Practice of immediate sequential bilateral cataract surgery (ISBCS): A teaching hospital experience in United Kingdom

BACKGROUND / OBJECTIVES

Utilisation of ISBCS has been encouraged since COVID-19 in line with the RCOphth recommendations. This study aims to share experience from a UK teaching hospital on ISBCS and to evaluate pre-, intra- and post-operative outcomes from the ISBCS cohort.

METHODS

Of 3402 cataract surgeries performed between July 2020 and July 2021 (1 year since the reopening of the cataract service from COVID-19), 208 eyes of 104 patients (6.1%) undergoing ISBCS were retrospectively studied on their demographics, biometry, surgeon grades, and pre-, intra- and post-operative data.

RESULTS

The mean age was 74.5 ± 9.4 years and 62% were female. Eighty-nine percent of the eyes were performed under local anaesthesia and 70% were 'routine' cases. Other risk factors included: short eyes requiring pre-operative mannitol infusion (10%), high myopia (8%), poor dilation (2%) and a 'glaucoma' cohort [angle closure (2%) and prior trabeculectomy (1%)]. Three eyes (1%) had complications intra-operatively in second eye (1 case each: posterior capsule rupture, corneal oedema and zonular dehiscence). Two patients (1%) had complications in the first eye (1 case each: suprachoroidal haemorrhage, conjunctival & iris haemorrhage), hence had their second eye postponed. Twelve months post-operatively, 20 eyes (10%) had recorded post-op complications with cystoid macular oedema being the commonest (4.5%) and no endophthalmitis. Eighty-six percent were discharged with satisfaction. No significant differences were found in pre-operative features, complication rates and post-operative outcomes between consultant and non-consultant surgeons (p > 0.05).

CONCLUSIONS

Our experience which included a cohort of high-risk patients showed safe and successful practice of ISBCS without having a negative impact on training.

Trends, Factors, and Outcomes Associated with Immediate Sequential Bilateral Cataract Surgery (ISBCS) Among Medicare Beneficiaries

PURPOSE

To report the incidence of immediate (ISBCS) and delayed sequential bilateral cataract surgery (DSBCS) and identify factors associated with undergoing ISBCS.

DESIGN

Retrospective cohort study.

SUBJECTS

Medicare beneficiaries aged ≥65 who underwent ISBCS and DSBCS from 2011 to 2019.

METHODS

Population-based analysis of the 100% Medicare fee-for-service carrier claims data. Logistic regression models were performed to evaluate factors associated with ISBCS.

MAIN OUTCOME MEASURES

1) Incidence of ISBCS and DSBCS, 2) demographic, ocular and medical characteristics associated with receipt of ISBCS, and 3) rates of endophthalmitis and cystoid macular edema (CME) after ISBCS or DSBCS.

RESULTS

A total of 4,014 (0.2%) ISBCS and 1,944,979 (99.8%) DSBCS patients were identified. Black (OR:2.31, 95%CI: 2.06-2.59), Asian (OR:1.82, 95%CI: 1.51-2.12), or Native American (OR:2.42, 95%CI: 1.81-3.23) patients were more likely to receive ISBCS compared to White patients. Patients residing in rural areas had higher likelihood of ISBCS (OR:1.26, 95%CI: 1.17-1.35) compared to metropolitan areas. Patients operated at a hospital compared to ambulatory setting (OR:2.71, 95%CI: 2.53-2.89) were more likely to receive ISBCS. Patients with bilateral complex vs. non-complex cataract (OR:3.23, 95%CI: 2.95-3.53) were more likely to receive ISBCS. Patients with a Charlson comorbidity index (CCI) of 1-2 (OR:1.45, 95%CI: 1.29-1.62), 3-4 (OR:1.70, 95%CI: 1.47-1.97), 5-6 (OR:1.97, 95%CI: 1.62-2.39), and CCI≥7 (OR:1.97, 95%CI: 1.55-2.50) were all more likely to receive ISBCS compared to those with CCI=0. In contrast, patients with glaucoma (OR:0.82, 95%CI: 0.76-0.89), macular degeneration (OR:0.75, 95%CI: 0.68-0.82), and macular hole/epiretinal membrane (OR:0.55, 95%CI: 0.48-0.65) were less likely to undergo ISBCS compared to those without. Cumulatively, there was no significant difference in endophthalmitis rate within 42 days between ISBCS (1.74 per 1,000 ISBCS) and DSBCS (1.01 per 1,000 DSBCS; p=0.15). Similarly, there was no significant cumulative difference between ISBCS (1.79 per 100 ISBCS) and DSBCS (1.96 per 100 DSBCS) CME rates (p=0.48).

CONCLUSION

Overall utilization of ISBCS among Medicare beneficiaries remains low over the past decade, though rates of endophthalmitis and CME were comparable to DSBCS. Race, geography, systemic and ocular comorbidities were associated with receiving ISBCS. ISBCS represents a potential opportunity to improve access to cataract surgery.

A survey exploring ophthalmologists' attitudes and beliefs in performing Immediately Sequential Bilateral Cataract Surgery in the United Kingdom

BACKGROUND

The standard approach to treat cataracts is Delayed Sequential Bilateral Cataract Surgery (DSBCS), during which patients have a separate operation date for each eye. An alternative method of delivery is Immediately Sequential Bilateral Cataract Surgery (ISBCS). The aim of this project was to examine the attitudes and beliefs of UK ophthalmologists towards ISBCS, explore their reasons to either practise or not practise ISBCS and identify barriers hindering its implementation in the UK.

METHODS

A questionnaire was distributed to consultant members of The Royal College of Ophthalmologists (RCOphth, UK) and collected electronically. An initial screening question in regards to prior experience with ISBCS directed the rest of the survey; participants were asked to rate the importance of several factors with regards to performing ISBCS. Free text options were also available. Descriptive analysis was subsequently performed.

RESULTS

Of the 1357 recipients, 130 (9.6%) ophthalmologists completed the survey. Of those, 13.9% were currently performing ISBCS, 83.1% had never performed, and 3.1% had previously done so but since stopped. The main factors that acted as barriers were lack of: (1) College approval (20.5%); (2) medico-legal approval (20.2%); (3) evidence to support the use of ISBCS (16.0%); and (4) hospital approval (13.3%). Additionally, the perceived risk of complications for patients played an important role when considering ISBCS, with the risk of endophthalmitis being most feared.

CONCLUSIONS

This survey demonstrates some of the barriers that prevent ophthalmologist's performing ISBCS in the UK. There is a need for further exploration in this field to evaluate the effect of addressing any of these concerns on the implementation of ISBCS.