Eyeworld

42 | EYEWORLD | MARCH 2021 ATARACT C Contact Braga-Mele: rbragamele@ rogers.com Chang: dceye@earthlink.net Holz: drhuckholz@gmail.com References 1. Ahmed I, et al. Bilateral same-day cataract surgery: An idea whose time has come #COVID-19. Ophthalmology. 2021;128:13–14. 2. iSBCS General Principles Com- mittee 2008–9. iSBCS General Principles for Excellence in ISBCS 2009. itgo.ca/eyefoundation- canada/wp-content/uploads/ sites/5/2020/05/2010-09-01- FINAL-ISBCS-SBCS-suggestions- from-ESCRS-Barcelona.pdf. Accessed Nov. 23, 2020. 3. DelMonte DW. Pros and cons of bilateral immediately sequential cataract surgery. Curr Ophthalmol Rep. 2020;8:88–92. 4. Herrinton LJ, et al. Immediate sequential vs. delayed sequential bilateral cataract surgery: retrospective comparison of postoperative visual outcomes. Ophthalmology. 2017;124:1126– 1135. Relevant disclosures Braga-Mele: None Chang: None Holz: None there was one case of postop endophthalmitis and two cases in 38,736 DSBCS eyes. Dr. Braga-Mele said she thinks the applica- tion of ISBCS will remain limited in countries where reimbursement for the second eye in ISBCS is reduced compared to single-eye sur- geries. "Even in my hands, if I'm doing 20–25 cases in an OR day, I'll only do three or four bilateral, maximum, because of the reimburse- ment issue. If reimbursement was full, I'd prob- ably do at least 50% or more bilateral, as long as patients were consented properly and fit the criteria," she said. Dr. Braga-Mele explained that the pro- cedure is just as difficult for the second eye and it requires the same amount of expertise and knowledge. While more efficient in some respects, coupling the procedures doesn't save a ton of surgical time. "The risk is the same to both me and the patient as the first eye and the amount of ex- pertise needed is the same. I think it should be reimbursed the same," she said. Dr. Chang weighed in on reimbursement as well, saying that the 50% reduction in reim- bursement for the second eye in the U.S. is a "strong disincentive to performing ISBCS." "This much of a reduction might be justified when performing bilateral vs. unilateral ptosis repair, but with cataract surgery, the ASC must treat each eye as a separate procedure from the standpoint of sterile protocols," he said. The future of ISBCS "I think this will be standard of care sometime within the next 10 years. I think as soon as in- surance reimbursements change, people will at least offer it to their patients," Dr. Holz said. If ISBCS were to become fully reimbursed, Dr. Braga-Mele said it would be a benefit to have an FDA-approved antibiotic. "If we're following guidelines, we need to have intracam- eral moxi or intracameral cefuroxime. We need to have something for guidelines set out in the U.S. that is FDA approved for there to be easier access for doctors to use," she said. Dr. Holz said COVID-19 has permanently changed the way we look at the world and will change how people view infectious disease. Whether ISBCS will become more accepted or if reimbursement will change as a result of the pandemic, he's not so sure. protocol provided to her by Dr. Arshinoff. David F. Chang, MD, also said he uses intracameral moxifloxacin (on all of his cases, not just ISBCS) and won't go forward with the second eye if the first eye had a complication. Dr. Holz said he avoids ISBCS in eyes with comorbidities like moderate to advanced glaucoma, high hypero- pia and high myopia, advanced diabetic retinop- athy, and those who could be prone to higher infection rates. Another concern of ophthalmologists with ISBCS is not being able to adjust the second eye in response to the first eye's outcome. Dr. Braga-Mele expressed this as a reason why she didn't do ISBCS pre-pandemic. Since starting it, however, she said she's actually found ISBCS patients complain less of dysphotopsia. "It's like when both eyes are done, they don't notice it as much, whereas when you do one unilateral there's more of a comparison effect," she said. Dr. Chang acknowledged the benefit de- laying the second eye for cataract surgery can have for patients seeking spectacle indepen- dence with a presbyopia-correcting IOL. Both the patient and surgeon learn from the first eye outcome, and this might result in selecting a different refractive target or even a different diffractive IOL for the second eye, "mix and match." However, he said the Light Adjustable Lens (LAL, RxSight) takes the need to "learn" from the first eye out of the equation. "I routinely offer ISBCS to patients needing bilateral LALs, and 95% of these patients elect this option. These patients nearly all get some amount of myopia in the second eye ranging from –0.5 to –2 D, and the LAL allows them to experience and change the amount of intention- al anisometropia before setting it permanent- ly," Dr. Chang said. "During the past year, my partner and I have done more than 110 patients with bilateral LALs and ISBCS." A couple of recent reviews of the pros and cons of ISBCS vs. delayed sequential bilateral cataract surgery (DSBCS) have found that the concerns regarding bilateral complications and poorer refractive outcomes with ISBCS are not supported by the literature. 3 A retrospective comparative study of 13,711 DSBCS and 3,561 ISBCS cases from Kaiser Permanente Northern California found no evidence to suggest ISBCS resulted in poorer refractive outcomes. 4 This study also noted that in 10,494 ISBCS eyes, continued from page 41

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