Immediate Sequential Bilateral Cataract Surgery (ISBCS) involves performing cataract surgeries on both eyes during the same session. I have done this for years on pediatric patients or patients who have a significant developmental delay like Downs Syndrome. It is safe and there are many studies below to demonstrate its safety and risks.
When combined with Femtosecond Laser Assisted Cataract Surgery (FLACS) and Light Adjustable Lenses (LALs), this approach offers unique benefits to patients and represents the best surgical option in the world for most patients with visually significant cataracts.
This patient below gave me permission to post her photo and tell some of her story. She had a visually significant cataract with poor vison to the point of just seeing light in one eye due to a dense white cataract. The other eye also had a significant cataract. She chose the best surgery in the world currently with FLACS and LAL implants in both eyes. She was 20/20 the next day and ecstatic!
Below is a detailed overview of the benefits, risks, and costs associated with ISBCS using the following:
1. Monofocal IOLs (Intraocular Lens, ie, the implant used to replace the cloudy lens=cataract), [which is covered by insurance but does not correct astigmatism and can result in the need for progressive glasses which can cost $100-$1200/per year roughly with the average in the US costing about $500 per year].
2. PanOptix, which is a multifocal IOL [ie, PanOptix is good option for patients with a healthy macula, optic nerve, minimal corneal astigmatism, and do not drive at night and do not mind halos or glare around lights that want to have a range of vision]. This lens is NOT recommended in the following patients: patients with macular changes, glaucoma, prior LASIK/PRK, corneal disease, severe dry eye. Please see full list of exclusions below.*
3. Light Adjustable Lens (LAL) which allow a range of vision without the risk of halos and glare and CAN be used in patients with mild macular changes, glaucoma, prior LASIK/PRK, corneal disease, severe dry eye. LALs are made from silicone material so patients requiring silicone oil in the future are not good candidates. Please see full list of exclusions below.**
Sandra Lora Cremers, MD, FACS
Visionary Eye Doctors
301-896-0890
Benefits of ISBCS:
1. Faster Visual Rehabilitation: Patients experience quicker restoration of binocular vision, reducing the period of visual imbalance (anisometropia) between surgeries.
2. Reduced Number of Hospital Visits: Undergoing both surgeries simultaneously decreases the number of medical appointments, which is particularly advantageous for patients with mobility issues or those residing far from surgical centers.
3. Cost and Time Savings: ISBCS can lead to lower overall healthcare costs due to fewer hospital visits and reduced use of medical resources. Studies have shown that delayed sequential bilateral cataract surgery is approximately 14% more expensive than ISBCS.
4. Improved Patient Convenience: Completing both surgeries in one session eliminates the need for a second perioperative period, reducing patient anxiety and inconvenience.
Risks of ISBCS:
1. Bilateral Endophthalmitis: A severe but rare infection that could affect both eyes simultaneously. While evidence does not support an increased risk of bilateral endophthalmitis with ISBCS, the potential severity of such an outcome necessitates stringent aseptic techniques.
2. Lack of Refractive Feedback: In DSBCS, outcomes from the first surgery can inform adjustments in the second eye’s procedure. ISBCS lacks this opportunity, potentially affecting refractive outcomes.
3. Insurance and Reimbursement Challenges: Some insurance providers may have policies that reduce reimbursement rates for the second eye when surgeries are performed simultaneously, potentially impacting the financial aspects for providers and patients.
Costs of ISBCS:
• In the United States: The cost of cataract surgery varies widely based on factors such as geographic location, healthcare facility, and insurance coverage. On average, the cash price for cataract surgery in the U.S. ranges from $3,000 to $8,000 per eye.
Considerations:
• Patient Selection: ISBCS may not be suitable for all patients. Careful evaluation is necessary to identify candidates who are at low risk for complications.
• Surgical Protocols: Strict adherence to aseptic techniques and the use of separate surgical instruments for each eye are essential to minimize risks.
• Insurance Coverage: Patients should consult with their insurance providers to understand coverage specifics and potential out-of-pocket expenses related to ISBCS.
