May 2013




Cataract editor's corner of the world

The debate around immediate sequential bilateral cataract surgery

by Ellen Stodola EyeWorld Staff Writer

Efficiency is a sought after attribute in many aspects of ophthalmology. We strive to improve the wait times, turnover, and even the recovery period for the patient. However, sometimes being too efficient can have drawbacks. This may be the case for the new approach of immediate sequential bilateral cataract surgery (ISBCS). In this issue, Dr. Claou describes the benefits of same day bilateral cataract surgery. While ISBCS is practiced in many countries, it is rare in the United States. We asked cataract surgeons in the U.S. and Canada their opinions about the advantages and disadvantages of ISBCS.

Bonnie An Henderson, MD, cataract editor


Initial phaco quick chop in cataract surgery

Second chop in cataract surgery

Final quadrant removal in cataract surgery using phaco chop Source (all): Brock Bakewell, MD

Immediate sequential bilateral cataract surgery (ISBCS) has elicited debate over how the advantage of operating on both eyes at the same time weighs against possible concerns and complications. When considering the benefits of both immediate sequential bilateral cataract surgery and delayed sequential bilateral cataract surgery, there are a number of factors to be examined. While addressing both eyes at the same time may be beneficial, there are also concerns for refractive results, safety, and a risk of infection. In addition, operating on both eyes at the same time is not routine in many places, with lack of reimbursement on the second eye playing a role.

Thoughts on immediate sequential bilateral cataract surgery

Brock Bakewell, MD, Fishkind, Bakewell and Maltzman Eye Care and Surgery Center, Tucson, Ariz., and clinical assistant professor of ophthalmology, University of Utah, said he is in favor of doing separate cataract surgery when both eyes are in need of the procedure. He thinks it best to separate the procedures by some period of time, although he recognizes that from a convenience standpoint, some patients might prefer to be more efficient and make only one trip to the OR. "I still don't think it's ideal from the standpoint of the refractive outcome," Dr. Bakewell said. He said doing separate procedures often helps to calm a patient's nerves for the second eye, and it would also give the patient a chance to see what happens with the first eye.

Potential complications are a concern with immediate sequential bilateral cataract surgery, but Dr. Bakewell said to avoid some of these problems, he would use a completely different set of instruments on each eye. "We would just treat the second eye like it's a completely different patient." He said this approach makes infection less of a concern.

Vance Thompson, MD, director of refractive surgery, Sanford Clinic, Sioux Falls, S.D., said he does not usually do ISBCS. "The standard of care in our country is to wait between eyes, in case there is a vision threatening complication like infection," Dr. Thompson said. He said it is also his own personal preference to stick with delayed sequential bilateral cataract surgery because of the risk of a complication.

He noted that there are some exceptions where it may be the best option to go with ISBCS. For example, for someone with mental deficiencies or with severe cataracts, it may be beneficial to do both eyes at the same time. However, he said if this is the case, the plan is well thought out ahead of time and discussed with the patients and caregivers. This treatment approach is rare in the United States.

Rosa Braga-Mele, MD, associate professor of ophthalmology, University of Toronto, said that ISBCS is not a procedure that she often performs. She said that she would reserve it mostly for cases where a patient is mentally incapacitated or has extreme mobility issues. In these cases, she said it might be easier for the patient to not have to come in for a second surgery. "Unless it is in the patient's best interest, I am still not convinced that it offers any benefits over staged phacoemulsification separated by one to two weeks," Dr. Braga-Mele said.

Are refractive results better with a delayed procedure when results from the first eye can be evaluated?

Dr. Braga-Mele said one of her primary reasons to stage cataract surgeries a week or two apart is refractive results. This helps especially if a patient is unhappy with his or her range of vision because it offers the option to change the refractive outcome in the second eye. However, if the two eyes were operated on at the same time, the lens powers would have been chosen at the same time.

Dr. Bakewell agreed with the advantages of delaying the second surgery. "If you're looking at results, like refractive results of cataract surgery, I don't think the immediate sequential is going to be as good as doing it two or three weeks apart," Dr. Bakewell said. "Frequently, we learn something on the first eye."

He said it could be beneficial to do a delayed procedure, especially if there was difficulty with the first eye of a patient, for example, if it was hard to calculate the lens power. "On the second eye, we can then adjust for that, so the refractive outcome for the second eye is frequently better because we've made an adjustment based on how the first eye came out," Dr. Bakewell said. "From a refractive standpoint, I can't see any benefit from doing it immediately."

However, Dr. Bakewell said there could be some benefits of using ISBCS. For example, if a patient is highly nearsighted and wants to get rid of all nearsightedness, it might be best to correct both eyes at the same time to avoid a high degree of anisometropia that can cause visual discomfort for the patient. "That would be a case where potentially immediate surgery would prevent that patient from having to deal with a week or two of unequal image sizes between the two eyes," he said.

The price factor

Another issue affecting ISBCS is the price, mainly that the first and second eye reimbursements are not equal. In the United States, although the first eye earns reimbursement through Medicare, the second eye in the procedure does not get the same consideration. A surgeon would only get a partial reimbursement for operating on both eyes at the same time and would therefore incur some personal cost.

Dr. Bakewell said for his practice, the facility fee is not affected, however, the fee on the second eye is cut 50% by Medicare when doing ISBCS rather than a delayed procedure. He said that the surgeon's payment is arbitrarily being cut by 50%, even though the same amount of work is being done. "Surgeons in this country would never adopt it for that reason alone," he said. Dr. Thompson said his decision of whether or not to do an ISBCS or a delayed sequential bilateral cataract surgery is not based on price of the procedure, as he considers that a minor issue. Although reimbursement for the surgeon is decreased for the second eye in an immediate procedure, he said cataract surgery is still reimbursed at a good enough rate that he would not be solely deciding on cost-based reasons. The risk of vision threatening complications is his major concern.

Dr. Braga-Mele said reimbursement for ISBCS is an issue that comes up in Canada as well. "Reimbursement in Canada is less for the second eye," she said. Despite the fact that the procedure requires a complete changeover of the OR and new instruments, there is less funding than if a surgeon is operating on just one eye.

However, she said pricing also has a minimal effect on her choice of whether or not to use this type of procedure. The biggest impediments are that if an infection occurs, it could affect both eyes. Possible problems like endophthalmitis or TASS occurring on the same day are bigger concerns than the cost of the procedure, she said.

Editors' note: Dr. Bakewell has financial interests with Abbott Medical Optics (Santa Ana, Calif.). Dr. Braga-Mele has no financial interests related to the article. Dr. Thompson has no financial interests related to this article.

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