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Sooner or later? The sequential bilateral cataract surgery debate

Cataract Clinical Care Standard

Sequential bilateral cataract surgery has been in the spotlight in recent months, prompting discussion around the risks and benefits of immediate versus delayed surgery. Insight explores both sides of the argument.

Same-day bilateral cataract surgery is not often performed in Australia; ophthalmologists are generally concerned about rare but serious complications, as well as sub-optimal refractive outcomes for people relying on the procedure to improve their vision and quality of life.

A retrospective study in the US using data from a registry of nearly two million bilateral cataract surgery patients, published in JAMA Ophthalmology last July, found immediate sequential bilateral cataract surgery (ISBCS) was associated with worse refractive outcomes than delayed sequential bilateral cataract surgery (DSBCS), although – the authors acknowledged – the small but statistically significant differences may not be clinically relevant.

The study results piqued the interest of the ophthalmology profession, locally. University of Sydney’s Associate Professor Chameen Samarawickrama discussed the study and the efficacy of same-day bilateral cataract surgery as a guest on ABC’s Radio National Health Report with Dr Norman Swan last July.

Samarawickrama told listeners the vast majority of ophthalmologists in Australia prefer delayed surgery, with most operating on the second eye within two weeks of surgery on the first eye. He delved further into the study and its implications in the Soapbox column in Insight’s December issue.

A/Prof Chameen Samarawickrama.

In August, about a month after the US study was published (although the timing was not intentional), the Australian Commission on Safety and Quality in Health Care (ACSQHC) released the nation’s first Cataract Clinical Care Standard, which included a quality statement relating to second-eye surgery.

“Options for a patient with bilateral cataract are discussed when the decision about first-eye surgery is being made,” the standard says.

“Second-eye surgery is offered using similar criteria as for the first eye, but the potential benefits and harms of a delay in second-eye surgery are also considered, leading to a shared decision about second-eye surgery and its timing.”

In most cases, the commission says this may result in a decision to schedule second-eye surgery some weeks after the first operation, which may avoid unnecessary delays for patients, particularly those for whom refractive differences may be considerable after the first eye surgery. In others, it may be the patient’s decision to wait and see.

The standard states “there is limited evidence to support second-eye surgery on the same or next day”, however there are circumstances when this is appropriate, with appropriate precautions and informed patient consent.

In light of these developments, Insight spoke with leading surgeons about their views on same-day surgery, and what lessons can be learned from the past.

RANZCO’S position

Associate Professor Andrew Chang is vitreoretinal surgeon and ophthalmologist at the Sydney Eye Hospital.

In his capacity as director on the RANZCO Board, Chang spoke with Insight about RANZCO’s position on immediate sequential bilateral cataract surgery (ISBCS) versus delayed sequential bilateral cataract surgery (DSBCS).

A/Prof Andrew Chang.

“Sequential bilateral cataract surgery, or bilateral sequential same- day surgery, is not the standard of care for the majority of patients,” Chang says.

“It is unlikely to be recommended by most RANZCO Fellows due to the advantages of sequential bilateral cataract surgery on separate days. This is evidenced in the survey results from RANZCO Fellows.”

The survey he is referring to was conducted by prominent Sydney cataract surgeon Professor Gerard Sutton and Dr Christopher Hodge who quizzed Australian ophthalmologists on their views about simultaneous bilateral cataract surgery (SBCS), which appears to have a limited local uptake.

Although it remains contentious, Sutton and Hodge point out it has become more prevalent in northern Europe with government compensation for day surgeries.

“Proponents may argue that the incidence of bilateral endophthalmitis is minimal, however it remains a primary concern for many,” they wrote in RANZCO’s Eye2Eye magazine (Q1, 2021), where the survey results were published.

“SBCS is undertaken in Australia, however our survey suggests it has minimal penetration at present with only 4.1% of respondents offering the service to patients. Furthermore, 95.4% of surgeons did not believe SBCS should be made mandatory as an alternate to routine practice of surgery on separate days. Of note, of those who complete SBCS, most surgeons (69%) only offered it to 5-10% of their patients, highlighting the current niche role in the patient/surgery discussion,” they wrote.

Chang says, in Australia and New Zealand, most surgeons and their patients chose timing of surgery on separate days. He says surgeons do this with consideration to best safety and outcomes for the individual.

“Cataract surgery is major intraocular surgery with defined risks. Although unlikely, unexpected complications and adverse outcomes may occur in preoperative preparation, during the surgery itself or in the postoperative course,” he says.

“Often this relates to the individual patient and their eye pathology. Surgeons will use this important information to learn, manage and avoid these patient eye-related issues when performing surgery on the second eye. This ensures safety and optimal outcomes for patients.”

Chang says operating on one eye at a time necessarily reduces the surgical and anaesthetic risk to both eyes and body.

“Further, depending on the regional anaesthetic block, having both eyes done at once would result in the patient being unable to see for up to six hours after the surgery,” he says.

