Lecture: Cataract Surgery: Maximizing Outcomes and Creating More Efficient Service

In this interactive lecture, Dr. Gomaa discusses the following in detail:
• Current situation of cataract surgery including the demand and future trends
• Methods to increase efficiency of the cataract service
• Risk stratification of cataract surgery and its importance in improving outcomes and efficiency of service
• Learn about Immediately Sequential Bilateral Cataract Surgery (ISBCS) and also, its pros and cons

Lecturer: Dr. Ahmed Gomaa, Blackpool Victoria Hospital, Blackpool, UK

Transcript

DR GOMAA: The problem — the cataract surgery as a technique, or as we call it, the actual cataract surgery, is kind of pretty exhausted now, when we look at the advances happening in the actual technique and the way that we are discussing this. So I want to discuss something maybe a bit different today with you, which, as you can see from the title of the talk: How we can maximize the outcomes and create more efficient service. I want to say, before we start, we just watched an elegantly done surgery at your hospital. This is a classic well done cataract surgery, as we can see. And I think the surgery took something like 10 to 15 minutes, so the actual surgery was not over time, actually. It took a very short time. And that actually creates some challenges for us as surgeons on how can we even improve better on this, and how can we make our service more efficient, knowing that the surgery now took something like 15 or 20 minutes. How much more we can do? How many surgeries we can do, and how can we improve the service we provide to our patients? Just before we start, I would like you to look at the screen now, and this is the question in front of you now. Maybe we go through the questions — so how do we assess the competency of a good — or let’s call it a safe cataract surgeon? As you can see, the choices in front of you: Maybe we get a quick vote in the classroom. What will be your choice? Is it his overall complication rate, less than 10%? His perceived capsular rupture rate is less than 5%? Or his best corrected visual acuity is more than 6/12 in 90% of cases? Or by annual auditing of his own surgical results, accounting for the case mix and the comorbidities that he’s dealing with? So what would be the choice in the classroom for the first question?

>> Okay, so most people are voting for option number four.

DR GOMAA: Excellent. So we’ll go for the second question now. Risk stratification of cataract surgery. I’m not sure if you’re familiar with the risks, but this is something we’re going to discuss. So for risk stratification of the cataract surgery, I would like you also to vote for one of the choices we have here. The first is: Ensures proper counseling of patients prior to surgery. Second will be: Facilitate efficient use of the available surgical time. The operating surgeon’s grade can be easily matched to the case difficulty. Hence we lower the surgical complications. It improves the overall safety of the cataract surgery. All of the above, or none of the above? What would be the choice?

>> So option number five.

DR GOMAA: Excellent. So the next will be: What helps in improving the efficiency of the service provided at cataract surgical units? Is it performing more cases per surgical session? Having less complications during the surgical day? Making more financial profit per case? Or optimizing the service to make use of the available resources to perform more cases and reduce overall cost while ensuring safety for our patients?

>> Okay, number four.

DR GOMAA: Excellent. And the last question before we start is: The immediately sequential bilateral cataract surgery, which means two eye surgeries done exactly on the same day, on the same session, one after the other. So for the immediately sequential bilateral cataract surgery, I would like you to choose one of the four most preferred answers to you. So the first is: Patching both eyes should be done following surgery for the first 24 hours. Second eye surgery is done by the same surgeon after just changing his gloves. The immediately sequential bilateral cataract surgery is safer for patients than attending another visit for the second eye surgery. The risk for having a road traffic accident is higher than having a vision threatening complication. Number four, contraindicated when general anesthesia is needed. So which one would be your choice?

>> Okay, three.

