Bilateral Cataract Surgery

[mb0329]

I just read at the link below, and elsewhere on the internet, that bilateral cataract surgery is slowly becoming more common. This is where a person has cataract surgery on both eyes...on the same day, one right after the other.

http://www.reviewofophthalmology.com/content/d/cover_story/c/54144/

Has anyone had this and if so, how did it go? Would you recommend it. I can see pros and cons to this.
I would imagine having cataract surgeries for each eye weeks apart would be a hassle for the patient..especially
if they have to deal with large refraction differences between eyes like I probably would (I am -5 diopters on left eye and -9.25 diopters in right eye..with cataracts).

Any thoughts?

[JohnHaganMD]

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[Garrry]

My wife work in a operating theatre The cataract surgery's are all NHS
Done just one eye per day Rights one day Left the next Around ten to fifteen minutes per eye
Only private patients have the option

If I had scheduled my second eye for the following day and found I had blured vision in the operated eye I would have gone ahead As I was told my vision could be blary for upto a week

[SoftwareDeveloper]

Most surgeons now perform LASIK on both eyes in the same day, even though the cost is usually paid by the patient themselves rather than an insurer. Its a question of statistics and risk assessment, and patient preference, as to whether cataract surgery should be any different. Each surgeon and patient needs to make their own decision and it will vary by patient. By their nature some doctors are more cautious than others  and not see reason to change if their current approach works for them.

I think some surgeons are going to be more cautious about whether to do surgery in both eyes the same day if the eyes don't both have problematic cataracts. If they both have visual issues, then even if there is a  problem with 1 eye, the other eye will still need to get cataract surgery. That said, I know there are surgeons that even do clear lens exchange for both eyes in the same day, viewing it as being comparable to doing lasik on both eyes in the same day.

If there is going to be a problem after cataract surgery, I gather it is usually going to be apparent by the time the surgery is finished. Usually if there is a problem with 1 eye, it isn't something that will preclude operating on the other eye.  I'm actually surprised that 2nd day cataract surgeries are less common  since that does at least give time for most problems to have been spotted, and gives a slightly  better chance for the patient to get a better sense of the results from the first eye after the initial recovery overnight.

Currently surgeons in most places make more money from *not* doing same day cataract surgery. They often receive far less money for the 2nd eye the same day than if they wait a few weeks,   so they don't even consider looking into the statistics involved in doing both eyes the same day, especially since they are so used to doing them on separate days.  Many  surgeons who do same day surgery for both eyes take a cut in their fees to do so compared to waiting on the 2nd eye but do it since they think it is better meeting patient needs.  There are exceptions, some entities are starting to give better terms for same day surgery on both eyes.

[Garrry]

Just to add I had one eye done Then the surgeon asked me if I was sure I would like to proceed with the second eye At that stage I could see better out of my operated eye than my un operated eye
As I have stated I had the procedure To correct my astigmatism in both eyes
Had I got up and  gone home and returned a day or week later
the cost would have been the same
Two weeks on apart from the drop[s my life is back to normal  My vision is perfect and im back to work

[Garrry]

Yes ive just had both lenses replaced on the same day
Absolute breeze No problems

[chazas]

Speaking as someone who has had "nonmatching" eyes since I had a detachment in April, followed by a vitrectomy and gas bubble to fix it, followed by a huge epiretinal membrane and cataract, followed by another vitrectomy and epiretinal peel and IOL implantation, followed by the realization that my refactive result is significantly wrong -  you'll live.  I don't expect that the "final" result in my already-operated eye will be apparent for several more weeks or months, and I am not going to decide what to do with the other eye until after all that settles down.  It's not ideal, but it's not the end of the world either.

[mb0329]

"While the first worst eye is being fixed your myopic RE lens is removed and you depend on the unoperated eye for driving and getting around. "

Does this mean I wear a patch on my operated on first eye for 3-4 weeks?!? and just use my other eye for that period of time? If the operated on eye isn't patched until the other eye is fixed, then would not the difference between the two eyes be too great...say 0 diopter in the 'fixed' eye and -5 diopter in my other eye?..would that make me dizzy and sick because of the difference?
Seems like a nightmare I am going to have to go through. Everyone I talk to says how 'easy' their cataract surgery was but...but...I don't think they had the eye difference in diopters that I have to deal with nor the myopia.

[JohnHaganMD]

That happens all the time. While the first worst eye is being fixed your myopic RE lens is removed and you depend on the unoperated eye for driving and getting around. When the second eye is done the first eye gets the new RX, the thick second lens is removed and you depend on the first eye.  In many instances after a week the first eye sees better than the second eye that still has a cataract. In that case usually the person does not wear glasses for distance and uses over the counter reading glasses till 3-4 weeks post op when a permanent RX is given. This happens successfully every week in our practice.

As for  simultaneous bilateral cataract surgery the sincerest criticism I can give is I would never consider it for myself or any member of my family.  Because it saves insurance companies, the government and capitated plans like Kaiser's money look for them to push it more and more.

JCH MD

[mb0329]

"I think it is a really bad idea and would avoid it under all circumstances"

OK, I can see why. But, then, if one gets the 2nd eye done, say a month later (or whenever), how do they deal with the diopter difference while they are waiting. In my case, My left eye is -5 diopter and my right eye is -9.25 diopters. If I get the cataract surgery on my right eye and they make it, say diopter  of 0, while my left eye remains at -5...this is too big a difference for eyeglasses, right? Is it too big for contacts as well? Would I have to walk around in a daze until the other eye is done, if it is done (they may not do it because the cataract there is just starting..so I was told by the Kaiser optometrist). Thanks.