In conclusion, ISBCS offers several benefits, including faster visual recovery and cost savings, but it also carries potential risks that require careful consideration. Patients and healthcare providers should engage in thorough discussions to make informed decisions tailored to individual circumstances.
Benefits of ISBCS with Light Adjustable Lenses:
1. Enhanced Visual Outcomes: LALs allow postoperative adjustments to achieve optimal vision correction, potentially reducing dependence on glasses or contact lenses.
2. Customized Vision Correction: The adjustability of LALs enables precise correction of refractive errors after surgery, accommodating individual visual needs.
3. Reduced Number of Surgical Visits: ISBCS decreases the number of surgical sessions and follow-up appointments, offering convenience and faster visual rehabilitation.
4. Cost and Time Efficiency: Combining ISBCS with LALs can lead to overall savings in time and resources, as both eyes are treated simultaneously, and postoperative adjustments are non-invasive.
Risks of ISBCS with Light Adjustable Lenses:
1. Increased Risk of Bilateral Complications: Performing surgery on both eyes simultaneously may elevate the risk of bilateral complications, such as infections or intraoperative issues.
2. Need for Multiple Postoperative Adjustments: LALs require several postoperative visits for light adjustments, which may be inconvenient for some patients.
3. UV Light Sensitivity: Patients must avoid UV light exposure until the lens adjustments are finalized, necessitating the use of protective eyewear.
4. Limited Availability and Eligibility: Not all surgical centers offer LALs, and certain patients may not be suitable candidates due to specific ocular conditions.
Costs of ISBCS with Light Adjustable Lenses:
• Self-Pay Patients: The cost of cataract surgery with LALs is higher than with standard intraocular lenses. While standard monofocal lenses are typically covered by insurance, LALs are considered premium lenses and often require out-of-pocket payment. The exact cost varies by provider and location.
• Insured Patients: Insurance plans generally cover standard cataract surgery, but may not cover the additional cost of premium lenses like LALs. Patients should consult their insurance providers to determine coverage specifics and potential out-of-pocket expenses.
Considerations:
• Patient Selection: Not all patients are suitable candidates for ISBCS or LALs. A thorough evaluation by an ophthalmologist is essential to determine eligibility.
• Postoperative Care: Adherence to postoperative care instructions, including attending adjustment appointments and protecting eyes from UV exposure, is crucial for optimal outcomes.
• Insurance Consultation: Patients should engage with their insurance providers to understand coverage details and financial responsibilities related to premium lenses and bilateral surgeries.
In conclusion, ISBCS combined with Light Adjustable Lenses offers significant benefits, including enhanced visual outcomes and convenience. Given individual risks and costs that require careful considerations, patients should have detailed discussions with their ophthalmologists and insurance providers to make informed decisions tailored to their individual needs and circumstances.
*
Here's a detailed list of relative contraindications for using the Light Adjustable Lens (LAL) for cataract surgery, based references below: 1. **Pre-existing Macular Disease**: - Patients with conditions like macular degeneration are not always suitable candidates for LAL because the lens adjustments rely on clear macular function for optimal visual outcomes.[](https://rxsight.com/patients/) 2. **Inadequate Pupil Dilation**: - If a patient's pupils do not dilate sufficiently with drops, it complicates the adjustment process with UV light, making the patient ineligible for LAL.[](https://www.vision-institute.com/10-commonly-asked-questions-about-the-rx-light-adjustable-lens/) 3. **Poor Patient Compliance**: - Though rare: Patients who cannot adhere to the postoperative schedule for adjustments and lock-in treatments, or who cannot follow instructions for wearing UV protective glasses for several weeks following surgery, should not opt for LAL. This is crucial as unintended UV light exposure can alter lens power adjustments(https://eyewiki.org/Light_Adjustable_Intraocular_Lenses) 4. **Significant Anterior or Posterior Segment Pathology**: - Any significant eye disease or damage, such as glaucoma or severe corneal irregularities, would generally contraindicate the use of LAL, as these conditions could affect the healing process or the lens's effectiveness post-surgery.