Eyeing a More Cost-Effective Option?

Study highlights ISBCS’s efficacy for cataract treatment

by Andrew Sweeney

One of the most significant public health crises faced today in the developing world is aging population. This means that state pension budgets are increasingly occupying higher shares of GDP, and public health systems are straining under the pressure of having to look after more people with more morbidities.

This problem can be observed across the medical industries of dozens of countries and is particularly acute in ophthalmology due to exploding rates of cataracts.

Cataract and old age

Cataract is associated with old age and is accepted as a natural part of the aging process. Indeed, according to the World Health Organization (WHO), cataract is one of the main diseases causing preventable blindness around the world, with an estimated number of 65.2 million people in need of treatment as of this moment.1

With the ever-increasing number of elderlies in the world, that number is only going to rise and rise until already strained healthcare systems could face new collapse.

At present, phacoemulsification cataract surgery with an intraocular lens (IOL) implantation is one of the most commonly performed types of surgery worldwide, thanks in no small part to its low rate of complications (1.2%) and high success rates (93%).2,3 The technique is also costeffective and can be performed in many healthcare facilities, but with the rising costs of healthcare — and with an estimated 6.9 billion US dollars needed to cover the gap of costs for unaddressed cataract globally — clinicians are still under pressure.

Thus, there is an acute need for ophthalmologists to identify techniques that can provide significant cost savings and increased efficiency.1

The search for a more efficient solution

One technique that could provide significant cost savings and improved efficiency is immediate sequential bilateral cataract surgery (ISBCS), which in layman’s terms refers to operating on both eyes on the same day in two separate procedures. This is opposed to the more conventional delayed sequential bilateral cataract surgery (DSBCS), which can involve gaps of days to months between procedures. As a result, the latter technique can cause a number of issues related to clinical efficiency and can delay the patient reaching their best possible outcome.

One might think that these issues would make ISBCS the preferred technique in most clinical settings. However, a number of countries’ healthcare systems and national guidelines recommend against it due to a perceived higher risk of complications. This is despite ISCBS being reported by a number of leading clinicians as offering faster visual rehabilitation with no visual imbalance (anisometropia) between first eye surgery and second eye surgery, avoidance of additional day-care admission, less use of home care, a reduction in hospital visits, and a reduction in overall costs.4,5

If ISBCS could be proven as safe and effective, without undue risk of complication to the patient, it could offer significant advantages to hospitals looking to save costs and improve their overall performance. That’s the consideration posed in one study, An Update on Immediate Sequential Bilateral Cataract Surgery, authored by two stalwarts of ophthalmology: Dr. Lindsay S. Spekreijse and Prof. Dr. Rudy M.M.A. Nuijts, a former president of the European Society of Cataract and Refractive Surgeons.6

The authors of the study focused on one of the most common reasons cited for not performing ISBCS, namely post-operative endophthalmitis. While pointing out that according to one review, “there is likely no significant difference in endophthalmitis rates between ISBCS and DSBCS,” they conceded that there was a low incidence of bilateral endophthalmitis overall, and that none of the included studies in the review was large enough to detect a bilateral case. This would need to be rectified for a fuller picture of ISBCS.6

The experts speak and Swedish results

To overcome this issue, they examined additional large nonrandomized studies and randomized registry studies, and they were able to find more information that backed up ISBCS as a safe and effective procedure.

In one Swedish review,7 endophthalmitis incidences were recorded in 1,457, 172 cataract extractions, of which 92, 238 were performed according to the ISBCS procedure. Independent risk factors for developing endophthalmitis were found to be less frequent in the ISBCS group, and only one case of bilateral endophthalmitis occurred in this group.

The other area the study focused on was ‘refractive surprise’ as “the level of success for cataract surgery is mostly determined by postoperative refractive outcomes.” According to the study, in Europe currently accepted deviations from target refraction lie within 1.0 and 0.5 D, and success rates reach 93 and 72.7%, respectively. The authors pointed out that in bilateral cataract surgery, the refractive outcomes of the first eye can be used to further optimize the prediction accuracy of the second eye, which does offer an advantage over ISBCS.7

However, they referred to a review on ISBCS that found moderate (one randomized controlled trial) and low-certainty (three nonrandomized studies) evidence that there was no difference in the percentage of eyes that did not achieve refraction within 1.0 D of target one to three months after surgery. No information on differences in relevant parameters (e.g. IOL calculation formulas or axial lengths) between groups was provided either. Although it was suggested that refractive adjustments during the interval between the first and second eye surgery may have accounted for better outcomes in DSBCS, no data were provided on whether these adjustments were performed or not.6

In their concluding remarks, Dr. Spekreijse and Prof. Dr. Nuts stated that, “ISBCS is an effective and cost-effective alternative to DSBCS, provided that patients are selected carefully and safety guidelines are taken into account.”

Although, it appears, based on the results of their research, that fears about the significantly increased risk of complications compared to DSCBS are present, it’s certainly a more efficient and cost-effective procedure.

If it leads to increased patient outcomes, and it should improve quality of life considerably — thanks to reduced overall treatment time, then everyone is a winner.

References

1. World report on vision. World Health Organization; 2019. Available at: https://www. who.int/docs/default-source/documents/publications/world-vision-report-accessible. pdf. Accessed on February 8, 2023.

2. Lundström M, Dickman M, Henry Y, et al. Changing practice patterns in European cataract surgery as reflected in the European Registry of Quality Outcomes for Cataract and Refractive Surgery 2008 to 2017. J Cataract Refract Surg. 2021;47(3):373-378.

3. Lundstrom M, Dickman M, Henry Y, et al. Risk factors for refractive error after cataract surgery: Analysis of 282 811 cataract extractions reported to the European Registry of Quality Outcomes for cataract and refractive surgery. J Cataract Refract Surg. 2018;44(4):447-452.

4. American Academy of Ophthalmology. Cataract in the Adult Eye. Preferred Practice Patterns, 2016. Available at: https://www.aao.org/preferred-practice-pattern/cataract-inadult-eye-ppp-2021-in-press. Accessed on February 8, 2023.

5. Grzybowski A, Wasinska-Borowiec W, Claoue C. Pros and cons of immediately sequential bilateral cataract surgery (ISBCS). Saudi J Ophthalmol. 2016;30(4):244-249.

6. Spekreijse LS, Nuits RMMA. An update on immediate sequential bilateral cataract surgery. Curr Opin Ophthalmol. 2023;34(1):21-26.

7. Dickman