A recent cross-sectional study conducted at Kaiser Permanente in San Rafael, California, sought to evaluate patient experience and satisfaction with same-day bilateral cataract surgery compared to delayed sequential cataract surgery.¹ In particular, researchers wanted to find out how important it was to patients to have the opportunity to delay the second eye surgery in order to make adjustments based on the first eye’s outcome. 

Traditionally, surgeons are reluctant to do both surgeries on the same day for a number of reasons, including reduced surgeon reimbursement for the second eye, decreased reimbursement to ASCs and hospital outpatient departments, and a theoretically higher malpractice risk. However, same-day proponents say that several benefits to bilateral same-day surgery have been documented, including faster visual recovery, time savings related to reduced office and OR visits, reduced copays for the patient and savings for the health-care system.

Cataract surgery patients at Kaiser Permanente were offered the choice of same-day bilateral cataract surgery or delaying the second eye; there were no financial disincentives for the surgeon, regardless of patient choice. (Currently, 46 percent of cataract patients at Kaiser have both eyes done on the same day.)

A survey was sent to 3,636 patients who had undergone cataract surgery between 2017 and 2018, who were active on the Kaiser Permanente patient portal and were at least six months postop following the second eye. Of those who responded, 672 had received same-day bilateral surgery and 618 had undergone delayed-second-eye surgery. The survey asked about the patients’ reasons for choosing same-day or delayed surgery, and whether the loss of the opportunity to revise the surgical plan that comes with delaying the second eye factored into their decision.

The findings included:

• Of patients receiving same-day bilateral surgery, 96 percent said they’d choose it again; of those receiving delayed-second-eye surgery, 80 percent said they’d choose that option again (p<0.0001).

• The leading reason for choosing same-day surgery was convenience (listed by 65 percent); the leading reason for choosing the delayed option was surgeon recommendation (listed by 68 percent).

• Fewer patients receiving same-day surgery thought that the possibility of modifying the plan for the second eye was important (16 percent vs. 38 percent of the other group, p<0.0001). In both groups, modifying the surgical plan for the second eye wasn’t seen as important by the majority of participants.

• Four percent of patients receiving same-day bilateral surgery said they’d switch to the other format; 20 percent of the delayed group said they’d switch to same-day surgery. (The survey didn’t ask participants to specify their reasons for this decision.)

• Patients who chose same-day surgery were more likely to recommend their choice to a family member or friend (94 percent) than those who chose to delay the second eye surgery (68 percent).

The researchers note that only a small number of patients receiving bilateral, same-day surgery actually require follow-up IOL exchanges or toric lens repositioning. Furthermore, patients with nonstandard circumstances such as previous refractive surgery, unreliable biometry or extreme axial lengths are rarely offered same-day surgery because of the increased risk of a refractive surprise.

James A. Carolan, MD, an ophthalmologist practicing in San Rafael who is affiliated with Kaiser Permanente and co-authored the study, says he suspects the fear of missing out on a better refractive outcome if both eyes are done on the same day may be more common among surgeons than among their patients. “I believe this has been used as a rationale for not providing same-day bilateral surgery,” he says. “The majority of cataract patients are elderly and don’t mind wearing glasses—or actually want to continue to do so. As a result, many of these patients tell us they’d much prefer the convenience of having both eyes operated on the same day, rather than being slightly closer to the target refraction, since they’re going to wear glasses anyway.”

Dr. Carolan notes that a previous study found a gender difference in terms of patient reaction to the choice: Males were less likely to express fear about having same-day bilateral surgery than female patients, which might be relevant information for doctors discussing these options with their patients.² “This is another question that remains to be answered,” he says.

He notes that for a normal patient, outcomes today are generally good. “The newer formulae, such as Barrett Universal and Kane, are excellent for the majority of patients with normal axial lengths,” he points out. “We’re not seeing large refractive errors that would benefit from adjustment to the second eye when these modern formulas are used in patients with axial lengths that fall within the normal range.