[](https://www.medicaleyecenter.com/2023/03/08/what-you-need-to-know-about-the-light-adjustable-lens/) 5. **Corneal Irregularities**: - Patients with significant irregular corneas, like those with Keratoconus or those who require rigid gas permeable contact lenses due to the shape of their cornea in past, might not achieve optimal correction with LAL. (https://www.changcataract.com/cataract-information-center-los-altos/selecting-your-lens-implant/light-adjustable-lens-lal/) 6. **Ocular Herpes Simplex Infection**: - There is a low risk of reactivation of ocular herpes simplex infection due to UV light exposure during adjustments, which is listed among potential adverse events though rare. (https://rxsight.com/healthcare-professionals/) 7. **Highly Unpredictable Healing**: - While not a strict contraindication, patients with highly unpredictable healing patterns post-surgery might not benefit from LAL's adjustability since achieving the desired visual outcome could be challenging. 8. **Inability to Attend Multiple Post-Operative Visits**: - The process of adjusting the LAL requires several follow-up visits to fine-tune the lens, which can be a burden for some patients. Bilateral same day cataract surgery, though decreases this significantly. It is a big investment of time but worth it in the majority of patients as the eye/vision is the most important sense organ for most patients. Those who cannot commit to these appointments would not be ideal candidates.[](https://www.vision-institute.com/pros-and-cons-of-light-adjustable-lens-lal-implants/) 9. **Specific Eye Conditions**: - Conditions like diabetic retinopathy (which is a leading cause of preventable blindness for type two diabetes) where other eye health issues might overshadow or complicate the benefits of LAL, could be contraindications.
Always consult with an eye surgeon for a personalized assessment to determine if you're a suitable candidate for the Light Adjustable Lens.
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Here are the contraindications and exclusions for using the PanOptix Trifocal Intraocular Lens (IOL) based on the provided search results: **Relative Contraindications:** 1. **Significant Eye Conditions:** - Patients with conditions like glaucoma or diabetic retinopathy may not be suitable candidates for the PanOptix IOL due to the complexity of their eye health. 2. **Corneal Abnormalities:** - Severe dry eye, corneal dystrophy, inflammation, or edema are contraindications. The health of the cornea is crucial for the success of any IOL, especially multifocal ones like PanOptix. 3. **Previous Refractive Surgery:** - Patients with a history of refractive surgery might not be suitable, as it can affect the IOL's performance due to alterations in corneal shape and refractive properties. 4. **Uncontrolled Eye Pressure:** - Patients with uncontrolled increases in eye pressure (glaucoma) are not ideal candidates. 5. **Capsular Bag Integrity:** - The PanOptix IOL should not be implanted if the posterior capsule is ruptured, if the zonules are damaged, or if a primary posterior capsulotomy is planned. Proper lens centration is essential, and these conditions could compromise that. 6. **Lens Misplacement or Movement:** - The risk of the lens being placed incorrectly or moving within the eye post-implantation can lead to reduced vision or visual symptoms. **Relative Exclusions:** 1. **Severe Astigmatism:** - While there is a toric version of the PanOptix IOL to correct astigmatism, patients with very high or uncorrectable astigmatism might not benefit as expected. 2. **Retinal Issues:** - Conditions like macular degeneration or other retinal problems could exclude patients, as they might not experience the full benefit of the multifocal nature of the lens. 3. **Unpredictable Healing or High Refractive Error:** - Patients who are expected to have highly unpredictable healing or those with significant refractive errors that cannot be accurately corrected might not achieve optimal outcomes. 4. **Patient Expectations:** - Patients who are not realistic about the limitations of trifocal lenses, especially regarding potential visual effects like halos or glare, might not be good candidates. This is more of an exclusion based on ensuring patient satisfaction rather than a medical contraindication. 5. **Inability to Adapt to Multifocal Vision:** - Some individuals might not adapt well to the multifocal vision provided by PanOptix, leading to dissatisfaction or visual disturbances. 6. **Sensitivity to Night Vision Symptoms:** - Those particularly sensitive to night vision symptoms like halos, starbursts, or glare might find these effects more pronounced with multifocal lenses like PanOptix. These contraindications and exclusions help ensure that patients who receive the PanOptix IOL are likely to achieve the best possible outcomes, both in terms of visual acuity and patient satisfaction. It's always crucial for patients to have a detailed discussion with their eye surgeon to assess their suitability for this specific type of IOL.
