Evolution of and developments in simultaneous bilateral cataract surgery. Update 2020

Trends in immediate sequential bilateral cataract surgery in Ontario

OBJECTIVE

Because of increased evidence for safety and increased demands, there appears to be a recent adoption and endorsement of immediate sequential bilateral cataract surgery (ISBCS). This study aims to determine whether a paradigm shift has occurred in the delivery of cataract surgery in the province of Ontario and its the extent, if any, and to analyze the current role of ISBCS.

DESIGN

Retrospective health records analysis.

METHODS

We analyzed aggregate Ontario Health Insurance Plan claim counts for cataract surgeries between 2016 and 2022, categorizing cases into unilateral, ISBCS, and delayed sequential bilateral cataract surgery (DSBCS) cases. We examined trends, compared wait times for second surgeries in the DSBCS cohort with wait times for first surgeries, and used previously published cost estimates for ISBCS to estimate annual savings in Ontario.

RESULTS

There were 1,122 ISBCS cases in 2016, which increased sixfold during the pandemic (2020-2021) and further increased to 11,876 cases in 2022. Unilateral and DSBCS cases decreased during the pandemic but rebounded in 2022 to 102% and 153% of baseline, respectively. ISBCS increased from 1% to 10%, unilateral cases decreased from 41% to 29% of total cases, and DSBCS increased from 58% to 61%. Median wait for patients' first and second surgeries increased from 65 to 87 days and 28 to 33 days, respectively. Using estimates, ISBCS saved approximately $19 million in 2022.

CONCLUSION

Our study demonstrates a paradigm shift in Ontario in favour of ISBCS. ISBCS also may be a strategy to reduce increasing wait times while saving health care system dollars.

Simultaneous versus Sequential Cochlear Implantation in Adults: Quantitative and Qualitative Outcomes

OBJECTIVE

To compare speech recognition and quality of life outcomes between bilateral sequentially and simultaneously implanted adult cochlear implant (CI) recipients who initially qualify for a CI in both ears.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

METHODS

Retrospective chart review identified adults who underwent bilateral CI, either simultaneously or sequentially, at a high-volume center between 2012 and 2022. Sequentially implanted patients were only included if the second ear qualified for CI in quiet (defined as best-aided AzBio quiet testing <60%), at time of initial CI evaluation.

RESULTS

Of 112 bilateral CI patients who qualified in both ears at initial evaluation, 95 underwent sequential implantation and 17 simultaneous. Age, duration, and etiology of hearing loss, and CI usage were similar between groups. Preoperatively, the sequential group had lower pure-tone average (PTA) in the 1st ear than the simultaneously implanted group (P = <.001) but, no difference in 2nd ear PTA (P = .657). Preoperative speech recognition scores were significantly higher for the sequential group; however, this was not true for postoperative scores. There was no difference in the proportion of patients showing significant CI-only or bilateral performance improvement between the groups. Both groups demonstrated similar benefit in quality of life measures.

CONCLUSION

Our findings indicate both simultaneous and sequential cochlear implantation are effective in improving hearing performance and quality of life. Thus, bilateral versus simultaneous implantation should be discussed and tailored for each individual patient.

Cytokines in aqueous humor of patients with congenital cataract during delayed sequential bilateral cataract surgery

BACKGROUND

To explore the changes of cytokines expression in aqueous humor (AH) of eyes of patients with congenital cataract (CC) who underwent delayed sequential bilateral cataract surgery (DSBCS).

METHODS

28 patients with CC underwent DSBCS. AH samples were collected from each eye before surgery. The contents of cytokines in AH were detected by Luminex xMAP Technology.

RESULTS

There was no significant difference in the expression of IL-8, IP-10, MCP-1 and PDGFAA in the AH of the first and second eyes (P = 0.35, 0.39, 0.17, respectively). The level of IL-8 in the first-eye AH was negatively correlated with age (ρ=- 0.519, P = 0.008). IP-10 and MCP-1 in the second-eye AH were negatively correlated with age (ρ=- 0.483, P = 0.009; ρ=- 0.445, P = 0.018,respectively).