DR GOMAA: Excellent, thank you. So the objectives for our talk today is to discuss the current situation of the current cataract surgery, the current situation of cataract surgery, including the demand that we are facing now and the future trends we are expecting. We would like to explore methods to increase the efficiency of our cataract service. We will describe risk stratification of the cataract surgery and its importance to improve outcomes and the efficiency of the service. And finally we will define what is immediately sequential bilateral cataract surgery, its advantages and disadvantages, and what will be the future for this trend. The cataract, as it stands right now, the situation that we are facing around the globe, as you can see here, Professor Carrie MacEwen was describing it as a perfect storm of increased demand, caused by more eye disease and an aging population, which is requiring long-term care. So we have actually a situation where the population is increasing in number, and at the same time, they are requiring long-term care. If we look at the actual numbers worldwide, it’s quite significant. It’s 10 million blind people due to cataract, which is less than 3/60 vision, and 35 million is visually impaired due to cataract, with their vision lying somewhere between 3/60 and 6/18. So this is quite a significant number, worldwide. Maybe it is a bit more. We don’t know exactly. But this is the estimate that we have. The cataract situation right now: More than a third of the cases here — I’m speaking now about the UK, which you can consider is a developed country, and we can say — so this is a situation in a country more advanced, with more number of surgeons, and very well run service in the National Health Service that we have here. So the cataract, even here, at the time when you reach the age of 75, more than a third of cases of impairment are due to cataract. So this is, again, another significant number. The prevalence of visually significant cataract or operated cataract with a vision less than 6/18, which — the vision legal for driving in the UK — is more than 35%, or about 35% in those who are above 65 years. The national dataset — you would be surprised to know that even here in the UK, at the time when they are listed for surgery, about 15% of them are blind. So they cannot see. It is not just visual impairment, with vision less than 6/60. So they are blind due to cataract, which is a very high percentage of the patients we see. Now, the prevalence of the cataract itself — this was a statistic in 2001 in the UK — we can see it is, again, a high number. 41 per 10,000 population. It is even higher in the USA. And I think this estimate might be even higher right now. There was a big project run by the Royal College of Ophthalmology here, to look at what will be the trend in the future. Are we doing enough to face the demand that we have in cataract or not? And you can see the graph here on the screen. Over the last 20 years, the number — there is a continuous increase in the number of surgeries done, and the crude rate per thousand population is getting even higher, and if anything, it’s expected to get even worse or more. So as you can see, the number of surgeries done in 1998 was about 200,000. In 2004, we are doing nearly 400,000. So double the number of the surgeries that we started doing. Double the number, but despite this, the demand is not actually managed properly yet. So this is the future. How it looks like. Now, there is an expectation by the year 2035, which is something around 15, 20 years from now, that we will have doubling of the aging population above — if you look at the table here, the people above 80, by the year 2035, will be 6 million. And this is now — in 2010, we’re dealing with about 3 million. So this — actually doubling the number of people at this age group, and if you look at other age groups as well — sorry about this — the other age groups as well, this is exactly the same. So there’s a continuous increase in the demand, the aging population increasing in number. They live longer, and definitely there is more demand for the service. So expecting increase around 50% of the number of cataract operations we are expected to perform over the next 20 years, 25% of this increase will happen over the next 10 years. And we can see here in the graph that this aged population here is where the most increase will happen, and that’s where we do our cataract surgeries most. So this is where the problem will be, within the next few years. Now, they looked at the number of the estimates of the cataracts that we would be dealing with in the UK, and this also gives you an idea of where the problem would be. So there are two estimates. Even with the lowest estimate, by just a very, very strict criteria for defining what is cataract, including the density of the cataract, the level of vision, and a very robust classification system, and this is the lowest estimate here of the number of the cataract that we are dealing with. And by the year 2035, we are having around a million cataracts that need to be done in the UK, and if we go to the higher estimate, it will be three times this number. And this accounts for any dissatisfaction with the patient’s vision. So he might come and say: I have a cataract. I’m not happy with my vision. And this will trip the number that we’re dealing with. So where is the problem right now? We have more people, they live longer, and we have a bigger demand on our service, and unfortunately, we do have less ophthalmologists worldwide. There is one thing happening in this area, in the practice, that we are not actually creating enough ophthalmologists to deal with the problem, even at the time being. So we expect if this happens in the future it will be even worse. In the Education for England study, they found that the number of ophthalmologists — it will increase only by 10%, even with all the plans they put in place. The number will only increase by 10%, and this is not enough to face the problem that we just discussed right now. So knowing the problem that we discussed right now, I would visually look at this question and say: We are surgeons. How can we help? In our units, in our hospitals, each of us, what can we do to help this problem? I know it is sometimes, as we usually say, it is beyond our control. We are dealing with whatever we are having every day on our plate, whether the patient is referred, whether the patient comes directly to the hospital, so we don’t have much control. The best I can do: I will do the cases that I have in my hospital, whatever it is. So the management’s problem around us creating the flow within the unit we are working is something that, of course, it sometimes is beyond our control. But as a surgeon, there is something definitely we can do, which I think: Two things we have in hand. One of them is to do whatever we are doing better than what we do, and try to increase the output of the service that we have. The allocated time to us — we increase the efficiency within the time. Some of the questions that I would like to share with my colleagues in the classroom right now: I want you to look at the questions on the screen now. And just have an answer in your mind, when I’m saying the question. Again, how do we define a competent cataract