[SoftwareDeveloper]

Even if the surgery isn't the next day, the time between surgeries might be limited to reduce inconvenience. An informal survey done at an American Cataract and Refractive Surgery Society event last year reports that most surgeons there did the surgeries within 1-2 weeks:

http://www.eyeworld.org/article-controversy-around-immediately-sequential-bilateral-cataract-surgery
"The 106 audience responses indicated that about 62% book cataract surgery in each eye 1 to 2 weeks apart. Nearly 30% said they book each eye 1 month apart. Meanwhile, 6.6% said they do both eyes on the same day, while just under 2% said they perform the surgeries 1 day apart."

The issue of doing them on the same day  is a controversial topic in the field. A large part of the issue is that some insurance reimbursement is less for doing both eyes simultaneously and so some doctors haven't had reason to even examine the evidence in detail. Some insurers however provide coverage for it (I recall seeing that Kaiser may) in which case the surgeons have had more reason to examine the literature. The fact that most surgeons don't do it says more about financial issues than about what the evidence says.

Due to the controversy it is best to be cautious, but unfortunately when surgeons disagree among themselves patients are stuck evaluating which side to go with themselves and evaluating whether they think the risk is worth the benefit in consultation with whatever surgeons they choose to consult.   Some older surgeons especially aren't used to the idea, and being naturally  conservative they object to the idea of any risk at all. However there are risks with even driving to the doctor for another operation, so the risks need to be kept in perspective as to whether they are so miniscule that  the  benefits  outweigh the costs. Unfortunately someone does wind up being the "statistic" of a rare side effect, but then someone else winds up being the statistic of the rare car accident on the way to a 2nd surgery day (and such statistics are likely rarely if ever collected by the eye surgeons involved). Or a rare accident because the difference in vision between their two eyes after the 1st surgery causes a problem.

Here is a recent interview done by Dr. Findl, one of the top cataract researchers (who unfortunately doesn't make his views clear in this) with one of the proponents of this who suggests growing acceptance:

https://player.vimeo.com/video/121228257?title=0&byline=0&portrait=0
"Simultaneous bilateral cataract surgery  Oliver Findl Interviews Steve Arshinoff"

Some other clips on the topic:

http://medicalxpress.com/news/2015-04-benefits-bilateral-cataract-surgery.html
"(HealthDay)—Immediately sequential bilateral cataract surgery seems beneficial, with faster rehabilitation, improved visual outcome, and savings in time and costs, according to a review published online March 30 in Clinical & Experimental Ophthalmology."

http://www.healio.com/ophthalmology/cataract-surgery/news/print/ocular-surgery-news/%7B6b9588ce-f9ef-48ed-af46-e5ce25aa9ca9%7D/same-day-bilateral-cataract-surgery-gains-ground-but-obstacles-remain
"Same-day bilateral cataract surgery gains ground, but obstacles remain

Brinton’s conservative practice in Florida adopted same-day surgery only after multiple studies demonstrated its safety. When performing same-day surgery, the vision center follows strict protocols. ..

Kaiser Permanente in Colorado, an HMO, decided a decade ago that “it was actually less expensive for Kaiser to perform bilateral surgery, even by paying the surgeons and staff the same for the second eye,” Arshinoff said. “Hence, Kaiser offers patients that option, suggesting that the main issue in the United States is money.”  "

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4485471/
"Immediate versus Delayed Sequential Bilateral Cataract Surgery: A Systematic Review and Meta-Analysis"

http://www.ncbi.nlm.nih.gov/pubmed/22995967
"Same-day cataract surgery should be the standard of care for patients with bilateral visually significant cataract."

http://onlinelibrary.wiley.com/doi/10.1111/ceo.12527/abstract
"Evidence, although limited, increasingly supports ISBCS for providing faster rehabilitation, improved visual outcomes, and cost and time savings. Evidence does not support the fear of bilateral endophthalmitis resulting from the simultaneous procedure. However, stronger and greater evidence is needed before ISBCSs can be considered the standard of care. "

http://crstodayeurope.com/2015/07/pointcounterpoint-when-is-the-time-for-isbcs
"Surgeons deliberate whether immediate sequential bilateral cataract surgery is ready for widespread adoption....

The Time for ISBCS is Now...

The iSBCS conducted a study of bilateral surgery in more than 100,000 eyes and found that, using intracameral antibiotics, there was an overall risk of 1 in 17,000 of getting an infection in one eye; based on this, the risk of SBE was calculated to be about 1 in 100 million, assuming that all iSBCS recommended precautions are taken.6 Li et al7 reported that the risk of SBE is lower than the risk of death from general anesthesia. ..
Until recently, the country most resistant to ISBCS was the United States. About 2 years ago, however, ophthalmologists in the Kaiser Permanente Health Plan of Colorado began doing ISBCS. They have found that, when given the choice, 80% of patients choose to have bilateral surgery.10 This is close to the percentage of patients in my practice who select ISBCS when asked to choose freely between ISBCS or DSBCS. Clearly, there is a strong interest among patients."

[JohnHaganMD]

It is becoming more common only for reasons of cost and not safety. I think it is a really bad idea and would avoid it under all circumstances. While things rarely go really bad with cataract surgery better in one eye than both; also the surgeon often learns something really useful about the eye's reaction to surgery or the accuracy of the IOL formula that can be used on the second eye when done weeks later not when done at the same sitting.

JCH MD