榴莲视频

NEW ORLEANS -- The American Academy of Ophthalmology (AAO) isn't ready to fully embrace same-day bilateral cataract surgeries, a practice that is common elsewhere. Their new guidelines suggest that eye surgeons perform them only after considering the potential disadvantages and letting patients make the final call.

The AAO released the recommendations via the document at their annual meeting here. In a point-counterpoint session, meanwhile, eye surgeons debated whether the same-day procedures are ready for prime time in the U.S.

"It's better for the patient, it's better for the doctor, it's better for the payer, it's actually better for everybody. I honestly think that either you will change on your own, or the government will when they find out they can save money by making the change," said Steve Arshinoff, MD, of the University of Toronto. But other speakers highlighted the risks and questioned whether the procedure has significant benefit for anyone other than insurers.

Same-day bilateral cataract procedures were performed way back in the 19th century, Arshinoff said, but multiple-day procedures took hold in the early 20th century amid concerns over eye infections. According to the AAO, same-day operations have become common in Europe and Canada in recent years (Arshinoff has been performing them since the 1990s), but make up just 2.4% of U.S. surgeries per the IRIS Registry database.

The new AAO guidelines note that research has suggested same-day bilateral surgeries result in "more rapid improvement of patients' self-reported visual function and similar long-term results. One study found a potential annual cost savings to Medicare of $522 million in 2012 dollars."

However, according to the guidelines, there are risks, such as infections that could threaten both eyes. In addition, operating rooms aren't likely to schedule the procedures because payments are typically below their cost.

Speakers at the AAO presentation warned of "refractive surprise" -- when the visual results of a procedure are unexpected and further reparative surgery on both eyes may be needed. Performing surgeries on separate days can head this off since surgeons will know what went wrong the first time around, said Randall Olson, MD, of the University of Utah in Salt Lake City.

Patients may be furious if their post-surgery vision isn't as improved as they'd like, or they may be extremely bothered by side effects like unwanted images, Olson added.

Mishaps can also strike cataract surgery patients and cause more havoc if they affect both eyes, warned Bonnie Henderson, MD, of Massachusetts General Hospital in Boston. She recalled a 57-year-old patient, a high-powered attorney, who underwent a unilateral cataract surgery and turned out to have a 2-diopter "refractive surprise." The team was targeting "plano" (zero correction), but the patient had a power of -2.00. What happened?

It turned out that the patient had undergone an earlier eye test while wearing her contact lenses, Henderson said. "These things happen," she added, before asking the audience whether they would choose same-day bilateral procedures for themselves if they needed cataract surgery. The wide majority said no.

But Neal Shorstein, MD, of Kaiser Permanente in Walnut Creek, California, said same-day bilateral procedures are routine at his clinic. Surgeons there understand that "the stakes are very high for the patient" since they could lose vision in both eyes. "We really go to extremes to minimize or eliminate adverse events such as infection, inflammation, and refraction surprises," he noted.

Shorstein recommended that these procedures be performed on non-complex patients. "You want to make sure that it's their choice to do bilateral the same day and document that in the chart. You want to discuss that there is a very, very low risk but potential for bilateral vision loss."

The new AAO guidelines emphasize the importance of informed patient consent: "Individual patient preferences and the best interests for the individual patient's visual health and refractive status should be the predominant factors in determining whether same-day bilateral cataract surgery should be performed."

Speakers agreed that same-day bilateral surgeries are unlikely to become more common in the U.S., at least for now, since insurers pay less than they would for two separate unilateral procedures, and pointed out that reimbursement for cataract surgeries is already low.