Arshinoff Steve A. Simultaneous Bilateral Cataract Surgery: 2009Poster ID # P-7 Worldwide status of...

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Arshinoff Steve A. Simultaneous Bilateral Cataract Surgery: 2009Poster ID # P-7

Worldwide status of simultaneous bilateral cataract surgery (SBCS) in 2009

Steve A. Arshinoff MD FRCSC *

Eye Associates, Humber River Regional Hospital,

University of Toronto, Toronto, Ontario, Canada.

McMaster University, Hamilton, Ontario, Canada.

ASCRS – 2009Sa Francisco, CA,

USA

Personal Background with SBCS (SAA):

I am probably the world’s foremost advocate of SBCS, having operated on in excess of 3,000 completely elective SBCS patients since 1996, and published the results of the first 1020 consecutive patients.1

In the >6,000 eyes completed, not a single eye suffered a deleterious effect because of the simultaneous bilaterality of their surgery.

I have never had a single patient express dissatisfaction with having chosen to undergo SBCS.

Many of my patients, who had chosen to undergo unilateral cataract surgery (UCS) x 2, were sorry they did not choose SBCS, when they

sat in the office waiting room on POD1 with SBCS patients.

Introduction:

Simultaneous bilateral cataract surgery (SBCS) offers potentially excellent advantages of rapid recovery, convenience, and economic savings for the patient and the health care system. Global acceptance of SBCS varies dramatically , but is increasing. This poster examines the current global status of SBCS.

1

Financial Disclosure : The author acknowledge no financial interest in anything discussed herein.

1 Arshinoff Steve A, Strube YNJ, Yagev R. Simultaneous Bilateral Cataract

Surgery. J. Cataract Refract Surg. July 2003. 29: 7; 1281-1291.

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Purpose & Method2

Purpose:

To review available literature and surgeon experiences with SBCS, from around the world, and assemble the information in a manner that might clarify the, prevalence, acceptance & issues surrounding SBCS.

Method:A literature review was conducted online (PubMed), along with preferred practice documents from different countries. Reviews of our own experience & that of members of the International Society of Bilateral Cataract Surgeons (iSBCS) raised by the literature review were conducted.

SBCS, or ISCS (Immediately Sequential Cataract Surgery), is not to be embarked upon lightly.

It is the obsessive, meticulous, sequential performance of 2 independent, separate & sterile cataract procedures on the same patient, in order to gain the benefits of immediate bilateral visual recovery, usually including normal stereopsis.

SBCS requires motivated staff, eager to do better, and access to current technology, as well as ongoing reassessment of performance standards.

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Background: Problems collecting SBCS data

Oh, it’s a custom from the old country?! Why didn’t you say so!

Collegial Hostility,

similar to what occurred with the

advent of the first IOLs &

phacoemulsification, prevents SBCS

surgeons from coming forward to

present data.

There has been a general failure in

Ophthalmology to consider SBCS, or

even to permit open discussion at

most academic meetings.

However, different jurisdictions offer

varying opportunities to discover what

is being done by surgeons.

Oh, it’s a customfrom the old country. Whydidn’t you say so?

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SBCS surgeon

Establishment

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Who Performs SBCS?SBCS in Ontario (ON), Canada

S B C S EYES UNDERGOING CATARACT (CAT) SURGERY in Ontario (ON)

ON SBCS

YEAR AUTHOR All ON AUTHOR / ON % ON Cats % of Cats

(Apr 1- Mar 31)

2003-4 498 1016 49.02% 99825 1.02%

2004-5 488 1346 36.26% 108480 1.24%

2005-6 682 1862 36.63% 126384 1.47%

2006-7 556 1642 33.86% 139387 1.18%

2007-8 538 2196 24.50% 139101 1.58%

The Government of Ontario collects data on all aspects of government-controlled health care, including which patients were billed for cataract surgery in both eyes on the same day.

Conclusion: SBCS is increasing in frequency Ontario. - Absolute numbers have increased >100% over 5 years (1016 2196) - Percent of total cataract cases has increased 56% over 5 years (1.02% 1.58%) - Preliminary data suggests that the other Canadian provinces are similar.

Ontario

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6.4% 6.6% 7.2% 7.8%

Y E A R

Source: ESCRS annual surveys conducted by David Leaming, MD, 2004-2007 (www.leamingsurveys.com)

US & Europe: Performing & Discussing SBCS

Probably because of financial penalties

for performing SBCS, very few

American surgeons (ASCRS members)

routinely perform SBCS.

