Risk analysis finds good safety for bilateral, same-day cataract surgery

Las Vegas-A review of bilateral, same-day cataract surgery cases performed over a 5-year period at Kaiser Permanente centers in California identified a very low rate of complications, said Neal H. Shorstein, MD.

Speaking at the 2015 meeting of the American Academy of Ophthalmology, Dr. Shorstein presented the findings based on review of 4,754 bilateral same-day cataract surgery procedures done at 21 centers in the network.

The complications involved single instances of unilateral unintended IOL implantation; dilution error in on-site compounded intracameral cefuroxime; and unilateral endophthalmitis (not considered associated with intraoperative circumstances).

There were no instances of bilateral endophthalmitis, toxic anterior segment syndrome (TASS), or issues involving manufacturer recalls of pertinent medicines or other products.

“Bilateral same-day cataract surgery offers convenience and time savings to patients through reduced time off from work, fewer appointments, less travel, and concurrent recovery of both eyes, and there are also cost savings that may be realized to payers, employers, and hourly employees,” said Dr. Shorstein, Department of Ophthalmology, Kaiser Permanente, Walnut Creek, CA.

However, there are potential serious disadvantages relative to unilateral episodes of surgery that include possible bilateral endophthalmitis, TASS, and unintended IOL implantation,” he noted.

“In light of the recent advances and recommendations pertaining to cleaning and sterilization practices, intracameral antibiotics, and separating tray and room setups for each eye in bilateral cases, many surgeons believe that bilateral same day cataract surgery poses no additional undue risk to the patient,” he said.

Dr. Shorstein noted, however, that this modality may still be less ideal for certain patients, and they would include individuals with some ocular comorbidity or when the reliability for predicting target refraction is expected to be reduced.

Speaking on behalf of the Kaiser Permanente Northern California Cataract Surgery Quality and Safety Program, Dr. Shorstein also presented recommendations from his own center that have been developed based on a failure modes and effects analysis (FEMA).

More on FEMA

He explained that FEMA is a systematic method for identifying and preventing failure before it occurs.

“It is ideal for new or redesigned systems and processes, particularly in a complex work environment,” he said.

FEMA involves first identifying the areas of focus.

Then, key stakeholders are assembled into a team and critical steps in the process are identified.

Next, the team brainstorms potential failures and their causes. The worst credible outcome is identified for each failure along with an estimation of relative severity and probability.

Then, the stakeholders develop mitigating countermeasures.

For bilateral same-day cataract surgery, the areas of focus were endophthalmitis, TASS, and unintended IOL implantation (type, power). Dr. Shorstein reviewed recommendations for cleaning and sterilization, pharmacy, and IOL/biometry.

“Finally, there is ongoing work to train surgeons and staff to maintain a high degree of reliability,” Dr. Shorstein said.

“This is accomplished by instilling in everyone a preoccupation with failure, promoting surgeon sensitivity to the role of others, cultivating nimbleness and resilience in the workplace to unexpected situations, and moving toward standardization and simplification whenever possible,” he said.