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EW FEATURE 50 Controversies in ophthalmology • June 2016 AT A GLANCE • Supporters of same-day bilateral cataract surgery say it's more convenient for the patient, safe, and yields a faster visual recovery. • Skeptics point to its risk for bilateral infection and how it eliminates the opportunity for the surgeon to learn from the first eye and make adjustments for the second. • Lower reimbursement for the second eye poses a significant barrier for some. by Liz Hillman EyeWorld Staff Writer good candidates: those with bilateral diabetic retinopathy (unless referred by a retina surgeon first because of limited retinal view for exam- ination) and those with advanced Fuchs' dystrophy due to the chance of postoperative corneal edema bilaterally. While Dr. Stiverson said he does not consider mild Fuchs' a contra- indication, he will not do ISBCS on a patient with diabetic retinopathy within the arcades of either eye, moderate glaucoma, significant keratitis sicca, RK, keratoconus, uveitis, and a few other cases. What's the appeal? In addition to reducing the number of trips a patient makes to the surgi- cal center and clinic, Dr. Arshinoff "Those special circumstances would be if the patient is from a long way away and the travel for 2 surgical procedures is a great hardship, or if the patient is men- tally challenged, for example, and requires general anesthesia for sur- gery," Dr. Mamalis said. Dr. Arshinoff presented data at the 2016 ASCRS•ASOA Symposium & Congress that showed only 5% of ASCRS members and 10% of European Society of Cataract & Refractive Surgeons (ESCRS) mem- bers perform ISBCS. In Finland, however, up to 50% of all cataract surgeries are performed as ISBCS. Although extensive experience with this procedure has Dr. Arshinoff being more inclusive in his patient selection for ISBCS than earlier on, he said there are a few patients who would not be Over the last few decades, as more research has been presented on the topic, Dr. Mamalis said he's seen people who were adamantly opposed to ISBCS beginning to look at some of the purported advantag- es compared to delayed sequential bilateral cataract surgery (DSBCS). Proponents of ISBCS say that when strict surgical procedures are followed, removing both cataracts on the same day is not only safe but convenient, efficient, beneficial, and could be cost-saving. Opponents cite the risk of bilateral infection, reduced opportunity to adjust an IOL for the second eye, and lower reimbursement rates as drawbacks. Choosing to do ISBCS The first time Dr. Arshinoff was faced with a case of ISBCS was in the 1980s. The patient was an Indian woman who had active tuberculosis, hypermature cataracts, and bilateral angle closure due to intumescent cataracts. Waiting until the TB was treated to do DSBCS, at the risk of her going blind, was not an option, Dr. Arshinoff said. She obtained an excellent visual result bilaterally. In the 1990s he encountered a woman who requested bilateral cataract surgery at the same time because as a race car driver, the patient couldn't afford the time it would take for her vision to recover after 2 separate surgeries. The day after ISBCS, this patient was 20/20 in both eyes and ecstatic, Dr. Arshinoff said. Since then, the number of his ISBCS patients has grown to 80% of his surgical practice; he's done more than 9,950 such cases. For some patients, it's a necessity; for most— the growing majority—it's a conve- nience and a hope for faster visual recovery. Richard Stiverson, MD, Lake- wood, Colorado, said half of his patients request same-day cataract surgery. "In the same way that our patients are given options as to what type of IOL they want, where they want their eyes to focus post-surgery, and whether they want laser-assisted surgery, I think they should have the option of choosing ISBCS," Dr. Stiverson said. Dr. Mamalis, on the other hand, reserves ISBCS only for extenuating circumstances. ISBCS is gaining interest as more data becomes available T he overwhelming standard for patients with cataracts in both eyes is to operate on the second eye several weeks after the first. An increasing group of surgeons, a growing body of literature, and a significant number of patients, how- ever, are supporting, if not advocat- ing for, both eyes to be done on the same day. The debate as to whether surgeons should perform what is formally known as immediately sequential bilateral cataract surgery (ISBCS) apparently dates back to the Middle Ages. Strong ISBCS propo- nent Steve Arshinoff, MD, FRCSC, associate professor, University of Toronto, and co-president of the International Society of Bilateral Cataract Surgeons (iSBCS), cited a 1986 study by del Castillo that ref- erenced how far back this "fiercely heated" topic goes in an article pub- lished in Ophthalmology Rounds, a publication from the Department of Ophthalmology and Vision Sciences at the university. 1 While still perhaps fiercely debated, some would say the tide is beginning to change. "I think this is something that people are looking at more closely than they would have in the past," said Nick Mamalis, MD, professor of ophthalmology, John A. Moran Eye Center, University of Utah, Salt Lake City. "At least in the United States though, it's still a relatively uncommon procedure." Immediately sequential bilateral cataract surgery: Should it be done? A patient with Duchenne muscular dystrophy developed cataracts at a young age, making reading or playing games on a tablet impossible. After careful planning to move him with a special lift from his wheelchair for surgery, Dr. Arshinoff performed ISBCS with monovision. Postop day 1, this patient was able to see 20/20 at distance and near. Source: Steve Arshinoff, MD continued on page 52

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