June 2016




Controversies in ophthalmology

Immediately sequential bilateral cataract surgery: Should it be done?

by Liz Hillman EyeWorld Staff Writer


Patient with Duchenne muscular dystrophy

A patient with Duchenne muscular dystrophy developed cataracts at a young age, making reading or playing games on a tablet impossible. After careful planning to move him with a special lift from his wheelchair for surgery, Dr. Arshinoff performed ISBCS with monovision. Postop day 1, this patient was able to see 20/20 at distance and near.

Source: Steve Arshinoff, MD

ISBCS is gaining interest as more data becomes available

The overwhelming standard for patients with cataracts in both eyes is to operate on the second eye several weeks after the first. An increasing group of surgeons, a growing body of literature, and a significant number of patients, however, are supporting, if not advocating for, both eyes to be done on the same day. The debate as to whether surgeons should perform what is formally known as immediately sequential bilateral cataract surgery (ISBCS) apparently dates back to the Middle Ages. Strong ISBCS proponent Steve Arshinoff, MD, FRCSC, associate professor, University of Toronto, and co-president of the International Society of Bilateral Cataract Surgeons (iSBCS), cited a 1986 study by del Castillo that referenced how far back this fiercely heated topic goes in an article published in Ophthalmology Rounds, a publication from the Department of Ophthalmology and Vision Sciences at the university.1 While still perhaps fiercely debated, some would say the tide is beginning to change. I think this is something that people are looking at more closely than they would have in the past, said Nick Mamalis, MD, professor of ophthalmology, John A. Moran Eye Center, University of Utah, Salt Lake City. At least in the United States though, its still a relatively uncommon procedure. Over the last few decades, as more research has been presented on the topic, Dr. Mamalis said hes seen people who were adamantly opposed to ISBCS beginning to look at some of the purported advantages compared to delayed sequential bilateral cataract surgery (DSBCS). Proponents of ISBCS say that when strict surgical procedures are followed, removing both cataracts on the same day is not only safe but convenient, efficient, beneficial, and could be cost-saving. Opponents cite the risk of bilateral infection, reduced opportunity to adjust an IOL for the second eye, and lower reimbursement rates as drawbacks.

Choosing to do ISBCS

The first time Dr. Arshinoff was faced with a case of ISBCS was in the 1980s. The patient was an Indian woman who had active tuberculosis, hypermature cataracts, and bilateral angle closure due to intumescent cataracts. Waiting until the TB was treated to do DSBCS, at the risk of her going blind, was not an option, Dr. Arshinoff said. She obtained an excellent visual result bilaterally.

In the 1990s he encountered a woman who requested bilateral cataract surgery at the same time because as a race car driver, the patient couldnt afford the time it would take for her vision to recover after 2 separate surgeries. The day after ISBCS, this patient was 20/20 in both eyes and ecstatic, Dr. Arshinoff said. Since then, the number of his ISBCS patients has grown to 80% of his surgical practice; hes done more than 9,950 such cases. For some patients, its a necessity; for mostthe growing majorityits a convenience and a hope for faster visual recovery.

Richard Stiverson, MD, Lakewood, Colorado, said half of his patients request same-day cataract surgery. In the same way that our patients are given options as to what type of IOL they want, where they want their eyes to focus post-surgery, and whether they want laser-assisted surgery, I think they should have the option of choosing ISBCS, Dr. Stiverson said. Dr. Mamalis, on the other hand, reserves ISBCS only for extenuating circumstances. Those special circumstances would be if the patient is from a long way away and the travel for 2 surgical procedures is a great hardship, or if the patient is mentally challenged, for example, and requires general anesthesia for surgery, Dr. Mamalis said. Dr. Arshinoff presented data at the 2016 ASCRS•ASOA Symposium & Congress that showed only 5% of ASCRS members and 10% of European Society of Cataract& Refractive Surgeons (ESCRS) members perform ISBCS. In Finland, however, up to 50% of all cataract surgeries are performed as ISBCS. Although extensive experience with this procedure has Dr. Arshinoff being more inclusive in his patient selection for ISBCS than earlier on, he said there are a few patients who would not be good candidates: those with bilateral diabetic retinopathy (unless referred by a retina surgeon first because of limited retinal view for examination) and those with advanced Fuchs dystrophy due to the chance of postoperative corneal edema bilaterally. While Dr. Stiverson said he does not consider mild Fuchs a contraindication, he will not do ISBCS on a patient with diabetic retinopathy within the arcades of either eye, moderate glaucoma, significant keratitis sicca, RK, keratoconus, uveitis, and a few other cases.

