eye as if it were a new patient altogether with fresh drapes, all new instrumentation and renewables, then the risk should not be any more than doing a single eye.
These factors have always been cited as barriers to sequential cataract surgery, but if all the necessary parties — the legislature, CMS, Medicare and third-party payers — decided that it did not make sense to bring a patient back twice, you would see a whole lot more sequential surgery happen overnight. If they made an exception for the 50% reduction in reimbursement for anything after the primary procedure, you would see a double-digit uptake in bilateral sequential cataract surgery almost immediately.
Steven M. Silverstein, MD, FACS, is an ophthalmologist at Silverstein Eye Centers in Missouri.
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