“Having said that,” he adds, “I think the survey needs to be repeated with larger numbers and subgroups such as patients whose axial lengths fall outside the normal range, patients who have astigmatism and opt for a toric lens, patients who opt for premium IOLs such as extended depth of focus and multifocal IOLs, and patients who’ve had prior refractive surgery such as LASIK or PRK. This survey wasn’t meant to be the final word. We just wanted to see if the fear of missing out on a better refractive outcome in the second eye was as prevalent as some have made it out to be.”

<sup>1. Carolan JA, Amsden LB, Lin A, et al. Patient experience and satisfaction with immediate sequential and delayed sequential bilateral cataract surgery. Amer J Ophthal 2022;235:241-48.
2. Shah V, Naderi K, Maubon L, et al. Acceptability of immediate sequential bilateral cataract surgery (ISBCS) in a public health care setting before and after COVID-19: A prospective patient questionnaire survey. BMJ Open Ophthalmol 2020;5:1:e000554.</sup>

E-cigarettes and Visual Impairment

E-cigarettes were found to be associated with increased odds of perceived visual impairment in a study published last month.¹ Researchers reviewed the self-reported e-cigarette usage data of nearly 1.2 million adults from the CDC’s 2016 to 2018 Behavioral Risk Factor Surveillance System annual telephone survey and found a higher odds of visual impairment among current e-cigarette users vs. those who had never used them, independent of traditional cigarette use. 

“The survey data is, of course, subjective, so going forward it’d be helpful to perform longitudinal observational studies to further investigate this association,” says Anne L. Coleman, MD, PhD, the Fran and Ray Stark Professor of Ophthalmology at the Stein Eye Institute, David Geffen School of Medicine, UCLA. “We asked questions such as, ‘Have you ever used an e-cigarette or other electronic vaping product, even just one time, in your entire life?’ and ‘Do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all?’ The primary outcome measure was visual impairment, determined by a yes or no response to, ‘Are you blind or do you have serious difficulty seeing, even when wearing glasses?’ ”

The adjusted odds ratios of visual impairment in current e-cigarette users vs. those who had never used e-cigarettes was 1.34 (95% confidence interval, 1.2 to 1.48), and 1.14 (95% CI, 1.06 to 1.22) among former e-cigarette users. Though e-cigarette users tended to be younger, the association with visual impairment was “relatively consistent” across age groups.

The researchers noted a statistically significant overlap of traditional and e-cigarette use, so they performed a subgroup analysis consisting of the 662,033 respondents who had never used traditional cigarettes (weighted 59.6 percent of the study population). They reported a small but significant association between e-cigarette use and perceived visual impairment. Adjusted odds ratios of visual impairment were 1.96 (95% CI, 1.48 to 2.61) among current vs. never e-cigarette users, and 1.02 (95% CI, 0.89 to 1.18) among former e-cigarette users. 

The mechanism by which e-cigarettes affect the eye and impair vision is still unknown, but Dr. Coleman says nicotine may play a role. “Nicotine can cause vascular constriction, so there could be some vascular or blood vessel constriction of the optic nerve,” she notes. “Another study suggested the solvent propylene glycol used for e-cigarette liquid may produce free radicals that damage the lipid layer of the tear film and result in dry-eye symptoms.

“Much of the work on traditional cigarette use has been associated with tobacco use, so the fact that the nicotine in e-cigarettes was associated with increased visual impairment was informative,” she continues. “We need to look further into e-cigarettes, because as traditional cigarette alternatives, one of the supposed advantages is that they contain only nicotine and some additives, but not any tobacco, which is already known to increase the risk of several ocular diseases.”

Dr. Coleman recommends including questions on e-cigarette usage in your history taking. “We need to ask our patients about their use of e-cigarettes, specifically,” she says. “Patients might not consider using an e-cigarette ‘smoking’ when you simply ask about smoking. For whatever reason, people don’t necessarily tell you they’re using e-cigarettes unless you ask directly.” 

^{1. Golla A, Chen A, Tseng VL, et al. Association between e-cigarette use and visual impairment in the United States. Am J Ophthalmol 2022;235:229-40.}