surgeon? Is it by his overall complication rate? Is it just by crude statistics? Is it by comparing a cataract surgeon to another cataract surgeon in the same unit or in another part of the world? So this is a really important concept. What is a good or a competent cataract surgeon? And what the agreement is about right now is: Just about auditing the number of cases you are doing, and the case mix that you are facing every day. You cannot compare a surgeon who is having very advanced or very difficult cases to someone who is doing average or routine cases every day, or even doing the same number. So it is really important that each individual surgeon is auditing his cases, accounting for the case mix that he is doing, and the problem that he is facing. And this will be very accurately done, and this will be a good reflection of his competency in dealing with the cataract surgery. Of course, this needs to be audited against an international standard. Against what is acceptable in the literature. But again, after looking at the case mix that he is dealing with, then the next step will be: After we define that he needs to identify his case mix, how will we know that this is the level acceptable for these kinds of cases that he is dealing with? If we don’t have risk stratification, if we don’t know what will be the risk in each of these cases, we will never reach an acceptable standard for which — against his audit will be done. And that’s one of the points that we’re going to discuss today. Then the second question I would like to have an answer in your mind again: What case do you remember most, out of your last month of surgery? Or a year of surgery? In your last cataract surgery a week ago, or a month before, what is the case that you keep remembering most? Any kind of answers from the classroom that anybody would like to share with us? About this question? Which cases do you remember most usually? I will go ahead and maybe answer this. I think it will be the complicated case. The case that we encountered a problem, and this will be the case that you keep remembering all the time. And that’s actually creating part of the problem. Because this is not giving you the whole picture. This is not giving you what is your actual standard or the level that you’re dealing with. We are focusing on the problem. We are not looking at the whole picture, and this can sometimes give a false impression, and at the same time, will demotivate some of the surgeons for taking more surgeries, and it is actually important to have such complications. But what is more important is to identify the risk factors that will help you in dealing with future patients, and also to look at the overall picture at the end of the year. So that’s really important. The second question is kind of related to the question that we just discussed right now. It’s how you counselor a cataract patient in the clinic. When you see a patient, what do you tell the patient? Do you tell them: Okay, you have a cataract. We are doing it tomorrow. Or do you go with the patient through the risks associated with the surgery, knowing that we are doing a surgery that might end in a vision loss? One in a thousand. Yes, it is a very small risk, but the patient has the right to know the risk, and we need to counsel them properly. For this to happen, we need to know what are the risks associated with each case. And this needs to be tailored to the patient that we are seeing every day. And without knowing the risks that we are dealing with, we won’t be able to counsel the patients properly in the clinic. Now, also is cataract surgery a minor surgery? How does it compare to tooth extraction? Sometimes we finish the surgery, and you find your patient telling you: Okay, this was better than the last tooth extraction. Or this compares to my dentist visit last time. I’m not sure what is the relation. Maybe it is we are working on the head as well. Why they usually correlate it to that or kind of relate it to tooth extraction. But if you look at cataract surgery, is it really as simple as tooth extraction? I’m not saying that tooth extraction is simple for dentists. I’m just saying that: Is cataract surgery really a minor procedure? Is it a minor procedure? The answer is definitely not. It is not a minor procedure. Yes, with the advancement happened in the techniques — as we just saw Dr. Fahad’s operating right now — it turned out to be a kind of straightforward simple surgery. Yes, it is a very successful surgery. The outcomes are expected in about 98% of our patients. We know we will have a success, we will have a satisfied patient, we will have a happy patient. But this is provided that we know all the risk factors associated with the surgeries we are dealing with. We are prepared to deal with it. And we do it right. If we do anything wrong with this, we will end up in a situation that it is not a minor tooth extraction. It is something even worse. Do we have the surgery canceled on the day? And what was the cause? So cancellation on the day of the surgery — in the UK, there was a study done here. And as we can see, the causes for cancellation — we had in a certain unit, in 2008, 400 cases were canceled, out of nearly 2,000 cases. So this is 25%. And I’m sure all of us sitting in the classroom encounter cancellations. Maybe yesterday, the week before, and there is usually cause for cancellation. And these were the causes that they found, at the time when they did the audit in this unit. Different reasons. But the end result is that we are wasting some time. A very precious time. Your time as a trained professional. The time for the hospital as a health providing unit. And overall for the community where we live, or for the country, that they allocated resources that they managed to put together, despite all the challenges and the demand, and it is not used efficiently. The national audit in the UK, over 300 units, found that 45% of the theater time allocated for surgery was not being used because of canceled operations. You can imagine that even in a very well developed system, in the year 2005, we have nearly 50% of the time that we have is not used. And when it comes to time, it’s actually — when it comes to cataract, number equals money. As you can look at the table here, if you increase your number of cases from 5 to 8, we are increasing the profit per case by nearly double. So by just increasing 2 patients or 3 patients to — let’s say the average number of cases you are doing every day is 5 to 6 cataracts. If you do 8 cataracts, I can guarantee that you increase the profit for the unit you are working in, just adding one or two patients. So this is really important. Number equals money. And we are actually wasting some more money, we are wasting more resources, by having cancellations done on the day. So what is risk stratification? Risk stratification — to risk-stratify patients is to sort them into high, low, and moderate risk tiers. So we are taking the patients we are dealing with, and we classify them. This patient has a high risk of complications. This patient has moderate risk. And this patient has a very low risk of having complications. Of course, complications can still happen, but the expectation of this complication to happen is very small, compared to the one with the high risk. Risk