Sequential Procedures Require Careful Surgical Planning and Execution

By Charles Claoué, MA(Cantab), MD, DO, FRCS, FRCOphth, FEBO, MAE
Immediate sequential bilateral cataract surgery (ISBCS) is not just two cataract operations on one patient immediately after one another. Nor is it a high-risk procedure. However, it does require careful planning and execution—two prerequisites within the realm of surgical training for most experienced ophthalmologists.

PREOPERATIVE PROCEDURE

My technique starts in the patient selection process, as ISBCS is appropriate only when both eyes are likely to benefit from surgery. In the United Kingdom, our threshold for general anesthesia is lower than in many other countries, and, although it is extremely safe, it makes sense to limit the risk to a single anesthesia session. Therefore, patients requiring general anesthesia—those with tremors, those with low levels of cooperation, and those who elect it—are good candidates for ISBCS. Other indications for ISBCS include patients with predictable significant postoperative anisometropia after first-eye surgery (eg, refractive lens exchange) or patients who select a multifocal IOL, as a deferred second-eye surgery will result in binocular retinal rivalry. In my practice, I often perform presbyopic lens exchange (PRELEX), and with the introduction of toric multifocal IOLs I believe that even more patients can benefit from ISBCS.

All of my cataract patients are educated about the risks associated with phacoemulsification, but when I propose ISBCS I explicitly discuss and document the risk of infection. I choose to use the realistic figure of one incidence of endophthalmitis in every 1,000 standard cases;^1,2 therefore, I explain, one in 1 million bilateral cases will contract bilateral endophthalmitis. However, the real risk of endophthalmitis after ISBCS is probably lower than this.

It is always the patient’s choice whether to have ISBCS or delayed sequential bilateral cataract surgery (DSBCS). The operating room (OR) staff must be informed prior to surgery of any patients who elect to have ISBCS prior to surgery, as there are significant changes from routine phaco surgery. On the day of the procedure, patients are offered the choice of which eye to have surgery on first. The eyes are subsequently marked “I” and “II.” I explain that I reserve the right to defer second-eye surgery if I am unhappy with the outcome of the first procedure (although I see merit in the argument that, if there are complications, the best time to operate on the second eye is immediately thereafter while it is fresh in my memory). To date, I have not postponed the procedure on the second eye.

ISBCS should be undertaken only by a fully competent surgeon using equipment and an OR staff he or she is comfortable with; this surgery should never be performed with visiting teams or locum tenens. The anesthesiologist should be reminded that bilateral surgery is planned to avoid administration of reversal drugs at the completion of the first surgery. All patients receive topical ofloxacin with their mydriatics plus iodine prophylaxis for a minimum of 3 minutes before the start of surgery. The details of the IOL type and power and the incision meridian are clearly posted on a board visible to all staff. We have adapted the World Health Organization’s preoperative checklist with our own local variation according to the Royal College of Ophthalmologists’ suggestions. This includes independent checking of biometry printouts.

SURGICAL PROTOCOL

After meticulous draping using an incise-aperture, full-length disposable drape and further lash concealment if necessary, I undertake a standard stop-andchop phacoemulsification technique via a triplanar clear corneal incision placed on the steepest corneal meridian. According to the recommendations of the International Society of Bilateral Cataract Surgeons (available at www.isbcs.org and on page 60 of this issue), for which I was a coauthor, each procedure must not only be undertaken as a completely separate surgery, but different batches of fluids must be used for the two eyes whenever possible. A full surgical scrub and redrape between the two procedures is therefore mandatory. At the end of each procedure, the operated eye receives 1 mg intracameral cefuroxime in accordance with the protocol of the European Society of Cataract and Refractive Surgeons (ESCRS) endophthalmitis study, the largest masked, prospective, randomized study of antibiotic use ever published.^1,2

After surgery in the first eye is complete, a cartella shield is placed over the eye to protect it during the second procedure. After the second procedure, if the patient is under general anesthesia, another cartella shield is placed over the second eye until the patient has fully recovered; if the surgeries are under topical anesthesia, the patient leaves the OR with both eyes uncovered.

POSTOPERATIVE CARE

The standard of care in the United Kingdom does not mandate a follow-up visit the day after or even in the few immediate postoperative days after surgery. This can seem extraordinary to practitioners in other countries, but we have seen no adverse outcomes from adopting this practice some 15 years ago. For DSBCS, it is routine for patients to return for their first postoperative visit as late as 2 weeks after surgery, and some units have devolved postoperative assessments to trained nurse practitioners or optometrists because of perceived financial savings.

