COVID-19 Strengthens the Case for Same-Day Bilateral Cataract Surgery

Sumit (Sam) Garg, MD


October 08, 2020

In practicing amidst a pandemic, ophthalmologists have been forced to make adjustments to ensure they maintain a high level of care while also limiting virus exposure for themselves and their patients. It was recently proposed that one means of achieving these goals is the broader adoption of immediately sequential bilateral cataract surgery (ISBCS).

Currently, most practices use delayed sequential bilateral cataract surgery. This is primarily driven by financial rather than clinical considerations, because a majority of payers cut reimbursement by 50% on secondary procedures done on the same day. For most cataract surgeons and the surgery centers and hospitals in which they operate, this makes ISBCS a nonstarter.

Yet ISBCS offers several advantages that made it a compelling option even before COVID-19, which have since only become more attractive to cataract surgeons. Compared with the traditional standard of delayed sequential cataract surgery, ISBCS can be accomplished with a streamlined workflow that reduces patient visits and hospital costs, while achieving faster visual recovery. In addition, both ISBCS and delayed sequential cataract surgery are reported to produce similar visual and safety outcomes.

Objections to ISBCS include a hypothetical increased risk for refractive surprises, toxic anterior segment syndrome, and endophthalmitis, but these concerns are not supported by the evidence. If accepted guidelines are followed, there have been no cases of bilateral endophthalmitis, and with the use of intracameral antibiotics, the risk is extremely low.

The advantages of ISBCS have led to a general shift toward adopting it in recent years. The Kaiser Permanente system in the United States is a strong proponent of ISBCS. As they are both the payer and the provider, ISBCS makes sense for its system — more streamlined use of the operating room, less interaction between patients and staff or physicians (of particular importance with COVID-19), fewer office visits, and reduced patient copays, which all lead to more efficient delivery of care.

In fact, both the American Society of Cataract and Refractive Surgeons and the American Academy of Ophthalmology have task forces who are working with governmental agencies, including Medicare, to figure out if there are ways to make ISBCS more available to patients and still allow practices to collect a "bundled" payment.

Certainly, ISBCS should only be considered in appropriate candidates. Ophthalmologists are advised to avoid eyes that are at the extremes of axial length, postrefractive eyes, and possibly those with presbyopia with or without toric intraocular lenses. In addition, patients who may have a higher risk for infection, a posterior capsule tear, or a retinal pathology (ie, diabetic macular disease) that may affect outcomes should probably undergo delayed sequential bilateral cataract surgery, as is customary.

Most proponents of ISBCS also recommend intracameral antibiotics to reduce the risk for postoperative endophthalmitis. However, in a recent ruling, the US Food and Drug Administration (FDA) stated their intention to remove moxifloxacin and ketorolac from the 503B list of active pharmaceutical ingredients that are allowed to be compounded. Moxifloxacin is the most common medication used for post–cataract surgery prophylaxis in the United States. If the FDA is successful in removing moxifloxacin, compounding pharmacies will no longer be able to provide this medication to cataract surgeons. There is no question that this would be a huge blow to proponents of ISBCS.

We are currently facing an increasingly aging population, while the rate of available cataract surgeons remains relatively static. I am therefore encouraged by the efforts to change our current reimbursement structure surrounding ISBCS and to safeguard continued access to valuable compounded medications. In doing so, we may ensure the more widespread adoption of ISBCS, during COVID-19 and beyond.

Sumit (Sam) Garg, MD, is the vice chair of clinical ophthalmology and an associate professor in the Department of Ophthalmology at the Gavin Herbert Eye Institute, University of California, in Irvine. He specializes in corneal and cataract surgery, as well as laser refractive surgery.

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