Download Immediately Sequential Bilateral Cataract Surgery

COVER STORY
Immediately
Sequential Bilateral
Cataract Surgery
The benefits, risks, and costs.
BY STEVE A. ARSHINOFF, MD, FRCSC
S
imultaneous bilateral cataract surgery—now more
accurately referred to as immediately sequential
bilateral cataract surgery [ISBCS] to clearly differentiate it from delayed sequential bilateral cataract
surgeries—is being performed with increasing frequency
worldwide.1 In Finland, many hospitals approach 50% of
cases as ISBCS, and in the Canary Islands of Spain, 80% of
cataract procedures are performed as ISBCS (data on file
with the International Society of Bilateral Cataract Surgeons). Ten percent of ESCRS members report routinely
performing ISBCS. These figures are not surprising, considering the incredible advances in cataract surgery and the
rapid decline in complication rates, especially since about
1990. Considerable published evidence shows ISBCS to be
at least as effective as delayed sequential bilateral cataract
surgery (DSBCS), and no published articles show that the
former is less safe.
Nevertheless, the subject of ISBCS generates heated
debate, and opponents invariably cite the risk of simultaneous bilateral endophthalmitis as the chief reason to avoid
ISBCS. To date, since 1950, four cases of simultaneous bilateral endophthalmitis have been published, all of which
included a demonstrable breach in what would be considered ideal aseptic protocol (S. A. Arshinoff, MD, unpublished data). A significant obstacle to the performance of
ISBCS is the severe financial penalties imposed on surgeons
who employ it in many countries, including Hungary, Israel,
Japan, the Philippines, and the United States. In these countries, ISBCS is therefore rarely performed under the prevailing governmental systems, but its use is much more frequent for patient-paid refractive lens exchange. Whereas
only 0.3% of ACSRS members report routinely performing
ISBCS, 5% of those performing refractive lens exchanges say
they frequently do so as ISBCS.2
When carefully executed, ISBCS has many advantages
worth fair-minded consideration by surgeons.
GUIDELINES ON ISBCS
The principles published by the International Society of
Bilateral Cataract Surgeons are based upon the experience
and recommendations of the most experienced surgeons
in this field worldwide (see “General Principles for Excellence
in ISBCS” by the International Society of Bilateral Cataract
Surgeons). Most of the guidelines are almost self-evident
and emphasize caution when performing ISBCS. The
points to highlight relate to the need for specific staff
training for ISBCS, the extra effort necessary to prevent
right-to-left confusion and errors, and the strict requirement for the complete aseptic separation of the two procedures. Nothing should go from the right to the left eye
or vice versa, and every effort should be made to use different ophthalmic viscosurgical devices, disposables, and
lot numbers of solutions for right and left eyes. Members
of the society believe that following these guidelines permits the safe execution of ISBCS.
THE BENEFITS OF ISBCS
Using the best available intracameral antibiotic techniques, Arshinoff and Bastianelli have calculated from currently reported rates of infection in bilateral cataract surgery
that the risk of simultaneous bilateral endophthalmitis is
about 1:100 million patients (S. A. Arshinoff, MD, unpublished data). This figure is considerably less than the calculated risk of death from driving to the extra visits required to
perform two separate cataract surgeries.3
One of the more interesting discussions lately regards the
cost of performing unilateral versus bilateral cataract surgery. Speaking at the ESCRS meeting in Berlin in 2008, Tina
MARCH 2011 ADVANCED OCULAR CARE 37
COVER STORY
“GENERAL PRINCIPLES FOR EXCELLENCE IN ISBCS”
BY THE INTERNATIONAL SOCIETY OF BILATERAL CATARACT SURGEONS
1. Cataract or refractive lens surgery should be indicated in both eyes.
2. Any concomitant relevant ocular or periocular disease should be managed.
3. The complexity of the proposed immediately sequential bilateral cataract surgery (ISBCS) procedure should be easily
within the competence of the surgeon.
4. The patient should be provided with suitable informed consent for ISBCS and be free to choose ISBCS or delayed sequential bilateral cataract surgery.
5. The risk for right-left eye errors should be minimized by listing all surgical parameters (selected IOL, astigmatism, etc.) for
both eyes on a board visible to all in the OR at the beginning of each ISBCS case. The World Health Organization operative checklists should also be used if possible.1
6. Errors in IOL power should be minimized by familiarizing OR personnel with the calculation methods used. The patient’s
original charts should be available in the OR, and everybody passing the IOL to the surgical table should confirm the IOL
chosen. ISBCS nursing staff should be specifically trained and experienced.
7. Complete aseptic separation of the first and second eye surgeries is mandatory to minimize the risk of postoperative bilateral simultaneous endophthalmitis.
a. Nothing in physical contact with the first eye during surgery should be used for the second eye’s surgery.
b. The separate instrument trays for the two eyes should go through complete and separate sterilization cycles with
indicators.
c. There should be no crossover of instruments, drugs, or devices between the two trays for the two eyes at any time
before or during the surgery of either eye.
d. Different ophthalmic viscosurgical devices and different manufacturers or lots of surgical supplies should be used
whenever reasonable (where the device or drug type has ever been found to be causative of endophthalmitis or toxic
anterior segment syndrome) and possible (if different lots or manufacturers are available) for the right and left eyes.
e. Nothing should be changed with respect to suppliers or devices used in surgery without a thorough review by the
entire surgical team to ensure the safety of the proposed changes.
f. Before the operation on the second eye, the surgeon and nurse should use acceptable sterile routines of at least regloving after independent preparation of the second eye’s operative field.
g. Intracameral antibiotics have been shown to dramatically reduce the risk of postoperative endophthalmitis2
(S. A. Arshinoff, MD, unpublished data). Their use is strongly recommended for ISBCS.
