Eyeworld

EW RESIDENTS 60 April 2015 by Jack Shao, MD, and Jeffrey M. Goshe, MD, Cole Eye Institute, Cleveland Clinic outcome measures included intraop- erative and postoperative complica- tions, final best spectacle-corrected visual acuity, and error in refractive outcome from intended target. Also recorded were economic factors for the patient, physician, ambulatory center, and third-party payer. Cost to the patient was measured by time and expenses required for surgery and recovery, number of visits required for care, and total distance required for travel. Economic factors for the physician, ambulatory sur- gery center, and third-party payer included total reimbursement for surgery and postoperative care, and C ataract surgery is the most performed outpatient surgery in the United States. 1 Advances in phacoemulsification tech- nology, foldable lenses, intracameral antibiotics, and smaller incisions have made modern cataract surgery one of the safest and most success- ful surgeries in history. Despite its growing popularity, simultaneous or same-day bilateral cataract surgery remains a topic of heated debate and controversy. Most same-day bilateral cataract surgeries are still performed outside the United States. Supporters of simultaneous surgery point out not only the similar safety and out- comes, but also the socioeconomic benefits to patients, healthcare pro- viders, and third-party payers alike. 2 Critics of same-day bilateral cataract surgery are wary of major safety con- siderations such as endophthalmitis and refractive surprises that could potentially alter planning for the second eye. 3 In the April issue of the Jour- nal of Cataract & Refractive Surgery (JCRS), Rush et al. investigated the outcomes and economic impact of same-day bilateral cataract surgery in the United States. In this non- randomized, prospective study, 42 patients (84 eyes) each were enrolled into the same-day bilateral cataract surgery study arm and the separate- day bilateral cataract surgery control arm. All patients enrolled had bilateral visually significant cataracts that met existing Medicare criteria. Patients were excluded from the study if they were deemed unsuit- able for topical anesthesia, had con- current visually significant retinal disease, active uveitis, advanced or poorly controlled glaucoma, visually significant corneal disease, previous history of corneal or refractive sur- gery, pseudoexfoliation syndrome, small pupils requiring intraoperative pupillary expansion techniques, or an immunocompromised state. The clinical trial was approved by the RCRC Independent Review Board in Austin, Texas. All phacoemulsi- fication surgeries were performed in a single private practice ambu- latory surgery center by 2 different surgeons. All patients underwent a standardized protocol, including administration of topical tetracaine 1% and/or proparacaine 1% and the use of 5% povidone-iodine cleansing solution to the ocular fornices prior to draping. The intraoperative rou- tine and technique was surgeon-spe- cific but all included the use of in- tracameral vancomycin 1 mg at the end of the surgery. In the same-day study group, the fellow eye was in- dependently and separately prepared using new sterile draping, gloves, gowns, surgical devices, and instru- ments. Patients in the control group received sequential cataract surgery within a 1–3 week time period from the first surgery. Postoperatively, all patients received topical ofloxacin for 1 week, and prednisolone drops 4 times a day for 21 days. In either group, surgery was aborted in the fellow eye if any significant intraop- erative complication occurred in the first eye. Baseline patient characteristics included standard demographic data as well as insurance type and logis- tical information regarding travel to and from the appointments. Key Review of "Prospective analysis of outcomes same-day bilateral cataract surgery in the A prospective analysis of outcomes and economic factors of same-day bilateral cataract surgery in the United States Sloan W. Rush, MD, Ashley E. Gerald, MA, Jason C. Smith, BA, J. Avery Rush, MD, Ryan B. Rush, MD J Cataract Refract Surg (April) 2015;41:732–739 Purpose: To investigate the visual and economic benefits of same-day bilateral cataract surgery versus separate-day bilateral cataract surgery in the United States. Setting: Single location private practice Design: Prospective controlled nonrandomized clinical trial Methods: A cohort of 42 subjects (84 eyes) underwent same-day bilateral cataract surgery and was age-matched with a cohort of 42 control subjects (84 eyes) that underwent standard separate-day bilateral cataract surgery. The primary outcome was a comparison of the direct cost for the patient, physician, ambulatory surgery center and third-party payer between cohorts. Results: The same-day cohort had similar baseline characteristics and postoperative outcomes to the control cohort. The same-day cohort had less total distance traveled for care (p=0.0039 and p<0.0001 for in-town and out-of-town residents, respectively), less total time spent traveling for care (p=0.0008 and p<0.0001 for in-town and out-of-town residents, respectively), less total number of visits required for care (p<0.0001), and less total time for vision recovery (p<0.0001) compared to the control cohort. The physician and ambulatory surgery center reimbursements were lower in the same-day cohort (p=0.0028 and p=0.0016, respectively), whereas the total physician time spent caring for the patient in surgery was not different among the two groups (p=0.7310), and the total ambulatory surgery center expenses were higher in the same-day cohort (p<0.0001). The total third-party payer cost was substantially less in the same-day cohort (p<0.0001). Conclusions: Visual and economic benefits for the patient can be achieved with same-day bilateral cataract surgery in the United States at the present time. Jack Shao, MD Jeffrey M. Goshe, MD The practice of bilateral sequential same-day cataract surgery is certainly controversial, and economic factors are very relevant to this debate. This month, the Cleveland Clinic residents review an interesting prospective analysis published in this month's JCRS. –David F. Chang, MD, chief medical editor EyeWorld journal club

• Cover