Eyeworld

EW FEATURE 126 Controversies in cataract surgery • April 2017 AT A GLANCE • Bilateral cataract surgery is more convenient for the patient. • A growing number of U.S. practitioners are interested in performing bilateral sequential cataract surgery; however, they must contend with lower Medicare reimbursement. • Use of intracameral antibiotics can help ensure that infection rates remain low with the bilateral cataract approach. by Maxine Lipner EyeWorld Senior Contributing Writer The pros and cons of immediately sequential bilateral cataract surgery P ractitioners often hear a request to get both of a pa- tient's cataracts treated in one fell swoop with imme- diately sequential bilateral cataract surgery (ISBCS), according to Kendall Donaldson, MD, asso- ciate professor of ophthalmology, Bascom Palmer Eye Institute, Miami. "Patients love the idea—it's a very efficient way to do things," Dr. Don- aldson said. "They would just like to have both of their eyes done and be on with it." Still, many practitioners shy away from the idea, worried about the potential for bilateral complications and financial barriers. all of those people you didn't want to do initially, you do after you have gained experience because they're simply better off with ISBCS," he said, adding that the patient with dense cataracts and glaucoma ulti- mately gains more with the bilateral approach. Patients with complicated cataracts would rather come in for 3–4 visits altogether than to have to do the same routine over twice. There is a much greater chance that they will be compliant with the bilateral approach, Dr. Arshi- noff stressed. "For me, now there is almost nobody that I won't do both eyes in," he said. "The only patients that I won't do are those that have Fuchs' dystrophy, with their border- line corneas. Furthermore, postop- erative refractive errors are rarely a significant concern with modern biometric techniques." Jonathan Solomon, MD, di- rector, Solomon Eye Physicians and Surgeons, Bowie Vision Institute, Bowie, Maryland, tends to look for cataract patients who are healthy and buy into the idea of rapid recov- ery. He points out that the bilateral approach is already used for refrac- tive procedures such as LASIK and PRK, as well as those who are under- going phakic IOL surgery. Likewise, individuals who come in for refrac- tive lens exchange have also been extended access to the approach, Dr. Solomon points out. "These are individuals who don't necessarily have an opacity to their crystalline EyeWorld took a closer look at this somewhat controversial procedure. Some surgeons in the United States who might otherwise be in- terested in pursuing ISBCS may find themselves constrained by finan- cial realities, Dr. Donaldson said. "Most of our insurance policies will not cover us for bilateral same-day surgery, or you need to get some type of exception," she said, adding that everyone needs to check their insurance coverage before they start using this approach. In California, Kaiser Permanente fully reimburses for it; however, Medicare will only pay 50% for the second eye, Dr. Donaldson notes. "So, most people are penalized for doing the second eye the same day," she said. As a result, many are inclined to reserve ISBCS for select patients. "We tend to only do it on a patient that, let's say, we have to put under gen- eral anesthesia," Dr. Donaldson said, adding that this may include a small child, perhaps someone who has Down syndrome, or an elderly pa- tient who's a little bit compromised and needs general anesthesia, where the risk of putting them under twice is a compelling factor. Growing U.S. contingent Nonetheless, many surgeons in the U.S. are intrigued by the concept and have joined the International Society of Bilateral Cataract Sur- geons (iSBCS), according to Steve A. Arshinoff, MD, associate professor, Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada, who is co-president of the society. "At our last count, we had 160 members from over 31 countries," he said. Initially, most members were Cana- dians, followed by those from the United Kingdom, and then India, he noted. "However, now the biggest group—twice as big as Canadi- ans—is Americans," Dr. Arshinoff said. Accounting for this is the fact that the United States itself is much larger than Canada and the fact that once some American groups started performing bilateral surgery, others didn't want to be left out. "If you own a surgical center in Los Ange- les and the guy next door is doing bilateral surgery because he belongs to Kaiser, you want to know what's going on," he said. When individuals do begin opt- ing for bilateral same-day cataract surgery, they usually carefully select their patients. "They look for people who don't have very dense cataracts, people who are cooperative, those who obviously need surgery in both eyes but both eyes aren't that terri- ble, with say one eye that is 20/50 and the other 20/80 with moderate nuclear sclerosis cataracts; and also a patient who will lie still and will tol- erate the procedure uneventfully," Dr. Arshinoff said. However, as the OR staff gain experience, it becomes a different story, he finds. "Almost Cataract double take Monthly Pulse Controversies in cataract surgery T he topic of this Monthly Pulse survey was "Controversies in cataract surgery." We asked participants to identify their concerns when using intracameral antibiotics: TASS, HORV, compounding/dosage issues, or all three. The majority of respondents to this question selected all three as concerns. The second question asked participants to identify "dropless" cataract surgery options at their practices: transzonular, pars plana, or intracameral injection of steroid/antibiotic mixture. The majority of respondents selected "none of the above." In the third question, we asked participants to complete the sentence, "I find that topical NSAIDs are beneficial to use in…" The majority of respondents to this survey said, "All cataract surgery patients (except those with corneal issues)." Finally, we asked participants to complete the sentence, "I would perform same day bilateral sequential cataract surgery on all patients if…" The majority of respondents said both "Medicare reimbursement was equal and fair for both eyes" and "There was an FDA-approved intraca- meral antibiotic injection."

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