Eyeworld

EW CATARACT 80 April 2017 Cataract editor's corner of the world by Rich Daly EyeWorld Contributing Writer emergency supplies," said Cynthia S. Chiu, MD, professor of ophthal- mology, University of California, San Francisco. "This may be feasible for large groups of cataract surgeons who practice together in the same facility, but it is impossible for small- er groups or surgeons who practice independently." Dr. Chiu, who also would not be comfortable performing office-based cataract surgery, said cataract surgery is best performed in specialized ASCs with dedicated staff who can opti- mize efficiency, safety, and cleanli- ness of the surgical environment. "I do not think it is prudent to encourage surgeons to compromise patient safety and outcomes with office-based surgery at this time," Dr. Chiu said. Divya Srikumaran, MD, assis- tant professor of ophthalmology, vice chair of education, and medical director, Cornea, Cataract Refrac- tive Service, Wilmer Eye Institute, Johns Hopkins University, Odenton, Maryland, noted her organization has high standards and regulations regarding the appropriate surgical environment and standard proce- dures. ment, a higher level of sterility and safety, and expert nursing care." Dr. Devgan, who would not be comfortable—for the most part— performing cataract surgery in the office, noted that cataract surgery is not the same as LASIK surgery in many aspects. "The level of sterility must be much higher for cataract surgery," Dr. Devgan said. "Also, the cataract patients are much older with many more comorbidities. Monitoring the vital signs during cataract surgery is a must, but for LASIK surgery it is essentially never done." Logistical hurdles Among the practical obstacles to office-based cataract surgery was the various equipment and staff sur- geons say would be needed. "I would need to have a minor procedure room equipped with the latest generation of surgical microscope, phaco machine, and femtosecond laser, and be able to maintain surgical instruments, packs, sutures, disposable supplies, and medications, in addition to anesthetics, medications to sup- port patients' systemic health, and Such a common response among surgeons recently inter- viewed followed the Centers for Medicare and Medicaid Services (CMS) seeking public comment in 2015 on the possibility of perform- ing cataract surgery in office-based settings. The CMS said shifting some procedures to the office might im- prove scheduling convenience and offer surgeons increased flexibility for performing routine cases on patients with no comorbidities. Although office-based cataract surgery was seen as potentially reducing Medicare spending below what is paid for cataract surgery in ambulatory surgery centers (ASCs) or hospital outpatient departments, some raised concerns about the health and safety of patients operat- ed on in an office. A 2015 survey of 493 ASCRS members found 52% would be willing to perform surgery in an of- fice-based surgical suite, while 48% said they would not. The largest population-based study to evaluate the safety and efficacy of in-office cataract surgeries found that among 99.7% of 21,501 consecutive procedures performed in minor procedure rooms between 2011 and 2014 at three large inte- grated healthcare centers, postop mean best corrected visual acuity measured 0.14 ± 0.26 logarithm of the minimum angle of resolution units (equivalent to 20/28 Snellen). Intraop ocular adverse events includ- ed 119 (0.55%) cases of capsular tear and 73 (0.34%) cases of vitreous loss, according to the study in the April 2016 issue of Ophthalmology. 1 Safety concerns Patient safety was the leading con- cern among surgeons who recently commented on the possibility of office-based cataract surgery "Most important is that I follow the Golden Rule of surgery—I give each patient the same care and experience that I would want for my own eyes," said Uday Devgan, MD, Devgan Eye Surgery, Los Angeles, Specialty Surgical Center, Beverly Hills, and clinical professor of oph- thalmology, University of California, Los Angeles. "There is an advantage to having surgery in a certified ASC, including the use of a dedicated anesthesiologist, specialized equip- Surgeons note a range of concerns—beginning with patient safety— surrounding the possibility of moving to an office- based setting for cataract surgery D espite previous support among polled surgeons for adding the option of of- fice-based cataract surgery, several surgeons recently voiced deep misgivings with the possibility. "No, I would not currently feel comfortable offering office-base cataract surgery," said John Ber- dahl, MD, Vance Thompson Vision, Sioux Falls, South Dakota. "Cat- aract surgery and other intraocu- lar procedures can become long, arduous, and complicated. Having a professional, highly trained surgical staff around makes you feel more comfortable with taking care of patients." Little appetite for office-based cataract surgery I n this issue's Cataract editor's corner of the world column, we explore the feasibility and issues surrounding office-based cataract surgery. It is an interesting topic to review as a recent article in Ophthalmology showed that although general outcomes seemed good, there were issues with intraoperative complications. Also, a recent ASCRS survey showed that 52% of those surveyed would be interested in performing cataract sur- gery in an office-based setting. However, when asking our panel consisting of John Berdahl, MD, Cynthia Chiu, MD, Uday Devgan, MD, and Divya Srikumaran, MD, they unanimously felt that office-based cataract surgery was not ready for prime time! Please read this article to understand their reasoning, learn more about the article and survey, and come to your own conclusions on this interesting issue. Rosa Braga-Mele, MD, MEd, FRCSC, Cataract editor The surgical suites and recovery areas of the Specialty Surgical Center, Beverly Hills, California, demonstrate the capabilities of cataract surgery facilities with which many surgeons are familiar. Source: Uday Devgan, MD

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