Bilateral surgery has clinical advantages but economic disadvantages

While there may be no scientific rationale to rule out same-day or immediately sequential bilateral cataract surgery (ISBCS) for routine cases, the strongest argument against its adoption in France may turn out to be economic, according to Guillaume Leroux les Jardins MD.
“In terms of evidence-based medicine, for selected patients there is a clear advantage and no objective scientific argument in terms of safety for not practising same-day bilateral cataract surgery. However, the fact that there is no payment corresponding to two separate ambulatory hospitalizations means an obvious financial loss for the surgeons and care establishments that might otherwise consider it, even if the practice was permitted by the health authorities,” Dr Leroux les Jardins told delegates attending the annual meeting of the French Implant and Refractive Surgery Association (SAFIR) in Paris.
The question of same-day bilateral cataract surgery has been the focus of some intense debate at international conferences and in the scientific journals in recent times, noted Dr Leroux les Jardins. “It is a hot topic at the moment even though the idea might seem completely incongruous at first glance,” he said, noting that countries such as Canada, Finland and Spain have been leading the way in same-day bilateral cataract surgery.
In 2008, the International Society of Bilateral Cataract Surgeons (iSBCS.org) was set up to promote education, mutual cooperation and progress in simultaneous bilateral cataract surgery. 
The Society has very strict criteria on good practice for bilateral same-day surgery, said Dr Leroux les Jardins. “Patient selection is obviously critical. Standard cataract patients only are allowed without ANY associated comorbidities. Cases with a potential to create unwanted surprises are also systematically excluded such as diabetics, immunosuppressed patients, pseudoexfoliation, Fuchs endothelial dystrophy, dense cataracts, epiretinal membrane, diabetic retinopathy, high ametropias, and previous refractive surgery,” he said.
Moreover, immediate sequential surgery should never be carried out if any unresolved complication occurred with the first eye, said Dr Leroux les Jardins.
For the surgery itself, it is essential to respect complete aseptic separation of right and left eyes, with all equipment and instruments changed for each procedure and mandatory use of intracameral antibiotic. There is a clear benefit for the patient in same-day bilateral surgery, said Dr Leroux les Jardins, including faster visual rehabilitation, less hospital visits and less demand on their entourage. 
The arguments against same-day surgery are the perceived risks of bilateral endophthalmitis, bilateral toxic anterior segment syndrome (TASS) and incorrect intraocular lens (IOL) power calculation for both eyes. 

ECONOMIC FACTORS
Economic factors must also be borne in mind, said Dr Leroux les Jardins. “There is the factor of less payment for the second eye for the surgeon and surgical centre and implications for reimbursement for the patient,” he said.
For bilateral endophthalmitis, Dr Leroux les Jardins said that only four cases in total have been reported in the scientific literature during the three past decades, but that the basic rules for complete separation of each surgery were not respected in each instance. 
In 95,606 same-day bilateral cataract cases reported by Steve Arshinoff MD, there were no cases of bilateral endophthalmitis and just one case of unilateral endophthalmitis (0.007 per cent).
In this context, the theoretical risk of bilateral endophthalmitis is of the order of one case in 11.9million procedures as a low estimate, or one case in four million bilateral procedures as a high estimate, said Dr Leroux les Jardins. In comparison, during a general anaesthesia the risk of death seems great with one case for 100,000 procedures.
Using modern biometry methods should greatly reduce any risk of power calculation errors for IOL implantation, he concluded.
Guillaume Leroux les Jardins: glerouxlesjardins@gmail.com