stratification actually helps in aligning the practice’s very limited time. And the resources. And making priority for the needs of our population. There were two big publications which I would like to share with you. Two studies done in the UK. And I think this is one of the two most important studies even done for cataract surgery worldwide, because it is a very strong study. This study actually included 55,000 patients. More than 55,000 patients. And this was over a long time. Using, like, five years. And they studied the risks associated with the cataract, audited the results to try to identify: What would be the risk factors for having complications? The most feared complication for all of us, which is the posterior capsule rupture or vitreous loss that we keep worrying about all the time — and they did this, as we can see here — they looked at the risk factors. I know that it’s a very small print on the screen. We are not going to look at each of them. But it just gives you an idea that they are trying to identify: What are the risk factors for having a complication? Including everything about the patient. Starting with the age. His gender. Is it male or female? Other associated comorbidities in the eye, including glaucoma, diabetic retinopathy, something about the cataract itself, something about the eye itself. There is no fundal view. It is a total mature cataract. Pseudoexfoliation. The pupil size. All these factors come into question when we are doing cataracts. So they adjusted the odds of having complications, according to each of these risk factors. And if you look even at the age, at the beginning, at the first slide, just being above 90 years old, we are actually having two or three times higher risk of having complications than a patient coming at the age of 60 to 70. So it is quite significant. We are doubling the risk factors by just having an older patient. And we know this. Just having a male older patient even increases your risk further. You can look at the risks in the table, and each of these factors just adds to your risk of having surgery. To the patient’s risk of having the surgery. At the bottom of the table, you can see the surgeon’s grade. So the surgeon’s grade, whether he’s a trainee at the beginning of his training, or a consultant, finished his training, and well trained on doing cataract surgery, also is very important when we look at the risk associated with cataract surgeries. So now this graph is very useful, because you can take the composite odds ratio, and you correlate it with your predicted probability of having vitreous loss. So the vitreous loss correlates to the odds ratio. And how can we calculate the odds ratio? Is it one plus the other? Or one multiplied by the other? So, for example, you have a male patient who is 80 to 90 years old, with a white cataract. He has no fundal view. A small pupil. It is done by a trainee. So you can look here at this screen. So the composite odds ratio will be multiplying all the odds together, which equates to 34.5, and if we go back to 34.5 here, it will be correlating to 20% increased probability of having complications during the cataract surgery. Yes, it is about 35% that you will run into a complication. It is not like a tooth extraction for him. It is not a minor operation anymore. It is quite a significant risk for him, for the patient. Complex cataracts/patients — there were different ways of trying to define what is complex cataract. And the different lists done around the world. You can have your own list in the region where you live or the country where you live. But there is kind of an agreement or a consensus that certain types of patients, they have higher risks. One of them: Patients with corneal problems. Pseudoexfoliation. And people with small pupil. Axial length too long. Or short axial length. A shallow anterior chamber. All of these risk factors listed in many different literature around the world. But there is a kind of agreement that this is the type of patient that we would be worried about, when we do the cataract surgery. Now, this is a second one, which is really important. Muhtaseb — as you can see, the publication was 2004, but of course he started the study earlier than this — he looked at the risk associated with cataract surgery, and he tried to develop a system for stratification of your cataract patient. And this is important, because now we knew that the risk was important to identify. But how we are going to know before the surgery: This is a patient who is low risk. I can give it to my trainee. Or this is a patient with a very high risk. I will do it myself, and I will pray that I will finish it without the complications. So that’s the difference that we need to identify. How are we going to find what is the risk for each of them and calculate a number that will guide us into stratifying our patients? So he divided them into four groups. And for each of the four groups, he used a category A, with no points allocated for each of the risk factors, or category B, with one point attached for each risk factor, and group 3, where we have three points for each of the risk factors. So in group one, you can see that the patient was a previous vitrectomy, for example. We take one point. Another one point would be for corneal scarring. Small pupil. As we go on, you can keep adding points. And category C will have three points for each of the risk factors associated. And he divided them according to the risk into low risk, moderate risk, and high risk. As we increase now in number, of course we are increasing the risk. And that’s the results. Clearly, as we increase the risks associated, we have more complications. So it is very clear. And this is overall complication rate, including all grades of cataract surgeons. So it is including trainees, consultants, top grades. They are all operating within the same units in the UK, and the risk increases from just 4% to 32%. This is a very high rate. By just increasing the risk. And this is acceptable, or this is what we found by auditing the cases. It is not like something that you encounter individually. This is national results. There is another system recommended by the Royal College, but it is more or less the same idea. There is allocating points for each of the risks we are encountering, and according to the number that we get, we can decide who will be the surgeon. Is it a trainee, a fellow, or a consultant with the very high risk cases? Here we have some difficult cases. And as I mentioned at the beginning of the talk, we are not going to discuss the techniques of the cataract surgery, because I know it is quite exhausted. Whenever we go to a meeting, that’s usually the topic that interests us more, that we keep looking at cases, and how we are dealing with each of the risk factors. I’m not going to go through the slides thoroughly as well. But let’s choose one or two of the risk factors we have here, and maybe we have a quick answer from the audience about how they will manage such cases. Let’s see. If a patient was coming to you with a deep-set eye, a very high brow, how will you manage this in your practice? Maybe one of my colleagues in the classroom can answer this question. How will you approach this case differently from the regular patients you are dealing with?

