Eyeworld

EW FEATURE 128 Controversies in cataract surgery • April 2017 cause I want them to do something frequently to reinforce that they keep their fingers out of their eyes." Four days should be long enough for the incisions to heal, he believes. "In the last few years there has been a huge increase in ISBCS in the United States, and you're going to have more," Dr. Arshinoff said. "Ev- eryone is going to find out that it is better." He remains convinced that it is a mistake for Medicare to limit reimbursement, since it is the gov- ernment who will ultimately save the most money as more surgeons perform ISBCS. "You have Americans taking tons of days off work to take their parents for surgery," he said, "You would reduce the time off work by half by doing bilateral surgery." But for now, at least, while the pro- cedure continues to gain followers, many must continue to deal with financial hurdles. EW Reference 1. ESCRS Study Group. Prophylaxis of postop- erative endophthalmitis following cataract sur- gery: Results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33:978988. Editors' note: Dr. Arshinoff has financial interests with Alcon (Fort Worth, Texas), Abbott Medical Optics (AMO, now Johnson & Johnson Vision [J&J Vision, Santa Ana, California]), Rayner (Hove, United Kingdom), and Carl Zeiss Meditec (Jena, Germany). Dr. Donaldson has financial interests with Alcon, AMO (now J&J Vision), and Bausch + Lomb (Bridgewater, New Jersey). Dr. Solomon has financial in- terests with Ocular Science (Manhattan Beach, California). Contact information Arshinoff: ifix2is@gmail.com Donaldson: KDonaldson@med.miami.edu Solomon: jdsolomon@hotmail.com When it comes to informed consent, Dr. Arshinoff notes that while those who are new to bilateral surgery may go into more detail in their consent form, those who have been doing this for a long time may not. "In the beginning, many orga- nizations demand a longer consent for all the risks of doing bilateral surgery, but there aren't any," he said. "According to the literature, there is no publication showing that the risks are greater." In performing the surgery itself, Dr. Arshinoff always starts with the left eye first to help assure better sterility. "It so happens that when I do the left eye, I'm on the left side of the patient, and the instruments for the other eye that they may be bringing in before the first eye is completed enter on the right side of the room, in our setup," he said. Deciding whether to move on to the second eye depends on what happens with the first. Dr. Don- aldson believes that all potential complications should be resolved before the second eye is attempted. She starts with the eye that is at slightly higher risk for complication if there is one. "You want to do the higher-risk eye first, to make sure that it goes OK before going towards the lower-risk case," Dr. Donaldson said. The fact that the second eye may need to be left for another day should be included in the informed consent, she said. "The patient has to understand that we're planning to do both eyes on the same day. However, we might not do that if the first eye does not go smoothly as expected," Dr. Donaldson said. Likewise, Dr. Arshinoff waits to see what happens with the first eye. If, for example, he breaks the capsule, he won't do the second eye. However, he has only halted five bi- lateral surgeries in his entire experi- ence of over 10,000 eyes undergoing ISBCS, most as a result of extraneous issues, such as a patient with severe back issues that day who couldn't relax properly for the second eye operation. After the surgery, Dr. Arshinoff recommends initially giving patients frequent drops. "I know there is a movement in the United States to give patients drop-free surgery, but I'm actually marginally against that," he said, adding that this reluctance stems from the tendency that when patients don't have to administer drops, they may forget that they need to be careful and avoid touching the eye. Instead, he instructs patients to wear a pair of glasses continuously for the first 4 days to "make them more comfort- able" and to put drops in 6 times a day. "The real role of the glasses is to keep their fingers out of their eyes," Dr. Arshinoff said. "I also tell them to put drops in 6 times a day be- a dozen of these studies now, and every one of them shows a differ- ence in the infection rate changing from the local rate with no IC agent to being one-eighth of what that was," Dr. Arshinoff said. Dr. Solomon said that results in his practice support simultane- ous sequential same-day surgery without increasing the likelihood of vision-threatening complications. When it comes to the informed con- sent process, he stresses to patients his high comfort level with the bi- lateral procedure. "I would certainly say that I am very comfortable with a family member or myself under- going the procedure in this way, because it is my sincere belief that overall we are reducing the relative risk of complications and increasing the benefits by providing this simple service," he said. "We have this as part of our consent form as well as our exam notes and also as part of our verbal communications, as part of our electronic health records." Cataract continued from page 127 " You want to do the higher-risk eye first, to make sure that it goes OK before going towards the lower-risk case. The patient has to understand that we're planning to do both eyes on the same day. However, we might not do that if the first eye does not go smoothly as expected. " —Kendall Donaldson, MD ascrseyeconnect.org/eyeconnect365app

• Blank Page
• Blank Page (1)