MAY 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Page 31 of 86

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 continued on page 30 EL CONQUISTADOR a Waldorf Astoria Property The Premier Innovative Educational Retreat for Anterior Segment Surgeons and Administrators Make your advance reservation today. www.WinterUpdate.org

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