Second eye interventions

The debate over the utility of second-eye cataract surgery in elderly patients would benefit greatly from more rigorous scientific data in order to help clinicians better defend the interests of their patients, according to Jean-Jacques Saragoussi MD.

“Many of the randomised studies in the literature have not been designed to look at the issue of second-eye surgery and few publications have the level of proof needed for the application of evidence-based medicine. We need more specific methodologies to look at this question and contribute to the debate with strong scientific arguments that defend the interests of the patient,” Dr Saragoussi told delegates attending the annual meeting of the French Implant and Refractive Surgery Association (SAFIR) in Paris, France.

The difficult economic climate has brought the question of the utility of bilateral cataract surgery to the fore, noted Dr Saragoussi. “We are seeing increased pressure on health services with restrained budgets and a need for insurance companies to prioritise healthcare with new restrictions and exclusions.”

Going forward, these healthcare priorities will be designated based on the proven efficacy of treatments in line with the strictures of evidence-based medicine, drawing on publications classified as “weak”, “moderate” or “strong” according to the level of proof provided, said Dr Saragoussi.

To assess the utility of second-eye surgery in older patients, four questions need to be answered, he said: Will it improve the patient’s vision? Will it improve the patient’s quality of life? What will the surgery cost to the health service as a whole? And finally, why and when is it useful to carry out second-eye cataract interventions in elderly patients?

In terms of vision, there is good evidence that second-eye surgery improves stereopsis, contrast sensitivity, stereoacuity and visual field over and above the benefits of first-eye surgery, said Dr Saragoussi.

For quality of life, those studies that used subjective patient questionnaires found that the improvement was not constant and was less clear-cut for second-eye surgery than it was after the first intervention. “This depended, however, on the level of visual acuity achieved in the first eye as well as the preoperative visual acuity of the second eye,” said Dr Saragoussi.

Using cost-utility analysis, however, a study by Brown et al in 2013 showed that bilateral surgery equated to a gain of 2.8 quality adjusted life years (QALYs) versus 1.6 QALYs for unilateral surgery.

In terms of cost to the health system, Brown et al also showed that the unit cost of cataract surgery has diminished by about 34.2 per cent between 2000 and 2012, while the number of operations has multiplied six-fold in the last 20 years, said Dr Saragoussi. The same study also found that cataract surgery – unilateral and bilateral – is very cost-effective in the long term.

Summing up Dr Saragoussi said that there was a clear need for additional trials examining this important procedure.

Jean-Jacques Saragoussi: saragoussi.oph@orange.fr