EyeWorld India June 2015 Issue

45 EWAP CATARACT/IOL June 2015 Arshinoff said, which suggests that most surgeons lack the experience with ISBCS and a desirable reimbursement system. Dr. Arshinoff performs bilateral surgery and said he is not worried about the issues posed in the question. “I think the paradigm is slowly changing as cataract surgery becomes progressively safer and more accurate,” he said. Dr. Stiverson feels that the concerns about performing bilateral cataract surgery may be disingenuous. “The majority of respondents indicated they are worried about bilateral endophthalmitis or bilateral TASS,” he said. “And yet, the ASCRS surveys on frequency of endophthalmitis and TASS continue to decline.” These are now rare, and he thinks the responses were a reaction to the hesitation felt by surgeons over the money aspect of bilateral surgery. “Over the years, I have had innumerable patients who would have truly benefited from same day bilateral surgery,” he said. “Transportation, infirmity, terminal diseases, anxiety, and finances are all appropriate reasons to consider bilateral surgery.” However, Dr. Stiverson said the major reason he chose separate surgeries was financial penalties. “I think that financial penalties are the main reason that same day bilateral surgery lags in the United States,” he said. If these penalties were taken away, Dr. Stiverson thinks that 50% of surgeries would be bilateral within 5 years. “I perform same day bilateral surgery because it benefits the patient, it benefits me surgically, it benefits the Kaiser [Permanente] healthcare delivery system, which I whole-heartedly believe in, and it benefits the United States taxpayer-funded Medicare system,” Dr. Stiverson said. “I think the fact that only 1 in 5 respondents are worried about bilateral endophthalmitis reflects an understanding and appreciation of the evidence.” Presentation Dr. Arshinoff stressed that “[ISBCS] is safe and effective, and the issues are mostly lack of experience with the procedure.” Dr. Stiverson’s presentation was about the experience and results of two Kaiser doctors in Colorado. “I believe this is the largest series of immediately sequential bilateral cataract surgery reported in the United States,” he said. “We are able to generate statistically meaningful numbers in a relatively short period of time.” The focus of his presentation was on complications, with endophthalmitis and TASS both being statistical worries. “At the time of my presentation, Colorado Kaiser had not had endophthalmitis in 25,000 cases or TASS in 40,000 cases,” he said. “Those numbers are now 30,000 and 45,000, respectively.” Qualitatively, ISAK is superior to the manual incisions we have made in the past. The intrastromal incisions are geometrically perfect and are created exactly as they are programmed. ISAK is less invasive than penetrating incisions, so we would expect it to be safer, minimizing the risk of infection and increasing patient comfort. High quality, 3D imaging is critical to the safety of femtosecond laser ISAK because accurate identification of the epithelium and endothelium helps prevent an accidental penetration of either the anterior or posterior cornea. The surgeon should take care to observe there is no shift in the identified structures prior to treatment. It is not yet clear where the ideal optical zone is for ISAK. Other surgeons have taken a variety of approaches, adjusting their LRI nomograms by a certain percentage and/or moving the optical zone to between 9.0 mm and 7.0 mm. More work remains to develop ISAK- specific nomograms, but once we can appropriately adjust existing nomograms for intrastromal incisions, we should be able to replicate or surpass the efficacy of manual LRIs with this technique, with enhanced safety and patient comfort. EWAP Reference 1. Ferrer-Blasco T, Montés-Micó R, Peixoto- de-Matos SC, et al. Prevalence of corneal astigmatism before cataract surgery. J Cataract Refract Surg . 2009;35(1):70–5. Editors’ note: Dr. Salz is a fellow at the New England Eye Center at Tufts Medical Center, Boston. Dr. Salz has no financial interests related to this article. Contact information Salz: dasalz@gmail.com Dr. Stiverson said it is thought that this “exceptionally low infection and inflammation rate” is due to the use of intracameral antibiotics, trusted vendors, and the increasing use of disposable products. “In determining whether a patient is a good candidate for immediately sequential surgery, I think corneal surface problems, epiretinal membranes, diabetic macular edema, and advanced glaucoma require the most consideration,” he said. Dr. Stiverson also discussed the surprise that so many people want bilateral surgery, even when presented with worse case scenarios. With the exception of a few comorbidities or patient acceptance, there is no reason to not operate on both eyes on the same day, he said. Knowing the behavior of the first eye is invaluable in performing surgery on the second eye. “Without question, I am a more competent, safer surgeon when I can immediately address a second eye when the first eye was not as easy as expected,” Dr. Stiverson said. “I think this has profound implications for how we should train residents (same day bilateral surgery whenever possible), but that is a controversial conversation for another day.” EWAP Editors’ note: Drs. Arshinoff and Stiverson have no financial interests related to this article. Contact information Arshinoff: i x2is@gmail.com Stiverson: richard.stiverson@kp.org Instrastromal - from page 40