Despite the percent of ESCRS members

performing SBCS gradually increasing,

academic societies are often unwilling

to permit courses on SBCS at meetings.

We (Charles Claoue, Steve Arshinoff, John Bolger,

Sulevi Kaipiainen, Richard Packard & Johann Kruger)

have submitted proposals for SBCS

courses at the last 5 ASCRS & ESCRS

meetings, with the following results:

ESCRS Members Performing SBCS (ASCRS = ± 0)

5

SBCS Courses

2005 2006 2007 2008 2009

ASCRS rejected accepted rejected accepted rejected

ESCRS rejected rejected rejected rejected accepted

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Why not do SBCS: The 3 big fears with SBCS

1. Post operative retinal detachment (R/D)• In almost all cases, R/D occurs sufficiently late that the

second eye would have already had surgery, whether SBCS or UCS (unilateral).

2. IOL power errors in 1st eye, correctable for 2nd eye ? • Errors are very rare using partial coherence interferometry,

new Haigis L equation, and ASCRS post refractive surgery calculator.

• *Jabbour : No benefit to inter-procedural recalculation of IOL power.

3. Bilateral post operative endophthalmitis (POE)& TASS (Toxic Anterior Segment Syndrome).• Only remaining significant concerns.

*Jabbour J, Irwig L, Macaskill P, et al. Intraocular lens power in bilateral cataract

surgery: Whether adjusting for error of predicted refraction in first eye improves

prediction in the second eye. JCRS 2006; 32:2091-2097.

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Arshinoff Steve A. Simultaneous Bilateral Cataract Surgery: 2009Poster ID # P-7 7

There have been 4 reported cases to date:1. * BenEzra 1978 Malawi bilateral blindness

Patient had septicemia & dysentery Both eyes operated with same instruments – ICCE.

2. ** Ozdek 2005 Turkey bilateral visual recovery70 yo healthy male, same irrigating fluids, new drape, flashed same instruments, no antibiotic prophylaxis. BCVA recovered to 20/50, 20/40, after 1 month.

3. *** Kashkouli 2007 Iran bilateral blindness67 yo male SBCS same instruments bilateral Pseudomonas1 eye phaco/foldable IOL, 2nd = unplanned ECCE & 6 mm PMMA IOL.Same doctor, preceding day, 1 SBCS patient blinding infectionwith the same Pseudomonas bacteria – 1 eye. (PDF protected from copying)

4. ****Puvanachandra 2008 UK bilateral visual recovery to 6/9 ou. 81 yo female. 3 piece acrylic IOLs with intracameral cefuroxime, postop Tobradex® QIDDifferent equipment used from the same autoclave sterilization cycle without indicators.4 days post op bilateral Staph. epidermidis endophthalmitis – same strain in both eyes.

Fears of SBCS: 3. Bilateral Endophthalmitis

* Benezra D, Chirambo MC. Bilateral versus unilateral cataract extraction: advantages and complications. Br J Ophthalmol 1978;62:770–3.

** Ozdek SLC, Onaran Z, Gurelik G, et al. Bilateral Endophthalmitis after simultaneous bilateral cataract surgery. JCRS 2005; 31: 1261-62.

*** Kashkouli MB, Salimi S, Aghaee H, et al. Bilateral Pseudomonas aeruginosa endophthalmitis following bilateral simultaneous cataract surgery. Indian J Ophth. 2007; 55: 374-5.

****Puvanachandra N, Humphry RC. Bilateral endophthalmitis after bilateral sequential phacoemulsification. JCRS 2008; 34: 1036-7.

commenting letter: Arshinoff S. Bilateral endophthalmitis after simultaneous bilateral cataract surgery. Letter. JCRS 2008; 34: 2006-7.

There have been no reported cases of bilateral endophthalmitis after SBCS when complete sterile separation of the 2 procedures has been followed, and no reported cases of TASS post SBCS.

