The State of Bilateral Cataracts

Poor reimbursement and hesitancy among surgeons continue to hamper broad adoption of same-day surgeries on both eyes, but this practice lauds the efficiency, outcomes and financial sustainability.

Most cataract patients suffer the condition in both eyes. So why not perform cataract surgery on both eyes on the same day? Well, for many surgeons and facilities… it’s complicated.

Unpacking obstacles

The first obstacle: Medicare and private insurers continue to decline paying (or paying enough) for the second eye. That means the financials don’t add up for most eye facilities. The second rests with the majority of eye surgeons who either fear patients contracting infections in (and potentially losing sight in) both eyes, or who simply prefer to continue the tried-and-true cadence of operating on one eye on a given day, then operating on the other a few days or weeks later. If you’re running a safe, profitable, high-volume cataract line with positive patient outcomes, the thinking goes, why mess with success?

After well over a decade in practice, bilateral same-day cataract surgery still faces a steep uphill climb to widespread adoption. For the select few that have restructured their practices to fully embrace the bilateral concept, however, the benefits in terms of both the patient experience and the bottom line have made their outlier status rewarding. We recently spoke with a South Florida facility that does almost nothing but bilateral same-day cataract surgeries. Its story illustrates the conditions needed to succeed with this enticing but rare subspecialty.

‘It’s all we do’

The winning formula for providing bilateral same-day cataract surgeries at SightTrust Eye Institute in Sunrise, Fla., incorporates a specialized workflow, implantations of premium intraocular lenses (IOLs), patients who don’t rely on private insurance or Medicare for payment, and a dedicated surgeon and facility that maintains an unblemished infection prevention strategy.

SightTrust’s setup developed quickly and has purred like a kitten for about a decade, says Victoria Wiltshire, MBA, RN, vice president and chief operating officer, who estimates at least 95% of the cataract surgeries performed at SightTrust are bilateral same-day procedures. “There’s rarely a time we’ll do a single eye unless the patient had an eye done somewhere else, or has a Grade III or denser cataract,” she says.

A decade ago, SightTrust performed cataract surgeries like most every other facility. “It was, ‘You’ll be back for the second eye in one week, two weeks,’” says Ms. Wiltshire, who noticed many patients got confused by the different drop schedules for each eye.

SightTrust Medical Director and CEO Andrew Shatz, MD, spent two years researching the safety and efficacy of bilateral same-day cataract surgeries. Ultimately comfortable with what he learned, he began performing them at SightTrust, and the surgeries soon dominated the practice. “I went off the beaten path,” says Dr. Shatz. “There aren’t too many people, even my fellow residents, who would even consider doing this kind of thing.”

“Suddenly 25% of our caseload was bilateral, then 50%, then 75%,” says Ms. Wiltshire. “We got to 100% quickly. We didn’t get a lot of pushback from patients when we’d say, ‘Hey, you can have both eyes done on the same day.’ They were like, ‘Great, how quickly can I sign up?’”

Go with the flow

The procedural quirk — and infection prevention requirement — of bilateral same-day cataract surgery is that each eye must be treated as a completely separate surgery. SightTrust’s two-OR facility and workflow is designed specifically to make the “dual surgery” system as routine and efficient as possible.

Suddenly 25% of our caseload was bilateral, then 50%, then 75%. We got to 100% quickly.
Victoria Wiltshire, MBA, RN

When a patient arrives, they’re immediately taken to prep. They sit in a stretcher chair and dilate for about 30 minutes. They meet the anesthesiologist, who provides very mild IV sedation with midazolam, which makes the patient calm and comfortable but also responsive and coherent throughout the procedure, while ensuring they can quickly talk and walk postoperatively. At this stage, Dr. Shatz says hello to the patient.

Once dilated and sedated, the patient is wheeled to the first OR, which houses a femtosecond laser. Dr. Shatz makes the necessary incisions, corrects any astigmatism and creates a checkerboard laser pattern that breaks up the cataracts and allows them to be extracted as small cubes. Ms. Wiltshire says this process takes five to seven minutes per eye. The laser OR is a “clean technique” room, not a sterile OR, she notes.

The patient is then wheeled to the sterile second OR, where phacoemulsification and IOL implantation is performed on the first eye. That takes 10 to 15 minutes. Then the room is completely sterilized around the patient. “Dr. Shatz ungowns and leaves the room, and we turn the room over,” says Ms. Wiltshire. “The OR is fully wiped down, new instrument trays are brought in, and we set everything up again. The patient is re-sterilized and re-draped, and the entire process is started over again.” The turnover takes about seven minutes. Dr. Shatz then returns, freshly gowned and scrubbed, and operates on the second eye.

The patient is then wheeled to recovery, which takes about 15 minutes. “Patients are here for an hour-and-a-half to two hours total,” says Ms. Wiltshire, who notes this process is repeated over and over each day of surgery.

Once patients are home, Dr. Shatz says there’s really no difference from traditional cataract surgery in terms of recovery, except the postoperative drop regimen is easier. “They’re putting the same number of drops at the same frequency in both eyes at the same time,” he says. “It’s really confusing for a patient if they wait weeks between eye one and eye two. As they’re tapering the medication, one eye needs less drops than the other. With bilateral same-day cataract surgery, they don’t need to think about that.”

Dr. Shatz doesn’t call the procedure “bilateral same-day cataract surgery” when explaining it to patients. “We tell them we’re going to take care of both eyes on the same day,” says Dr. Shatz. “But I always stress that it’s two eye surgeries done on the same day, that we’re not operating on both eyes together.”

