Focus on Cataract Surgery

The ‘problem’ with short-interval bilateral surgery

Is an inherent bias holding us back from the next leap forward in cataract?

By Robert P. Rivera, MD

There is a bias that, at least in the United States, is inhibiting an important innovation in cataract surgery — something I refer to as the Normalcy-in-Profession Bias.

Sociologists define the normalcy bias in stark terms: the mental state people enter when they face a disaster. Unfortunately, the human psyche is naturally prone to underestimate the possibility of a tragedy, even as it occurs right in front of us. It seems that we are wired by default to exclaim, “This can’t be happening … that’s impossible … not here, not now, not me!” The consequence of this mental bias against disaster is quite simply to make the outcome of the disaster worse.

What does this have to do with us as ophthalmologists? Granted, we rarely encounter sudden catastrophes, and most of us live in fairly comfortable and safe circumstances, where a tragedy is more likely to be witnessed on a television screen, or discussed at morning coffee from the security of our own office or surgery lounge.

Yet the day-in, day-out comfort we enjoy breeds in us something much more insidious in its direct effect: the Normalcy-in-Profession Bias. Let me explain how it’s holding us back in cataract surgery.

THE BIAS IN ACTION

Same as it ever was

The problem is, we are creatures of habit, and become so accustomed to the way we do things in our practice that we end up accepting this routine as “The Way Things Are Done.” Yet the only reason this is how we do things is that this is how we have always done things — the classic example of a circular argument. Worse yet, this becomes our “practice pattern,” officially described as such in our journals and approved and sanctioned by committees.

What happens, though, when new technology or new procedures emerge? This is when the normalcy-in-profession bias best demonstrates itself in a rather heterogeneous group known as “The Detractors.” The newer or more disruptive the technique, the louder and more diverse the detractors become. A few historical examples demonstrate in classic fashion how the bias operates:

• “Ticking time bomb,” used to describe IOLs.

• “Unnecessary and dangerous,” a description of phacoemulsification.

• “A solution looking for a problem,” used more recently to describe femtosecond laser cataract surgery.

The first two scenarios have long since proven the detractors wrong, and the last is rapidly changing cataract surgery as we know it.

Call it by its proper name

Yet another area facing the normalcy-in-profession bias to its detriment here in America is that of simultaneous bilateral cataract surgery (SBCS) or immediately sequential bilateral cataract surgery (ISBCS). Either term often engenders the same type of reaction that phacoemulsification did 40 years ago.

“Yes, but this is not phaco,” says the typical modern-day detractor, yet 40 years ago, phaco itself was the object of similar scorn. One way we might improve upon the negative perceptions of SBCS would be to correct the inaccuracy of the phraseology itself: This is not simultaneous nor immediately sequential in the classic sense, and better understanding of the technique may well lead to better acceptance.

In the truest sense, bilateral laser refractive surgery is simultaneous or immediately sequential in its approach. In LASIK, the first eye undergoes surgery, immediately followed by the fellow eye, utilizing the same instruments.

The surgeon and staff do not step away from the patient, and the two procedures are separated only by the amount of time it takes to swing from one eye to the next.

Not really ‘simultaneous’

In contrast, “simultaneous” bilateral cataract surgery is not simultaneous. In this instance, the first eye undergoes surgery, and at its conclusion, everything stops. Let me say this again: everything stops.

The drape is removed, the instruments are taken away, and a separate prep, drape, gown and glove ensue. The surgeon uses a different instrument set from a different autoclave, different phaco tubing, BSS bottle and even different eyedrops.

Taken to the highest level, no item that comes in contact with the second eye has touched the first, and the team even confirms the items — gowns, gloves, drops, solutions, viscoelastic, even IOLs — came from different lot numbers,

SIBS: A BETTER LABEL FOR IT

The all-important interval

Consequently, a time interval occurs between the first eye and second eye procedures; precisely the steps that occur during this interval that differentiate “simultaneous” bilateral cataract surgery from simultaneous surgery. A better term would be “short-interval bilateral surgery,” or SIBS.

