key: cord-0799515-164xysiz
authors: Ike K Ahmed, Iqbal; Hill, Warren E.; Arshinoff, Steve A.
title: Bilateral Same Day Cataract Surgery: An Idea Whose Time Has Come #COVID-19
date: 2020-09-02
journal: Ophthalmology
DOI: 10.1016/j.ophtha.2020.08.028
sha: 5d8ca7d7697a8a4248ef373d178e0af0721af8a6
doc_id: 799515
cord_uid: 164xysiz

nan

Iqbal Ike K Ahmed Warren E. Hill Steve A. Arshinoff COVID-19 shut down the world in the Spring of 2020. With that, the delivery of healthcare dramatically changed, perhaps forever. The pandemic has led to the need to physically distance, minimize non-essential exposure, acquire appropriate PPE for both providers and patients, enhance sanitization and hygiene practices, and cope with the additional costs of doing so. This crisis has made us rethink the status quo and reframe age-old debates. Many of the abrupt changes made during the pandemic in the name of safety have resulted in a more immersive and connected patient experience. For these reasons, many of these measures will likely continue well past the end of this crisis.

Cataract surgeons have instituted many changes in practice during COVID-19. The move to more digitized and virtual healthcare delivery, online education tools, electronic intake, consolidating inperson visits, and increased spacing between cases have become the norm for cataract surgery. The one change in practice that could have the most significant benefit in reducing infection exposure risk is immediately sequential bilateral cataract surgery (ISBCS). Furthermore, ISBCS is less expensive, reduces PPE burn, is more efficient, and provides faster binocular recovery of vision for the patient. 1 ISBCS has been debated for years, while the evidence in its support has grown over time. 2 Hospitals achieve higher productivity and cost savings of over 30% when performing ISBCS instead of delayed sequential bilateral cataracts surgery (DSBCS). 3 4 5 The new normal of the COVID-19 era requires extra spacing, cleaning, and time between cases, resulting in increased costs. When considering the additional patient costs for travel, family/caregiver time, and absence from work with the extra postoperative visits and recovery requirements of DSBCS, the cost efficiency is even greater with ISBCS. 6 The principles of safe ISBCS have been laid out by the International Society of Bilateral Cataract Surgeons. They include treating each eye as a separate independent procedure with new instruments, packs, gloves, gowns, drapes, and different lot numbers for pharmaceuticals and viscoelastics. Intracameral antibiotics are recommended. Caution is suggested in those eyes with a higher risk of refractive surprises (prior refractive surgery, extreme axial lengths), and increased risk of complications due to ocular co-morbidities. If there is a complication in the first eye of a planned ISBCS unresolved at the time of surgery, it is advised to defer the second eye.

Opponents who argue against ISBCS argue on two clinical points: the risk of bilateral postoperative endophthalmitis or TASS, and second eye refractive planning. However, there is no evidence to substantiate these fears. There have been no cases of bilateral endophthalmitis where the proper aseptic technique had been followed, nor has there been any cases of bilateral TASS reported with ISBCS. In a series of 95,606 ISBCS surgeries, there were no bilateral endophthalmitis cases. The overall infection rate was 1 in 16,890 (0.006%) with the use of intracameral antibiotics. 7 The theoretical risk of simultaneous bilateral postoperative endophthalmitis with proper aseptic technique is estimated to be less than 1 in 100,000,000.

Ocular risks must be compared with systemic risks, as rare as either may be. Anesthesia and traveling risks are doubled with DSBCS versus ISCBS. Currently, the most feared and substantial systemic risk during the pandemic era is COVID-19 exposure. After the initial consultation and diagnostic testing, ISBCS reduces the number of patient visits (including waiting), and contact exposures by half. Exposure to other patients is critical for our elderly cataract population, whose risk of dying is higher with COVID-19 infection. In our opinion, this tips the safety balance further in favor of ISBCS. 8 Much has been written about the fear of performing ISBCS because of a need to adjust the IOL power for the second eye after checking the result of the first eye. These concerns have been negated in the modern era of IOL calculations, excluding patients with risk factors for refractive surprises. In addition, optimizing the ocular surface preoperatively, using the latest optical biometers, applying validation criteria, and using the latest generation formulas such as the Barrett Universal II, Hill-RBF, Olsen, and Kane methods would all be useful for enhancing refractive outcomes. Furthermore, adjusting the second eye IOL power based on the first eye result is controversial, and it is not completely clear that it is beneficial in average eyes with modern generation formulas. 9 10 In support of ISBCS, a recent sizeable comparative study found that ISBCS performed no worse than DSBCS for postoperative BCVA, refractive error, or complications. 11 Beyond the clinical concerns, the fear of malpractice as an outlier with potential complications remains, as does reimbursement. 12 Both pose significant barriers to adoption, but times are changing. We are unaware of any successful malpractice claim based upon the performance of ISBCS. COVID-19 has forced and allowed us to push boundaries and reconsider priorities. Prepandemic, ISBCS had been commonplace in many parts of the world and growing in North America. While more high-quality studies are needed, there is a growing body of evidence in support of ISBCS. Improvements in technology, approach, and aseptic technique have made ISBCS a low-risk, precise and cost-effective procedure. Patients and their families overwhelmingly express a preference for ISBCS when given a choice. In today's COVID-19 world and beyond, patients should be given an informed option between ISBCS versus DSBCS. It's time for our national societies to advocate for patient safety, quality-of-life, and preference, and resolve the financial penalty for performing the second eye on the same day as the first.

With the COVID-19 crisis upon us, we must rethink the delivery of healthcare. Just like digitized medicine, virtual care, and artificial intelligence, ISBCS truly enhances care. The arguments for these paradigm shifts go well beyond the setting of a pandemic, but now more than ever is the time to start.

Prospective analysis of outcomes and economic factors of same-day bilateral cataract surgery in the United States

Immediate versus delayed sequential bilateral cataract surgery: A systematic review and meta-analysis

Economic modelling of immediately sequential bilateral cataract surgery (ISBCS) in the National Health Service based on possible improvements in surgical efficiency

Immediately sequential bilateral cataract surgery versus delayed sequential bilateral cataract surgery: potential hospital cost savings

Immediately sequential bilateral cataract surgery: a cost-effective procedure

Simultaneous bilateral cataract surgery: economic analysis; Helsinki simultaneous bilateral cataract surgery study report 2

Incidence of postoperative endophthalmitis after immediate sequential bilateral cataract surgery

Factors associated COVID-19-reated death using OPENSAFELY

An inter-eye comparison of refractive outcomes following cataract surgery

Intraocular lens power in bilateral cataract surgery: whether adjusting for error of predicted refraction in the first eye improves prediction in the second eye

Immediate sequential vs delayed sequential bilateral cataract surgery

A cost and policy analysis comparing immediate sequential cataract surgery and delayed sequential cataract surgery from the physician perspective in the United States