Riding the Sea Change

The first wave of the aging demographic of the baby boom generation has been accompanied by a dramatic increase in the demand for cataract surgery. As cataract surgeons become even busier, new strategies for efficiency must be considered. Having reached the point of diminishing returns, the next paradigm shift is immediate sequential bilateral cataract surgery. In my opinion, this is the change coming in cataract surgery, whether we like it or not. Therefore, we must look at the three biggest obstacles standing in the way as opportunities for advancement – and adjust our thinking for the future.

Challenge 1: The Second Eye Payment Reduction

It has been said: “No margin, no mission.” In the US, physicians performing multiple surgeries on the same day are subject to reimbursement reduction of 50 percent on the second procedure and 75 percent on the third, and so on. By doing immediate sequential bilateral cataract surgery, a cataract surgeon would be taking a net 25 percent reduction in surgical income. If surgical income accounted for 50 percent of the surgeon’s revenue, and if he or she were running a 60 percent overhead, the result would be a 62.5 percent reduction in net income – all for doing an identical amount of work and assuming the same amount of risk. Though this policy may make sense for general surgery, where a single incision and general anesthesia can apply to multiple abdominal or thoracic procedures, this antiquated policy need not apply to ophthalmology, and should be updated so that efficiency and progress can be made. Without this change in policy, no surgeon will be able to provide this patient benefit.

Challenge 2: The need for adjustable, exchangeable and upgradeable optics

As the old saying goes: fool me once shame on you, fool me twice shame on me. The adage implies that being tricked is only acceptable, if you learn from the miscalculation. The same can be said of cataract surgery. The first surgery can be considered a forerunner for the second. If we miss our target in the first eye, additional measurements and scenario planning can help improve the result in the second eye. With immediate sequential bilateral cataract surgery, we give up the opportunity to judge the result of the first eye before tackling the second cataract. However, with the new category of exchangeable and adjustable lens platforms from RxSight, PerfectLens, Clarvista and others, that is all about to change. No longer will we need to consult the oracles or crystal balls before surgery. In the very near future, the visual result of the eye will be able to be fine-tuned, upgraded or even allow for a simplified exchange of technology, if the patient is dissatisfied. Once exchangeable and adjustable lenses become widely available, the case for immediate sequential bilateral cataract surgery will be even stronger.

Challenge 3: Risk management: endophthalmitis prevention.

The final challenge is endophthalmitis prevention. Though there is a wide range of endophthalmitis incidence, an approved antibiotic for intracameral use is nevertheless desirable. Haripriya et al studied 194,252 patients undergoing phacoemulsification and showed a seven-fold decrease in endophthalmitis in patients receiving intracameral moxifloxacin at the end of surgery (1). With endophthalmitis rates below 1 in 1000, the chance of bilateral infection is less than 1 in a million. With rates at 1 in 5,000, that would equate to one case in the US every 8 years. However, ophthalmologists need medicolegal protection from the FDA – assurance that proper indications for the use of these have been clinically vetted, and to ensure proper manufacturing standards have been met. Examples of ophthalmic antibiotics being approved for bacterial conjunctivitis while being promoted entirely for off-label purposes put doctors at risk if bad outcomes occur. Additionally, substandard compounding facilities have created batches of drugs with similar untoward consequences. It’s time for the FDA, industry, and doctors to find a way forward to help protect physicians and patients in a responsible way.

These three challenges can be met, clearing the way for immediate sequential bilateral cataract surgery to become the new standard of care.