EyeWorld India September 2016 Issue

September 2016 22 EWAP FEATURE Richard Stiverson, MD , Lakewood, Colorado, said half of his patients request same-day cataract surgery. “In the same way that our patients are given options as to what type of IOL they want, where they want their eyes to focus post- surgery, and whether they want laser-assisted surgery, I think they should have the option of choosing ISBCS,” Dr. Stiverson said. Dr. Mamalis, on the other hand, reserves ISBCS only for extenuating circumstances. “Those special circumstances would be if the patient is from a long way away and the travel for two surgical procedures is a great hardship, or if the patient is mentally challenged, for example, and requires general anesthesia for surgery,” Dr. Mamalis said. Dr. Arshinoff presented data at the 2016 ASCRS•ASOA Symposium & Congress that showed only 5% of ASCRS members and 10% of European Society of Cataract & Refractive Surgeons (ESCRS) members perform ISBCS. In Finland, however, up to 50% of all cataract surgeries are performed as ISBCS. Although extensive experience with this procedure has Dr. Arshinoff being more inclusive in his patient selection for ISBCS than earlier on, he said there are a few patients who would not be good candidates: those with bilateral diabetic retinopathy (unless referred by a retina surgeon first because of limited retinal view for examination) and those with advanced Fuchs’ dystrophy due to the chance of postoperative corneal edema bilaterally. While Dr. Stiverson said he does not consider mild Fuchs’ a contraindication, he will not do ISBCS on a patient with diabetic retinopathy within the arcades of either eye, moderate glaucoma, significant keratitis sicca, RK, keratoconus, uveitis, and a few other cases. What’s the appeal? In addition to reducing the number of trips a patient makes to the surgical center and clinic, Dr. Arshinoff said one great benefit of ISBCS to patients is the ability to produce the desired refractive result postop day 1 in both eyes, whatever the patient wants. A study published in the Journal of Cataract & Refractive Surgery compared clinical and patient-reported refractive outcomes of ISBCS with those of DSBCS. 2 The study found that in the 2 months postop, those in the DSBCS group were “significantly worse.” After 4 months though (2 months after their second eye surgery and 4 months after their first, 4 months after surgery in both eyes for ISBCS), the differences between the two groups was insignificant. “I haven’t had a single patient who came back and told me they were unhappy with having both eyes done at once,” Dr. Arshinoff said. “I’ve had a lot of patients who came back and told me they wish they had chosen to do both eyes at once rather than DSBCS.” To achieve this level of satisfaction though, Dr. Arshinoff said discussing patient expectations is exceedingly important. Dr. Arshinoff said if surgeons are using modern methods for IOL power calculations and have had extensive discussions with their patients about their day-to-day activities and expectations, refractive outcomes should not be a problem. He also said that he finds doing the surgery on the same day actually better prepares him for the surgical procedure on the second eye. “The best time to do the other eye is just after I finish the first eye because I know exactly what kind of problems I’ll have in the second eye,” he said. Dr. Stiverson said despite the fact that he rarely changes his original IOL choice for the second eye, he still recommends patients wishing for spectacle independence have cataract surgery on different days. Dr. Mamalis also related to this idea of delaying the second surgery in order to learn from the first eye and make adjustments in the second in the event of a poorer than expected refractive outcome. “If a patient experiences problems with an implant in one eye, for example dysphotopsia or another visual phenomenon, you may want to reconsider what implant you’re going to put in the second eye,” Dr. Mamalis said, noting that he has not yet encountered such an issue with his ISBCS patients. What are the concerns? Physicians have cited the risk of bilateral endophthalmitis and toxic anterior segment syndrome (TASS) among primary concerns for performing ISBCS. A review published in 2015 in Clinical & Experimental Ophthalmology , however, stated that “evidence does not support the fear of bilateral endophthalmitis resulting from the simultaneous procedure.” 3 The risk for infection is at least theoretical, but as Dr. Arshinoff put it, “everything you do in life has a risk. We choose the path with the least risk, not no risk.” “How do you reduce the risk? Use intracameral antibiotics,” he said. “To not use intracameral antibiotics with ISBCS is not defensible in my opinion,” Dr. Stiverson said. However, intracameral antibiotics are not yet approved by the U.S. Food and Drug Administration (FDA) for this indication. The FDA has approved a randomized, double blind clinical trial, which has not begun recruiting participants, that will determine the safety but not efficacy of intracameral vancomycin and moxifloxacin. Recent reports of hemorrhagic occlusive retinal vasculitis after intracameral vancomycin use present a significant obstacle in studying vancomycin intracamerally. 4 Dr. Stiverson said that he is more comfortable with the off-label use of these antibiotics because Kaiser Colorado has a compounding pharmacy with a good reputation for ophthalmic preparations. Dr. Arshinoff also advised surgeons doing ISBCS to make sure incisions are sealed to help reduce the risk of endophthalmitis. “Leaking incisions are a leading cause of postoperative endophthalmitis.” As for reducing risk of TASS, Dr. Arshinoff pointed to the “ISBCS General Principles for Excellence in ISBCS 2009,” guidelines established by the society for various best practices, which include the use of intracameral antibiotics as well as treating the second eye as a completely separate surgery, redraping the patients, rescrubbing, etc. If any part of the surgery is changed, Dr. Arshinoff said Immediately - from page 21 continued on page 24