TWO FOR ONE Performing dual cataract procedures on the same day improves clinical efficiencies and patient satisfaction, but reimbursement incentives are lacking.

Cataract surgery on both eyes at the same time? Why not? Patients only have to endure the inconvenience of surgery once. And forward-thinking surgeons get to practice progressive ophthalmic care. But if it makes such perfect sense, why is same-day bilateral cataract surgery so rare? Follow the money. When surgeons operate on both eyes during the same visit, Medicare cuts both its facility and physician fees for the second eye in half. But as surgeons and health systems continue to show that same-day bilateral cataract surgery is beneficial to patient care and healthcare spending, Medicare will begin to incentivize bringing in patients for a single cost-saving surgical visit. Will your facility and surgeons be ready when it does? Patients already are.

Eighty percent of cataract patients would prefer to have both their eyes done at once, according to a paper presented at a recent ASCRS meeting. But several barriers are blocking same-day bilateral cataracts from becoming commonplace.

• Reimbursements. A study conducted by Rush Eye Associates in Amarillo, Texas, compared post-op outcomes and the economics of same-day bilateral cataract surgery and separate-day procedures (osmag.net/RsyCE6). The findings show patients who underwent same-day bilateral cataract surgery spent less time traveling for care, required fewer total care visits and recovered post-op vision faster. Facilities and physicians made less than they would have by operating on separate days, but treating both eyes at the same time saved healthcare dollars.

Surgeons don't always have to be left holding the short end of the stick, however. Each time a surgeon with the Colorado Permanente Medical Group performs same-day bilateral cataract surgery, he earns more for himself. How? Kaiser Permanente uses capitation payments, which are based on a fixed payment per person, rather than a payment per service. The economics must improve for surgeons in private practice before same-day bilateral cataract surgery truly catches on, but the success of the Colorado Permanente group backs Medicare's interest in bundled payments and accountable care organizations, which are shifting the focus to more efficient and cost-effective care.

FRESH START Supplies used during surgery on the first eye must be replaced before the second procedure begins.

• Safety. I was the founding president of the International Society of Bilateral Cataract Surgeons (isbcs.org), which was launched in 2008 to let surgeons who perform same-day bilateral cataract surgery share their experiences and best practice ideas, and to provide physicians with access to safety-centered guidelines of care and feedback from colleagues from around the world. The society's membership now exceeds 150 physicians, with Americans accounting for 90% of members who signed on over the last 2 years. Yes, interest in immediately sequential bilateral cataract surgery is growing in the United States, where healthcare capitalism has surgeons looking for new ways of doing things to gain even the slightest advantage over their competitors.

I co-authored a study in 2014 that assessed rates of endophthalmitis in more than 100,000 eyes of patients who underwent same-day bilateral cataract surgery. We noted infection rates of 1 in 17,000 patients instead of the 1 in a few hundred or few thousand patients that's typical when surgery is performed on one eye at a time. The results could have been biased — only highly experienced surgeons performed the procedures in high-functioning facilities — but the study does show that the risk of infection is small when skilled physicians care for patients in the right clinical setting using proven protocols.

Overall, the risks associated with same-day bilateral cataract surgery are minimal, but the risk of retinal detachment is a concern, especially in myopic patients who are between -4 and -8 diopters. I believe it's best to have a retina surgeon examine these high-risk patients before surgery and at 1 month post-op to ensure no retinal-related issues arise, and that any tears are treated before detachments occur.

Clinical considerations
A vast majority of same-day bilateral cataract surgery patients do as well as if not better than patients who undergo procedures on separate days, because it's physically easier on patients with several comorbidities to do both eyes at once. The primary exclusions of the past — patients with severe corneal issues or uncontrolled glaucoma — are not as worrisome today, thanks to improvements in cataract surgery technology and practice enhancements. There's little clinical difference in the vast majority of patients, excluding borderline failing Fuchs' dystrophy and diabetics with significant retinopathy, in performing procedures back to back, but it does require extra attention to these details:

• Separate supplies. All patients must receive intracameral antibiotics and both surgeries must be treated as distinct procedures. Nurses must ensure that all supplies, instruments and lenses intended for each eye are kept separate in the OR. When one case is finished, they must discard the supplies and start setting up for the second eye as if it's a completely new procedure on a different patient. Whenever possible, buy 2 sets of supplies from different manufacturers, so your surgical team can tell right and left devices apart. That's especially true for viscoelastic products, which are complex molecules that possess the highest bioburden standard of acceptance of anything we use in the OR. If you can't buy viscoelastics from different manufacturers, try to purchase products with different lot numbers, so the surgical team can easily tell them apart.
• Implant management. Keeping track of the IOLs that are to be implanted in the 2 eyes is a critical challenge to address. In my practice, we write down in the OR — for both the left and right eyes — biometry calculations, the axis of astigmatism, the IOL we will implant and the backup lens that's on standby. I bring a similar list that my clinic created and tape it to the surgical microscope. Before operating on each eye, I review the information on my list with the circulating nurse, checking to be sure no errors have been made, and that the 2 lists match exactly. We've never implanted the wrong lens, thanks to that process of checks and balances.

It's also possible to confuse the left and right eye, especially when operating on both within minutes of each other. We make sure all supplies in the OR are labeled "right" or "left" and more than 1 person always confirms that the eye we're about to operate on is correct. If there's a discrepancy, we confirm the surgical site by reviewing the information in the patient's original chart.

• Improved efficiencies. Performing same-day bilateral cataract surgery is a timesaver. Staff organize paperwork — even if you use electronic health records, surgeons and nurses often want hard copies of the patient's information for double-checking in the OR — and it's easier to admit patients, administer medications, review medication histories, administer anesthetic and dilating medications and discharge patients once instead of twice. Those streamlined efficiencies shave about 10% off the time spent managing patients and could let you perform more cases in a day.

Thinking ahead
Even with increased scheduling efficiency, surgeons will have a tough time breaking even under Medicare's current payment structure. But healthcare professionals always strive to find better ways of caring for patients. Clinical innovations such as incredibly accurate biometry, improved phaco machines and the development of femtosecond lasers eventually outdate assumed best practices and and older paradigms. We're on the cusp of that happening with same-day bilateral cataract surgery. OSM