CEDARS/ASPENS Debates

Debate continues over immediate sequential bilateral cataract surgery

P. Dee Stephenson, MD, FACS, and Sumitra Khandelwal, MD, tackle the pros and cons of this surgical approach.

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

One topic that is gaining interest but always stirs controversy is the idea of immediate sequential bilateral cataract surgery. While the fear of the well-known risks remains, there are also many perceived benefits. This month, P. Dee Stephenson, MD, FACS, and Sumitra Khandelwal, MD, discuss the pros and cons of this method. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

No to same-day surgery

Immediate sequential bilateral cataract surgery (ISBCS) is currently a hot topic. There are well-documented advantages in terms of quicker visual recovery and decreased costs, but the risk is the same as it has ever been: bilateral simultaneous endophthalmitis and bilateral blindness, even though minuscule, occurring in only 0.02% to 0.5% of all cataract surgeries. Even with the advent of intracameral antibiotics and management of preop, intraop and postop inflammation, the risks are still a reality. I also worry about the rise of MRSA/MRSE infections, with the treatment of choice being vancomycin, as well as toxic anterior segment syndrome and cystoid macular edema.

P. Dee Stephenson

For me, refractive surprises are an issue but are rare in normal eyes with the use of sophisticated optical biometry and intraoperative aberrometry. A fundamental and to me overriding principle that should be followed is to treat each eye surgery as individual and autonomous, as recommended by the International Society of Bilateral Cataract Surgeons.

On the journey to emmetropia, patient satisfaction outcomes become so important, and effective lens position, residual astigmatism and refractive outcome are the things that will set you up for failure. I follow my outcomes in a database to give my patients the best outcomes I can. I learn so much about the first eye, and I use that knowledge to obtain the result I want with the second eye. With the new EDOF and low add multifocal lenses, I would be doing an injustice to my patients to perform same-day cataract surgery. I need to know about their near vision and their satisfaction level with the first eye before proceeding with the other eye. With the advent of femtosecond laser-assisted cataract surgery, it is clearly more efficient to use the laser bilaterally.

That being said, it has now become apparent that once the laser is used, prostaglandins are released and miosis ensues. What happens to the pupil is crucial for safe surgery. If the pupil in the first eye becomes miotic while you are lasering the second, think about what happens to the safety profile. Again, we may defeat the purpose of safe surgery. This ideally should be an easy decision, and to me, it has only complicated things by adding more unpredictable variables that we have been striving to decrease and control. I want the process to be as streamlined and safe as possible, but we cannot keep changing the bar and expect no consequences. Other difficulties for adoption of ISBCS are financial barriers for private practices, ASCs and surgeons. In the United States, Medicare and Medicaid reimburse at 100% for the first eye but at only 50% for the second eye if done on the same day. This in itself would fill up another chapter and verse. So for me, bilateral cataract surgery today is a “no.”

Disclosure: Stephenson reports no relevant financial disclosures.

Yes to same-day surgery

Like many disruptive ideas, the thought of immediate simultaneous bilateral cataract surgery (ISBCS) caused a roar among ophthalmologist when first introduced. Concerns included safety, outcomes and reimbursement issues.

However, ISBCS offers tangible benefits, as our colleagues in Europe and Canada can attest. It offers one event of anesthesia, including some patients who may require more sedation or even general anesthesia. It alleviates issues with anisometropia and difficulty functioning without proper correction between surgical dates. One surgical date for both eyes provides savings in cost to the patient for travel, co-pays and time off work for recovery and visits. It also provides savings to the health care system in OR time for anesthesia and the provider, which often signals red flags to providers. The financial implications may be the most concerning for surgeons.

Sumitra Khandelwal

The arguments against same-day sequential surgery are good ideas but not substantiated by the literature and may be less important with time for the average cataract patient. With improvements in phaco techniques, most patients see well on day 1, arguing against the concern of waiting for the surgical eye to recover. Complications such as retinal detachment are extremely rare bilaterally, and the occurrence of retinal detachment is on average 6 months after surgery, which is outside the current standard of care between eyes. Macular edema in patients without diabetes is rare and resolved by 3 months without treatment; although the use of NSAIDs has been debated, the most recent large cohort showed topical NSAIDs reduced the rate further.

Infection is often described as the reason to not perform sequential same-day surgery and has merit. However, with the introduction of intracameral antibiotics, the rate of endophthalmitis has diminished fivefold. In a series of more than 90,000 cases of ISBCS, no cases of bilateral endophthalmitis were reported.

Same-day bilateral cataract surgery may not be for every patient. Those whose cases are challenging, in which outcomes are unpredictable, and those whose risk for complications is high may not be candidates. Refractive outcomes have improved tremendously, with 90% within 1 D and 60% within 0.5 D in a normal eye, but for a patient who wants a more accurate outcome on the second eye, then ISBCS may not be the answer. But for patients who require general anesthesia, travel long distances or will have anisometropia, we may be doing a disservice in not offering treatment. Steps to protect the patient and surgeon during these cases are outlined in the iSBCS 2009 memo on principles for excellence. These include careful informed consent about potential blinding complications that may affect both eyes, an operative checklist to avoid wrong eye IOLs, treatment of the case in the operating room as two separate surgical cases including break out and rescrub, new sets of instruments and tubing, and repeating the timeout. Lastly, additional “safety” mechanisms could be considered, such as requiring intracameral antibiotics and placing glue or suturing the corneal wounds if there are any concerns.