CONCLUSION

The first-eye surgery in patients with CC may not cause the change of cytokines in the contralateral eye. The expression of IL-8, IP-10 and MCP-1 in the AH was negatively correlated with the age of patients.

TRIAL REGISTRATION

The study was registered at www.chictr.org.cn on March 22, 2022 and the clinical trial number is ChiCTR2200057927.

A novel two-surgeon technique of simultaneous bilateral cataract surgery with complete delinking

Though technological advancements have transcended beyond expectation, phacoemulsification remains a challenge in uncooperative patients, where the procedure may be contemplated under general anesthesia, with simultaneous bilateral cataract surgery (SBCS) being the surgery of choice. In this manuscript, we have reported a novel two-surgeon technique of SBCS on a 50-year-old mentally subnormal patient. Under general anesthesia, two surgeons performed phacoemulsification simultaneously, using two separate microscopes, irrigation lines, phaco machines, instruments, and assistants. Intraocular lens (IOL) implantation was performed in both eyes (OU). The patient had a visual recovery from 5/60, N36 in OU preoperatively to 6/12, N10 in OU on post-operative day 3 and 1 month, with no complications. This technique can potentially reduce the risk of endophthalmitis, repeated and prolonged anesthesia, and the number of hospital visits. To the best of our knowledge, this two-surgeon technique of SBCS has never been reported in the literature.

Pros and Cons of Immediate Sequential Bilateral Cataract Surgery from a Patient Perspective: A Survey

The aim of the study was to analyze patients' experiences with immediate sequential bilateral cataract surgery (ISBCS). An anonymous survey was sent by post to patients who underwent ISBCS between 1 May 2020 and 30 April 2022. A total of 195 participants completed the survey. Specifically, 94.6% of the respondents were satisfied with the possibility of having both eyes treated during one surgical procedure, 89.7% would choose ISBCS again if offered a choice, and 89.2% would recommend this procedure to their family members. ISBCS provided a subjective benefit for 84.6% of the respondents. The most commonly reported ISBCS-related problems were the necessity to sleep in a supine position (32.8%), inability to read shortly after the surgery (27.7%), having both eyes protected with a dressing (24.6%), and application of eyedrops to both eyes at the same time (17.4%). All patients were able to identify some pros of ISBCS, with the most common being single stay in the operating room (82.6%), lower number of visits to the clinic (62.6%), quick normalization of eyesight (61%), time savings for family members (54.9%), quick adjustment of reading glasses (32.3%), and economical aspects (23.6%). The perception of difficulties associated with ISBCS and the benefits offered by this procedure differed depending on patients' gender, age, marital status, education, place of residence, occupational activity, level of care dependence, and everyday activities. Understanding patients' opinions about ISBCS provides insight into the advantages and disadvantages of this procedure from a broader perspective.

An update on immediate sequential bilateral cataract surgery

PURPOSE OF REVIEW

The aim of this study was to present an overview of recent publications and opinions in the field of same-day bilateral cataract surgery.

RECENT FINDINGS

A Cochrane review was published comparing immediate sequential bilateral cataract surgery (ISBCS) and delayed sequential bilateral cataract surgery (DSBCS) with regard to safety outcomes, costs and cost-effectiveness. In addition, several large database studies provided more information on incidences of rare complications such as unilateral and bilateral endophthalmitis rates.

SUMMARY

Recently available evidence showed that ISBCS is an effective and cost-effective alternative to DSBCS. Nonetheless, additional (randomized) registry studies, randomized controlled trials and cost-effectiveness studies are needed to evaluate bilateral endophthalmitis rates, refractive outcomes and cost-effectiveness of ISBCS compared with DSBCS.