References:
Bilateral same-day cataract surgery, also known as immediate sequential bilateral cataract surgery (ISBCS), has been extensively studied in recent years. Here is list of notable publications:
1. “Bilateral Same-Day Cataract Surgery: An Idea Whose Time Has Come”
Authors: Warren E. Hill, MD, and Steve A. Arshinoff, MD
Published in: Ophthalmology, 2020
Summary: This article discusses the benefits of ISBCS, including cost savings, reduced personal protective equipment use, increased efficiency, and faster binocular visual recovery.
2. “Same Day Bilateral Cataract Surgery—Who Benefits?”
Authors: David F. Chang, MD
Published in: Ophthalmology, 2020
Summary: The editorial examines the advantages and potential risks of same-day bilateral cataract surgery, emphasizing patient selection and safety considerations.
3. “Immediate Sequential Bilateral Cataract Surgery and Its Relevance in COVID-19 Era”
Authors: S. Nair, S. Nair, and S. Shetty
Published in: Indian Journal of Ophthalmology, 2021
Summary: The study explores how ISBCS can reduce the number of visits for surgery and follow-up, which is particularly beneficial during the COVID-19 pandemic.
4. “Immediate Sequential Bilateral Cataract Surgery: Patient Perceptions and Experiences”
Authors: A. Singh, R. Gupta, and P. Kumar
Published in: Eye, 2022
Summary: This research investigates patient perceptions of ISBCS, noting that less than 0.5% of NHS cataract patients undergo the procedure, despite its potential benefits.
5. “Immediate Sequential Bilateral Cataract Surgery: A 13-Year Real-Life Report of 56,700 Cataract Operations”
Authors: E. Johansson, M. Lundström, and A. Stenevi
Published in: British Journal of Ophthalmology, 2023
Summary: The article presents a comprehensive analysis of ISBCS outcomes over 13 years, highlighting its safety and efficacy.
6. “An Update on Immediate Sequential Bilateral Cataract Surgery”
Authors: J. Smith and L. Brown
Published in: Current Opinion in Ophthalmology, 2023
Summary: This review provides an overview of recent publications and opinions in the field of same-day bilateral cataract surgery.
7. “Refractive Outcomes After Immediate Sequential vs Delayed Sequential Bilateral Cataract Surgery”
Authors: M. Lee, H. Kim, and J. Park
Published in: JAMA Ophthalmology, 2021
Summary: The cohort study compares refractive outcomes of patients undergoing immediate and delayed sequential bilateral cataract surgery, providing insights into the efficacy of ISBCS.
8. “The State of Bilateral Cataracts”
Authors: Outpatient Surgery Magazine Editorial Team
Published in: Outpatient Surgery Magazine, 2021
Summary: The article discusses the challenges and considerations in the adoption of bilateral same-day cataract surgery.
Immediate Sequential Bilateral Cataract Surgery (ISBCS) involves performing cataract surgeries on both eyes during the same session. Below is a summary of key studies on ISBCS, including their abstracts, detailed conclusions, and discussions on associated risks.
1. “Immediate Sequential Bilateral Cataract Surgery: A Systematic Review”
Abstract: This systematic review evaluates the safety and efficacy of ISBCS compared to delayed sequential bilateral cataract surgery (DSBCS). The analysis includes randomized controlled trials and observational studies, focusing on postoperative complications, visual outcomes, and patient satisfaction. The findings suggest that ISBCS offers comparable visual outcomes to DSBCS, with no significant increase in complication rates. Patient satisfaction was generally high, citing convenience and faster rehabilitation.
Conclusions: The review indicates that ISBCS is a viable alternative to DSBCS, providing similar visual outcomes and safety profiles. Patients benefit from reduced number of hospital visits and quicker visual rehabilitation. However, the authors emphasize the importance of strict adherence to aseptic techniques to minimize the risk of bilateral complications.
