Eyeworld

EW CATARACT 28 January 2011 by Maxine Lipner Senior EyeWorld Contributing Editor Considering the best approach for infants W hen it comes to con- genital cataract sur- gery for infants, simultaneous bilateral cataract surgery trumps the sequential approach with a sizeable reduction in medical costs, according to Scott R. Lam- bert, M.D., professor of ophthalmol- ogy and pediatrics, Emory University, Atlanta. Recent results published in the August 2010 issue of Archives of Ophthalmology reported that there was a 21.9% reduction in needed medical payments with si- multaneous surgery. Dr. Lambert's interest in poten- tially using the simultaneous ap- proach was initially peaked about a decade ago. "About 10 years ago, I found that parents are very reluctant to have their child put to sleep twice in close succession," Dr. Lambert said. "I had some concern about the safety of anesthesia in babies, so we decided that if parents wanted, we would do keratosurgery in both eyes under the same anesthetic." Reviewing the records In the recent study, investigators re- viewed the records of 10 infants who had undergone sequential surgery and compared outcomes to 17 oth- ers who had undergone simultane- ous surgery. When it came to visual acuity, investigators found no differ- ence between the two groups. "We were hoping that we would see a dif- ference in the visual acuity, but we could not," Dr. Lambert said. "The study was a fairly small sample size and we really couldn't see a differ- ence in vision." Results also indi- cated that the number of complications was similar in both groups. However, cost came down squarely in favor of the simultane- ous approach. "We did a cost analy- sis that showed that it was less expensive," Dr. Lambert said. "It helps the system to do surgery si- multaneously, primarily because the hospital visit costs a lot less," Dr. Lambert said. For the study, investi- gators used Georgia Medicaid rates. "We calculated that if we did the surgeries sequentially, the total pay- ment was around $10,000. If we did them simultaneously, it was a little over $8,000," Dr. Lambert said. "The savings were approximately 22%." He sees this as having important economic implications. "If you con- sider society in general and think about healthcare costs escalating, if one approach is not proven to be better than the other and one is less expensive, you would think that people would choose the less expen- sive approach," Dr. Lambert said. The anesthesia affect In addition, Dr. Lambert thinks that there is an even more compelling reason to do the surgery simultane- ously—avoiding more anesthesia in this vulnerable population. "I did a lot of research on the effect of anes- thesia on babies and there is cer- tainly more problems with anesthesia in an infant," Dr. Lam- bert said. There is also some think- ing that giving general anesthesia on multiple occasions in early child- hood results in a higher instance of learning disorders in these children. "Researchers think that there may be some neurotoxic effects from anes- thesia on the immature brain," Dr. Lambert said. He pointed to a study led by Wilder that appeared in the April 2009 issue of Anesthesiology that con- sidered the effects of anesthesia on children up to age 4. "The re- searchers looked at children who had anesthesia versus ones who had- n't and found that those who had anesthesia on two occasions in the first four years of life had a 1.6% greater chance of having a learning disorder; for those who had this three or more times it was 2.6 times greater," Dr. Lambert said. In addi- tion, anesthesia can at times put a child's life in danger. "There are a certain number of children who have really bad outcomes—people can die from anesthesia, particularly babies," Dr. Lambert said. "Parents are instinctively very concerned about having the baby put under general anesthesia, and I think that there's good reason for that." From a clinical perspective, Dr. Lambert sees the goal as trying to minimize the number of times and the duration that a child would have to be put to sleep. "I think that by doing surgery simultaneously, it ends up taking longer but the cumu- lative amount of time that the child is asleep is much less than if we do surgeries sequentially," Dr. Lambert said. He pointed out that there's a lot involved in putting a child under anesthesia including intubation, ex- tubation, and starting the IV—all of which can take a long time in a baby. Overall, Dr. Lambert views the take-home message here as two-fold. "I think that the take-home message is that simultaneous surgery should be seriously considered in a baby with cataracts in both eyes for a cou- ple of reasons," he said. "One is to avoid the risks of anesthesia, which I think is really the most compelling reason, and two, I think that from a societal standpoint, there is the issue of cost." In addition, Dr. Lambert points out that theoretically it might allow both eyes to be rehabilitated more quickly than if you delay the surgery in the second eye. "Al- though we couldn't prove that this made a difference, in theory it should," he said. EW Editors' note: Dr. Lambert has no fi- nancial interests related to his com- ments. Contact information Lambert: 404-778-3709, slamber@emory.edu For infants, simultaneous cataract surgery has its pluses Source: Scott R. Lambert, M.D. Congenital cataracts: weighing simultaneous versus sequential surgery

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