Eyeworld

EW FEATURE 60 Controversies in ophthalmology • June 2016 by EyeWorld Staff S urgeons have varying protocols for cataract and refractive procedures. In the 2015 ASCRS Clinical Survey, ASCRS members were surveyed about their surgical practices. Here are some of the re- sults regarding the more controver- sial issues in ophthalmology. Ophthalmologists were asked about their antibiotic use before, during, and after cataract surgery. The survey found no consensus majority protocol, and antibiotics were used preoperatively (either 1 day or 3 days preop) by one-third of respondents. "Europeans have led the way in studying the use of intracameral an- tibiotics," said John Berdahl, MD, Sioux Falls, South Dakota. "Ameri- can surgeons are using them more and more, but I think non-U.S. sur- geons, and particularly Europeans, will continue to lead the way as they have the most experience and have generated the most data. Additional- ly, there is a financial disincentive in the U.S. to use intracameral antibi- otics (even though it saves patients and the system money) because they are currently not reimbursed in the surgical setting." Surgeons were asked how often they perform simultaneous bilat- eral cataract surgery. Seventy-two percent said that they don't per- form simultaneous bilateral cataract surgery (79% for U.S. surgeons and 65% non-U.S.), while 11% said they perform it for extenuating circum- stances (7% for U.S. surgeons and 16% for non-U.S. surgeons). Surgeons who perform simulta- neous bilateral cataract surgery were asked their primary reason for doing so. The most common reason was extenuating circumstances followed by patient convenience (Figure 1). According to Boris Malyugin, MD, Moscow, there are several reasons explaining the modest popularity of simultaneous bilateral cataract surgery today. "There are patient-related reasons. Often, when a patient with a cataract is admitted to the eye clinic, his or her vision in 1 eye is worse than in the other, and it is hard to convince the patient [to have] 2 surgeries at the same time rather than doing that in a sequen- tial manner," he explained. He noted that there are also surgeon-related factors. "Many surgeons think that if any kind of devastating event happens during or after the surgical procedure (i.e., intraocular hemorrhage, infection, etc.), it is better to 'preserve' the second eye and keep it intact," he added. There are economic reasons because "in many health systems, the simultaneous second eye surgery is either not reimbursed at all or reimbursed at a fraction of the price of the first surgery. So in many cases, it is economically unreasonable to perform 2 surgeries at 1 time," he explained. Additionally, he noted that sev- eral published studies show the ben- efit of adjusting the IOL power in the second eye based on the refrac- tive results of the first eye surgery. Regarding laser vision correc- tion, surgeons were asked, "What category of ablations are the majori- ty of your corneal refractive proce- dures, currently and in the next 2 to 3 years?" Eighty-one percent of U.S. surgeons said that they currently use wavefront ablations (52% use customized and 29% use optimized). Non-U.S. surgeons were evenly split among wavefront-customized (26%), wavefront-optimized (27%), and standard ablations (27%) (Figure 2). Seventy-nine percent of U.S. surgeons said that they plan to use wavefront in the next 2 to 3 years (44% customized and 34% opti- mized). For non-U.S. surgeons, the percentage who will use topography- customized ablations increases to 18%, and the percentage who will use femtosecond intrastromal lenti- cule extraction increases to 16%. Surgeons were also asked, "What percentage of your current corne- al refractive procedures involves femtosecond intrastromal lenticule extraction?" Controversies in ophthalmology Figure 1. Surgeons who perform simultaneous bilateral cataract surgery were asked their primary reason for doing so. I don't perform bilateral cataract surgery 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Faster overall visual recovery Improved safety Patient convenience Surgeon convenience Lower cost Extenuating circumstances (general anesthetic/mentally challenged patients) Other Eighty-three percent of surgeons said that none of their current cor- neal refractive procedures involves femtosecond intrastromal lenticule extraction (90% of U.S. surgeons and 76% of non-U.S. surgeons), while 13% said that 10% or more of their procedures involves femtosecond intrastromal lenticule extraction. EW Editors' note: Dr. Berdahl and Dr. Malyugin have no financial interests related to their comments. Contact information Berdahl: john.berdahl@vancethompsonvision.com Malyugin: boris.malyugin@gmail.com Figure 2. Surgeons were asked, "What category of ablations are the majority of your corneal refractive procedures currently?" Source: ASCRS Wavefront-customized 0% 10% 20% 30% 40% 50% 60% Wavefront-optimized Topography-customized Femtosecond intrastromal lenticule extraction Standard ablations Other All U.S. Non U.S. All U.S. Non U.S.

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