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EW CATARACT 82 March 2015 by Ellen Stodola EyeWorld Staff Writer are worried about reimbursement issues for the second eye. The rest, 51.52%, worried about all of these factors. Booking cataract surgery Dr. Arshinoff said the audience responses reflect that "a surprisingly large number performs ISBCS," and a number of people perform cataract surgery 2 weeks apart at the most. "This suggests that the majority would perform ISBCS if the obstacles in the U.S. were removed," he said. Dr. Stiverson thinks the respons- es of the audience indicate support for same day bilateral surgery. "Two-thirds of respondents are booking at 1 to 2 weeks," he said. "I would have thought it would be two-thirds at 3 to 4 weeks." When booking cataract sur- gery, Dr. Stiverson will do each eye reasons bilateral cataract surgery is not performed. The 106 audience responses indicated that about 62% book cata- ract surgery in each eye 1 to 2 weeks apart. Nearly 30% said they book each eye 1 month apart. Meanwhile, 6.6% said they do both eyes on the same day, while just under 2% said they perform the surgeries 1 day apart. The audience was asked why they do not perform bilateral cata- ract surgery, with choices ranging from worries about an infection or toxic anterior segment syndrome (TASS), refractive outcomes, or reim- bursement issues for the second eye. Of the 66 responses, about 21% indi- cated that they are worried about an infection or TASS, about 15% said they are worried about refractive outcomes, and about 12% said they ISBCS is performed around the world, but some physicians still show hesitation and concern S teve A. Arshinoff, MD, Toronto, and Kent Stiverson, MD, Denver, Colo., discussed immedi- ately sequential bilateral cataract surgery (ISBCS) during the "Cataract Dilemmas" symposium at the 2014 ASCRS•ASOA Symposium & Congress in Boston, with Dr. Arshinoff highlighting the interna- tional perspective and Dr. Stiverson focusing on the U.S. perspective. Audience response Audience members at the sympo- sium were asked to weigh in on the topic. Responses focused on how far apart patients are booked for cata- ract surgery in each eye and for what Controversy around immediately sequential bilateral cataract surgery At the 2014 ASCRS•ASOA Symposium & Congress, the "Cataract Dilemmas" symposium highlighted many con- troversial and cutting-edge issues, in- cluding immediate sequential bilateral cataract surgery (ISBCS) and the opin- ions of 2 thought leaders from Canada and the U.S. It was interesting to note that of the responses from the audience, about 7% of audience members were already performing same day sequential bilateral cataract surgery, while about 64% preferred a staged surgery and booking the second eye within 2 weeks after the first eye. Reasons listed for not performing ISBCS were fear of TASS, refractive outcome, and reimbursement issues. The following article highlights why our opinion leaders perform ISBCS and the issues or non-issues they have encountered. –Rosa Braga-Mele, MD, ASCRS Cataract Clinical Committee chair Audience members who do not perform immediately sequential bilateral cataract surgery were asked to give their reasons. Source: ASCRS on the same day 75% of the time when there are operable cataracts in both eyes. "Of these patients, 10% will call back and request different day surgery," he said. He goes into patient consultations assuming that most will be undergoing same day surgery, but comorbidities and pa- tient comfort can play a role in per- forming surgery on different days. "The fact that only 7% of doctors who responded book eyes for same day surgery would seem to support the status quo," Dr. Stiverson said. "Conversely, I am encouraged that so many doctors are doing eyes 1 to 2 weeks apart." Why don't surgeons perform bilateral cataract surgery? The concerns expressed in the second question were evenly split Operating on patients with Fuchs' dystrophy Fuchs' dystrophy patients are at risk for needing endothelial keratoplasty (EK) even with intermediate-grade disease, so leave these patients myo- pic and avoid hydrophilic IOLs, Dr. Lee said. EK procedures leave patients hyperopic, even with advanced surgical techniques. "Even with DMEK we still see hyperopic shifts, anywhere from –0.5 [to] –1 D," Dr. Lee said. Aim for about –0.50 [to] –1 D of residual myopia if you think the patient will need EK surgery in the future, he said. IOL opacification has also been described in Fuchs' patients who have undergone DSAEK (Descemet's stripping automated endothelial keratoplasty) after cataract surgery. The opacification is due to hy- droxyapatite deposition on the IOL surface as a result of a reaction to the air bubble, Dr. Lee said. It occurs in the center of the visual axis and often requires an IOL exchange, he said, so avoid placing hydrophilic IOLs in Fuchs' patients to circum- vent this problem. EW Editors' note: Dr. Lee has no financial interests related to his comments. Contact information Lee: lee0003@aol.com Complex cataract continued from page 80

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