I used to see all my ISBCS patients the day after surgery because of paranoia regarding bilateral endophthalmitis. After a decade of experience, and with the increasing evievidence- based opinion of my colleagues, I have now abandoned seeing these patients the day after surgery as a matter of routine. All patients are invited to come to see me if they wish; however, this has not yet occurred.

CONCLUSION

The advantages of ISBCS, not least the potential financial savings, are overwhelming. The only counterargument with any credibility—bilateral endophthalmitis—is demonstrably such a rare event that the evidence base is persuasive. As Victor Hugo said, “There is nothing more powerful than an idea whose time has come,”³ and as Theodore Roosevelt said during his speech, “Citizen in Republic,” at the Sorbonne, in Paris in 1910:

It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.⁴

I have no doubt that ISBCS is an idea whose time has come, and I would encourage you to join us and become a “man in the arena.”

Charles Claoué, MA(Cantab), MD, DO, FRCS, FRCOphth, FEBO, MAE, is a Consultant Ophthalmic Surgeon at Queen’s Hospital, BHR University Hospitals NHS Trust, London, and Secretary to the United Kingdom & Ireland Society of Cataract and Refractive Surgeons. Professor Claoué states that he is a paid consultant to Rayner Intraocular Lenses Ltd., and also has a patent or part ownership and a royalty agreement with the company. He may be reached at tel: +44 20 88 52 85 22; fax: +44 20 75 15 78 61; e-mail: eyes@dbcg.co.uk.

1. Seal D,Barry P,Gettinby G,et al.ESCRS study of prophylaxis of post-operative endophthalmitis after cataract surgery: case for a European multicentre study. J Cataract Refract Surg.2006;32:396-406.
2. Barry P,Seal D,Gettinby G,et al.ESCRS study of prophylaxis of post-operative endophthalmitis after cataract surgery: preliminary report of principal results from a European multicentre study. J Cataract Refract Surg.2006;32:407- 410.
3. Memorable quotes Web site.Memorable Quotes and Quotations from Victor Hugo.http://www.memorablequotes. com/victor+hugo,a605.html.Accessed August 2,2011. Seal D,Barry P,Gettinby G,et al.ESCRS study of prophylaxis of post-operative endophthalmitis after cataract surgery: case for a European multicentre study. J Cataract Refract Surg.2006;32:396-406.
4. The Almanac of Theodore Roosevelt.The Man in the Arena—April 23,1910.http://www.theodoreroosevelt. com/trsorbonnespeech.html.Accessed August 2,2011.

Breaking the Taboo: ISBCS is a Credible Procedure

By Christopher Liu, FRCOphth
When contemplating the addition of a new technique or technology to one’s surgical practice, it is imperative that a risks-and-benefits analysis be performed. However, it seems that, for immediate sequential bilateral cataract surgery (ISBCS), many surgeons already have made up their minds that the risks outweigh the benefits. The purpose of this article is to break the taboo associated with this procedure and to offer my approach to ISBCS as a testament to its surgical and practical advantages.

The main argument against the use of ISBCS is the risk of endophthalmitis. However, its incidence is rare when adequate preventive measures are used. For instance, we use a phaco pack from the previous week’s surgeries for one of the two eyes to ensure sterility. This phaco pack is of proven sterility, as that batch of sterilization has already been tested and proven on patients operated on the previous week. Additionally, we use different batch numbers or manufacturers for any device, medicinal product, and irrigating solution for each of the two eyes. We also reduce the use of intracameral substances as much as possible by prohibiting the use of adrenaline, antibiotics, and anesthetic agents. These are measures that reduce the risk of infection for each and both eyes.

The use of ISBCS can be broken down into three categories: (1) benefits for the patient, (2) benefits for the hospital, and (3) benefits for society. For the patient, ISBCS means a quicker improvement in visual function and quality of life and one visual rehabilitation process, as there is no longer a period of anisometropia.^1,2 Additionally, patients after ISBCS are less likely to show no visual improvement than patients undergoing unilateral cataract surgery.³ Lastly, there are fewer visits to the hospital and only one trip to the optometrist for glasses. For the hospital, there is only one preoperative assessment, one episode in the operating room, and one postoperative process. ISBCS is a more efficient use of OR time; in our OR, we have found that tacking on a sequential surgery in the fellow eye adds only 12 minutes to our usual case time of 28 minutes; this includes scrubbing. This translates into completion of surgery on eight eyes per list compared with five. For society, ISBCS reduces the sometimes long waiting lists for cataract surgery, as 35% of cataract procedures today are for second-eye surgery.^4,5