Semi-Autologous Corneal Transplantation with Simultaneous Bilateral Surgery: A Case Report

The present report describes a case of semi-autologous corneal transplantation with bilateral surgery using two operating microscopes simultaneously. An 86-year-old man with history of six prior failed penetrating keratoplasties in his right eye presented with decreased vision. His other eye was deeply amblyopic but had a clear 30-year-old Castroviejo-square graft with an endothelial cell count of 803 cells/mm2. A semi-autologous graft was performed from the left eye to the right. Surgery was performed simultaneously on both eyes by two different surgeons using a standard ophthalmic operating microscope as well as a second ENT microscope. Upon trephination of the right failed corneal graft, vitreous opacities were noted and sent for culture. The semi-autologous tissue was directly transferred from the left eye to the right without any storage in preservation media to avoid endothelial cell loss. The semi-autologous graft remained clear in the immediate postoperative period. However, the vitreous cultures grew coagulase-negative Staphylococcus. Despite all efforts, the patient eventually developed a retinal detachment and vision in the right eye decreased to light perception. Autologous penetrating keratoplasty is an option for patients with loss of corneal function in a potentially seeing eye and a clear cornea in a contralateral eye with poor visual potential due to non-corneal disease. This case is unique in that part of the autologous penetrating keratoplasty had an old square graft in the center and corneal transplant surgery was done simultaneously in both eyes. It also highlights chronic indolent endophthalmitis as a potential cause of multiple graft failures.

Immediately sequential bilateral cataract surgery in Down syndrome

The exponential increase in world population and average human lifespan is expected to result in geriatric population globally. The problem of preventable blindness due to cataract will increase manifold. Simultaneous Bilateral cataract surgery (SBCS) is a viable option in such subset of patients. Despite faster visual recovery, economic benefits to patients and health care providers, decreased risk of complications associated with General anaesthesia, there is significant resistance in accepting SBCS as a routine procedure. Bilateral endophthalmitis is the main deterrent in performing ISBCS. This case highlights successful ISBCS in 36 years old female patient with Down's syndrome.

Immediate sequential bilateral surgery versus delayed sequential bilateral surgery for cataracts

BACKGROUND

Age-related cataract affects both eyes in most cases. Most people undergo cataract surgery in both eyes on separate days, referred to as delayed sequential bilateral cataract surgery (DSBCS). An alternative procedure involves operating on both eyes on the same day, but as two separate procedures, known as immediate sequential bilateral cataract surgery (ISBCS). Potential advantages of ISBCS include fewer hospital visits for the patient, faster visual recovery, and lower healthcare costs. Nevertheless, concerns exist about possible bilateral, postoperative, sight-threatening adverse effects with ISBCS. Therefore, there is a clear need for evaluating evidence regarding the safety, effectiveness, and cost-effectiveness of ISBCS versus DSBCS.

OBJECTIVES

To assess the safety of ISBCS compared to DSBCS in people with bilateral age-related cataracts and to summarise current evidence for the incremental resource use, utilities, costs, and cost-effectiveness associated with the use of ISBCS compared to DSBCS in people with bilateral age-related cataracts (primary objectives). The secondary objective was to assess visual and patient-reported outcomes of ISBCS compared to DSBCS in people with bilateral age-related cataracts.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 5); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov; the WHO ICTRP; and DARE and NHS EED on the CRD Database on 11 May 2021. There were no language restrictions. We limited the searches to a date range of 2007 onwards.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) to assess complications, refractive outcomes, best-corrected distance visual acuity (BCDVA) and patient-reported outcome measures (PROMs) with ISBCS compared to DSBCS. We included non-randomised (NRSs), prospective, and retrospective cohort studies comparing ISBCS and DSBCS for safety assessment, because of the rare incidence of important adverse events. To assess cost-effectiveness of ISBCS compared to DSBCS, we included both full and partial economic evaluations, and both trial-based and model-based economic evaluations.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures and assessed risk of bias for NRSs using the ROBINS-I tool. For cost-evaluations, we used the CHEC-list, the CHEERS-checklist, and the NICE-checklist to investigate risk of bias. We assessed the certainty of evidence with the GRADE tool. We reported results for economic evaluations narratively.