>> Hi. How are you? Posterior polar cataract.

DR GOMAA: Yes, you choose a posterior polar cataract. 35% increase of complication rate. Thank you. Yes, for the posterior polar cataract, what will we do differently?

>> Normally I don’t do hydrodissection in these cases. I like to do a small anterior capsulorrhexis. And the most important thing is not to do a hydrodissection. Because most of the cases you will open the posterior before. Then, after you remove the cataract, and you’re doing the aspiration, my recommendation is to use bimanual technique and go slow from the periphery to the center. From the periphery to the center, leaving the center of the lens, the remaining lens, that is attached to the posterior capsule, for the very, very end. And even if I have some remaining, trying to aspirate it as most delicate as I can.

DR GOMAA: Thank you very much. Excellent. Exactly. So you know your risk. You dealt with it in an excellent way, without running into the complication. Even if you run into the complication, you are prepared for it. You know you will have vitreous coming, if you go through the hole in the posterior capsule. 35% will have this kind of complication in these cases. So we go to this case. You went to this case well prepared. When you started the case, you know it is a posterior polar cataract. You didn’t do hydrodissection, as a usual case. Luckily it was a soft cataract, compared to others that we are dealing with, and you left a good rim in case you need to implant on the anterior capsule, so you made a perfect plan, just by realizing that you are dealing with a case which is not the usual case. It is not the usual case that we are dealing with every day. Let’s go with a patient with a small pupil. What will we do different for this case?

>> You could try using intracameral phenylephrine. If that doesn’t work, then obviously the ring is the next step, rather than trying to do it through a small pupil. You have much higher risk of getting vitreous loss or other complications.