Whats the appeal?

In addition to reducing the number of trips a patient makes to the surgical center and clinic, Dr. Arshinoff said 1 great benefit of ISBCS to patients is the ability to produce the desired refractive result postop day 1 in both eyes, whatever the patient wants. A study published in the Journal of Cataract & Refractive Surgery compared clinical and patient-reported refractive outcomes of ISBCS with those of DSBCS.2 The study found that in the 2 months postop, those in the DSBCS group were significantly worse. After 4 months though (2 months after their second eye surgery and 4 months after their first, 4 months after surgery in both eyes for ISBCS), the differences between the 2 groups was insignificant. I havent had a single patient who came back and told me they were unhappy with having both eyes done at once, Dr. Arshinoff said. Ive had a lot of patients who came back and told me they wish they had chosen to do both eyes at once rather than DSBCS. To achieve this level of satisfaction though, Dr. Arshinoff said discussing patient expectations is exceedingly important. Dr. Arshinoff said if surgeons are using modern methods for IOL power calculations and have had extensive discussions with their patients about their day-to-day activities and expectations, refractive outcomes should not be a problem. He also said that he finds doing the surgery on the same day actually better prepares him for the surgical procedure on the second eye. The best time to do the other eye is just after I finish the first eye because I know exactly what kind of problems Ill have in the second eye, he said. Dr. Stiverson said despite the fact that he rarely changes his original IOL choice for the second eye, he still recommends patients wishing for spectacle independence have cataract surgery on different days. Dr. Mamalis also related to this idea of delaying the second surgery in order to learn from the first eye and make adjustments in the second in the event of a poorer than expected refractive outcome. If a patient experiences problems with an implant in 1 eye, for example dysphotopsia or another visual phenomenon, you may want to reconsider what implant youre going to put in the second eye, Dr. Mamalis said, noting that he has not yet encountered such an issue with his ISBCS patients.

What are the concerns?

Physicians have cited the risk of bilateral endophthalmitis and toxic anterior segment syndrome (TASS) among primary concerns for performing ISBCS. A review published in 2015 in Clinical & Experimental Ophthalmology, however, stated that evidence does not support the fear of bilateral endophthalmitis resulting from the simultaneous procedure.3

The risk for infection is at least theoretical, but as Dr. Arshinoff put it, everything you do in life has a risk. We choose the path with the least risk, not no risk. How do you reduce the risk? Use intracameral antibiotics, he said. To not use intracameral antibiotics with ISBCS is not defensible in my opinion, Dr. Stiverson said. However, intracameral antibiotics are not yet approved by the U.S. Food and Drug Administration (FDA) for this indication. The FDA has approved a randomized, double blind clinical trial, which has not begun recruiting participants, that will determine the safety but not efficacy of intracameral vancomycin and moxifloxacin. Recent reports of hemorrhagic occlusive retinal vasculitis after intracameral vancomycin use present a significant obstacle in studying vancomycin intracamerally.4

Dr. Stiverson said that he is more comfortable with the off-label use of these antibiotics because Kaiser Colorado has a compounding pharmacy with a good reputation for ophthalmic preparations. Dr. Arshinoff also advised surgeons doing ISBCS to make sure incisions are sealed to help reduce the risk of endophthalmitis. Leaking incisions are a leading cause of postoperative endophthalmitis. As for reducing risk of TASS, Dr. Arshinoff pointed to the iSBCS General Principles for Excellence in ISBCS 2009, guidelines established by the society for various best practices, which include the use of intracameral antibiotics as well as treating the second eye as a completely separate surgery, redraping the patients, rescrubbing, etc. If any part of the surgery is changed, Dr. Arshinoff said everyone from the nursing staff to the surgeon to whoever buys materials is involved in the decision about what is being changed and why. He also said nothing used on the patients first eye during surgery is used for the second. By doing that, there hasnt been a single case of TASS reported in bilateral cataract surgery in the world, he said.

Is reimbursement a barrier?