Overcoming obstacles

TWO ROOMS FOR TWO EYES In the photo at the top of this page, surgical technician Ashley Manohar and ophthalmologist Dr. Andrew Shatz break up and extract cataracts using a femtosecond laser in a clean OR. Here, they perform phacoemulsification and lens implantation in a sterile OR that is completely turned over between eyes. | SightTrust Eye Institute

Fear of patients developing devastating infections like endophthalmitis or toxic anterior shock syndrome in both eyes is minimal at SightTrust, because among the thousands of bilateral same-day cataract surgeries performed there over the last decade, there has never been a bilateral infection. “Not a single one,” says Ms. Wiltshire. “We run a tight ship. It’s as if the patient physically left here between eyes and came back on a different day. The sterile technique is the same. Every standard of care is upheld in that moment.”

“I’m always concerned about risk of infection, but the fact of the matter is, studies have shown the safety of bilateral same-day surgery,” says Dr. Shatz. “I think that’s because most of us doctors who perform bilateral same-day surgery are that much more cautious that everything is done perfectly. We’re a lot more fastidious about making sure everything is sterilized properly, cleaned properly, that we’re not using the same equipment each time. We don’t cut any corners.”

In terms of qualifying patients, Dr. Shatz calls on his experience. “I think there are more people who it’s better to do it on than not,” he says. “For instance, you’d think an elderly person shouldn’t do this, but if you want to save them from a second anesthesia session, it’s a good idea. Where I may hold off doing two eyes on the same day is with people who have very dense cataracts that take longer to heal. They may be better off having one eye helping them while the other heals.”

Clinically, then, bilateral same-day surgeries appear to be safe, and deliver positive outcomes. The true obstacles to widespread adoption are financial and operational.

Making it work

SightTrust dropped out of Medicare last year because CMS doesn’t pay enough for the second eye, and has largely eschewed reluctant private payors as well in favor of a cash-pay model. Asked whether CMS and other payors are coming around to bilateral same-day cataracts, Ms. Wiltshire has moved on. “We don’t try to lobby or stay up to date with reimbursement,” she says. “We gave it a good shot to try to make it work. Ultimately, the technology has advanced, our business model has advanced, and insurance hasn’t really kept up with the times. To delay a procedure just for reimbursement didn’t make sense to us.”

Bolstering this model is a heavy focus on patients paying out of pocket for not only their surgeries but also high-margin premium IOLs, which Ms. Wiltshire says well over 95% of patients receive. “It comes with a different level of handholding and expectation-setting with the patient initially, but it’s amazing technology that should definitely be offered if a patient is a candidate,” she says, adding it’s not a tough sell. “Dr. Shatz does it every day,” she says. “He’s got a speech prepared.”

Dr. Shatz says pairing premium IOLs with bilateral same-day procedures makes clinical as well as financial sense. “If you’re having premium lens surgery, the sooner you get both eyes operated on relative to each other, the quicker the brain adapts,” he says. “It readjusts much faster to their quality of vision. If you wait days, weeks or months between eyes, some patients have a very hard time adapting.”

Many eye surgeons reject bilateral same-day surgery because they prefer to do one eye days or weeks before the second, which affords them the refractive insight to confirm quality of vision in the first eye and adjust their plan for the second if needed. “A lot of doctors want to see the result of the first eye, so they’re scared to do both the same day,” Dr. Shatz acknowledges. “We’ve seen no real difference in frequency of patients having one eye’s prescription significantly off.”

READY FOR ‘CATARACTION’ Patients spend about 30 minutes dilating, receiving sedation and meeting their providers in SightTrust’s pre-op area.

Dr. Shatz says most eye surgeons, fairly conservative and risk-averse in their practices, lack strong incentive to embrace bilateral same-day surgery due to the lack of insurance reimbursement combined with the fear of the unknown that comes with such a big change in practice. In South Florida, SightTrust has no competitors in this subspecialty. The rest of the market is doing fine offering traditional cataract surgeries under the Medicare/insurance model, and doesn’t feel competitive pressure to change.

Even if the reimbursement piece was in place, Dr. Shatz doesn’t believe it would spur wide adoption. “A doctor has to see in their mind that it really provides a major benefit,” he says. “If the majority of their patients are in their mid-to-late 70s with significantly dense cataracts and health issues, they may want to wait until the first eye heals.” He adds that while younger ophthalmologists get the concept, those who might perform it are stymied because most join larger surgeon groups that forbid the practice.

Dr. Shatz says high patient volumes are vital to make bilateral same-day surgery work. “If you’re doing less than 500 surgeries a year, there’s no incentive to clear up your space and do half the amount of patients in a day,” he says. ASCs, he says, will likely not be interested in the practice due to the poor reimbursement picture unless their surgeon-owners collectively make a strong push for adoption.

Efficiencies abound

Ultimately, bilateral same-day cataract surgery is a patient pleaser for SightTrust due to time savings: halved surgical and postoperative visits, less confusing post-op drop regimens, and a quicker pathway to improved binocular vision.

“We live in a time where convenience is king, and to pay a little extra to not be out of work or contend with childcare and different things that really inconvenience a person’s day-to-day, it’s self-care to some degree,” says Ms. Wiltshire, who notes SightTrust consistently receives five-star Google reviews. “The market has shown us this is here to stay. Patients will pay out-of-pocket for premium IOLs, for laser, for same-day surgery. We just believe in it, and we never went back.

“If we were to tell our patients after surgery, ‘Oh, by the way, you could have had the eyes done individually,’ they’d probably look at us like we were crazy,” she says. “There really haven’t been any negatives or downsides to it that I can think of.” OSM