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The clinical practice of ophthalmology is based on a foundation of strong scientific evidence. But one exception may be simultaneous—sometimes called sequential—bilateral cataract surgery (SBCS), according to Steven I. Rosenfeld, MD, voluntary professor of ophthalmology at Bascom Palmer Eye Institute in Miami, and in practice with Delray Eye Associates in Delray Beach, Fla.
“It is such a hot topic today because there is more emotion than science dictating whether or not ophthalmologists opt to perform this procedure,” said Dr. Rosenfeld. “Reluctance seems to date back to what we were taught in our residencies: Never operate on both eyes at the same time. Yet no study indicates that these fears are founded when it comes to cataract surgery.
“The studies that have been done on this topic are small, but they seem to show that there is no increased risk for the patients when they undergo simultaneous bilateral surgery. As our field continues to advance, it appears that you can’t always believe the dogma you were taught—you have to approach these seemingly new approaches with an open mind.” Despite these observations, Dr. Rosenfeld does not perform SBCS.
As with any controversial procedure, there are pros and cons to SBCS, as well as proponents and detractors. After weighing all the factors—from safety concerns to patient convenience to financial considerations—the decision to perform SBCS ultimately may come down to a physician’s comfort level ... and the bottom line.
The Benefits of SBCS
Steve A. Arshinoff, MD, a partner with York Finch Eye Associates in Toronto, Ontario, Canada, also on the academic staffs of the University of Toronto and McMaster University in Hamilton, Ontario, is an advocate for what the International Society of Bilateral Cataract Surgeons calls “immediately sequential bilateral cataract surgery.” Dr. Arshinoff began performing SBCS in 1996 because of patients’ requests for it. Today, 2.5 percent of all cataract surgeries in Ontario are performed as same-day procedures.
Dr. Arshinoff maintains that the advantages of SBCS outweigh what he perceives as the minimal risks, as demonstrated by an increasing number of these procedures being performed worldwide. For example, 40 percent of bilateral cataract surgery in Finland is simultaneous. He added that this steady growth in SBCS cases led to the creation of the International Society of Bilateral Cataract Surgeons (www.isbcs.org), of which Dr. Arshinoff serves as president.
In an article he coauthored, Dr. Arshinoff noted that the benefits of SBCS include fewer medical visits as well as faster recovery of binocular vision and more rapid return to normal living.1
Convenience and cost. Dr. Rosenfeld noted that this reduction in medical visits contributes to the “convenience factor” and cost savings of undergoing two cataract surgeries at one time. “Many of our older patients must arrange for caregivers, and the need for two surgeries doubles this expense,” he said. “And our patients who are still working need to take twice the number of days off work. These costs are really ramped up for out-of-town patients, who must make two trips to undergo this surgery.”
Visual function. Stereopsis is disrupted during the time between the two cataract surgeries. “Many [surgeons] don’t take the importance of stereopsis into consideration when they perform delayed cataract surgery,” Dr. Arshinoff said. “When eyes continue to function monocularly, patients lose depth perception, and visual rehabilitation is delayed.”
Dr. Arshinoff cited a clinical study reporting that although the visual system recovers almost immediately after SBCS, it takes up to four months after surgery on the second eye to achieve similar results.2
Dr. Rosenfeld said, “I think that patients who are very farsighted or very nearsighted are inevitably unhappy after the first surgery because this particular population feels visually unbalanced. They can’t wear their old glasses, and if you pop out one of the lenses of their old pair of glasses, they may see double, feel woozy and have problems with depth perception. If they walk around without glasses, they are functioning monocularly with just the operated eye. These patients are champing at the bit to have their second eye done just to be balanced. They may be better served with a simultaneous procedure.”
Arguments for One Eye at a Time
Douglas D. Koch, MD, professor and chairman of ophthalmology at Baylor College of Medicine in Houston, said he does not perform any bilateral intraocular surgery, including cataract surgery, given the potential for serious problems.
Safety considerations. “There are good reasons to be extremely cautious when operating on two eyes at the same time,” Dr. Koch said. “Except in unusual circumstances, I don’t want to put patients at any risk, no matter how small, for bilateral infection.”
Dr. Rosenfeld noted that “additional risks of simultaneous surgery include simultaneous bilateral toxic anterior segment syndrome and simultaneous postoperative cystoid macular edema as well as the inability to alter one’s surgical plan for the second eye.”
Endophthalmitis. “While the risk of bilateral endophthalmitis is not necessarily greater with SBCS, if it were to occur, it would be devastating for the patient,” Dr. Rosenfeld said.
In addressing this concern, Dr. Arshinoff noted that the reported rates of unilateral endophthalmitis after SBCS are comparable to, or lower than, those reported for unilateral cataract surgery. 1 No cases of bilateral endophthalmitis have been reported following SBCS when full precautions were taken (see General Principles for Excellence in ISBCS at www.isbcs.org).
He also quoted findings from a study by the European Society of Cataract and Refractive Surgery (ESCRS) showing that intracameral antibiotics reduced the rate of endophthalmitis by 80 percent.3 Dr. Arshinoff has used intracameral moxifloxacin in more than 4,000 eyes and believes that this is the most effective prophylactic approach for cataract surgery. In contrast, he said, U.S. ophthalmologists tend to use postoperative topical fluoroquinolones.