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Post SBCS Endophthalmitis: ASCRS & ESCRS SBCS Course Speakers’ Cases

Post op Endophthalmitis Eyes Unilateral Bilateral

Steve Arshinoff Toronto, Canada >6,000 0 0

Charles Claoué London, England ~1,000 0 0

Richard Packard London, England 750 0 0

John Bolger London, England >6,600 3 0

Sulevi Kaipiainen Joensuu, Finland >12,000 2 0

Johann Kruger Cape Town, South Africa ~7,000+ 5 0

~33,000+ 10 0

Overall incidence = 10/33,000 = 1/3,300 = 0.03 % unilateral, 0.00 % bilateral

* (Cefuroxime arm - ESCRS study = 1/1,400 = 0.07 %)

The incidence of post operative endophthalmitis among these experienced SBCS surgeons is half that of the intracameral cefuroxime treated arm of the ESCRS study, and none were bilateral infections.

* ESCRS Endophthalmitis Study Group. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. JCRS 2007;33: 978-988.

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Enhancements instituted by author, SAA, to reduce risks of SBCS1. Intracameral antibiotics (Vigamox (moxifloxacin) 100

µg/0.1 cc BSS)

- Post op antibiotics 6x/day x 3d, then QID x 7 days

(Vigamox). No patches.

2. Separation of R & L OR tables.

-Strict avoidance of cross contamination.

-Always do L eye first (far from R table).

- Nothing goes from RL or L R.

3. List criteria (IOL type, power & astig.) for

R & L eyes on board in OR, visible to all.

4. “Everyone who touches the IOL must make

sure it is correct.” - Staff taught to review IOL calculations, & to recite them,

as IOL is passed.

5. Different OVDs for R & L eye, & everything as different

as possible.

6. Avoid changing scrub nurse in the middle of one eye’s

surgery.

Pt data:R&L

IOLs & cylinder

s

Phaco machine screen faces surgeon

Second table is far from surgical

field.

Second table remains untouched by nurse,

until 1st eye is finished and she has changed

her gloves.

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The cost of UCS compared to SBCS At the Annual ESCRS meeting, 2008, Berlin:

• Tiina Leivo, Helsinki University Eye Hospital, Finland

• Risk of Bilateral Simultaneous Endophthalmitis (BSE) ≤1/1,000,000 (& it may be much lower ? 1: 10,000,000 ?):

• Savings of SBCS is estimated at €1,600 per patient.

- Including social and administrative costs (not incl. doctors’ fees),

The additional cost to prevent 1 case of BSE, by avoiding SBCS is:

€ 739 M / case $ 1B USD(Remember, mathematically, this same individual would still experience unilateral

endophthalmitis x 2 separately)

Conclusion: There are better ways to spend $1B USD, in health

care, than by performing elective UCS, instead of SBCS.

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SBCS is: “The obsessive, meticulous, sequential performance of 2 independent,

separate & sterile cataract procedures on the same patient, in order to gain the

benefits of immediate bilateral visual enhancement.”

SBCS restores binocular vision, as nature gave it to us, not monocular acuity. We should

begin to think of ourselves as capable of restoring “normal sight.”

Progressive interest. SBCS is common in:

Finland, Great Britain, Spain, Turkey, Sweden, Poland, Canada,

Austria, China, Iran, South Africa.

Many jurisdictions financially penalize doctors for SBCS leading to

reluctance to perform SBCS*. USA, Israel, Japan.

Finland: many hospitals perform more than 50% of all cataract surgeries

as SBCS (Sulevi Kaipiainen MD - personal communication).

Worldwide evolution and acceptance of SBCS

*Arshinoff SA, Chen SH. Simultaneous bilateral cataract surgery: Financial differences among nations and jurisdictions. J Cataract Refract Surg 2006; 32:1355–1360.

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International Society ofBilateral Cataract Surgeons Founding members www.iSBCS.org

iSBCS was founded because we believe that as cataract surgery moves to refractive lens

exchange in 55 year olds, for multifocal or accomodating IOLs, we will all do predominantly

SBCS. SBCS is becoming rapidly more common around the world, and an open, honest,

forum for information exchange is needed to make the transition informed and safe. Please

join us, and take part in this exciting transition.

SURGEON LOCATION #SBCS EYES PERFORMED

Steve Arshinoff Toronto, ON, Canada > 6,000

Charles Claoué London, England, UK ~ 1,000

Richard Packard London, England, UK 750 +

John Bolger London, England, UK > 6,600

Sulevi Kaipiainen Joensu, Finland >12,000

Johann Kruger Cape Town, South Africa 7,000 +

David Pérez Silguero + group Gran Canaria, Spain 28,000

TOTAL SBCS EYES 61,000

Steve Arshinoff MD [email protected] [email protected]

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