MAIN RESULTS

We included 14 studies in the review; two RCTs, seven NRSs, and six economic evaluations (one study was both an NRS and economic evaluation). The studies reported on 276,260 participants (7384 for ISBCS and 268,876 for DSBCS) and were conducted in Canada, the Czech Republic, Finland, Iran, (South) Korea, Spain (Canary Islands), Sweden, the UK, and the USA. Overall, we considered the included RCTs to be at 'high to some concerns' risk of bias for complications, 'some concerns' risk of bias for refractive outcomes and visual acuity, and 'high' risk of bias for PROMs. The overall risk of bias for NRSs was graded 'serious' regarding complications and 'serious to critical' regarding refractive outcomes.  With regard to endophthalmitis, we found that relative effects were estimated imprecisely and with low certainty, so that relative estimates were not reliable. Nonetheless, we found a very low risk of endophthalmitis in both ISBCS (1/14,076 participants) and DSBCS (55/556,246 participants) groups. Based on descriptive evidence and partially weak statistical evidence we found no evidence of an increased risk of endophthalmitis with ISBCS. Regarding refractive outcomes, we found moderate-certainty (RCTs) and low-certainty (NRSs) evidence there was no difference in the percentage of eyes that did not achieve refraction within 1.0 dioptre of target one to three months after surgery (RCTs: risk ratio (RR) 0.84, 95% confidence interval (CI) 0.57 to 1.26; NRSs: RR 1.02, 95% CI 0.60 to 1.75). Similarly, postoperative complications did not differ between groups (RCTs: RR 1.33, 95% CI 0.52 to 3.40; NRSs: 1.04, 95% CI 0.47 to 2.29), although the certainty of this evidence was very low for both RCTs and NRSs. Furthermore, we found low-certainty (RCTs) to very low-certainty (NRSs) evidence that total costs per participant were lower for ISBCS compared to DSBCS, although results of individual studies could not be pooled. Only one study reported on cost-effectiveness. This study found that ISBCS is cost-effective compared to DSBCS, but did not measure quality-adjusted life years using preferred methods and calculated costs erroneously. Finally, regarding secondary outcomes, we found limited evidence on BCDVA (data of two RCTs could not be pooled, although both studies individually found no difference between groups (very low-certainty evidence)). Regarding PROMs, we found moderate-certainty evidence (RCTs only) that there was no difference between groups one to three months after surgery (standardised mean difference -0.08, 95% CI -0.19 to 0.03).

AUTHORS' CONCLUSIONS

Current evidence supports there are probably no clinically important differences in outcomes between ISBCS and DSBCS, but with lower costs for ISBCS. However, the amount of evidence is limited, and the certainty of the evidence was graded moderate to very low. In addition, there is a need for well-designed cost-effectiveness studies.

Immediate sequential bilateral cataract surgery in adults with Down's syndrome

PURPOSE

To describe the cataract surgery outcomes in 34 adult patients with Down's syndrome in our center between 1996 and 2019.

SETTING

Clinical practice, tertiary hospital in Madrid, Spain.

DESIGN

Retrospective, descriptive study in which 34 patients with Down's syndrome who underwent cataract surgery in our center between 1996 and 2019 were included.

METHODS

Socio-demographic and clinical data such as the type of cataract, the keratometry and biometry, the type of surgery, the IOL material, and the complications before and after surgery were recovered.

RESULTS

Fifty-four eyes of 34 patients (23 female, 11 male, mean age 49 ± 8 years) underwent cataract surgery with general anesthesia. Immediately sequential, bilateral cataract surgery was performed in 18 patients (90% of bilateral cases). White cataract was found in 11 eyes (20.4%). Phacoemulsification technique was used in 51 eyes, extracapsular technique in 2 eyes (3.7%), and intracapsular technique in 1 eye (1.85%) (the only aphakic eye after surgery). The mean Km was 48.73 ± 4D, and the mean axial length was 25.2 ± 2.5 mm. The most frequent ocular comorbidity was myopia (27 eyes, 50%) followed by strabismus (11 eyes, 20.4%) and keratoconus (10 eyes, 18.5%). Posterior capsular rupture as a complication during surgery was found in 3 eyes (5.5%). The mean preoperative visual acuity was 0.8 ± 0.2 logMAR, and the mean postoperative visual acuity was 0.5 ± 0.18 logMAR.

