Eyeworld

EW CATARACT 34 October 2015 "What's important is that if you do the first eye and there is any side effect or complication that can't be dealt with at the time of the surgery, surgery for the second eye should be aborted. If the capsule breaks on the first eye, even if you manage to clean it up nicely like nothing went wrong, you should not proceed to the second eye," she said. Clinics will one day acknowl- edge the benefits of ISBCS in terms of saving time and money with decreased surgical workload, less staff, and fewer visits required, Dr. Braga-Mele said. "I don't think ISBCS is ready for primetime just yet. Reimbursement issues are a fact, and we still have cases, although very uncommon, of endophthalmitis and TASS that can be devastating for vision," she said. "Unilateral for me is also a tradition. I've being operating for 18 years and have been being doing it in a de- layed fashion. It will be hard to get into [a new] momentum, but patient requirements are what ultimately matter." EW Editors' note: Dr. Braga-Mele has no financial interests related to this article. Contact information Braga-Mele: rbragamele@rogers.com by Timothy Norris EyeWorld Contributing Writer "It is recommended to have the patient sign two separate consent forms, one for each eye. You need a separate set of instruments, a whole separate scrub setup, and different lot numbers for viscoelastics and lenses," she said. Reimbursement issues are still a major hurdle in the adoption of ISBCS, Dr. Braga-Mele pointed out. "I think the biggest drawbacks right now are the financial impli- cations to the physician. In the U.S., 100% of the first eye is paid, but only 70% or 80% of the second eye is paid. In Canada it's the same way, and in some places around the world such as Japan or Israel, the second eye is not paid at all. This is a huge financial disincentive," she said. Another drawback involves the patient's feedback after first-eye surgery. Delayed surgery allows more accurate calculation of the IOL pow- er in the second eye to obtain better overall visual outcomes. "If you do one eye at a time, you can ask patients about their visual perfor- mance after surgery, and you don't have that benefit if you do ISBCS," Dr. Braga-Mele said. A protocol for second-eye surgery is very important before starting ISBCS. are driving it and it's in the patient's best interest to have ISBCS, I think the option needs to be there," she said. ISBCS leads to considerable Medicare savings in terms of patient visits and cost per case, she noted. Individual and social savings come from the patient not having to trav- el as much and taking less time off work. Visual rehabilitation is faster, as binocular vision is gained imme- diately after surgery. "ISBCS should be highly con- sidered in cases requiring general anesthesia due to health or mental issues—no matter what the costs are. If you're going to put a patient to sleep for a surgery that is normally done under topical and local anes- thetic, it's important to be ready to do both eyes in one sitting if needed because the risks of general anesthe- sia are high," Dr. Braga-Mele said. Specific protocols with addition- al safety and sterility measures are needed for ISBCS to avoid contami- nation and prevent endophthalmitis and TASS, she pointed out. These can be found on the wesbite of the International Society of Bilateral Cataract Surgeons (iSBCS.org). Physician shares why she thinks immediately sequential bilateral cataract surgery (ISBCS) is likely to become a patient-driven phenomenon in the future C ataract surgery has tradi- tionally been staged in two separate sessions, 1–2 weeks or even 1 month apart. "Delayed sequential bilateral cataract surgery is still the standard procedure nowadays," said Rosa Braga-Mele, MD, professor of ophthalmology, University of Toronto, and director of cataract surgery, Kensington Eye Institute, Toronto. "However, ISBCS, in which both eyes are operated on the same day, is gradually gaining popularity. In Finland, 47% of cataracts are per- formed simultaneously, and in Can- ada and the U.S., the current rate is somewhere between 2% and 7%. "It will be hard to get into that momentum, but ultimately the patients matter and if the patients Benefits of ISBCS to patients and clinics Specific protocols with additional safety and sterility measures are needed for ISBCS to avoid contamination and prevent endophthalmitis and TASS. Dr. Braga-Mele recommends having patients sign two separate consent forms, one for each eye. Source: Nick Mamalis, MD " Unilateral for me is a tradition. I've being operating for 18 years and have been being doing it in a delayed fashion. It will be hard to get into [a new] momentum, but patient requirements are what ultimately matter. " –Rosa Braga-Mele, MD

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