March 2015




Controversy around immediately sequential bilateral cataract surgery

by Ellen Stodola EyeWorld Staff Writer


Audience members who do not perform immediately sequential bilateral cataract surgery were asked to give their reasons. Source: ASCRS

At the 2014 ASCRS•ASOA Symposium & Congress, the Cataract Dilemmas symposium highlighted many controversial and cutting-edge issues, including immediate sequential bilateral cataract surgery (ISBCS) and the opinions of 2 thought leaders from Canada and the U.S. It was interesting to note that of the responses from the audience, about 7% of audience members were already performing same day sequential bilateral cataract surgery, while about 64% preferred a staged surgery and booking the second eye within 2 weeks after the first eye. Reasons listed for not performing ISBCS were fear of TASS, refractive outcome, and reimbursement issues. The following article highlights why our opinion leaders perform ISBCS and the issues or non-issues they have encountered.

Rosa Braga-Mele, MD, ASCRS Cataract Clinical Committee chair

ISBCS is performed around the world, but some physicians still show hesitation and concern

Steve A. Arshinoff, MD, Toronto, and Kent Stiverson, MD, Denver, Colo., discussed immediately sequential bilateral cataract surgery (ISBCS) during the Cataract Dilemmas symposium at the 2014 ASCRS•ASOA Symposium & Congress in Boston, with Dr. Arshinoff highlighting the international perspective and Dr. Stiverson focusing on the U.S. perspective.

Audience response

Audience members at the symposium were asked to weigh in on the topic. Responses focused on how far apart patients are booked for cataract surgery in each eye and for what reasons bilateral cataract surgery is not performed.

The 106 audience responses indicated that about 62% book cataract surgery in each eye 1 to 2 weeks apart. Nearly 30% said they book each eye 1 month apart. Meanwhile, 6.6% said they do both eyes on the same day, while just under 2% said they perform the surgeries 1 day apart.

The audience was asked why they do not perform bilateral cataract surgery, with choices ranging from worries about an infection or toxic anterior segment syndrome (TASS), refractive outcomes, or reimbursement issues for the second eye. Of the 66 responses, about 21% indicated that they are worried about an infection or TASS, about 15% said they are worried about refractive outcomes, and about 12% said they are worried about reimbursement issues for the second eye. The rest, 51.52%, worried about all of these factors.

Booking cataract surgery

Dr. Arshinoff said the audience responses reflect that a surprisingly large number performs ISBCS, and a number of people perform cataract surgery 2 weeks apart at the most. This suggests that the majority would perform ISBCS if the obstacles in the U.S. were removed, he said. Dr. Stiverson thinks the responses of the audience indicate support for same day bilateral surgery. Two-thirds of respondents are booking at 1 to 2 weeks, he said. I would have thought it would be two-thirds at 3 to 4 weeks. When booking cataract surgery, Dr. Stiverson will do each eye on the same day 75% of the time when there are operable cataracts in both eyes. Of these patients, 10% will call back and request different day surgery, he said. He goes into patient consultations assuming that most will be undergoing same day surgery, but comorbidities and patient comfort can play a role in performing surgery on different days. The fact that only 7% of doctors who responded book eyes for same day surgery would seem to support the status quo, Dr. Stiverson said. Conversely, I am encouraged that so many doctors are doing eyes 1 to 2 weeks apart.

Why dont surgeons perform bilateral cataract surgery?

The concerns expressed in the second question were evenly split among the 3 choices, Dr. Arshinoff said, which suggests that most surgeons lack the experience with ISBCS and a desirable reimbursement system. Dr. Arshinoff performs bilateral surgery and said he is not worried about the issues posed in the question. I think the paradigm is slowly changing as cataract surgery becomes progressively safer and more accurate, he said.

Dr. Stiverson feels that the concerns about performing bilateral cataract surgery may be disingenuous. The majority of respondents indicated they are worried about bilateral endophthalmitis or bilateral TASS, he said. And yet, the ASCRS surveys on frequency of endophthalmitis and TASS continue to decline. These are now rare, and he thinks the responses were a reaction to the hesitation felt by surgeons over the money aspect of bilateral surgery.

Over the years, I have had innumerable patients who would have truly benefited from same day bilateral surgery, he said. Transportation, infirmity, terminal diseases, anxiety, and finances are all appropriate reasons to consider bilateral surgery. However, Dr. Stiverson said the major reason he chose separate surgeries was financial penalties. I think that financial penalties are the main reason that same day bilateral surgery lags in the United States, he said. If these penalties were taken away, Dr. Stiverson thinks that 50% of surgeries would be bilateral within 5 years.

I perform same day bilateral surgery because it benefits the patient, it benefits me surgically, it benefits the Kaiser [Permanente] healthcare delivery system, which I whole-heartedly believe in, and it benefits the United States taxpayer-funded Medicare system, Dr. Stiverson said. I think the fact that only 1 in 5 respondents are worried about bilateral endophthalmitis reflects an understanding and appreciation of the evidence.


Dr. Arshinoff stressed that [ISBCS] is safe and effective, and the issues are mostly lack of experience with the procedure. Dr. Stiversons presentation was about the experience and results of 2 Kaiser doctors in Colorado. I believe this is the largest series of immediately sequential bilateral cataract surgery reported in the United States, he said. We are able to generate statistically meaningful numbers in a relatively short period of time. The focus of his presentation was on complications, with endophthalmitis and TASS both being statistical worries. At the time of my presentation, Colorado Kaiser had not had endophthalmitis in 25,000 cases or TASS in 40,000 cases, he said. Those numbers are now 30,000 and 45,000, respectively. Dr. Stiverson said it is thought that this exceptionally low infection and inflammation rate is due to the use of intracameral antibiotics, trusted vendors, and the increasing use of disposable products. In determining whether a patient is a good candidate for immediately sequential surgery, I think corneal surface problems, epiretinal membranes, diabetic macular edema, and advanced glaucoma require the most consideration, he said.

Dr. Stiverson also discussed the surprise that so many people want bilateral surgery, even when presented with worse case scenarios. With the exception of a few comorbidities or patient acceptance, there is no reason to not operate on both eyes on the same day, he said. Knowing the behavior of the first eye is invaluable in performing surgery on the second eye. Without question, I am a more competent, safer surgeon when I can immediately address a second eye when the first eye was not as easy as expected, Dr. Stiverson said. I think this has profound implications for how we should train residents (same day bilateral surgery whenever possible), but that is a controversial conversation for another day.

Editors note: Drs. Arshinoff and Stiverson have no financial interests related to this article.

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