Controversies in Anterior Segment Surgery

As technology and technique advance, controversies are inevitable in anterior segment surgery. Three current questions were explored in the Journal of Cataract and Refractive Surgery (JCRS) symposium at the 2023 American Society of Cataract and Refractive Surgery annual meeting in San Diego, US. JCRS Editor Dr William J Dupps Jr and Associate Editor Professor Sathish Srinivasan chaired the symposium.

Immediate sequential bilateral cataract surgery (ISBCS): clinical evidence versus economic model

While the merits of ISBCS have been debated for a decade, delayed sequential bilateral cataract surgery (DSBCS) is still dominant in the US, accounting for more than 99% of procedures, despite its safety, lower costs, and greater convenience.

“The main reason for this is economic,” Dr Fasika A Woreta said. The [US] federal Medicare insurance for seniors covers same-day second eye surgery at only 50%, and anaesthesia for the second eye is not covered, resulting in losses of about $400 per case in ambulatory surgery centres.¹

The situation is similar in the UK, where same-day second eye surgery is paid at 25% of the first-eye rate by some private payers, said Dr Charles Claoué, who noted the resulting losses are a major reason why just 0.4% of cases were done simultaneously in 2020.

However, one US system paid a flat rate per cataract procedure, reversing the financial incentive, resulting in more than 40% of patients receiving immediate sequential surgery. But, Dr Woreta added, not all patients should receive ISBCS due to ocular comorbidities or previous refractive surgery, complications in the first eye, and surgeon comfort with bilateral procedures.

Fear of lawsuits and blinding patients with bilateral endophthalmitis also limit ISBCS, Dr Claoué said, declaring these fears are overblown.

Adherence to recognised standards of care, which are well-established for ISBCS, limits legal liability, Dr Claoué pointed out. The risk of bilateral endophthalmitis is about 1 in 11.9 million procedures—or 23.8 million eyes—and should it occur, it can be successfully treated. At current endophthalmitis rates, “if there were 3 million cataract surgeries in the US every year, and all were done as ISBCS, one American would not meet driving [visual acuity] standards because of simultaneous bilateral endophthalmitis every 59 years.”

Studies also show ISBCS outcomes are similar to DSBCS, Dr Woreta said.²

The procedure saves about €1,600 per case—including patient travel and aftercare—and can increase surgeon productivity by 30%, Dr Claoué said.^3–4

“There is no reasonable doubt that ISBCS is safe, cheaper, and increases productivity,” Dr Claoué said. And patients generally prefer it.⁵ Both Dr Claoué and Dr Woreta advocated payment reforms to encourage ISBCS in appropriate cases.⁶

Optimising cataract surgery sedation—is less more?

Cataract surgery anaesthesia is more likely to be administered by an anaesthesiologist or nurse anaesthetist than for many common, low-risk outpatient procedures, at least in the US. Yet cataract surgery has a much lower systemic complication rate than procedures including cardiac catheterisation and bronchoscopy, said Dr Catherine L Chen.

Dr Chen and colleagues also found no association between anaesthesia care during cataract surgery and a composite outcome of death, hospitalisation, or systemic complications within seven days of surgery. However, she noted the study of Medicare beneficiaries did not examine cataract outcomes.⁷

Further, unpublished registry research suggests patients receiving general anaesthesia or monitored anaesthesia care were more likely to have at least one intraoperative event (mostly hypertension) than those receiving no intravenous sedative or only fentanyl or midazolam, Dr Chen added.

“This begs the question of whether the risk of cataract surgery is actually being increased because of the presence of anaesthesiologists.”

However, Professor Mor M Dickman and colleagues found topical anaesthesia had a significantly higher rate of posterior capsule rupture than general, sub-Tenon’s, or regional anaesthesia, based on a study of more than 4 million case records from the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) from 2008 to 2018.⁸ This may be due to more eye movement with topical approaches, he said.

Endophthalmitis rates were lower in regional anaesthesia cases than in topical as well—but not significantly different for other approaches, a finding consistent with earlier studies, Prof Dickman said. Over the period, topical anaesthesia use increased from 30% to 75% while regional approaches, including retrobulbar, decreased from 38% to 6% and sub-Tenon’s from 27% to 15%. General anaesthesia and combined topical and intracameral anaesthesia remained steady at about 2% each. More research is needed to better understand anaesthesia risks and optimise procedures for cataract surgery, he concluded.

For citation notes, see page 40.

Fasika A Woreta MD, MPH is Eugene de Juan Pr ofessor of Ophthalmic Education at the Wilmer Eye Institute, Johns Hopkins University, Baltimore, US. fworeta1@jhmi.edu

Charles Claoué MA (Cantab), MD, DO, FRCS, FRCOphth, FEBO, MAE is an ophthalmologist at The Harley Street Eye Centre and head of chambers at Ey e-Law Chambers, London, UK. eyes@dbcg.co.uk

Catherine L Chen MD, MPH is an anaesthesiologist and associate professor at the University of California, San Francisco, US. catherine.chen@ucsf.edu

Mor M Dickman MD, PhD is professor of ophthalmology at the University Eye Clinic, Maastricht UMC, Netherlands. m.dickman@maastrichtuniversity.nl