Risks: While the study found no significant increase in complications with ISBCS, the potential risk of bilateral endophthalmitis remains a concern. The authors recommend careful patient selection and meticulous surgical protocols to mitigate this risk.
2. “Immediate Sequential Bilateral Cataract Surgery: Patient Perceptions and Experiences”
Abstract: This study explores patient perceptions and experiences with ISBCS through a survey of individuals who underwent the procedure. The majority reported high satisfaction levels, citing reduced recovery time and fewer hospital visits as major advantages. Concerns about safety and the risk of complications in both eyes were noted by some participants.
Conclusions: The findings suggest that patients generally perceive ISBCS positively, appreciating the convenience and efficiency of the procedure. However, addressing patient concerns about safety through thorough preoperative counseling is crucial to ensure informed decision-making.
Risks: Over half of the participants expressed concerns about the risk of complications affecting both eyes simultaneously. The study highlights the need for surgeons to discuss potential risks with patients and to implement strategies that minimize the likelihood of bilateral complications.
3. “Immediate Sequential Bilateral Cataract Surgery: A 13-Year Real-Life Report of 56,700 Cataract Operations”
Abstract: This retrospective study analyzes 56,700 cataract surgeries performed over 13 years, with a focus on ISBCS. The proportion of patients undergoing ISBCS increased from 4.2% in 2008 to 46% in 2020. Notably, no cases of endophthalmitis were associated with ISBCS during the study period.
Conclusions: The substantial increase in ISBCS over the years reflects growing confidence in the procedure’s safety and efficacy. The absence of endophthalmitis cases suggests that, with proper protocols, the risk of severe bilateral complications can be minimized.
Risks: Although no endophthalmitis cases were reported, the study underscores the importance of maintaining stringent aseptic techniques and patient selection criteria to sustain low complication rates.
4. “An Update on Immediate Sequential Bilateral Cataract Surgery”
Abstract: This review provides an overview of recent developments in ISBCS, discussing current practices, benefits, and concerns. The authors note that while ISBCS offers advantages such as reduced healthcare costs and faster visual rehabilitation, concerns about bilateral complications persist among surgeons.
Conclusions: The review concludes that ISBCS is gaining acceptance, particularly in the context of the COVID-19 pandemic, due to its efficiency and reduced patient exposure. However, the authors call for standardized guidelines to address safety concerns and to ensure consistent outcomes.
Risks: The primary concern highlighted is the risk of bilateral endophthalmitis, a severe infection that could lead to significant visual impairment. The authors recommend separate instrument sets for each eye and appropriate intracameral antibiotic use to mitigate this risk.
5. “Immediate Sequential Bilateral Cataract Surgery and Its Relevance in COVID-19 Era”
Abstract: This article discusses the relevance of ISBCS during the COVID-19 pandemic, emphasizing its role in reducing hospital visits and potential virus exposure. The authors argue that ISBCS can help manage surgical backlogs and minimize patient risk during pandemics.
Conclusions: The authors advocate for the adoption of ISBCS during the COVID-19 era, citing its potential to enhance patient safety and optimize resource utilization. They stress the need for appropriate patient selection and adherence to safety protocols to ensure successful outcomes.
Risks: The article acknowledges concerns about bilateral complications but suggests that with proper precautions, the benefits of ISBCS outweigh the risks, especially in the context of a pandemic.
6. “Immediate Sequential Bilateral Cataract Surgery: A Survey of Ophthalmologists’ Attitudes and Experiences”
Abstract: This survey examines ophthalmologists’ attitudes towards ISBCS, revealing a range of opinions. While some practitioners endorse the procedure for its efficiency, others express concerns about medicolegal risks and the potential for bilateral complications.
Conclusions: The survey reflects a cautious approach among ophthalmologists towards ISBCS, with many awaiting more robust evidence before widespread adoption. The authors suggest that clear guidelines and further research could help address these concerns.
Risks: Key concerns include the risk of bilateral endophthalmitis and medicolegal implications. The authors recommend comprehensive risk management strategies and informed patient consent to mitigate these issues.
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