Eyeworld

EW FEATURE 52 Controversies in ophthalmology • June 2016 the ambulatory surgical center, and cost to the third-party payer. The economic benefit fell on the patient, not the surgeon, the study authors found. "From the physician's per- spective, same-day bilateral cat- aract surgery had similar clinical outcomes but almost an entirely negative economic impact compared with separate-day bilateral cataract surgery," the study authors wrote. Based on these conclusions, the study authors made reimbursement recommendations to the Centers for Medicare and Medicaid Services. Based on the number of Medicare patients receiving cataract surgery and the percentage of them hav- ing their second eye operated on within 3 months, the study authors wrote that adopting their recom- mendations could yield a net 2% savings—$72 million annually—on the $3.4 billion annually spent by Medicare on cataract surgery. Since his first ISBCS in the 1980s, Dr. Arshinoff has watched the conversation about same-day cataract surgery change from "total- ly negative" toward a conversation where he thinks "everyone is going to start doing [same-day] bilateral cataract surgery." But for now, the centuries-long debate continues. EW References 1. del Castillo M. Operación de las cataratas bilaterales en sesión única. Studium Ophthalmologicum. 1986;5:84–8. 2. Lundström M, et al. Benefit to patients of bilateral same-day cataract extraction: Randomized clinical study. J Cataract Refract Surg. 2006;32:826–830. 3. Lansingh VC, et al. Benefits and risks of immediately sequential bilateral cataract surgery: a literature review. Clin Experiment Ophthalmol. 2015;43:666–72. 4. Witkin AJ, et al. Postoperative hemorrhagic occlusive retinal vasculitis: Expanding the clin- ical spectrum and possible association with vancomycin. Ophthalmology. 2015;122:1438– 1451. 5. Rush SW, et al. Prospective analysis of outcomes and economic factors of same-day bilateral cataract surgery in the United States. J Cataract Refract Surg. 2015;41:732–739. Editors' note: The physicians have no financial interests related to their comments. Contact information Arshinoff: ifix2is@gmail.com Mamalis: nick.mamalis@hsc.utah.edu Stiverson: rkstiverson@live.com What are the concerns? Physicians have cited the risk of bilateral endophthalmitis and toxic anterior segment syndrome (TASS) among primary concerns for per- forming ISBCS. A review published in 2015 in Clinical & Experimental Ophthalmol- ogy, however, stated that "evidence does not support the fear of bilateral endophthalmitis resulting from the simultaneous procedure." 3 The risk for infection is at least theoretical, but as Dr. Arshinoff put it, "everything you do in life has a risk. We choose the path with the least risk, not no risk." "How do you reduce the risk? Use intracameral antibiotics," he said. "To not use intracameral antibi- otics with ISBCS is not defensible in my opinion," Dr. Stiverson said. However, intracameral antibi- otics are not yet approved by the U.S. Food and Drug Administration (FDA) for this indication. The FDA has approved a randomized, double blind clinical trial, which has not begun recruiting participants, that will determine the safety but not efficacy of intracameral vancomycin and moxifloxacin. Recent reports of hemorrhagic occlusive retinal vasculitis after intracameral van- comycin use present a significant obstacle in studying vancomycin intracamerally. 4 Dr. Stiverson said that he is more comfortable with the off-la- bel use of these antibiotics because Kaiser Colorado has a compounding pharmacy with a good reputation for ophthalmic preparations. Dr. Arshinoff also advised surgeons doing ISBCS to make sure incisions are sealed to help reduce the risk of endophthalmitis. "Leak- ing incisions are a leading cause of postoperative endophthalmitis." As for reducing risk of TASS, Dr. Arshinoff pointed to the "iSBCS General Principles for Excellence in ISBCS 2009," guidelines estab- lished by the society for various best practices, which include the use of intracameral antibiotics as well as treating the second eye as a com- pletely separate surgery, redraping the patients, rescrubbing, etc. If any part of the surgery is changed, Dr. Arshinoff said every- one from the nursing staff to the surgeon to whoever buys materials is involved in the decision about what is being changed and why. He also said nothing used on the patient's first eye during surgery is used for the second. "By doing that, there hasn't been a single