DR GOMAA: Absolutely. So intracameral phenylephrine. Kind of an overlooked extra step by most of the surgeons. But it is a really, really important one. Especially if you have a patient on alpha blockers. And it makes a huge difference for you. You are prepared again. Your tunnel may be a bit longer, if you are dealing with someone who has a floppy iris. You put the ring — whatever you are comfortable with — is it the Malyugin ring or the iris hooks — so by just planning, and you’ll be ready, when you are briefing with your stuff, before starting the surgery, you stand up with them in the theater, and you look at them, and we are doing the brief now. So we are going through the cases. You look at this case, and you say: We have a case with a small pupil. How are they prepared? Do we have iris hooks? Do we have a Malyugin ring? Or any kind you are comfortable with using? Did you allocate more time for this patient? For the case like Dr. Fahad was just doing — took 15 minutes. This patient will take double the time. So are we prepared with this? Or we’re going to end up with canceling one case because we did a case which ran over the time allocated for them? So that’s exactly what we mean by risk stratification. Now, after we discussed all this, none of us now or none of my colleagues as well mentioned — of course, because they are comfortable with whatever they are doing, they volunteered an answer. But have we allocated this case to someone more senior? Or not senior — someone who was comfortable doing it. For example, Dr. Fahad was working temporally now. Maybe I’m not a temporal surgeon. I’m not comfortable working in the temporal incision. I usually work from the top. I have a patient with a very deepset eye. He has a very high brow. It is better for him to have this surgery done temporally. So if I am not comfortable with this, I will speak with my colleague and say: Oh, okay, you are doing your technique all the time temporally. It’s better if you do this patient. So I used my time efficiently. He is using his time efficiently. And overall on the unit we have less cancellations and more efficient use of our time. So now we know that risk factors are important and the risk stratification is important. Even after identifying risk stratification, they did an audit here in the UK to see: As a surgeon, you know that the risk factor is important. Do we still report it? And interestingly enough that even surgeons, after they know that the risk is existing and it needs to be reported, there is underreporting of the risks. And we have a tendency that we only look at the risk factors after the complication happens. Not before. And this is really serious. If anything, we need to actually stratify patients and document it in our record, and even account for it when we are doing our audit. Because if I record my surgery and it went uneventful, I’m happy, I finished the surgery, even if it was very risky to me, I finish the surgery, and I just recorded the surgery, I didn’t mention any of the risk factors I encountered, later on at the end of the year, I don’t have my statistics, really. I am not able to audit my cases to know which case had the risk factors. It is only when we encounter complications sometimes — and some of them, even one of them didn’t report in any case, even if he runs into complications. So this is quite significant. Reporting this risk is as important as identifying the risk. And this is — will actually be reflected, when we come at the end of the year and do the auditing of the cases, or when we look at the overall picture on the unit. How many challenging cases we are dealing with. Maybe you will ask for more money, if you are working in a health system where you are charging money from the National Service. You will charge more for this patient, because you are dealing with a different type of cases. A more challenging type of cases. Thank you. So now we finished the big first part of our talk. The second part, I hope it will be short. I know that we need to finish now in five minutes. So the concept of the immediately sequential bilateral cataract surgery is not new. The immediately sequential bilateral cataract surgery, which means two eyes done at the same time on the same session by the same surgeon is not new. As you see here on the screen. It is since 1952. Even done in intracapsular cataract extraction. Of course, as we had the phaco introduced, it is becoming more common. I know it is done by manual small incision cataract surgery in India, but it is gaining popularity now. Finland is a leading country. In 1996, even 40% to 60% of the ISBC cases, done worldwide. Spain — the region of Canary Islands — 80% of the cases. And the government is even encouraging them to do more. Is done as immediately sequential bilateral cataract surgery. In Ontario, in Canada, the number doubled from just 1% of the cases to 2%, nearly 2% of the cases, and taking into account that even the number of cataracts itself has increased, this will give you an indication that the actual surgery is becoming more popular in Canada. Australia, it’s encouraging more practice. But in other countries, as we can see, in the USA, you will be penalized as a service if you do both eyes at the same time. They will give you a penalty. The insurance will not agree on this. And Israel and Japan, you can do it, but you will not take money. Do it at your own expenses. So of course, you won’t be able to go and do it. Here in the UK, for the second eye, if you do it on the same session, they actually give you less money for the second eye, if you do it on the same session. So this is actually — this encourages trust, to take more on the surgeons. Because if I do two eyes in two different sessions, as a unit, I’m charging more. So this is more money. Of course I will do this option. I will not go for more risk with less money. So as we discussed, I would like maybe to get one of my colleagues, maybe Antonio, my colleague sitting next to you, what he thinks about the immediately sequential bilateral cataract surgery. What scares you most when you hear the word “immediately sequential bilateral cataract surgery”? How about if you take this option as a patient?

>> I believe it is endophthalmitis. The first thing that is going to your mind.

