Transcript OPHTHALMIC VISCOELASTICS 1997 WHERE DO WE GO FROM …

Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
Worldwide status of simultaneous bilateral
cataract surgery (SBCS) in 2008
Steve A. Arshinoff MD FRCSC *
Eye Associates, Humber River Regional Hospital,
University of Toronto, Toronto, Ontario, Canada.
McMaster University, Hamilton, Ontario, Canada.
Silvia Odorcic BA MD (Candidate)
ASCRS – 2008
Chicago, Illinois, USA
University of Toronto, Toronto, Ontario, Canada
Introduction:
Personal Background with SBCS (SAA):
Simultaneous bilateral cataract

surgery (SBCS) offers potentially
excellent advantages of
convenience, rapid recovery and

economic savings for the patient.
Yet the global acceptance of

SBCS varies dramatically from
country to country. This poster

examines some of the issues.
Financial Disclosure :
The authors acknowledge no financial
interest in anything discussed herein.
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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.
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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Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
Purpose & Method
Purpose:
To review available literature and
personal experiences with SBCS, from
around the world, and assemble the
information in a manner that might
clarify the issues pertinent to the
practice of SBCS.
Method:

A literature review was conducted online
(Scopus & PubMed), along with preferred
practice documents from different
countries. A review of our own experience
was conducted with respect to issues
raised by the literature review.
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.
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SBCS can never performed in a cavalier manner, sacrificing single eye sterility, IOL
calculation accuracy, or anything else.
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Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
Purpose & Method
Purpose:
To review available literature and
personal experiences with SBCS, from
around the world, and assemble the
information in a manner that might
clarify the issues pertinent to the
practice of SBCS.
Method:

A literature review was conducted online
(Scopus & PubMed), along with preferred
practice documents from different
countries. A review of our own experience
was conducted with respect to issues
raised by the literature review.
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.
SA
Research
SBCS can never performed in a cavalier manner, sacrificing single eye sterility, IOL
calculation accuracy, or anything else.
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Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
Background: Reasons to perform SBCS
There are numerous reasons to perform SBCS:
1.
Overwhelming patient preference (in our experience - echoed by others who perform SBCS)
1.
Fewer visits for patient (6, instead of 10).
*The risk of bilateral endophthalmitis has been estimated to be
much lower than the risk of dying in a traffic accident while
driving the extra miles needed for UCS x 2, compared to SBCS.
2.
Relatives often unable to accommodate UCS x 2 visit schedule.
3.
Rapid return to normal daily life & schedule.
4.
Particular preference of busy people (professionals).
2.
Some patients cannot tolerate 2 procedural visits to the OR.
3.
Most patients present with bilateral cataracts.
4.
Less stress for the patient with one procedure instead of two.
5.
Reduced period of anisometropia and possible consequent falls & injury.
6.
Patients who develop a problem after surgery in the first eye are often reluctant to proceed with
the second eye, resulting in many years of potentially treatable visual disability.
7.
**There is more improvement in vision after the second eye is done, than after first eye surgery.
8.
Improved care by hospital staff (cataract surgeries have become so brief that the rapid patient
turnover is a problem for the staff).
9.
Everybody: patient, hospital, insurer, saves money (except surgeon, who usually gets less).
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* Bolger J. JCRS 1998.
**Javitt 1995, Swedish outcome study 1977, RCO UK 2001.
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Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
A SBCS benefit: Immediate return of binocular vision & stereopsis

Patients undergoing SBCS have their post-operative refractive state determined prior to
surgery. Immediately post-operatively they have balanced refractions and no significant
anisometropia (unless monovision was planned).

Johansson* showed that unlike unilateral surgery (UCS) patients undergoing same-day
bilateral phacoemulsification (SBCS) did not suffer binocularity problems.

Lundstrom et al** demonstrated, in a randomized clinical study, that
the rapid rehabilitation of the visual system achieved in SBCS, was
not replicated in UCS procedures until the 4 month post-operative
assessment (after the 2nd eye), and UCS patients had significantly
more difficulty performing daily life activities for the intervening period.

Harwood et al.*** showed that first eye cataract surgery significantly
reduced the rates of falling in elderly women, improving visual function and general health
status. Foss et al.**** tried to extend this data to visual function enhancement after second
eye surgery, and despite trends showing reduced falls and better visual performance, the
numbers were not large enough in the series to be conclusive.
*Johansson B. Resulting refraction after same-day bilateral phacoemulsification. J Cat Refract Surg 2004; 30: 1326-34.
**Lundstrom M, Albrecht S, Nilsson M, et al. Benefit to patients of bilateral same-day cataract extraction: Randomized clinical study. J Cat
Refract Surg. 2006; 32: 826-830.
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*** Harwood RH, Foss AJE, Osborn F, et al. Falls and health status in elderly women following first eye cataract surgery: a randomized
controlled trial. BJO 2005; 89: 53-59.
**** Foss AJE, Harwood RH, Osborn F et al. Falls & health status in elderly women following 2nd eye cataract surgery: a randomized controlled
trial. Age & Ageing 2006; 35: 66-71
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Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
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Fears of SBCS: 1. Bilateral Endophthalmitis
There have been 3 reported cases to date:
1.
2.
3.
* BenEzra 1978 Malawi  resulting in blindness
Patient had septicemia & dysentery
Both eyes operated with same instruments – ICCE.

