Two Eyes, One Surgery

cataract surgery

Simultaneous Bilateral Cataract Surgery (SBCS) lets patients have cataract surgery on both eyes, on the same day.  But this procedure sparks debate in the professional community. While frequently performed in Europe, it is still a rarity in the U.S.—and MedStar Washington Hospital Center ophthalmologists Jay Lustbader, MD, and Mark Gonzalez, MD, say the lack of popularity of the procedure in this country is well-deserved.

“I don’t perform them—and I don’t know anyone in the area who performs the procedure,” says Dr. Lustbader, chair of Ophthalmology.  “Post-operative endophthalmitis—a complication that results in inflammation of the eye—may be rare, but the worst case scenario would be infection in both eyes, and possible blindness, and as a physician, I wouldn’t want to put myself or my patients in that situation. There simply hasn’t been enough research to quell my concerns.”

“I can understand the patient perspective. Some will want to get the procedures completed at one time. But I dissuade them from this.  Even without the complication of infection, patients could be affected by swelling or irritation following the procedure.  It’s best to have the full capacity of one eye.”

Dr. Gonzalez agrees.  “Why take the risk of bilateral blindness? While not common, there have been cases of endophthalmitis linked to manufactured products we use during surgery. If SBCS was being performed at that time, the possibility of bilateral endophthalmitis would have been much greater,” he adds.

Infection Prevention

“Pro SBCS” physicians argue that the use of stringent antiseptic protocols—literally, operating on the second eye as if it were a second surgery—can prevent infection. They also promote the use of antibiotics, injected into the eye, as an effective preventive.

Dr. Lustbader explains that the use of injected antibiotics is another area of controversy, separate from the bilateral surgery question. “In the U.S., there is no commercially available antibiotic approved for this use,” he says.  “Many of us will consider using them, once there is an FDA-approved option.”

“Currently, I do not use this type of antibiotic, because of a recent association to retinal vasculitis—an inflammation of the eye,” says Dr. Gonzalez. “I simply think the topic needs further examination.”

First Procedure Informs Second

Both Drs. Lustbader and Gonzalez note there is another benefit to performing surgery weeks apart.  “Outcomes from the first surgery can give us some advantage.  We can make refinements when we perform the second procedure,” Dr. Lustbader notes.

“The patient’s visual recovery from the first surgery can serve as a good guideline for the second,” Dr. Gonzalez agrees.

Proponents of SBCS also point to reimbursement, as the major deterrent to its lack of acceptance in the U.S.  When both eyes are operated on simultaneously, Medicare pays 100 percent for the first eye, and 50 percent for the second.

“I understand that the cost savings to insurance could be millions of dollars, but I still feel it’s best to err on the conservative side of this issue,” Dr. Gonzalez says.  He adds that he has performed the procedure at least once under very special circumstances, but states he certainly would not consider it as a routine part of his practice.

The American Academy of Ophthalmology guidelines for preferred practice of treatment of adult cataracts takes the middle road.  It cites the pros and cons, seemingly leaving the decision to individual physicians.