Timing of surgery on the second eye is in part driven by the results of the first operation.

“The surgical and optical result from cataract surgery in the first eye is used to guide the patient and surgeon for any changes required when the second eye is done,” Chang says.

“The focus point for reading or distance in the first eye can be assessed for appropriateness and desirability allowing the power of the intraocular lens to be altered to match the focus in the first eye or to achieve monovision with blended vision.

“Uncommonly, the calculated power of the intraocular lens preoperatively does not give the predicted focal point once implanted in the patient (known as refractive surprise). Separate day surgery will allow this undesired situation to be detected and managed.”

Ophthalmologists say delaying surgery on the second-eye allows a ‘customisation opportunity’, to recalibrate based on the outcome of the first eye.

Even for a highly myopic patient, bilateral sequential same-day surgery would not be necessary, in Chang’s opinion.

“In this example, if the patient were to have one eye rendered focused in the far distance (emmetropia) this would pose issues with seeing with both eyes together (binocularity) until the second eye undergoes surgery to match the first eye. In this situation, most surgeons and patients would choose to have surgery timed close together, when safe to do so,” he says.

Chang acknowledges that in certain circumstances SBCS may be an option – for example, those requiring general anaesthetic, such as the very young, very elderly, or patients with dementia.

“Patients do have a right to choose. This is reflected in the consumer section of the [Cataract Clinical Care] Standard,” he says.

However, RANZCO has “strongly disagreed” with the need to routinely discuss same or following day second-eye surgery, which some have interpreted as a recommendation in the Standard.

“Due to the low rates of bilateral sequential same-day surgery and the very particular set of circumstances that may cause a patient to require it, there should be no need to make discussions about bilateral sequential same-day surgery routine,” Chang says.

“The vast majority of surgeons and their patients chose timing of surgery on separate days. A small minority of surgeons perform bilateral sequential same-day surgery in selected patients. This would include medical or logistical issues of access and travel.”

Financial disincentives 

Dr Michael Lawless from the Vision Eye Institute is one of Australia’s most experienced eye surgeons, having performed more than 30,000 surgical procedures. He is a Clinical Associate Professor at Sydney Medical School (University of Sydney) and is recognised as a global authority on laser eye surgery.

Lawless is also a contributing author in a new textbook Immediately Sequential Bilateral Cataract Surgery (ISBCS): Global History and Methodology, due for publication this year. Working with chief author and editor, Dr Steve Arshinoff, he has penned a chapter on the Australian perspective.

Dr Michael Lawless.

From an ophthalmologist’s point of view, Lawless says the prevalence of ISBCS depends on where you are in the world, and whether your peers see it as a sensible proposition.

“In some Scandinavian countries, such as Finland, approximately 50% have same-day cataract surgery but in Australia, it has very low uptake. But both are in the right – there are no absolutes on this,” he says.

“There are definite benefits to same-day cataract surgery. There are clear benefits to society in terms of cost and efficiency; patients, who tend to be over 60 and sometimes need help getting to and from surgery, only need to come in once, and there are fewer post-op visits. There are clearly efficiencies in day surgery, requiring only one visit, and one aesthetic. Why wouldn’t you do it more commonly?”

Lawless says the fear of potential rare bilateral clinical complications is keeping same-day cataract surgery at bay among Australian ophthalmologists.

However, reliable data analysis from the University of Toronto’s Dr Steve Arshinoff – who Lawless describes as “the person who has thought about and published the most on ISBCS in 25 years” – shows a low rate of infection in both eyes in same-day surgery.

“If you’ve got the right protocols in place in theatre, the risk of infection in the second eye is almost immeasurably low. So, why don’t we do same- day? Partly because it’s not the norm – our peers aren’t doing it – but the main barrier is financial,” Lawless says.

“As Paul Keating said, back self-interest every time,” Lawless quips. [Paul Keating often quoted his long-time mentor former NSW Premier Jack Lang: “In the race of life, always back self-interest – at least you know it’s trying”].

Under the current system, Lawless says there are financial disincentives for the surgeon and the day surgery or facility to perform same-day surgery. Simply put, in order for same-day cataract surgery to be more commonplace in Australia, the financial incentives need to be sensible.

“In the US, for example, when a surgeon removes a lens for refractive purposes – not because of cataract – the patient pays the total cost of surgery. This means the patient has a financial incentive to have both eyes operated on the same day and so the uptake is higher. In the US, bilateral same-day cataract surgery is low but bilateral same-day lens extraction is significantly higher. That’s a reflection of financial incentives,” Lawless says.

“Another thing to consider is the Indigenous population, especially in remote areas. Patients commonly find it difficult to get to a clinic and don’t come back for the second eye and my understanding is that in Western Australia, they are increasingly doing bilateral same day surgery for that reason.”

