April 2017




Controversies in cataract surgery
Cataract double take

by Maxine Lipner EyeWorld Senior Contributing Writer


Dr. Arshinoff beginning ISBCS, left eye first. The left eye is always done first, because it allows the tray for the right eye to be brought into the room, and placed with no risk to sterility, on the opposite side of the room.
Source: Steve A. Arshinoff, MD

“You want to do the higher-risk eye first, to make sure that it goes OK before going towards the lower-risk case. The patient has to understand that we’re planning to do both eyes on the same day. However, we might not do that if the first eye does not go smoothly as expected.”
—Kendall Donaldson, MD


The pros and cons of immediately sequential bilateral cataract surgery

Practitioners often hear a request to get both of a patient’s cataracts treated in one fell swoop with immediately sequential bilateral cataract surgery (ISBCS), according to Kendall Donaldson, MD, associate professor of ophthalmology, Bascom Palmer Eye Institute, Miami. “Patients love the idea—it’s a very efficient way to do things,” Dr. Donaldson said. “They would just like to have both of their eyes done and be on with it.” Still, many practitioners shy away from the idea, worried about the potential for bilateral complications and financial barriers. EyeWorld took a closer look at this somewhat controversial procedure.
Some surgeons in the United States who might otherwise be interested in pursuing ISBCS may find themselves constrained by financial realities, Dr. Donaldson said. “Most of our insurance policies will not cover us for bilateral same-day surgery, or you need to get some type of exception,” she said, adding that everyone needs to check their insurance coverage before they start using this approach. In California, Kaiser Permanente fully reimburses for it; however, Medicare will only pay 50% for the second eye, Dr. Donaldson notes. “So, most people are penalized for doing the second eye the same day,” she said.
As a result, many are inclined to reserve ISBCS for select patients. “We tend to only do it on a patient that, let’s say, we have to put under general anesthesia,” Dr. Donaldson said, adding that this may include a small child, perhaps someone who has Down syndrome, or an elderly patient who’s a little bit compromised and needs general anesthesia, where the risk of putting them under twice is a compelling factor.

Growing U.S. contingent

Nonetheless, many surgeons in the U.S. are intrigued by the concept and have joined the International Society of Bilateral Cataract Surgeons (iSBCS), according to Steve A. Arshinoff, MD, associate professor, Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada, who is co-president of the society. “At our last count, we had 160 members from over 31 countries,” he said. Initially, most members were Canadians, followed by those from the United Kingdom, and then India, he noted. “However, now the biggest group—twice as big as Canadians—is Americans,” Dr. Arshinoff said. Accounting for this is the fact that the United States itself is much larger than Canada and the fact that once some American groups started performing bilateral surgery, others didn’t want to be left out. “If you own a surgical center in Los Angeles and the guy next door is doing bilateral surgery because he belongs to Kaiser, you want to know what’s going on,” he said.
When individuals do begin opting for bilateral same-day cataract surgery, they usually carefully select their patients. “They look for people who don’t have very dense cataracts, people who are cooperative, those who obviously need surgery in both eyes but both eyes aren’t that terrible, with say one eye that is 20/50 and the other 20/80 with moderate nuclear sclerosis cataracts; and also a patient who will lie still and will tolerate the procedure uneventfully,” Dr. Arshinoff said. However, as the OR staff gain experience, it becomes a different story, he finds. “Almost all of those people you didn’t want to do initially, you do after you have gained experience because they’re simply better off with ISBCS,” he said, adding that the patient with dense cataracts and glaucoma ultimately gains more with the bilateral approach. Patients with complicated cataracts would rather come in for 3–4 visits altogether than to have to do the same routine over twice. There is a much greater chance that they will be compliant with the bilateral approach, Dr. Arshinoff stressed. “For me, now there is almost nobody that I won’t do both eyes in,” he said. “The only patients that I won’t do are those that have Fuchs’ dystrophy, with their borderline corneas. Furthermore, postoperative refractive errors are rarely a significant concern with modern biometric techniques.”
Jonathan Solomon, MD, director, Solomon Eye Physicians and Surgeons, Bowie Vision Institute, Bowie, Maryland, tends to look for cataract patients who are healthy and buy into the idea of rapid recovery. He points out that the bilateral approach is already used for refractive procedures such as LASIK and PRK, as well as those who are undergoing phakic IOL surgery. Likewise, individuals who come in for refractive lens exchange have also been extended access to the approach, Dr. Solomon points out. “These are individuals who don’t necessarily have an opacity to their crystalline lens but who are undergoing the same cataract-like procedure but for the purposes of modifying their prescription,” he said. “In that context, how is it any different?”
It really has to do with general health and expectations, Dr. Solomon said. “When you’re allowed to broach it that way, it really doesn’t change much as to who really should or shouldn’t be a candidate, other than making sure that the general health is good, as long as the eye is stable and we’re not looking at high-risk characteristics,” he said, adding, that in the context of retinal detachment, macular edema, or concerns about infection, he is likely to shy away from treating both eyes at the same time.

