Simultaneous Bilateral Endophthalmitis After Immediate Sequential Bilateral Cataract Surgery: What’s the Risk of Functional Blindness?

I applaud Li and associates for their thoughtful discussion concerning the risk of endophthalmitis after immediate bilateral cataract surgery. The punch line is this: that in view of burgeoning health care costs and limited resources, the authors believe that the risk of blindness from bilateral endophthalmitis is so low that “widespread introduction of immediate sequential bilateral cataract surgery [I take this to mean same-day bilateral procedures]” is justified. I am not sure I want to explain to the unfortunate bilaterally blind patient my risk/benefit and cost/convenience thinking that leads to the collaborative decision to undertake bilateral simultaneous surgery. Some of my concerns follow.

The authors write that “assuming segregation protocols [are adhered to] … the 2 surgeries may be regarded as largely independent …” I do not know if “segregation protocols” are reliably adhered to, but more importantly, the 2 eyes and surgeries are not independent and we know that. A recent meta-analysis of post–cataract surgery endophthalmitis risk factors identified ocular or surgical factors including “extra- or intracapsular cataract extraction, a clear corneal incision, without intracameral cefazolin (1 mg in 0.1 ml solution), without intracameral cefuroxime (1 mg in 0.1 ml solution), post capsular rupture, [and] silicone intraocular [lens].” Patient factors found (which were protective) included male sex and old age (85 years and older). A surgeon who uses a clear corneal incision in 1 eye is likely to use it in the other and one who does not use intracameral cefazolin in the first eye will not likely use it in the other. A 90-year-old male right eye will reliably be paired with a 90-year-old male left eye. The 2 eyes and 2 surgeries are not independent.

The point that the procedure is cost saving is a good one. A downside is there is no chance to use the first-eye outcome data to “tweak” the intraocular lens measurement for the second eye. There are accumulating data that consideration of the first-eye refractive outcome can allow adjustment of the lens selection for the second eye, for example from Aristodemou (database study) or Jivrajka (prospective series). The new requirement from the Centers for Medicare & Medicaid Services (“CMS”) to assess visual function data before and after cataract surgery, while recently delayed, is expected to be in place in 2015. Once you do the first eye, visual function ought to improve and the indication for the second eye may be diminished. At least, bilateral simultaneous surgery will need to be considered when reporting visual function data.

I agree with Li and associates that the risk of bilateral blindness from endophthalmitis following simultaneous bilateral cataract surgery is tiny. For me, I doubt I would choose to have bilateral simultaneous surgery. I applaud those who seek to develop additional data concerning the risks and benefits so, as a society, we can make wise and cost-effective health care decisions.

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Jan 8, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Simultaneous Bilateral Endophthalmitis After Immediate Sequential Bilateral Cataract Surgery: What’s the Risk of Functional Blindness?

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