CONCLUSIONS

Phacoemulsification technique can be performed in adults with Down's syndrome with an acceptable rate of complications. The lack of patient cooperation, the ocular comorbidities and the challenging biometric estimation must be considered in surgical planning. It seems reasonable to perform immediately sequential, bilateral cataract surgery when possible, in order to reduce the exposure to general anesthesia.

Impact of COVID-19 pandemic on cataract surgical volume: A North Indian experience

Purpose:

To analyze the impact of the pandemic on trends in cataract surgical volume in 2020 in a high-volume tertiary care academic center in North India.

Methods:

The monthly cataract surgical volume for a large, high-volume, tertiary care academic center in North India was obtained from January 2018 through December 2020. Based on historical trends, we used time-series forecasting, probability sensitivity analysis, and linear regression models to estimate what the expected monthly cataract volume should have been from March 2020 onward.

Results:

In 2020, we expected to perform 7500 cases (assuming historical trends) but performed only 2500 cases (33% of the expected volume). The remaining 5000 cases (67% cases) constituted the “fixed” backlog. Assuming the ramp-up in cataract surgical volume starts in January 2021, results of the Monte Carlo simulation revealed that for our system, it would take on average 5 months (May 2021) under the optimistic scenario and 10 months (October 2021) under the ambivalent scenario to reach pre-pandemic expected surgical volume. There would be a collective backlog of 5500 cases under the optimistic scenario (8.8 months’ worth of cases) and a collective backlog of 6900 cases under the ambivalent scenario (11 months’ worth of cases).

Conclusion:

An intuitive approach and out-of-the-box solutions are required by the government and private institutes’ collaborative efforts to help mitigate the disruptions caused by the pandemic and lessen the backlog without causing provider burnout.

Use of Simultaneous Bilateral Cataract Surgery (SBCS) to Optimize Parameters Affecting the Subjective Perception of the Procedure

Introduction

Simultaneous Bilateral Cataract Surgery (SBCS) is still a relatively controversial procedure. The main objection is the risk of bilateral endophthalmitis or bilateral refractive error. However, SBCS has also some advantages (faster visual rehabilitation, lower risk of nosocomial infection, and lower cost). Performing surgery on both eyes in one session has one additional advantage which has not yet been described in the literature (according to the information available to authors). It allows surgeons to distinguish the effect of minor differences in the surgical protocol on the subjective perception of the procedure more accurately, which is a more suitable method than comparing two independent groups of patients.

Purpose

To compare the effect of minor changes in the surgical protocol during SBCS on intraindividual subjective perception of surgery (pain, pressure, glare, and perception of the duration of the surgery).

Methods

During the surgery of the right and left eyes of one patient, we randomly changed one surgical parameter (use of intracameral anesthesia, light intensity of the operating microscope, type of eyelid speculum, creation of the posterior circular capsulorhexis, and communication with the patient during surgery). Patients immediately after both surgeries subjectively evaluated the perception of pain (on the scale 0–10), pressure, and glare (on the scale 0–5) and estimated the duration of the surgery, separately for each eye. Each change was evaluated in a group of 50 patients.

Results

In the control group with no parameters changed, we noted no difference in subjective perception of the first and second surgery. In subgroups, where we changed the protocol, we detected only minor differences in subjective perception of pain, pressure, glare, and duration of the surgery. Only one statistically significant difference in subjective pain perception was in the subgroup where we used eye intracameral anesthesia (0.34 eyes with intracameral anesthesia, 0.44 eyes with only topical anesthesia). We did not note any statistically significant differences in the perception of the time of surgery.

Conclusion

SBCS can be used to optimize the parameters of cataract surgery. In our study, we noted a positive effect of intracameral anesthesia on subjective perception of surgery.