Dr Angus Turner, from the Lions Eye Institute in WA, confirmed this to Insight. He started offering same-day surgery to select patients in 2013.

“I started doing this with a policy for hospitals accepting it and writing out a document that essentially said it was a separate operation,” Turner says.

At the time, he cited an article in Ophthalmology Management for reference, titled ‘Doubling Down on Cataract Surgery’, by Jerry Helzner, senior editor. Since then, several ISBCS reviews and meta-analysis have been published in international peer-reviewed journals.

“I don’t routinely do bilateral surgery however, when patients have high refractive error and outreach surgery visits are infrequent, then I do offer it. Also, if patients have large logistical or geographical barriers to care, I will discuss same-day surgery with the patient,” Turner says.

Geographic and financial motivations aside, Lawless points out that while refractive outcomes used to be a reasonable argument against same-day cataract surgery, that is no longer the case because lens selection and surgical precision are of such excellence, surgeons can achieve the desired refractive outcomes in immediate sequential operations.

“If the argument against ISBCS is the refractive outcome then surgery should be scheduled six weeks apart, which is not commonly done, and so this argument is clearly nonsense,” he says.

In his own practice, Lawless routinely schedules bilateral cataract surgery one week apart.

“Occasionally I do one day apart. I don’t have a conversation with patients about doing same-day – and I won’t have that conversation until the authorities and the regulatory framework are supportive. Otherwise, you leave yourself open or vulnerable to criticism for being outside the mainstream.”

Customisation opportunity 

Associate Professor Chandra Bala is managing director at personalEYES, comprising 10 clinics in NSW and ACT, and subspecialises in cataract, cornea, glaucoma and refractive surgery.

On the balance of risk, Bala is “not a big fan” of same-day bilateral cataract surgery and would perform it only in extenuating circumstances.

A/Prof Chandra Bala verifies his outcome at week one and rarely operates after a two-day gap, provided the vision is where he expects it to be.

He says usually cataract surgery is uncomplicated but there are patients who develop corneal edema as part of removing their dense cataract.

“They would need to recover from the first eye before one could commit them to the second,” Bala says.

“Then there are known risks associated with cataract surgery. You can execute a perfect operation but have an adverse outcome, including endophthalmitis or toxic anterior segment syndrome or refractive surprises. Adverse outcomes only occur in a very small number of cases, but they still exist, it’s not a figment of imagination. To have this happen to both eyes would be terrible for the patient,” Bala says.

There are also unknown or unexpected risks. Health systems are not immune to catastrophic failure; these can – and do – still happen. To illustrate his point, Bala recalls more than one significant health system failure resulting in cataract patients losing sight.

“It happens in Australia from time to time. The last time it happened was in 1999. Several patients had their vision affected in one eye following cataract surgery at Dubbo Base Hospital. The case went to the NSW Health Care Complaints Commission (HCCC),” he says.

According to the HCCC’s report, 12 out of 19 patients who underwent cataract surgery at Dubbo Base Hospital on 8 February 1999 experienced significant permanent damage to their corneas and visual impairment.

The report stated that it appeared supplies of the usual irrigating and intraocular agent (a balanced salt solution) were low due to errors in ordering and/or delivery and that an alternative solution was used as a substitute. On the evidence available, the substitute solution may have been responsible for the adverse outcomes on the basis that it contained a preservative, benzalkonium chloride, which is not present in the usual solution.

Another negative outcome Bala recalls involved 11 eyes of six patients from six different institutions in the US.

In 2015, the American Academy of Ophthalmology published a retrospective study on postoperative hemorrhagic occlusive retinal vasculitis (HORV) that developed in six patients who underwent otherwise uncomplicated cataract surgery, receiving prophylactic intracameral vancomycin during the procedure.

Despite good initial vision on post-operative day one, between one to 14 days after surgery, all eyes demonstrated painless vision loss resulting from HORV, a rare and devastating condition linked to the use of intraocular vancomycin.

“Five of those six patients went bilaterally blind. They walked in through the surgery doors seeing, but within two weeks were bilaterally blind,” Bala says.

“You are not offering a better outcome by doing same-day cataract surgery.”

Bala usually delays second-eye cataract surgery two weeks after the first eye, but he does offer bilateral same-day LASIK surgery, a 10-minute operation, and bilateral same-day ICL surgery (implantable collamer lens).

“I believe in technology – I’m a technophile – but I don’t trust it. In cataract surgery, I verify my outcome at week one. Rarely, I’ll operate after a two-day gap provided the vision is where I expect it to be. I haven’t had a patient with an infection in 15 years but I always worry about it,” he explains.

“Delaying surgery on the second-eye allows a ‘customisation opportunity’, to recalibrate based on the outcome of the first eye.”

More reading

Survey provides insight into Australian cataract surgery landscape

Issues around same day bilateral cataract surgery

Reducing cataract surgery wait to three months would prevent thousands of falls, Aussie research finds

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