Same-Day Bilateral Cataract Surgery Increases During Pandemic

By Carolyn Crist

September 14, 2020

NEW YORK (Reuters Health) - Immediately sequential bilateral cataract surgery, or ISBCS, has become a more popular method for cataract surgery in recent years, and the pandemic dramatically increased interest in the approach, according to a group of eye surgeons.

Operating on both eyes in the same day reduces patients' risk for exposure to infection and reduces the amount of personal protective gear that surgeons use, the authors write in an editorial in Ophthalmology.

"ISBCS is the way things are going and the way of the future," said co-author Dr. Steve Arshinoff of the University of Toronto, in Canada.

Dr. Arshinoff began performing elective same-day cataract surgery in 1996 and has written extensively about it. Repairing the entire visual system seems to be better for patients than repairing one eye at a time, he said.

"Patients recover with excellent function in one day and benefit greatly," he told Reuters Health by email. "As do their families, for whom the whole experience of getting their eyes fixed is much easier."

Dr. Arshinoff and colleagues write about ISBCS as "an idea whose time has come" during the pandemic. Healthcare facilities implemented physical distancing protocols, minimized non-essential exposure, spaced out appointments and stocked up on personal protective gear and sanitization products for both doctors and patients.

Cataract surgeons instituted changes as well by moving more appointments online, consolidating in-person visits and increasing the time between surgery cases, the authors note.

"This crisis has made us rethink the status quo and reframe age-old debates," they write. "Many of the abrupt changes made during the pandemic in the name of safety have resulted in a more immersive and connected patient experience."

Some of the changes should continue after the pandemic, they argue, including the higher demand for same-day bilateral cataract surgery. The method has been debated for years, though more research has supported it over time, they add.

Several studies have shown that hospitals have higher productivity rates and a cost savings of about 30% when performing ISBCS instead of delayed sequential bilateral cataract surgery. The cost differential likely increased during the pandemic since a two-day appointment requires extra time, cleaning and personal protective gear. Patients and families likely spend more on travel, caregiver time, postoperative visits and absence from work as well.

Opponents who oppose ISBCS tend to cite two major points: the risk of bilateral postoperative endophthalmitis and second-eye refractive planning. However, the research doesn't back up these fears, according to the authors. In a study of more than 95,600 ISBCS surgeries, no bilateral endophthalmitis cases were found, and the overall infection rate was one in 16,890, or 0.006%. If the proper aseptic technique is followed, the risk of postoperative endophthalmitis is about 1 in 100,000,000, the authors write.

Eye surgeons have also written about the fear of performing ISBCS due to concerns of adjusting the intraocular lens power for the second eye after checking the results of the first eye. However, modern calculations that use the latest optical biometers and most recent formulas should help with refractive outcomes, the authors write. Surgeons shouldn't need to adjust the second eye based on the first-eye result.

Beyond that, systemic risks should be considered alongside ocular risks, according to the authors. The risks associated with anesthesia and patient travel are lower with same-day surgery, as well as the current risk of COVID-19 exposure.

"Exposure to other patients is critical for our elderly cataract population, whose risk of dying is higher with COVID-19 infection," they write. "In our opinion, this tips the safety balance further in favor of ISBCS."

One of the biggest issues to date is financial reimbursement under Medicare, where reimbursement for the second eye is about 50% of the first eye, said Dr. Neal Shorstein of Kaiser Permanente in Walnut Creek, California. Dr. Shorstein, who wasn't involved with this article, has written about same-day versus delayed bilateral cataract surgery.

"The momentum for adoption would be greatly enhanced by a Medicare rule change," he told Reuters Health by email. "Letting your congressional representatives know your concerns may be a way to influence the way Medicare pays for this procedure so that it is more widely offered by cataract surgeons and surgery centers."

SOURCE: Ophthalmology, online September 1, 2020.