** Ozdek 2005 Turkey  bilateral visual recovery
70 yo healthy male, same irrigating fluids, new
drape, flashed same instruments, no antibiotic prophylaxis.
BCVA recovered to 20/50, 20/40, after 1 month.

*** Kashkouli 2007 Iran  resulting in blindness
67 yo male SBCS same instruments  bilateral Pseudomonas
1 eye phaco/foldable IOL, 2nd = unplanned ECCE & 6 mm PMMA IOL.
Same doctor, preceding day, 1 SBCS patient  blinding infection
with the same Pseudomonas bacteria – 1 eye. (PDF protected from copying)
There have been no reported cases of bilateral endophthalmitis after SBCS
when complete sterile separation of the 2 procedures has been followed.
* 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.
Research
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Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
Fears of SBCS: 2. Bilateral post-operative retinal detachment
In our published series of 1024 consecutive SBCS patients, we had 4 postoperative retinal detachments.
 They occurred 3 months to 3 years post-operatively.
 All occurred in patients in high risk categories:
 Young (<60 yo), Caucasian, Male
 Myopia (axial length 24-26.5 mm)
 Vitreous loss at surgery
 Post YAG capsulotomy
Courtesy of ASCRS – submitted by Dr. Anand Sudhalkar
 All detachments occurred long enough after surgery that the second eye
would most likely have already been operated upon if we had chosen to
do the procedures unilaterally (UCS x 2).
 As a result of our experience, all high risk SBCS and UCS patients
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undergo examination and, if necessary, prophylactic laser treatment
by a retinal surgeon.
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Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
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Fears of SBCS: 3. Bilateral Intraocular lens power errors
In our published series of 1024 consecutive SBCS patients, we had 5
intraocular lens power errors sufficient to require IOL exchange.
 Our study began in 1996, and all of these patients had IOL powers determined by
ultrasonic biometry using the SRKT formula (US-SRKT).
 All errors occurred in patients in whom inaccuracy of US-SRKT was known:
 3 extreme hyperopes
 2 high myopes with the macula on the slope of a staphyloma.
 The accuracy of preoperative IOL power determination has been
greatly enhanced by partial coherence interferometry with the
Zeiss IOL Master, and we have had no IOL power errors requiring
IOL exchange in our subsequent 2,000 SBCS patients.
 The ASCRS website Post-Refractive Surgery IOL Calculator has
greatly reduced the error in calculations for these patients.
Zeiss IOL Master
 *Jabbour et al have recently shown that there is no benefit to inter- procedural
recalculation and adjustment of planned IOL power between R & L eye surgeries.
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*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.
Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
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Fears of SBCS: 4. Fear of Preferred Practice Patterns

When the Journal of Cataract & Refractive Surgery, in its monthly
consultation section of Dec 1997*, asked selected surgeons their
opinions about SBCS, one of the common negative comments
was that SBCS was not consistent with the AAO cataract PPP of
1996. Since then, a consistent negative comment about SBCS is:
“SBCS is not consistent with current published standards of practice.”

It is, by definition, impossible for anything “new” to be consistent with current
practice. It is either current practice, and therefore not new, or new, and therefore not
current practice.

A review of both US (AAO preferred practice patterns) and British (Royal College of
Ophthalmologists cataract surgery guidelines), reveal a gradual progressive
acceptance of SBCS into the main stream over the past decade, although both
groups still do not consider it standard.

This author firmly believes:
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“It is the responsibility of all those following the path of innovation, not to do what is
current practice, but to do better than common current practice, and to work to
demonstrate the superiority of the new techniques. Without this, science and medicine
can never progress.”
*Masket S. Under what conditions do you perform SBCS, J Cataract Refract Surg.1997; 23:10;1437-41.
Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
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Enhancements instituted by author SAA to reduce the risks of SBCS
Intracameral antibiotics (Vancomycin to 2004  Moxifloxacin since Oct ’04)
1.
2.
1.
Post op antibiotics 6x/day x first 3 days, begin immediately post op, then QID x 7 days.
2.
No patches
Phaco machine screen
faces surgeon
Separation of R & L OR tables with strict
avoidance of cross contamination.
Always do L eye first (far from R table).
3.
Second table remains
untouched by nurse, until
1st eye is finished and she
has changed her gloves.
Pt data:
R&L IOLs
&
cylinders
Second table is far
from surgical field.
List criteria (IOL type, power & astig.) for
R & L eyes on board in OR, visible to all.
4.
Nurses taught to review IOL calculations
and to recite them, as IOL is handed from person to person.
“Everyone who touches the IOL must make sure it is correct.”
5.
Use different OVDs for R & L eye, & everything else
as different as possible between R & L eyes. Nothing goes
from R  L or L  R eye table. Asepsis is strict & separate!
SA 6.
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Avoid changing scrub nurse in the middle of one eye’s surgery.
Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
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Worldwide evolution and acceptance of SBCS

As cataract surgical techniques have progressed, surgeons have shown
progressive interest in SBCS. The first publication I know of is:
Bilateral cataract extraction in one sitting. J Philipp Med Assoc. 1952 Dec;28(12):700-5.
SBCS publications per decade have steadily increased since then.