SURGICAL APPROACH

Patient selection. In our practice, we assume that all patients presenting with symptomatic cataract in both eyes are candidates for ISBCS unless a preexisting condition could increase the risk of infection, corneal decompensation, high intraocular pressure, or intraocular inflammation (Table 1). We also avoid performing ISBCS if we suspect the patient will have an inaccurate biometry reading or if the patient has a history of ocular trauma, lens subluxation, phacodonesis, or pseudoexfoliation. We have found that approximately one-third of patients are excluded from candidacy according to these criteria; however, we do not perform extensive preoperative systemic examinations, and therefore we are at risk for missing a preexisting condition such as leukemia.

We always discuss the benefits and risks of ISBCS with patients who are deemed choice candidates for the procedure (Table 2) and allow them to choose between ISBCS and DSBCS. Surgical benefits and risks are once again reviewed before informed consent is obtained.

Preoperative process. On the day of the procedure, both eyes are examined one more time to ensure that the patient did not develop any conditions that contraindicate bilateral surgery. The eyes are then marked according to first and second surgeries, and topical phenylephrine 2.5% plus cyclopentolate 1% and topical diclofenac 0.1% are instilled to dilate both eyes, stabilize the blood-aqueous barrier, and inhibit intraoperative miosis, four times an hour before surgery.

Usually, the eye with the worse cataract is operated on first. An exception is when the cataract is very dense (white or dark brown cataract). By operating on the better eye first, we can give the patient the best chance of having both eyes done at the same sitting, as having a significant intraoperative complication in the first eye would mean not proceeding with surgery in the second.

Intraoperative technique. Surgery can be performed under topical, sub-Tenons, or general anesthesia. Before placing the eye drape, aqueous povidone-iodine 5% is instilled into the conjunctival fornices of both eyes and, working concentrically away from the eyes, the eyelids, eyebrows, nose, and cheeks are cleaned and the skin is dried. The surgeon should ensure that the speculum traps the lashes and keeps the meibomian gland orifices away from the surgical field.

Unless an intraoperative complication occurs, such as posterior capsular breach or zonular dehiscence, or excessive operating time or phacoemulsification energy are required, surgery proceeds with the identical procedure in the fellow eye. However, a mandatory rescrub is required, and the second eye is recleaned with povidone-iodine 5%. Once the second surgery is complete, the patient is taken to the recovery room. Before discharge, the eye patches are replaced with clear cartella shields prior to discharge. The eyes are also checked for any sign of complications, and steroid and antibiotics are prescribed for use four times daily. If a condition precludes second-eye surgery, the patient is told that the procedure will be rescheduled for a later date, after the first eye has recovered. In either case, the patient is informed to contact the office at any sign of increased redness or pain or decreased vision.

CONCLUSION

I am confident that I, along with my OR team and hospital staff, have the ability and track record to successfully perform ISBCS in patients who present with symptomatic bilateral cataract. The three careful steps that we follow when selecting appropriate patients are (1) avoiding high-risk cases, (2) postponing surgery in the second eye if the first procedure has not gone well, and (3) separating the procedure into two distinct operations, one for each eye. I believe that other surgeons can be just as successful performing ISBCS if they follow a similar protocol.

Christopher Liu, FRCOphth, is a Consultant Ophthalmic Surgeon at the Sussex Eye Hospital, Brighton, United Kingdom, and Honorary Clinical Senior Lecturer at the Brighton and Sussex Medical School. He is also Director of the Tongdean Eye Clinic, in Hove, United Kingdom. Dr. Liu states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: CSCLiu@aol.com.

1. Laidlaw A,Harrad R.Can second eye cataract be justified? Eye.1993;7:690-696.
2. Desai P,Reidy A,Minassian DC,et al.Gains from cataract surgery:visual function and quality of life.Br J Ophthalmol. 1996;80:868-873.
3. Javitt JC,Bremner HM,Curbow B,et al.Outcomes of cataract surgery.Improvement in visual acuity and subjective visual function after surgery in the first,second and both eyes.Arch Ophthalmol.1993;111:686-691.
4. Desai P,Reidy A,Minassian DC.Profile of patients presenting for cataract surgery in the UK:national data collection. Br J Ophthalmol.1999;83:893-896.
5. Wegener M,Alsbirk PH,Hojgaard-Olsen K.Outcome of 1000 consecutive clinic- and hospital-based cataract surgeries in a Danish county.J Cataract Refract Surg.1998;24(8):1152-1160.