An objective look at ISBCS
The right answers to a few key questions will tell if you’re ready for immediately sequential bilateral cataract surgery.
By Steve A. Arshinoff, MD
Every time a new surgical technique is published, we all wish we were as expert as the author and already prepared to perform the new procedure flawlessly. Unfortunately, performing any new procedure requires time and effort to learn the finer points, to educate staff about their roles, and to reorganize work flow so the new procedure is used as efficiently as possibly, thereby ensuring a new enhanced level of achievement and patient satisfaction.
Bilateral cataract surgery is no different
The first step is to study your recent experiences. How many of your cataract patients, within the past year, had their second cataract removed fewer than six months after the first? A simple record review will tell you this. I am sure you will be surprised to discover that your answer approaches 70% (excluding those who had one eye done elsewhere; were monocular; or for whatever reason [a trauma-caused cataract, for example] were not candidates for bilateral cataract surgery. If it is over 25%, you probably should begin thinking about immediately sequential bilateral cataract surgery (ISBCS).
Rethinking the approach to second surgery
If your percentages meet the ISBCS criteria, then consider the following. Did you discuss with those 25%+ patients the eventual need for cataract surgery in their “other” eye — before operating on the first eye — and if so, what did you say? How certain were you that the patient would want the second surgery soon after the first?
This is easy to answer if the patient was a high ametrope; all ametropes complain about being “unbalanced” due to their unequal eyes after their first surgery, and they cannot wait for that second procedure. But, were you honest in telling the relatively emmetropic patients that they would notice an enormous difference between their two eyes after surgery number one, and so to expect to immediately begin complaining about the poor vision in the unoperated eye?
ISBCS: General Principles
1. Cataract or refractive lens surgery should be indicated in both eyes.
Only patients who would benefit from ISBCS should be considered for the procedure.
2. Any concomitant relevant ocular or periocular disease should be managed.
These should include stabilizing diabetes. Forgoing surgery on these patients should be considered if they have the earliest signs of diabetic macular edema. DME might be a serious problem after surgery. Extra preparation for surgery should be routine for myopes between -4 and -8 D who carry the highest risk of retinal detachment. A careful peripheral retinal examination should be given to these patients. My general policy is that a retinal surgeon should examine these patients pre- and postoperatively, who can prophylactically treat suspicious retinal areas with laser. We also want to make sure that rosacea, lid margin disease, Fuchs’ endothelial dystrophy, and any ocular or systemic disorder that could increase the risk of surgery is recognized and optimally managed before surgery.
3. The surgeon should be capable of performing the proposed ISBCS procedure.
Every surgeon will begin with the most straightforward cases, and gradually take on excluded patients as his comfort and expertise levels with ISBCS increases. In other words, each surgeon should stay within his own comfort zone.
4. The patient should provide suitable informed consent for ISBCS, and be free to choose ISBCS or DSBCS (delayed sequential bilateral cataract surgery).
As with all surgical procedures, the patient should be informed that it is he who elects to have unilateral or bilateral surgery, and free, informed consent should be provided to him.
5. The risk for right–left eye errors should be minimized.
All surgical parameters (selected IOL, astigmatism, etc.) for both eyes should be listed on a board, or computer screen at the beginning of each ISBCS case. The list should be visible to all in the OR. The WHO operative checklists should also be used if possible.
The surgeon can enhance this risk minimization method by always doing surgery on the same eye first. For me, I always do the left eye first, and have configured my operating room so that the right-eye tray is opened the farthest away from the left eye surgery as possible.
6. ISBCS nursing staff should be specifically trained and experienced.
Minimize IOL errors by having personnel who know how to make these calculations do so. The surgeon must learn to trust his trained staff who can check IOL powers and calculations almost as well as he can. It is another added safety factor. The original patient charts should be available in the OR, and everybody passing the IOL to the surgical table should confirm the IOL choice. Additional training to ISBCS nursing staff about the specific details of ISBCS further enhances the safety of the procedure.
7. Complete aseptic separation of the first and second eye surgeries is mandatory to minimize the risk of postoperative bilateral simultaneous endophthalmitis (BSE).