case of TASS reported in bilateral cataract surgery in the world," he said. Is reimbursement a barrier? While patient safety is always the physician's top priority, some can- not ignore the reimbursement fac- tor. In the United States for example, Medicare reduces reimbursement of the surgeon's and the facility's fees to 50% for the second eye if operat- ed on the same day. "Obviously, this is not sustain- able because the cost of doing the second eye is about the same as the first—we are doing 2 completely sep- arate procedures," Dr. Stiverson said. Dr. Mamalis agreed that the financial burden is a factor in a surgeon's decision-making process regarding ISBCS in the U.S. "I think being convinced of the safety issues and advantages of the efficacy are going to be things that we're going to think about first, but we do have to think about the finan- cial aspects," he said. Dr. Arshinoff said that due to recent reimbursement changes in Ontario, Canada, which went from 85% for the second eye to "essential- ly nothing," he no longer practices in a hospital setting. In January 2016 he started performing ISBCS in a private center and now has a 6-month wait list. "The patient has to think, 'How much does it cost me to take a month off work and how much does it cost me to pay for the surgery?'" he said. "It's a lot cheaper to pay for the surgery." Even with some of the reim- bursement disparity, Dr. Arshinoff said it might still be worth it for physicians to consider performing ISBCS as savings could be realized through fewer visits to the clinic and time saved in the operating room, which could allow for more patients to be seen in the long run, for example. A prospective, controlled, non- randomized clinical trial involving 42 patients in a private practice by Sloan Rush, MD, Panhandle Eye Group, Amarillo, Texas, et al published in 2015 in the Journal of Cataract & Refractive Surgery evaluat- ed the visual and economic benefits of ISBCS and found that the over- all cost of ISBCS was lower. 5 The economic factors included the total number of patient visits, distance and time traveled for patients, phy- sician reimbursement for bilateral surgery, total reimbursement for said 1 great benefit of ISBCS to patients is the ability to produce the desired refractive result postop day 1 in both eyes, whatever the patient wants. A study published in the Journal of Cataract & Refractive Surgery com- pared clinical and patient-reported refractive outcomes of ISBCS with those of DSBCS. 2 The study found that in the 2 months postop, those in the DSBCS group were "significantly worse." After 4 months though (2 months after their second eye surgery and 4 months after their first, 4 months after surgery in both eyes for ISBCS), the differences between the 2 groups was insignificant. "I haven't had a single patient who came back and told me they were unhappy with having both eyes done at once," Dr. Arshinoff said. "I've had a lot of patients who came back and told me they wish they had chosen to do both eyes at once rather than DSBCS." To achieve this level of satis- faction though, Dr. Arshinoff said discussing patient expectations is exceedingly important. Dr. Arshinoff said if surgeons are using modern methods for IOL power calculations and have had extensive discussions with their patients about their day- to-day activities and expectations, refractive outcomes should not be a problem. He also said that he finds doing the surgery on the same day actually better prepares him for the surgical procedure on the second eye. "The best time to do the other eye is just after I finish the first eye because I know exactly what kind of problems I'll have in the second eye," he said. Dr. Stiverson said despite the fact that he rarely changes his orig- inal IOL choice for the second eye, he still recommends patients wish- ing for spectacle independence have cataract surgery on different days. Dr. Mamalis also related to this idea of delaying the second surgery in order to learn from the first eye and make adjustments in the second in the event of a poorer than expect- ed refractive outcome. "If a patient experiences prob- lems with an implant in 1 eye, for example dysphotopsia or another visual phenomenon, you may want to reconsider what implant you're going to put in the second eye," Dr. Mamalis said, noting that he has not yet encountered such an issue with his ISBCS patients. Immediately continued from page 50

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