Lindstrom's PerspectivePublication Exclusive

Bilateral same-day sequential cataract surgery will eventually become commonplace

We ophthalmic surgeons perform bilateral same-day sequential procedures quite routinely for many indications. These include oculoplastic surgery, strabismus surgery and laser corneal refractive surgery, including LASIK and PRK. Some intraocular procedures, such as argon laser trabeculoplasty, selective laser trabeculoplasty, laser peripheral iridotomy and YAG laser capsulotomy, are also fairly common, even in the U.S. We do these procedures when we, as individual surgeons, believe they are in our patients’ best interest and the benefits outweigh the risks.

Years ago, it was extremely controversial to perform bilateral same-day sequential LASIK. Our group and many others performed prospective trials measuring objective visual acuity outcomes, complication rates and patient satisfaction, comparing surgery 1 week to 1 month apart vs. operating both eyes sequentially on the same day. Patient satisfaction was significantly higher in the same-day bilateral sequential surgery group, and we could find no measurable outcome or risk benefit to waiting between eyes.

The strongest argument against this approach was the real but extremely rare possibility of a bilateral sight-threatening infection. At an infection rate of one per 5,000, the likelihood of a bilateral infection occurring was about one per 25 million patients, and even if it did occur, there was a good chance it could be treated without permanent visual loss. One of my friends even suggested, somewhat tongue in cheek, that it was not ethical to do one eye at a time because the extra travel required put the patient at risk of a life-threatening automobile accident, which was more likely statistically than a bilateral sight-threatening complication.

Bilateral same-day sequential LASIK is my partners’ and my current preference, although I always offer the patient the option of doing one eye at a time. Less than 1% of patients in my practice choose this option, and — knock on wood — in 25 years of doing well more than 60,000 eyes, we have never encountered a bilateral infection in our practice. We have seen bilateral diffuse lamellar keratitis and flap slips, but this has responded to treatment without any cases of bilateral permanent visual loss. Still, without a doubt, there has been, in the entire world experience, a few patients with bilateral visual loss after same-day sequential LASIK.

The question remains: Should the patient with proper informed consent be allowed to take this risk? Most surgeons worldwide agree that bilateral same-day sequential LASIK is justified and an appropriate option for the patient. (As an aside, one could easily argue whether a patient should be allowed with proper informed consent to take the risk of bilateral contact lens wear, in which we have all seen many patients with bilateral sight-threatening infections and scarring.) Most ophthalmologists would answer in the affirmative if no significant risk factors are present.

Now we face the same controversy with the intraocular procedures of phakic lens implantation and cataract surgery. Patients are definitely open to this option because it is convenient with less time commitment by the patient and their family or friends who assist in the process. The resistance comes mainly from ophthalmic surgeons, who generally counsel against it. In addition, in many countries, including the U.S., there are reimbursement barriers that penalize the surgeon who takes this approach.

In my opinion, in the reimbursement world of our near future, as capitation increases, these financial barriers will shift until the surgeon will actually be incented to perform bilateral same-day sequential cataract surgery. We have seen this occur already in some of our larger health care systems. The critical issue to me will remain, one patient at a time, trying to do what I believe is in his or her individual best interest and allowing the patient to play a significant role in the decision.

We are not alone in this controversy. Many patients with bilateral degenerative arthritis of the knees are opting for bilateral same-day sequential knee replacements in the face of a 1% per surgery infection rate, much higher than the rate the cataract patient faces. Patients are informed of the risks and given the option, and many select bilateral same-day knee replacement surgery. I am even considering it for myself.

Today, with a healthy ocular surface, povidone-iodine antisepsis and intracameral antibiotics, the infection rate in cataract surgery is approaching that of LASIK, one per 5,000. Of course, bilateral endophthalmitis is a nightmare that will occur if bilateral same-day sequential cataract surgery becomes routine. Should the patient be allowed, in consultation with the surgeon, to accept this risk? While certainly controversial, and I suspect a minority position, my answer is yes.

In very select cases — for example, a young patient or an intellectually disabled patient requiring general anesthesia — I have always offered the option of bilateral same-day sequential cataract surgery, and most patients or their families have agreed it was in their loved one’s best interest. I am not yet offering this option to my current “routine” patients, partly because of the reimbursement barriers, partly because of tradition, partly because of the potential medicolegal risks and partly because I am still struggling with the decision. However, I am not critical of my colleagues who are pioneering this approach, and I find it quite compatible with our society’s directive to provide high-quality care and generate high patient satisfaction and to do so at lower cost. Achieving this “triple aim” of the Affordable Care Act will require innovative approaches, such as bilateral same-day sequential cataract surgery.

Of course, every patient should be given the option of surgery on their two eyes separated by any length of time they prefer, but my crystal ball tells me that in the lifetime of the cataract surgeon being trained today, bilateral same-day sequential cataract surgery will be routine. As always, surgeon judgment will be critical in selecting appropriate patients, and any significant intraoperative complication in the first eye will lead to aborting the second eye surgery. The same is true in LASIK, in which, for example, a bad flap in the first eye leads to replacement of the flap and no further surgery in either eye.

Not all ophthalmic surgeons will embrace bilateral same-day sequential cataract surgery, but many will, and I look forward to more data that I expect will continue to confirm it as a reasonable alternative for the well-informed patient.

