Issue: June 10, 2020
Source: Oetting T. VA driven efficiencies. Presented at: Cataract Surgery: Telling It Like It Is; Feb. 12-16, 2020; Orlando.
Disclosures: Oetting and Terveen report no relevant financial disclosures.
June 05, 2020
3 min read

Efficiencies decrease cataract surgery case costs, improve quality at VA clinic

Surgeons have implemented immediate sequential bilateral cataract surgery and other cost-saving measures.

Issue: June 10, 2020
Source: Oetting T. VA driven efficiencies. Presented at: Cataract Surgery: Telling It Like It Is; Feb. 12-16, 2020; Orlando.
Disclosures: Oetting and Terveen report no relevant financial disclosures.
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The decision to undertake immediate sequential bilateral cataract surgery at a Veterans Affairs medical center, as well as incorporating other surgical efficiencies, decreased procedure costs and patient congestion, according to a speaker at Cataract Surgery: Telling It Like It Is.

Switching to immediate sequential bilateral cataract surgery (ISBCS) at the Iowa City VA Medical Center also saved time in the operating room and reduced travel time for families.

“We are fortunate at the VA to be able to take a larger view when caring for our patients. As we looked at our process, it became clear that doing same-day bilateral cataract surgery saved lives from less travel, saved loss of work for patients’ families and relieved congestion in our clinics, allowing us to see new patients,” Thomas A. Oetting, MS, MD, told Ocular Surgery News.

Saving time and money

Daniel C. Terveen, MD
Daniel C. Terveen

Oetting credited Daniel C. Terveen, MD, a resident on the VA team, for spearheading efforts to discover the cost- and time-saving efficiencies put into practice at the center.

A switch to ISBCS, as opposed to delayed sequential bilateral cataract surgery (DSBCS), saved hundreds of dollars per case, Oetting said. Operating room time was reduced by about 10 minutes per case. On average, 1 minute of operating room time costs $44, so 10 minutes saved is equivalent to a $440 reduction for each procedure.

With ISBCS procedures taking place in just 1 day, patients have two fewer visits compared with DSBCS. Each visit typically costs $50, so $100 is saved for each case.

“Many of these patients are traveling to these appointments and often require a driver. In Iowa, our patients drive an average of 60 miles one way to come to the VA. By reducing the number of preoperative and postoperative visits and actual days in surgery, we vastly reduce the time and distance these patients need to drive,” Terveen said.

The economic benefits of ISBCS trickle down further if a patient’s family member has to take time off of work or find child care for the visits, he said.

Surgery risks

The most cited risks are bilateral toxic anterior segment syndrome (TASS) and endophthalmitis, but the odds are low. No cases of TASS in ISBCS have been reported, and only a handful of cases of bilateral endophthalmitis have been seen, according to Terveen.

“Each of those cases had a break in sterile technique or did not use intracameral antibiotics. Simply put, our patients in Iowa are more likely to die in a car accident driving to the second eye surgery than they are to get bilateral endophthalmitis,” he said.


Several studies have shown refractive outcomes in ISBCS and DSBCS are similar, Terveen said.

Further efficiencies save costs

Other methods have also saved money for each ISBCS case. Registered nurse-monitored cataract surgeries are significantly cheaper than certified registered nurse anesthetist-monitored procedures. According to Oetting, less than 1% of his cases have required intraoperative assistance from CRNAs, so RN-monitored procedures are an effective cost-saving measure.

In addition, oral sedation has similar safety outcomes as IV sedation and is less expensive per case. These efficiencies save nearly $100 a procedure, according to Oetting.

The use of intracameral antibiotics saves nearly $100 a case, and intracameral mydriasis saves an additional $50 a case and reduces the need for topical dilation. Intracameral mydriasis for dilation allows the surgeon to use fewer Malyugin rings (MicroSurgical Technology) per procedure as well, Oetting said.

The VA does not use postoperative antibiotic drops as there is no evidence they provide additional endophthalmitis prophylaxis when a surgeon uses intracameral antibiotics, Terveen said.

“We have gone to only tropicamide preoperatively to save costs as each patient requires a separate bottle per VA policy. The most interesting result of using this on all patients was our huge reduction in the number of Malyugin rings. For resident surgery, it has greatly increased the safety profile,” he said.

Additionally, the use of ReSure sealant (Ocular Therapeutix) instead of 10-0 nylon suture has reduced operating room time by nearly 7 minutes per case and eliminates the need for a 1-week postoperative visit to remove the suture. This 7-minute reduction in the operating room saves about $308 per case. On average, ReSure sealant costs $95.40 per case.