Lessons from the first eye. According to Dr. Koch, the patient can benefit from what the surgeon learns from the first surgery; this may be particularly relevant with the use of presbyopiacorrecting IOLs. He said, for example, “What was the refractive outcome and how will we adjust for the second eye? Will the patient be a candidate for monovision? Does the implant design create unwanted optical images, prompting selection of a different design for the fellow eye? Does the multifocal or accommodating IOL work, or is there a better alternative for the second eye? If we don’t correct astigmatism in the first eye, does the patient need it corrected in the second eye? These are all questions that can only be answered if we do one eye at a time. It allows us to take a customized approach to our patients.
“While I understand the rationale in rare, selected cases, in general, SBCS does not allow for the overall optimal care for our cataract patients,” Dr. Koch said. “Doing each eye one at a time can lead to greater satisfaction in the second eye. And, personally, I would want my surgeries done separately.”
It May Come Down to Money
Dr. Arshinoff noted that, according to a 2008 American Society of Cataract and Refractive Surgery survey, only 0.3 percent of U.S. ophthalmologists perform SBCS, but 5 percent routinely perform simultaneous refractive lens exchange procedures. Drs. Arshinoff and Rosenfeld both attribute this to financial issues.
Medicare. “In terms of Medicare, surgeons who perform SBCS are reimbursed 100 percent for the first eye, but only 50 percent for the second eye—a profound financial disincentive,” Dr. Rosenfeld said. “This isn’t an issue with refractive lens exchange, as patients pay cash for the procedure. This may be why you see more U.S. doctors performing simultaneous LASIK or RLE.”
Dr. Arshinoff said that even if Medicare paid the same amount for each eye in bilateral surgery, there would still be cost savings in terms of reduction in medical visits as well as personnel and facilities costs. He estimated that the U.S. government could save about $2 billion more per million operated eyes by paying fully for SBCS.
Malpractice insurance. A surgeon’s medical malpractice carrier might also place conditions on SBCS. Dr. Rosenfeld, who is a committee member of the Ophthalmic Mutual Insurance Company (OMIC), said that ophthalmologists interested in performing SBCS should contact their carrier for its particular guidelines (for example, see “OMIC Weighs In on SBCS”).
OMIC Weighs In on SBCS
As the Academy says in its Information Statement titled Cataract Surgery in the Second Eye,1 simultaneous bilateral cataract surgery may be indicated in certain circumstances, but the advantages must be carefully weighed against the disadvantages, including the risk of potentially blinding complications such as bilateral endophthalmitis. OMIC shares this position.
OMIC recognizes that SBCS may sometimes be in the best interest of the patient. For example, a patient may have health issues that increase the risks associated with multiple surgeries and anesthesia. In other instances, unusually long travel distances can cause an undue hardship for the patient that might compromise adequate follow-up care. Thus, OMIC has not implemented underwriting requirements, policy conditions or exclusions that prohibit the performance of SBCS.
OMIC does, however, encourage insureds who are considering the performance of SBCS to contact risk management staff before proceeding. OMIC’s risk managers can provide advice and assistance in developing appropriate protocols for determining when SBCS is indicated, obtaining adequate informed consent that addresses the increased risks of SBCS, implementing safeguards to reduce the risk of bilateral endophthalmitis or other complications, and creating proper medical record documentation.
Although OMIC has not established a minimum interval requirement for cataract surgery, the company does require a minimum interval of one week between primary intraocular refractive surgery procedures (refractive lens exchange and phakic implants).
—Paul Weber, JD, OMIC Vice President of Risk Management, Legal Department
1 www.aao.org/one. Select “Practice Guidelines” and “Clinical Statements,” and then choose “Cataract/Anterior Segment.”
Keys to Success in SBCS
Two factors stand out in achieving good outcomes in SBCS.
Careful patient selection. “Not every patient is a candidate for SBCS,” said Dr. Rosenfeld. “Patients with underlying AMD, diabetic retinopathy or advanced open-angle glaucoma may experience a worsening of their disease after surgery on the first eye. In addition, patients with a preexisting macular epiretinal membrane are at increased risk for postoperative CME.”
Dr. Arshinoff added that exclusions may include patients with a significantly increased risk of infection; with significant corneal, lenticular or retinal abnormalities; or with tremor, personality issues or dementia.
Scrupulous surgical procedures. A review of the ophthalmologist’s personal surgical procedure is vital. Surgeons should carefully consider which eye to operate on first. In addition, they need to be meticulous in their draping routine and in maintaining complete sterile separation between the two eyes. Dr. Arshinoff also suggested listing details of the procedure—such as IOL type, power and astigmatism axis—for the right and left eyes on an operating room board that is visible to the entire OR staff.
“When the proper steps are taken, SBCS offers benefits for both the physician and the patient,” Dr. Arshinoff said. And Dr. Rosenfeld added, “If the government can get on board and see that SBCS is two separate procedures and reimburse accordingly, I think you will see a growing acceptance of SBCS in the United States—given the potential advantages. Although I have seen nothing in the literature that indicates there is any greater risk in doing the two eyes together, the patient should be counseled about the greater potential risk for complications.”
1 Arshinoff, S. A. et al. Curr Opin Ophthalmol 2009;20(1):3–12.
2 Lundström, M. et al. J Cataract Refract Surg 2006;32(5):826–830.
3 Endophthalmitis Study Group, ESCRS. J Cataract Refract Surg 2007;33(6):978–988.
Dr. Arshinoff is a consultant to Alcon and Arctic Dx. Dr. Koch reports no related financial interests. Dr. Rosenfeld is a lecturer for Allergan and a consultant to Inspire.
Take a Poster Tour
Get the most from the posters! Experts in six subject areas—including cataract—will guide you through the highlights of the Annual Meeting scientific poster sessions. See page 76 for more information.