At the risk of seeming like just another surgeon whining about ever-declining insurance reimbursements, I hereby sound the alarm. When I learned that our Medicare Part B carrier, Noridian Administrative Services, LLC, intends to deny monitored anesthesia care (MAC) to patients undergoing lens procedures in 11 states, money was not my worry. Rather, I was (and still am) truly fearful for the safety of my cataract patients.

I believe MAC is indicated for cataract patients whether they receive topical anesthesia or regional blocks.

• Topical anesthesia. MAC is needed for patients who receive topical anesthesia because topical (with or without intracameral) anesthesia does not cause akinesia and renders both the head and eye fully mobile. To avoid the risk of damaging delicate ocular structures, the surgeon must be 100 percent attentive to the microscopic view of the eye and should never avert his gaze. This level of attention is simply impossible if there is no anesthesiologist present, because the only way to balance patient comfort with the need for awareness and cooperation is to provide constant anesthesia care. Although we can do some guesswork up front by knowing the risk factors for pain during cataract extraction, we cannot predict with any degree of certainty which patients will experience pain, when they might experience pain during the procedure and how much medication they will need. A dose that "snows" one patient may have no perceptible effect on another.
• Regional blocks. MAC is also clearly needed for patients who require blocks, such as those who are incapable of controlling their reflexes, in part because they often need significant sedation to avoid the anxiety and pain associated with peri- and retrobulbar injections. Furthermore, regardless of the type of anesthesia, the surgeon who operates alone has no choice but to sacrifice the eye to attend to the patient should an untoward cardiopulmonary event occur.

Insurers like Noridian must understand that there is no cookbook methodology when it comes to performing cataract extraction under topical or regional anesthesia. In fact, the commonly used topical approach actually requires a heightened level of MAC to avert surgical complications. I feel so strongly about this that I personally employ the anesthesiologist for elective IOL refractive procedures at my own expense, even though these patients are typically young and healthy. But this is well worth it because topical anesthesia with MAC is the safest approach for the vast majority of cataract patients. It frees them from the serious risks associated with general or regional anesthesia - including globe perforation or inadvertent damage to adjacent structures in the case of periocular injection anesthesia; loss of the globe or even systemic catastrophe from intravascular or nerve sheath injection; and, more commonly, damage to adnexal structures that can lead to ptosis and/or strabismus repair.

Unfortunately, the declining reimbursement for Medicare cataract procedures does not afford me this same economic freedom for "routine" cataract patients, and I fear I will face an ethical dilemma if my patients are denied MAC. Denying cataract patients MAC will impact outcomes, comfort and safety, and will significantly decrease quality of care. Beyond this, I fear for my own safety when I inevitably become the patient.