Generally, it takes some time after we become eye surgeons for us to realize that cataractogenesis begins at a young age. This realization is the origin of the recent “dysfunctional lens syndrome” label. Things do not appear as bright and as vivid to a 30-year-old as to a 10-year-old, and then the 30-year-old slowly experiences the onset of presbyopia. We finally admit a problem exists when our distance acuity cannot be corrected to make out the 20/30 line, even with the most precise correction, ignoring how advancing age has impacted our color vision, focusing capabilities and image brightness. Once you admit that most single cataract patients would benefit from — and want — dual eye surgery at the outset because of the lenses’ dysfunctional state, you are ready to start doing ISBCS.
But don’t think of ISBCS as one surgery: Simply put, the two procedures should be regarded as completely independent, and full presurgical preparation should be done before starting the procedure on the second eye.
A communication breakdown
When seniors see very well out of one eye, they usually do not complain much. When the good eye starts to decline, they panic and seek medical advice. So, it helps to remember that the vast majority of cataract patients complain about “their vision,” not their “worse eye vision”. And by “their vision,” patients mean the better eye’s vision is declining and hampering their lifestyle. But we usually fix the worst of the two eyes. Before I started to perform ISBCS, I wondered why so many patients complained immediately after unilateral cataract surgery. Now I know; it was not the worst eye that they came in complaining about! I did the wrong procedure.
The inevitable issue of cost
It would be dishonest to suggest that surgeons should rush to perform ISBCS, even if they will lose income by doing so; Medicare does not fully reimburse for the second simultaneous surgery. All of us must pay our staffs and work to support our families. It is simply unreasonable to expect any surgeon to practice and promote ISBCS if it means a loss of income. It is our responsibility as surgeons to suggest what we think is best for patients, but not our responsibility to perform procedures at significant personal loss of income because the patient or the third party payer does not want to pay for what we believe is better. It is ultimately up to the purchaser, in our economic system, to purchase what he/she wants to pay for, and for us as surgeons to perform that task to the best of our abilities. So, let’s assume that the financial picture is reasonable, and proceed.
Reducing the risk of infection
1. Nothing used in the first surgery that came in contact with that eye should be used in the second. The word nothing should be taken literally.
2. The separate instrument trays for the two eyes should go though complete, separate sterilization cycles with indicators.
3. There should be no crossover of instruments, drugs or devices between the two trays pre- or postsurgery.
4. Different ophthalmic viscosurgical devices (OVDs), and different manufacturers or lots of surgical supplies should be used for the right and left eyes AS A PREVENTIVE MEASURE if the device or drug type has ever been found to be causative of endophthalmitis of toxic anterior segment syndrome (TASS).
OVDs generally carry the highest bio burden of anything we use in surgery, and invariably there is a manufacturer that makes one very similar to the surgeon’s favorite OVD. I prefer to use OVDs from different manufacturers for right and left eyes on the same patient. Any drug or device planned for an ISBCS surgery should be carefully investigated for history of contamination. If possible, prevent using the same lots of anything that pose any significant risk to the eyes of the same patient.
5. Nothing should be changed with respect to surgical suppliers or devices without a thorough review by the entire surgical team to ensure the proposed changes meet all safety demands.
It has long been recognized that TASS frequently occurs after a practice switches out one of its surgical device suppliers to a more economical, but sometimes not thoroughly investigated, new supplier. As a general rule, the risk can be minimized if the entire surgical team reviews and then consents to a device change. I am not aware of any reports of TASS after ISBCS.
6. Before the operation of the second eye, the surgeon and nurse shall use acceptable sterile routines of at least re-gloving after independent preparation of the second eye’s operative field.
7. Intracameral antibiotics have been shown to dramatically reduce the risk of postoperative endophthalmitis. Their use is strongly recommended for ISBCS.
The evidence supporting prophylactic intracameral antibiotics at the end of cataract surgery is overwhelming. The two globally leading antibiotics being cefuroxime3 and moxifloxacin.3 ISBCS should be performed using this added safety measure, which has been shown repeatedly to reduce the risk of infection by over 80%.