When we compared SIBS to cataract surgery as performed routinely, separated by a long interval — that is to say, each eye a few days to weeks apart — SIBS simply shortens the interval between both procedures, and does so in a way that still creates a totally different surgical experience for the second eye.

The events surrounding SIBS are similar to what would occur when the patient shows up a month later for surgery on the fellow eye: different autoclave, different instruments, different gown, glove, drape, lot numbers, etc.

Limitations of SIBS

Of course, not all patients are suitable for this approach. Certain situations demand a one-eye-until-it-heals procedure over SIBS. Patients with compromised immune systems, ocular or periocular comorbidity, unusual or unreliable biometric parameters (post-refractive surgery patients, excessively long or short axial length eyes) and patients with poorly controlled diabetes are not good candidates.¹

Experienced surgeons know which patients to select. Further, experienced surgeons are compelled to insist upon 100% compliance with the most basic SIBS principle that nothing touches the second eye that has touched the first.

WHAT’S HOLDING IT BACK?

The insurance company factor

Worldwide, SIBS has become an increasingly popular approach to treating cataracts, while in the United States the procedure has found a niche in refractive lens exchange and non-insured patients. The region with the highest percentage of same-day bilateral cataract surgeries may well be the Canary Islands of Spain, where up to 80% of cataract surgeries fit this category.²

In most US patients, however, insurance considerations have prevented wider adoption of SIBS, given the standard insurance practice of deducting 50% of fees for any second procedure performed on the same day.³ Indeed, with no scientific backing to support the safety or validity of sequentially staging cataract procedures so they happen on different days, my patient can have right eye surgery on Monday evening at 11:55 p.m. and surgery on the left eye at 12:01 a.m. Tuesday, with full 100% reimbursement for both procedures performed separately.

But if the second eye surgery occurs at 11:59 p.m. on the same day, the 50% reduction rule applies — penalizing both surgeon and facility to the tune of hundreds of dollars for that one minute of indiscretion. No wonder we find such a profound bias against cataract surgery for both eyes on the same day!

Medical concerns

This is hardly a fair scenario, nor does it measure up to any rigorous scientific analysis. While not mentioning the 50% penalty, the default argument of US surgeons (in my opinion a direct result of the normalcy-in-profession bias) is the pressing need to prevent bilateral endophthalmitis.

Yet, while every patient undergoing cataract surgery in both eyes is subject to the inherent risk of contracting endophthalmitis in each eye separately, no evidence shows this risk increases when the interval between surgeries is short, provided the surgeon adheres to the published guidelines of the International Society of Bilateral Cataract Surgeons.⁴

The time has come — I hope

In our modern information age, I increasingly find patients requesting same-day surgery on both eyes, particularly when both eyes equally suffer the symptoms of visual decline related to cataract. Patients are better informed today than ever, and they know from their social circles that this is an easy procedure to undergo.

Their level of frustration (and mine, too) only increases when we discuss with them the limitations of their insurance coverage, which requires that they undergo two completely separate surgeries with totally separate recovery processes, if I am to be able to afford my own expenses to provide them with care.

Will this ever change?

Will the normalcy-in-profession bias continue to affect us so that we exclaim to our patients, “But this is always how we’ve done it, so this is how we’ll always do it”? I have been in practice long enough to have seen both sides of that argument, and the consequences of one over the other.

It takes a creative, intelligent, and systematic approach to decide to break the mold, and I sincerely hope the time for change has arrived. If our societies could lead the charge, would a change in the reimbursement scheme allow us to now join our international colleagues and perform cataract surgery OU as a SIBS approach? OM

REFERENCES

About the Author
	Robert P. Rivera, MD, is an intraocular lens and refractive surgeon and director of clinical research, at Hoopes Vision in Sandy, Utah. His e-mail is rpriveramd@aol.com. Disclosure: Dr. Rivera recieves grants from Alcon and Avedro, and is a consultant for Abbott Medical Optics, STAAR Surgical, AcuFocus and Sonomed.