What is your opinion of same-day bilateral intraocular surgery?
Eric D. Donnenfeld, MD
Many surgeons currently perform same-day surgery on children and adults who require general anesthesia. The risk of general anesthesia is perceived as greater than that of bilateral surgery. The major risks of same-day intraocular surgery are infection and the surgeon's inability to titrate refractive results based on his or her experience with the first eye. The benefits are reduced expense to the patient as well as less time out of work, fewer postoperative visits, and a lower requirement for familial oversight. In my opinion, economics will drive the eventual move toward same-day bilateral surgery, as there should be significant cost savings to the patient, insurance company, surgical center, and ophthalmologist. Same-day bilateral surgery will become more viable with smaller incisions, improved surgical technology, and better refractive results. Same-day bilateral cataract surgery with the implantation of an IOL is an idea that, in time, will come, but we are not quite there yet.
Karl G. Stonecipher, MD
Same-day bilateral sequential surgery makes sense for many reasons, with cost's being the most pressing. Cataract surgery is the No. 1 line item for cost to Medicare. Sameday bilateral surgery would require less time in the OR and therefore dramatically reduce the expenses associated with cataract surgery.
The second important point is patients' return to productivity. Many of our cataract patients work. They provide day care, volunteer, or are productive members of the workforce. Same-day, bilateral, sequential surgery would enable these individuals to return to work in a timely fashion. Same-day bilateral sequential surgery in the elderly population also makes sense. Many older patients are disabled because of the anisometropia produced by surgery on one eye. These patients often become less productive between surgeries or are injured from a fall or trauma due to their loss of depth perception.
Although not every patient will qualify, many will be candidates for same-day bilateral sequential surgery. The only argument against this option is the potential risk associated with it. I started performing bilateral refractive surgery in 1991 and bilateral laser vision correction in 1995. I recently submitted the results of over 24,000 bilateral cases. The rate of problems I encountered was low and not much different than for unilateral surgery.1,2
The real question is if the medicolegal environment will support same-day surgery. I do not believe we will get push back from patients; the legal system will limit this surgical option. Until Medicare or one of the third-party payment plans pushes for reduced costs with same-day bilateral sequential surgery, it will be business as usual in my opinion.
Stephen A. Updegraff, MD
I believe this is a question of medical ethics. Billing, efficiency, and ego have to be set aside. The truth is, none of us is immune to unforeseen complications. Do you want to be responsible for turning a unilateral problem into a bilateral one? Experiencing an outbreak of toxic anterior segment syndrome cured any inclination I had toward bilateral intraocular surgery. Furthermore, from a refractive standpoint, I still believe ophthalmologists learn a lot about the effective lens position that can greatly increase the refractive accuracy of surgery on the second, dominant eye.
Section Editor John F. Doane, MD, is in private practice with Discover Vision Centers in Kansas City, Missouri, and he is a clinical assistant professor with the Department of Ophthalmology, Kansas University Medical Center in Kansas City, Kansas. Dr. Doane may be reached at (816) 478-1230; firstname.lastname@example.org.
Eric D. Donnenfeld, MD, is a professor of ophthalmology at NYU and a trustee of Dartmouth Medical School in Hanover, New Hampshire. Dr. Donnenfeld may be reached at (516) 766-2519; email@example.com.
Karl G. Stonecipher, MD, is the director of refractive surgery at TLC in Greensboro, North Carolina. Dr. Stonecipher may be reached at (336) 288-8523; firstname.lastname@example.org.
Stephen A. Updegraff, MD, is the medical director of Updegraff Vision in St. Petersburg, Florida. Dr. Updegraff may be reached at (727) 822-4287; email@example.com.
- Stonecipher KG, Meyer JJ, Stonecipher MN. Laser in situ keratomileusis flap complications and complication rates using mechanical microkeratomes versus femtosecond laser: retrospective review. J Refract Surg. In press.
- Stonecipher KG, Potvin R, Meyer JJ, et al. Refractive surgery outcomes comparison—all wavefront-guided versus a decision tree for selecting wavefront-guided or wavefront-optimized. US Ophthalmic Review. 2012;5(1):14-17.