Many countries and state/provincial jurisdictions significantly
financially penalize doctors for performing SBCS, and this
has led to reluctance to perform SBCS*.

Almost everywhere, SBCS is performed far more than it is reported or admitted to.

In Finland, where SBCS is not penalized, many hospitals perform more than 50% of
cataract surgeries as SBCS (Sulevi Kaipiainen MD - personal communication).

Countries where SBCS is common and interest is spreading, include: Finland,
Great Britain, Turkey, Sweden, Poland, Canada, Austria, China, Iran, South Africa.

Countries where financial disincentives yield little interest in SBCS include:
USA, Israel, Japan.
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Research
*Arshinoff SA, Chen SH. Simultaneous bilateral cataract surgery: Financial differences among nations and
jurisdictions. J Cataract Refract Surg 2006; 32:1355–1360.
Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
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Some problems in performing SBCS


SBCS should not be undertaken lightly. The surgeon must have:
•
A low surgical complication rate (preferably <1%).
•
Reliable staff, eager to change to do better for patients.
•
Good access to current technology, medications, etc.
•
A reasonable collegial environment.
Oh, it’s a custom from the old
country?! Why didn’t you say so!
(SAA) I expect I am not alone, among SBCS surgeons,
having to admit, that among the greatest difficulties I
have encountered, has been the hostility of many of my colleagues.
Despite my having performed SBCS on over 3,000 patients,
without a single complaint about the bilaterality of their surgery, and without a single
case of any bilateral complication, or any detriment due to the bilaterality of the
procedure, I am constantly harassed by some of my
colleagues. One and a half years ago, I was forced by the
government of Ontario, to move a large proportion of my
surgeries to another hospital. That hospital, whose chief
of Ophthalmology has always been a vocal, hostile opponent of
SBCS, has refused to permit me to perform SBCS there, despite repeated
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submissions by me about my track record, and the record of SBCS around the world.
Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
Additional problems in performing SBCS

Many Ophthalmology meetings are reluctant to accept papers & courses
about SBCS.

(SAA) I have defended SBCS, reciting my own record, and those of Finnish and
other surgeons, to numerous audiences. I have had medical societies bring
litigation lawyers to quash my arguments, restrict what I say, and even “mock
sentence” me to jail. I can find few colleagues, no matter how strongly they
believe in something, who are willing to be subjected to such attacks.

My patients are strong supporters of SBCS, and I receive weekly thanks and
accolades from them for making their experience of cataract surgery much less
stressful, and with much quicker recovery. I have had the privilege of having
some of the highest ranking lawyers, doctors and politicians as my patients,
along with my favorites – the people of my neighborhood.

Unfortunately, the history of innovation and progress in Ophthalmology is full,
not only of congratulatory awards, but even more so of exhibitions of malice and
anger to innovators. Sir Harold Ridley and Charles Kelman suffered far more
vicious attacks than SBCS surgeons have. I feel very strongly that SBCS is
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simply better, and I intend to continue to practice and speak about it.
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Poster ID # 413217
Arshinoff Steve A. & Odorcic Silvia SBCS 2008
Summary: SBCS around the world

We are not the only ones to do SBCS !
•
Phacoemulsification of bilateral cataracts in a loggerhead sea turtle
(Caretta caretta). Vet Rec. 2005 Jun 11;156(24):774-7.
•
Cataract surgery with foldable intraocular lens implants in captive lowland
gorillas (Gorilla gorilla gorilla). J Zoo Wildl Med. 2004 Dec;35(4):520-4.

•
Bilateral cataract surgery in a Suffolk ewe. Vet Rec. 1986 May 3;118(18):512-3.
•
Phacoemulsification in an adult Savannah monitor lizard. Vet Ophthalmol. 2002 Sep;5(3):207-9.
SBCS is being practiced with increasing frequency & safety around the world.
The vast majority of surgeons who have followed recommended sterility precautions,
and reasonable guidelines (such as “If any significant problem occurs in the first eye,
the second eye surgery is deferred”) have not reported any problems with any greater
frequency than those that normally occur in UCS.

SBCS is, in its complexity, a step above UCS, and therefore demands added attention
to detail, and enhanced performance standards, compared to UCS, but the rewards are
great for the patient, the patient’s family, and ultimately society.
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Thank you Silvia Odorcic BA
[email protected]
Steve A. Arshinoff MD FRCSC
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