While patient safety is always the physicians top priority, some cannot ignore the reimbursement factor. In the United States for example, Medicare reduces reimbursement of the surgeons and the facilitys fees to 50% for the second eye if operated on the same day. Obviously, this is not sustainable because the cost of doing the second eye is about the same as the firstwe are doing 2 completely separate procedures, Dr. Stiverson said. Dr. Mamalis agreed that the financial burden is a factor in a surgeons decision-making process regarding ISBCS in the U.S. I think being convinced of the safety issues and advantages of the efficacy are going to be things that were going to think about first, but we do have to think about the financial aspects, he said. Dr. Arshinoff said that due to recent reimbursement changes in Ontario, Canada, which went from 85% for the second eye to essentially nothing, he no longer practices in a hospital setting. In January 2016 he started performing ISBCS in a private center and now has a 6-month wait list. The patient has to think, How much does it cost me to take a month off work and how much does it cost me to pay for the surgery? he said. Its a lot cheaper to pay for the surgery. Even with some of the reimbursement disparity, Dr. Arshinoff said it might still be worth it for physicians to consider performing ISBCS as savings could be realized through fewer visits to the clinic and time saved in the operating room, which could allow for more patients to be seen in the long run, for example. A prospective, controlled, nonrandomized clinical trial involving 42 patients in a private practice by Sloan Rush, MD, Panhandle Eye Group, Amarillo, Texas, et al published in 2015 in the Journal of Cataract & Refractive Surgery evaluated the visual and economic benefits of ISBCS and found that the overall cost of ISBCS was lower.5 The economic factors included the total number of patient visits, distance and time traveled for patients, physician reimbursement for bilateral surgery, total reimbursement for the ambulatory surgical center, and cost to the third-party payer. The economic benefit fell on the patient, not the surgeon, the study authors found. From the physicians perspective, same-day bilateral cataract surgery had similar clinical outcomes but almost an entirely negative economic impact compared with separate-day bilateral cataract surgery, the study authors wrote. Based on these conclusions, the study authors made reimbursement recommendations to the Centers for Medicare and Medicaid Services. Based on the number of Medicare patients receiving cataract surgery and the percentage of them having their second eye operated on within 3 months, the study authors wrote that adopting their recommendations could yield a net 2% savings$72 million annuallyon the $3.4 billion annually spent by Medicare on cataract surgery. Since his first ISBCS in the 1980s, Dr. Arshinoff has watched the conversation about same-day cataract surgery change from totally negative toward a conversation where he thinks everyone is going to start doing [same-day] bilateral cataract surgery. But for now, the centuries-long debate continues.

ISBCS article summaryReferences

1. del Castillo M. Operacin de las cataratas bilaterales en sesin nica. Studium Ophthalmologicum. 1986;5:848.

2. Lundstrm M, et al. Benefit to patients of bilateral same-day cataract extraction: Randomized clinical study. J Cataract Refract Surg. 2006;32:826830.

3. Lansingh VC, et al. Benefits and risks of immediately sequential bilateral cataract surgery: a literature review. Clin Experiment Ophthalmol. 2015;43:66672.

4. Witkin AJ, et al. Postoperative hemorrhagic occlusive retinal vasculitis: Expanding the clinical spectrum and possible association with vancomycin. Ophthalmology. 2015;122:14381451.

5. Rush SW, et al. Prospective analysis of outcomes and economic factors of same-day bilateral cataract surgery in the United States. J Cataract Refract Surg. 2015;41:732739.

Editors note: The physicians have no financial interests related to their comments.

Contact information

: ifix2is@gmail.com
Mamalis: nick.mamalis@hsc.utah.edu
Stiverson: rkstiverson@live.com

Related articles:

Retinal evaluation before cataract surgery by Steve Charles, MD

The role of cataract surgery in glaucoma management by Tony Realini, MD

The challenges of cataract surgery with co-existing macular disease by Ellen Stodola EyeWorld Staff Writer

Cataract surgery in the setting of nanophthalmos by Hart Moss, M.D., and Douglas D. Koch, M.D.

Cataract surgery in the setting of prior pars plana vitrectomy: Surgical pearls by Arup Chakrabarti, M.S.

Sequential bilateral cataract surgery Sequential bilateral cataract surgery
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