8. Any complication with the first eye’s surgery must be resolved before proceeding. The patient’s safety and benefit are
paramount in deciding to proceed to the second eye.
9. ISBCS patients should not be patched. Postoperative topical drops are most effective immediately after surgery and
should be begun immediately postoperatively, in high doses, which can be tapered after the first few days. Other ophthalmic medications (eg, for glaucoma) should be continued uninterrupted.
10. ISBCS surgeons should routinely review their cases and the international literature to be sure that they are experiencing
no more than the acceptable levels of surgical and postoperative complications. Membership in the International Society
of Bilateral Cataract Surgeons (www.isbcs.org) is highly recommended to keep abreast of the latest ISBCS information.
1. Haynes AB,Weiser TG,Berry WR,et al.A surgical safety checklist to reduce morbidity and mortality in a global population.N Engl J Med.2009;360(5):491-499.
2. Endophthalmitis Study Group,European Society of Cataract & Refractive Surgeons.Prophylaxis of postoperative endophthalmitis following cataract surgery:results of the ESCRS multicenter study and identification of risk factors.
J Cataract Refract Surg.2007;33(6):978-988.
38 ADVANCED OCULAR CARE MARCH 2011
COVER STORY
Leivo reported that, in Finland, the performance of ISBCS saves about €1,670 per
patient.4 Dr. Leivo then assumed that the risk of simultaneous bilateral endophthalmitis was about 1:1 million, and she calculated the additional cost of performing DSBCS instead of ISBCS, if the prevention of a single case of simultaneous
bilateral endophthalmitis was the goal. The figure was €739 million per case of
simultaneous bilateral endophthalmitis or about $1 billion USD, an astronomical
sum.
O’Brien and colleagues recently published a study of hospital costs for cataract
surgery in Ontario, Canada.5 After dividing cataract surgical costs into hospital,
social (those borne by the patient, family and society), and medical visit, they
arrived at a hospital cost for DSBCS of $1,566.30 versus $1,059.10 CAD. These figures agree well with the data presented by Leivo. Using the aforementioned risk
of simultaneous bilateral endophthalmitis calculated by Arshinoff and Bastianelli,
however, approximately $100 billion USD is spent to “avoid” one case of this complication. Mathematically, of course, one patient will suffer endophthalmitis postoperatively in both eyes, but with DSBCS, that will occur on different dates. As
Dr. Leivo stated, “There appear to be far better places to invest this huge amount
of money in health care.”4
Nobody is advocating the performance of ISBCS to save money. Rather, the
suggestion is that unreasonable prejudices be abandoned and new data be evaluated for their medical merits. ISBCS has numerous benefits:
• overall greater convenience for patients and their families, with fewer clinical
evaluations and hospital visits
• quicker visual rehabilitation, with normal stereopsis and binocular functionality rapidly regained after surgery
• higher productivity of the surgical facility, allowing faster OR turnover, shorter
hospital waiting lists, and possibly a lesser overall burden of disease on society
• huge amounts of money saved for society and the health care system
(S. A. Arshinoff, MD, unpublished data)
CONCLUSION
If ISBCS can benefit patients, if the risk of devastating complications is minimal, and if ISBCS can save society vast sums of money that can be better spent
on other medical needs, perhaps it is time that those involved in eye care seriously consider the procedure. When they do, however, they must make every
effort to carefully follow the International Society of Bilateral Cataract Surgeons’
principles and use intracameral antibiotics, which have been demonstrated to
dramatically reduce the risk of endophthalmitis.6 ■
Steve A. Arshinoff, MD, FRCSC, is a partner with York Finch Eye
Associates in Toronto. He is on the academic staffs of The University
of Toronto and McMaster University in Hamilton, Ontario, Canada.
Dr. Arshinoff may be reached at (416) 745-6969; [email protected].
1. Arshinoff SA.Bilateral cataract surgery:iSBCS suggestions for safe ISBCS.Presented at:The United Kingdom & Ireland Society of Cataract and Refractive
Surgeons;November 11,2010;Brighton,United Kingdom.
2. Arshinoff SA,Strube YN,Yagev R.Simultaneous bilateral cataract surgery.J Cataract Refract Surg.2003;29(7):1281-1291.
3. Bolger J.Comments about bilateral simultaneous cataract surgery.J Cataract Refract Surg.1998;24:430-431.
4. Leivo T,Sarikkola AU,Uusitalo R,et al.Helsinki simultaneous bilateral cataract surgery study:economic analysis.Paper presented at:XXVI Congress of the
ESCRS;September 16,2008;Berlin,Germany.
5. O'Brien JJ,Gonder J,Botz C,Chow KY,Arshinoff SA.Immediately sequential bilateral cataract surgery versus delayed sequential cataract surgery:potential hospital cost savings.Can J Ophthalmol.2010;45(6):596-601.
6. Endophthalmitis Study Group,European Society of Cataract & Refractive Surgeons.Prophylaxis of postoperative endophthalmitis following cataract surgery:
results of the ESCRS multicenter study and identification of risk factors.J Cataract Refract Surg.2007;33(6):978-988.
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