Eyeing infection

Use of intracameral antibiotics is also something that has aided physicians and patients alike in reducing the complication rate, Dr. Solomon continued. While not necessary, he finds that intracameral antibiotics give him peace-of-mind when performing bilateral procedures. “We certainly feel better knowing that we have antibiotics within the walls of the eye at the conclusion of the surgical procedure,” he said, adding that this gives a measure of confidence since practitioners do see infection rates go down with intracameral antibiotics at their disposal.
Dr. Arshinoff points out bilateral endophthalmitis, which everyone worries about, has been far from rampant, and has been decreasing in frequency over the past decade. “There have been 4, maybe 5, cases of bilateral infections after surgery going all the way back to 1980 or so,” he said. “In every one of the first three cases it was because the patient was operated on in a cataract camp, somewhere that was septic, or in a room where there was Pseudomonas and other infected cases,” he said. “Also, there were no precautions taken against any infections for the first few days.” In a fourth case, the staff failed to put indicators in the autoclave with the instruments or to turn it on, he stressed. “The instruments weren’t sterile,” Dr. Arshinoff said. “It’s not the operation that was dangerous, but rather the fact that their protocol for sterilization was unacceptable.” A possible fifth case involved a very old patient who was close to death when the surgery was performed. While the person died after getting an eye infection, the question was whether they were perhaps septic beforehand, Dr. Arshinoff noted.
Still, he views intracameral antibiotics as an important component because they control infections better. Intracameral antibiotics decrease the infection rate by 8 or 9 times, he said. While everyone touts the original European Society of Cataract and Refractive Surgeons study,1 there are also many large database studies that show the intracameral (IC) approach helps to better quell infection, he notes. “There are about a dozen of these studies now, and every one of them shows a difference in the infection rate changing from the local rate with no IC agent to being one-eighth of what that was,” Dr. Arshinoff said.
Dr. Solomon said that results in his practice support simultaneous sequential same-day surgery without increasing the likelihood of vision-threatening complications. When it comes to the informed consent process, he stresses to patients his high comfort level with the bilateral procedure. “I would certainly say that I am very comfortable with a family member or myself undergoing the procedure in this way, because it is my sincere belief that overall we are reducing the relative risk of complications and increasing the benefits by providing this simple service,” he said. “We have this as part of our consent form as well as our exam notes and also as part of our verbal communications, as part of our electronic health records.”
When it comes to informed consent, Dr. Arshinoff notes that while those who are new to bilateral surgery may go into more detail in their consent form, those who have been doing this for a long time may not. “In the beginning, many organizations demand a longer consent for all the risks of doing bilateral surgery, but there aren’t any,” he said. “According to the literature, there is no publication showing that the risks are greater.”
In performing the surgery itself, Dr. Arshinoff always starts with the left eye first to help assure better sterility. “It so happens that when I do the left eye, I’m on the left side of the patient, and the instruments for the other eye that they may be bringing in before the first eye is completed enter on the right side of the room, in our setup,” he said.
Deciding whether to move on to the second eye depends on what happens with the first. Dr. Donaldson believes that all potential complications should be resolved before the second eye is attempted. She starts with the eye that is at slightly higher risk for complication if there is one. “You want to do the higher-risk eye first, to make sure that it goes OK before going towards the lower-risk case,” Dr. Donaldson said. The fact that the second eye may need to be left for another day should be included in the informed consent, she said. “The patient has to understand that we’re planning to do both eyes on the same day. However, we might not do that if the first eye does not go smoothly as expected,” Dr. Donaldson said.
Likewise, Dr. Arshinoff waits to see what happens with the first eye. If, for example, he breaks the capsule, he won’t do the second eye. However, he has only halted five bilateral surgeries in his entire experience of over 10,000 eyes undergoing ISBCS, most as a result of extraneous issues, such as a patient with severe back issues that day who couldn’t relax properly for the second eye operation.
After the surgery, Dr. Arshinoff recommends initially giving patients frequent drops. “I know there is a movement in the United States to give patients drop-free surgery, but I’m actually marginally against that,” he said, adding that this reluctance stems from the tendency that when patients don’t have to administer drops, they may forget that they need to be careful and avoid touching the eye. Instead, he instructs patients to wear a pair of glasses continuously for the first 4 days to “make them more comfortable” and to put drops in 6 times a day. “The real role of the glasses is to keep their fingers out of their eyes,” Dr. Arshinoff said. “I also tell them to put drops in 6 times a day because I want them to do something frequently to reinforce that they keep their fingers out of their eyes.” Four days should be long enough for the incisions to heal, he believes.
“In the last few years there has been a huge increase in ISBCS in the United States, and you’re going to have more,” Dr. Arshinoff said. “Everyone is going to find out that it is better.” He remains convinced that it is a mistake for Medicare to limit reimbursement, since it is the government who will ultimately save the most money as more surgeons perform ISBCS. “You have Americans taking tons of days off work to take their parents for surgery,” he said, “You would reduce the time off work by half by doing bilateral surgery.” But for now, at least, while the procedure continues to gain followers, many must continue to deal with financial hurdles.


1. ESCRS Study Group. Prophylaxis of postoperative endophthalmitis following cataract surgery: Results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33:978988.

Editors’ note: Dr. Arshinoff has financial interests with Alcon (Fort Worth, Texas), Abbott Medical Optics (AMO, now Johnson & Johnson Vision [J&J Vision, Santa Ana, California]), Rayner (Hove, United Kingdom), and Carl Zeiss Meditec (Jena, Germany). Dr. Donaldson has financial interests with Alcon, AMO (now J&J Vision), and Bausch + Lomb (Bridgewater, New Jersey). Dr. Solomon has financial interests with Ocular Science (Manhattan Beach, California).

Contact information

Arshinoff: ifix2is@gmail.com
Donaldson: KDonaldson@med.miami.edu
Solomon: jdsolomon@hotmail.com

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