Disclosure: Khandelwal reports no relevant financial disclosures.

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

One topic that is gaining interest but always stirs controversy is the idea of immediate sequential bilateral cataract surgery. While the fear of the well-known risks remains, there are also many perceived benefits. This month, P. Dee Stephenson, MD, FACS, and Sumitra Khandelwal, MD, discuss the pros and cons of this method. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

No to same-day surgery

Immediate sequential bilateral cataract surgery (ISBCS) is currently a hot topic. There are well-documented advantages in terms of quicker visual recovery and decreased costs, but the risk is the same as it has ever been: bilateral simultaneous endophthalmitis and bilateral blindness, even though minuscule, occurring in only 0.02% to 0.5% of all cataract surgeries. Even with the advent of intracameral antibiotics and management of preop, intraop and postop inflammation, the risks are still a reality. I also worry about the rise of MRSA/MRSE infections, with the treatment of choice being vancomycin, as well as toxic anterior segment syndrome and cystoid macular edema.

P. Dee Stephenson

For me, refractive surprises are an issue but are rare in normal eyes with the use of sophisticated optical biometry and intraoperative aberrometry. A fundamental and to me overriding principle that should be followed is to treat each eye surgery as individual and autonomous, as recommended by the International Society of Bilateral Cataract Surgeons.

On the journey to emmetropia, patient satisfaction outcomes become so important, and effective lens position, residual astigmatism and refractive outcome are the things that will set you up for failure. I follow my outcomes in a database to give my patients the best outcomes I can. I learn so much about the first eye, and I use that knowledge to obtain the result I want with the second eye. With the new EDOF and low add multifocal lenses, I would be doing an injustice to my patients to perform same-day cataract surgery. I need to know about their near vision and their satisfaction level with the first eye before proceeding with the other eye. With the advent of femtosecond laser-assisted cataract surgery, it is clearly more efficient to use the laser bilaterally.

That being said, it has now become apparent that once the laser is used, prostaglandins are released and miosis ensues. What happens to the pupil is crucial for safe surgery. If the pupil in the first eye becomes miotic while you are lasering the second, think about what happens to the safety profile. Again, we may defeat the purpose of safe surgery. This ideally should be an easy decision, and to me, it has only complicated things by adding more unpredictable variables that we have been striving to decrease and control. I want the process to be as streamlined and safe as possible, but we cannot keep changing the bar and expect no consequences. Other difficulties for adoption of ISBCS are financial barriers for private practices, ASCs and surgeons. In the United States, Medicare and Medicaid reimburse at 100% for the first eye but at only 50% for the second eye if done on the same day. This in itself would fill up another chapter and verse. So for me, bilateral cataract surgery today is a “no.”

Disclosure: Stephenson reports no relevant financial disclosures.

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Yes to same-day surgery

Like many disruptive ideas, the thought of immediate simultaneous bilateral cataract surgery (ISBCS) caused a roar among ophthalmologist when first introduced. Concerns included safety, outcomes and reimbursement issues.

However, ISBCS offers tangible benefits, as our colleagues in Europe and Canada can attest. It offers one event of anesthesia, including some patients who may require more sedation or even general anesthesia. It alleviates issues with anisometropia and difficulty functioning without proper correction between surgical dates. One surgical date for both eyes provides savings in cost to the patient for travel, co-pays and time off work for recovery and visits. It also provides savings to the health care system in OR time for anesthesia and the provider, which often signals red flags to providers. The financial implications may be the most concerning for surgeons.

Sumitra Khandelwal

The arguments against same-day sequential surgery are good ideas but not substantiated by the literature and may be less important with time for the average cataract patient. With improvements in phaco techniques, most patients see well on day 1, arguing against the concern of waiting for the surgical eye to recover. Complications such as retinal detachment are extremely rare bilaterally, and the occurrence of retinal detachment is on average 6 months after surgery, which is outside the current standard of care between eyes. Macular edema in patients without diabetes is rare and resolved by 3 months without treatment; although the use of NSAIDs has been debated, the most recent large cohort showed topical NSAIDs reduced the rate further.

Infection is often described as the reason to not perform sequential same-day surgery and has merit. However, with the introduction of intracameral antibiotics, the rate of endophthalmitis has diminished fivefold. In a series of more than 90,000 cases of ISBCS, no cases of bilateral endophthalmitis were reported.

Same-day bilateral cataract surgery may not be for every patient. Those whose cases are challenging, in which outcomes are unpredictable, and those whose risk for complications is high may not be candidates. Refractive outcomes have improved tremendously, with 90% within 1 D and 60% within 0.5 D in a normal eye, but for a patient who wants a more accurate outcome on the second eye, then ISBCS may not be the answer. But for patients who require general anesthesia, travel long distances or will have anisometropia, we may be doing a disservice in not offering treatment. Steps to protect the patient and surgeon during these cases are outlined in the iSBCS 2009 memo on principles for excellence. These include careful informed consent about potential blinding complications that may affect both eyes, an operative checklist to avoid wrong eye IOLs, treatment of the case in the operating room as two separate surgical cases including break out and rescrub, new sets of instruments and tubing, and repeating the timeout. Lastly, additional “safety” mechanisms could be considered, such as requiring intracameral antibiotics and placing glue or suturing the corneal wounds if there are any concerns.

Disclosure: Khandelwal reports no relevant financial disclosures.