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EW SHOW DAILY 10 Tuesday, April 29, 2014 ASCRS Symposia Immediate vs. delayed sequential bilateral cataract surgery and other dilemmas "I had two patients that were referred to me because they had a severe problem with their first eye and refused to have their second eye done," said Steve Arshinoff, MD, Toronto. "They're both now legally blind and still refuse, 10 years later, to receive cataract surgery." This, he said, is not a situation that would occur with immediately sequential bilateral cataract surgery (ISBCS)—the standard terminology chosen by the International Society of Bilateral Cataract Surgeons (iSBCS) for simultaneous bilateral cataract surgery. Dr. Arshinoff is co-president of iSBCS. About 80% of Dr. Arshinoff's cataract procedures are ISBCSs. He said the approach has several advantages. First, it avoids the fear from situations such as those of his two patients who had a problem with the first eye. There is also evidence that there is greater visual improve- ment after the second eye surgery than the first, and the procedure allows immediate rehabilitation of the visual system when they come in at postop day 1. "You can plan the refractive result better," said Dr. Arshinoff. "Doesn't matter if they're myopic, hyperopic or whatever, there's no anisometropia." Surgeons can target monovision, both eyes for distance, occasionally both eyes for reading, or multifocal, and in every case, he said, patients do better with bilateral cataract surgery. Performing ISBCS also means fewer patient visits. This, said Dr. Arshinoff, saves lives. He was being facetious, but not without reason: He recalled how an Englishman named John Bolger once made a risk comparison be- tween ISBCS and delayed sequential bilateral cataract surgery (DSBCS) by correlating the number of patient visits required for immediate versus delayed bilateral cataract surgery with the rate of road fatalities reported by the Royal Society for the Prevention of Accidents per kilometer of road traveled in Britain in 1996. Based on this computation, the risk of just one rare case of bilateral endophthalmitis following ISBCS would be equivalent to the risk of three road fatalities associated with the number of trips patients would have to make with DSBCS, said Dr. Arshinoff. ISBCS also allows you to per- form surgery on unusual patients. Christopher, a 29-year-old patient with Duchenne muscular dystrophy who developed bilateral cataracts in response to his medication, is Dr. Arshinoff's "poster child" for simultaneous bilateral surgery. With a bone density of only 10%, no one would contemplate performing surgery on one eye, sending him home, then bringing him back for surgery on the other eye. Instead, Dr. Arshinoff performed 1-hour bilateral cataract surgery, from which Christopher came away |20/20 in both eyes, very happy, able to return to using his tablet computer, which was, said Dr. Arshinoff, about all he could do. Dr. Arshinoff talked about ISBCS in a symposium on "Cataract Dilemmas," moderated by Rosa Braga-Mele, MD, Toronto. Also at the symposium were Kent Stiverson, MD, Lakewood, Colo., who presented the U.S. perspective on ISBCS, calling it the "most efficient" approach to bilateral cataracts, preferred by 80% of patients; Abhay Vasavada, MS, Ahmedabad, India, who discussed "Anterior Limbal Vitrectomy Versus Pars Plana Vitrectomy," and who prefers the slow motion technique with low parameters and the pars plana rather than limbal approach to vitrectomy; Neal Shorstein, MD, Walnut Creek, Calif., who discussed the controversy of intracameral antibiotics, saying "Evidence is overwhelming that we need to inject intracameral antibiotics in every patient"; Richard Hoffman, MD, Eugene, Ore., who discussed "ACIOLs Versus Sutured or Glued PCIOL," concluding that surgeons should use the approach they are most comfortable with; and Mitch Weikert, MD, Houston, presenting for Elizabeth Yeu, MD, on the as- sessment of corneal astigmatism. EW Editors' note: Dr. Weikert has financial interests with Ziemer Ophthalmics (Port, Switzerland). The remaining doctors consult for various pharmaceu- tical and medical device companies; however, none were relevant to the content of their talks. by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer Dr. Braga-Mele moderated the "Cataract Dilemmas" symposium.

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