Buy One, Get One (Almost) Free?

“Nothing is more powerful than an idea whose time has come!” – Victor Hugo

Immediate Sequential Bilateral Cataract Surgery (ISBCS) isn’t new – it was topical when Jacques Daviel invented cataract extraction in 1752. But it’s still a subject of discussion in 2017. Why? Cataract hasn’t really changed; it’s still predominantly a bilateral disease. Patients haven’t really changed either, and they still question why a bilateral disease needs separate episodes of care. In repeated surveys, around eight in every 10 of patients would prefer ISBCS. This is because they want rapid visual rehabilitation (days rather than weeks or months), reduced costs for travel and spectacles, and reduced payments if they’re funding the treatment themselves. What’s not to like? Unfortunately, surgeons haven’t really changed their views on the subject, with many not reviewing the evidence for years. This often means their objections haven’t changed in over a decade! Predictably, the concerns include the risk of infection, toxic anterior segment syndrome (TASS), corneal or retinal edema, and refractive surprise…

However, if the recommendations of The International Society of Bilateral Cataract Surgeons (1) are followed, all these risks are minimized to such an extent that they become acceptable to most patients. The recommendations also specify that patients at risk of cystoid macular edema or corneal decompensation should not be offered ISBCS, and nor should those at risk of refractive surprises (e.g. post-LASIK patients). And with the advent of optical biometry and the newest IOL formulas such as the Hill-RBF calculator, the predictability of IOL power for normal eyes is so high that the refractive surprise argument simply doesn’t hold up.

We’re also beyond the era of high-risk IOL exchange for refractive surprises, with tools such as supplemental (piggy-back) IOLs and LASIK at our disposal. TASS remains an “unknowable unknown” – it’s a systems failure, not a random event. The guidelines make it clear that nothing used for surgery can be changed without consultation. Under these circumstances, in the unlikely event of an occurrence should there be a “bad batch” of a regular product, it can be argued that it becomes a product liability issue, rather than a medical one.

Finally, infection remains the front-line argument for non-believers. We all have mental scars from patients with fulminant endophthalmitis and a bad outcome, and I believe this prevents us from thinking rationally about the issue. The risk of infectious endophthalmitis with the use of intracameral antibiotics is around 1 in 5,000, or better (2). It follows that, as a chance event, the risk of bilateral simultaneous endophthalmitis is just 1 in 25,000,000! And of course, the risk is identical for bilateral sequential endophthalmitis. Compare this to the risk of unexpected death from a general anesthetic in a healthy adult – a risk of 1 in 100,000. And even if endophthalmitis occurs, a third of eyes will regain sufficient vision to be able to drive, making the risk of functional blindness even lower. Compared with the other risks people face on a daily basis, this is a very remote risk, and our patients understand this.

Looking at the financial aspect, it is well documented that ISBCS carries financial disadvantages for surgeons in many countries. But in addition to the financial savings for the patient, there are some major societal financial advantages to ISBCS. Healthcare providers can save about €500 per patient, and hospitals can increase throughput, as one ISBCS takes less time than two unilateral cases. The increasing demand for cataract surgery is relentless, and funding is limited – making the widespread adoption of ISBCS seem even more attractive. I believe that once healthcare providers start to appreciate the productivity and financial advantages of ISBCS, they will start to exert pressure on ophthalmologists to take ISBCS into consideration in appropriate cases. And who knows, we might even be offered a premium for ISBCS in the future. Time will tell whether this is a realistic possibility, or simply a joke!

“A wise man changes his mind, a fool never does.” – Spanish proverb