DR GOMAA: Exactly. That would be the nightmare for all of us. We would be scared. Oh, what happens if I have endophthalmitis in both eyes? That’s really scary for any surgeon to attempt this kind of surgery. But as we can see here on the screen, there is now a society, the International Society for Bilateral Cataract Surgeons, and I know the slide is very busy, and it’s full of the precautions they take. I would like this as well. But just to give you an idea, over the three slides here, that the precautions are very robust. They look at this as very serious. They take it very seriously. And they try to reach a protocol which works safely for you and for the patient, without running into complications. We can have an example here of what we have. Of course, it has to be indicated. Any concomitant or any other morbidity should be managed. The patient should be counseled. You should be prepared to do it as a surgeon. You are ready to take this risk. You know what you are doing about the cataract. You are comfortable with your technique. And when it comes to the precautions about the eye itself, which scares us most, as we just said, about the endophthalmitis, you can see here on the screen: Again, it is a very thorough protocol, which takes into account every single step, to make it risk-free for the patient and for you. So, for example, nothing in physical contact with the first eye surgery should be used for the other eye. A separate instrument tray. Completely separate. We should rescrub. Change the gloves. You should use different viscoelastics, maybe, from different manufacturers. Nothing will be in the theater from the first case that will go into the second case. You are dealing with it in a completely different way. Even you need to debrief on the case before you start. You have to have the WHO checklist done. Exactly like when you do each eye separately. Now, of course, any complication that happens during the first eye, you postpone the second eye. You will not go to the second eye if you encounter something with the first eye. The patient for the surgery should not be patched. Actually, topical drops — it’s better to be used immediately after the surgery. For the first few hours, we are increasing the risk by using the drops most immediately after the cataract surgery — we know this, that the risk of endophthalmitis becomes less if we start using the drops immediately. I would really encourage my colleagues to stop the practice of patching the eye for a long time after the cataract surgery. If you would like maybe, until the anesthesia — he’s recovered from the anesthesia, and he’s awake and comfortable, using the drops, but after that, definitely start using the drops as soon as we can. And this is here the recommendation for the immediately sequential as well. So no patching. None of the eye will be patched after the surgery. Is it better to be done under general anesthesia? Of course, yes. We are reducing the risk by doing both eyes in the same session. We are not taking an extra risk of another general anesthesia. So actually, it’s better to be done under general anesthesia. Now, what are the advantages of having the immediately sequential bilateral cataract surgery provided at our units? Some of my colleagues, when I discuss this with them, will say that we will not have time to assess the outcome of the first eye, before we will go to the other eye. So the recovery of the first eye — we don’t know what will happen. But actually, same-day surgery offers the patient better recovery. Because now the binocular vision is happening on the spot, from the first day. We don’t need to wait for the other eye, for four weeks at least, to see his optician, or to see someone to give him glasses. And then we plan for the other eye. That time means anisometropia, in some patients, and it’s really troubling for some of them, and they actually cannot tolerate it. Taken into account now that maybe there is even more delay. Patients will wait six months or a year before having the other eye done. So both eyes at the same time would be better for this. Overall, it is less cost for the hospital. I know that we will take it cautiously, because if we take into account the very thorough protocol, we might need to use even more instruments or more manufacturers, so it will end up in more cost on the service. So that’s something important to account for when we look at this. We make efficient use of staff and resources? Yes. Because we are using less time of theater. We are increasing our output, as we discussed in the first slide or the second slide. So we are making the service more efficient just by increasing the number of cases we are doing. Patients’ overall satisfaction, when they have both eyes done, and they’ve got rid of the cataract, is higher. And of course, I as the surgeon, if I manage to reach to this stage where I’m doing both eyes on the same day, I would be very happy with my achievement in my practice. I can do both eyes confidently on the same day. And the risk, the overall risk, in getting hit in a traffic accident on your way to the hospital is actually statistically-wise two times more than the risk from having the vision-threatening complication. Now, as we are surgeons, we worry most about the complication which is the endophthalmitis. Endophthalmitis risk, overall now, in our cataract surgery, reduced to a very significant level. I think it’s something around 0.02%. In overall cataract patients. Especially after the introduction of intracameral antibiotics. I’m quite sure that all of you will be using some kind of intracameral antibiotics, whatever it is, in your unit. But we are using intracameral antibiotics, and this has significantly reduced the incidence of endophthalmitis. Now, the risk of having endophthalmitis in such cases is something very, very, very small. They may be