8. Any complication with the first eye surgery must be resolved before proceeding. Patient safety and benefit are paramount in deciding to proceed to the second eye.
If any complication occurs with the first eye, it is prudent to defer the second eye until all issues with the first eye are resolved. As the surgeon gains more experience, minor complications, such as the incision requiring a suture to seal well or an imperfect capsulorhexis, can be resolved at the end of the procedure, so the surgeon can proceed with the second eye. ISBCS surgeons’ experience has convinced us that “the best time to operate on an eye is immediately after performing surgery on the patient’s fellow eye.” Even the subtle nuances of each patient are most apparent at this point to the surgeon (such as degree of intra-operative floppy iris syndrome, the challenges of the patient’s deep orbit, dealing with the patient’s kyphosis, and so on), and any additional risk for the second eye is probably lower than at another sitting.
9. ISBCS patients should not be patched. Topical drops are most effective immediately postoperatively and begun in high doses, which can be tapered after the first few days. Medications for other ophthalmic conditions (glaucoma) should be continued.
Regardless of whether dropless therapy is used, patients are most attentive and concerned about their postoperative state immediately after surgery. This is the best time to encourage them to keep their hands away from their eyes, to begin taking whatever drops the routine calls for, and to ask how well they can see, and encourage them. Bilateral patching is a terrible idea. Patients should be encouraged to walk around and do things, but keep their hands out of their eyes. Any kind of protective eye wear is a good idea, as it acts as a barrier to fingers. If the patient has glaucoma, an extra dose of regular glaucoma medication should be given immediately postop as the surgery washed out whatever the patient had taken before.
10. ISBCS surgeons should routinely review their cases and the international literature to be sure that they are experiencing no more than acceptable levels of surgical and postoperative complications.
Remaining obstacles
Once the surgeon decides that the majority of patients need bilateral cataract surgery, the next step is to book these surgeries closer together. After doing so even for a short time, it becomes evident that ISBCS has many advantages.
Initially we are all afraid to jump in because we have heard about the risk of bilateral endophthalmitis, the need to correct biometry for the second eye based upon the results of the first eye, and the rare risks of other bilateral complications (retinal detachment, corneal decompensation, macular edema and so on). However, a recent review says that “evidence does not support the fear of bilateral endophthalmitis resulting from the simultaneous procedure,”1 and this article supports findings from an earlier review.2
Next, the surgeon should access the International Society of Bilateral Cataract Surgeons (ISBCS) at www.isbcs.org, and review the General Principles for Excellence in ISBCS 2009. This document, prepared by a multinational group of experienced bilateral cataract surgeons, outlines the main issues involved in preparing and performing bilateral cataract surgery.
It’s simpler than you think
In summary, preparing for ISBCS is similar to preparing for any other new surgical procedure, except that the groundwork involves doing what we already know, only twice consecutively. It is mostly a matter of the surgeon convincing him/herself of the benefits, and then getting organized to be sure patient selection and patient safety procedures are in line with international expectations and practices. It is important to work out the financial feasibility of the private or public model in which the surgeon works, and to plan carefully as to which patient to include and exclude when you start ISBCS. After the first 50 patients, the number of exclusions will gradually decrease. OM
REFERENCES
1. Lansingh VC, Eckert KA, Strauss G. Benefits and risks of immediately sequential bilateral cataract surgery: a literature review. Clin Experiment Ophthalmol. 2015;43:666-672.
2. Arshinoff SA, Bastianelli PA. Incidence of postoperative endophthalmitis after immediate sequential bilateral cataract surgery. J Cataract Refract Surg. 2011;37:2105-14.
3. ESCRS Endophthalmitis Study Group. Prophylaxis of postoperative endophthalmitis following cataract surgery: Results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33: 978-988.
About the Author | |
| Steve A. Arshinoff, MD, is associate professor of ophthalmology at the University of Toronto. Disclosures: Dr. Arshinoff disclosed relationships with Alcon Laboratories, Abbott, Rayner, Bausch + Lomb, Carl Zeiss Meditec and i-MED Pharma. |
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