We ophthalmic surgeons perform bilateral same-day sequential procedures quite routinely for many indications. These include oculoplastic surgery, strabismus surgery and laser corneal refractive surgery, including LASIK and PRK. Some intraocular procedures, such as argon laser trabeculoplasty, selective laser trabeculoplasty, laser peripheral iridotomy and YAG laser capsulotomy, are also fairly common, even in the U.S. We do these procedures when we, as individual surgeons, believe they are in our patients’ best interest and the benefits outweigh the risks.

Years ago, it was extremely controversial to perform bilateral same-day sequential LASIK. Our group and many others performed prospective trials measuring objective visual acuity outcomes, complication rates and patient satisfaction, comparing surgery 1 week to 1 month apart vs. operating both eyes sequentially on the same day. Patient satisfaction was significantly higher in the same-day bilateral sequential surgery group, and we could find no measurable outcome or risk benefit to waiting between eyes.

The strongest argument against this approach was the real but extremely rare possibility of a bilateral sight-threatening infection. At an infection rate of one per 5,000, the likelihood of a bilateral infection occurring was about one per 25 million patients, and even if it did occur, there was a good chance it could be treated without permanent visual loss. One of my friends even suggested, somewhat tongue in cheek, that it was not ethical to do one eye at a time because the extra travel required put the patient at risk of a life-threatening automobile accident, which was more likely statistically than a bilateral sight-threatening complication.

Bilateral same-day sequential LASIK is my partners’ and my current preference, although I always offer the patient the option of doing one eye at a time. Less than 1% of patients in my practice choose this option, and — knock on wood — in 25 years of doing well more than 60,000 eyes, we have never encountered a bilateral infection in our practice. We have seen bilateral diffuse lamellar keratitis and flap slips, but this has responded to treatment without any cases of bilateral permanent visual loss. Still, without a doubt, there has been, in the entire world experience, a few patients with bilateral visual loss after same-day sequential LASIK.

The question remains: Should the patient with proper informed consent be allowed to take this risk? Most surgeons worldwide agree that bilateral same-day sequential LASIK is justified and an appropriate option for the patient. (As an aside, one could easily argue whether a patient should be allowed with proper informed consent to take the risk of bilateral contact lens wear, in which we have all seen many patients with bilateral sight-threatening infections and scarring.) Most ophthalmologists would answer in the affirmative if no significant risk factors are present.

Now we face the same controversy with the intraocular procedures of phakic lens implantation and cataract surgery. Patients are definitely open to this option because it is convenient with less time commitment by the patient and their family or friends who assist in the process. The resistance comes mainly from ophthalmic surgeons, who generally counsel against it. In addition, in many countries, including the U.S., there are reimbursement barriers that penalize the surgeon who takes this approach.

In my opinion, in the reimbursement world of our near future, as capitation increases, these financial barriers will shift until the surgeon will actually be incented to perform bilateral same-day sequential cataract surgery. We have seen this occur already in some of our larger health care systems. The critical issue to me will remain, one patient at a time, trying to do what I believe is in his or her individual best interest and allowing the patient to play a significant role in the decision.

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We are not alone in this controversy. Many patients with bilateral degenerative arthritis of the knees are opting for bilateral same-day sequential knee replacements in the face of a 1% per surgery infection rate, much higher than the rate the cataract patient faces. Patients are informed of the risks and given the option, and many select bilateral same-day knee replacement surgery. I am even considering it for myself.

Today, with a healthy ocular surface, povidone-iodine antisepsis and intracameral antibiotics, the infection rate in cataract surgery is approaching that of LASIK, one per 5,000. Of course, bilateral endophthalmitis is a nightmare that will occur if bilateral same-day sequential cataract surgery becomes routine. Should the patient be allowed, in consultation with the surgeon, to accept this risk? While certainly controversial, and I suspect a minority position, my answer is yes.

In very select cases — for example, a young patient or an intellectually disabled patient requiring general anesthesia — I have always offered the option of bilateral same-day sequential cataract surgery, and most patients or their families have agreed it was in their loved one’s best interest. I am not yet offering this option to my current “routine” patients, partly because of the reimbursement barriers, partly because of tradition, partly because of the potential medicolegal risks and partly because I am still struggling with the decision. However, I am not critical of my colleagues who are pioneering this approach, and I find it quite compatible with our society’s directive to provide high-quality care and generate high patient satisfaction and to do so at lower cost. Achieving this “triple aim” of the Affordable Care Act will require innovative approaches, such as bilateral same-day sequential cataract surgery.

Of course, every patient should be given the option of surgery on their two eyes separated by any length of time they prefer, but my crystal ball tells me that in the lifetime of the cataract surgeon being trained today, bilateral same-day sequential cataract surgery will be routine. As always, surgeon judgment will be critical in selecting appropriate patients, and any significant intraoperative complication in the first eye will lead to aborting the second eye surgery. The same is true in LASIK, in which, for example, a bad flap in the first eye leads to replacement of the flap and no further surgery in either eye.

Not all ophthalmic surgeons will embrace bilateral same-day sequential cataract surgery, but many will, and I look forward to more data that I expect will continue to confirm it as a reasonable alternative for the well-informed patient.