calculated at something 1 in 14,000. If you look at this risk, you can actually neglect the risk. If you look at the overall picture. And now, if we look at this complication as catastrophic, which means that the vision will be completely lost, we have now to remember that even if it happens in one eye, most likely it won’t be both eyes. And even better: That endophthalmitis doesn’t mean that the patient is losing vision. We are actually treating endophthalmitis, and we have success in treating endophthalmitis. So the picture is not like endophthalmitis should defer us from considering the option of having immediately sequential bilateral cataract surgery. If we are well informed with the statistics, and we know that the unit is running efficiently enough to offer the service. Now, what is the disadvantage of having the service? Or might be the potential disadvantage? As we just mentioned, we usually worry about the catastrophic events. As a complication that we can classify as non-catastrophic will actually resolve and can be completely managed. But just to remind you here that, as we said in the protocol, if you run into a complication in the first eye, you will not do the second eye. So we are not actually dealing with complications that will happen in both eyes. Because it’s not acceptable for immediately sequential bilateral cataract surgery. So if your first eye went without a problem, then you are doing the second eye. Still it is one eye that is affected. And this is most likely a non-catastrophic complication. The catastrophic complication we just mentioned is very, very, very low small risk, and we are actually, if anything — we can neglect it. Actually, in places where — immediately sequential bilateral surgery — no cases are reported with endophthalmitis. In countries like Finland or the leading countries doing the immediately sequential bilateral cataract surgery. In literature, there are four cases reported. And the four cases reported were actually done completely against the protocol that we just mentioned. Some of them, they used the same viscoelastic between both eyes. Others, they just changed gloves. And this is completely not acceptable. So this is not an excuse, again, to say that the surgery is not acceptable. Never events, like round IOL put in the wrong eye, or a wrong axis for the astigmatism correction, can still happen, but as we mentioned, we have a WHO checklist. We have a very robust system to make sure that we are using the right lens. Checks during the implementation of the lens. Checking and rechecking, as we usually do. This is really important, and this minimizes the never events to a very minimal degree. Again, it is not acceptable. We call it a never event. We don’t have the chance to optimize the outcome. As some of the colleagues mentioned, between the surgeries, sometimes we see the recovery, and then we look at the other eye, and we deal based on this. I have maybe a refractive surprise, something like this. But in these cases here, we are dealing with the average eye. We are dealing with the eye which is acceptable to have the risk. Something between 21 to 26 axial lens. And these cases — these outcomes are, again, very, very low risk. So optimizing the outcome should, again, not be an excuse for not to do the surgery. This is the debate. Again, I’m just mentioning to you what is the debate between the two. One of the important things that we look at, when we mention everything should be changed — different manufacturer, different viscoelastic so that makes the surgery more demanding on the team. The service needs more time, more money sometimes, to offer it. So if we reach this stage, of course it will not be a big motivation to move to the service, because it creates a problem. It’s not sorting a problem. And the last is: Elite versus average cataract surgeon. Most of these cases, of course, the results that we have so far, it is done by elite surgeons. The surgeon who is happy to offer this surgery is usually a very senior surgeon, very confident surgeon. So what happens when this surgery moves to be a standard practice, and we have more average surgeons doing the cataract service? Doing the immediately sequential bilateral cataract surgery? We don’t know yet, of course, and if this becomes a future trend, the results might change, and the outcome might change, and we’d need to discuss it again. So in conclusion, before we finish the talk today, we definitely face unprecedented increase in demand, with shortage in trained personnel, trained ophthalmologists and ophthalmic care teams at different grades. Now, ophthalmologists are encouraged to practice risk stratification routinely. This should be a part of our team practice, that we risk-stratify our cases, report it, and then at the end of the year, we need to` audit it. So report the risk stratification ahead of the surgery, and at the end of the year, audit the results. Risk stratification of cataract service results in improved outcome, and it is a more efficient use of the service that we have. This by default should be our aim as surgeons, as we just mentioned, to improve the efficiency of the service we do. And improve the outcomes as well to our patients. The immediately sequential bilateral surgery can be the future. We don’t know yet, of course. It is still early to see if this will be the case in the future, knowing there’s more demand on the service and less trained personnel, and we will have more aging population, but at least at this stage if we are not offering the service, we should be following up on the advances, the guidelines, and the practices that might result in the improvement of the efficiency of the service that we are providing. Thank you very much.

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November 11, 2018

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