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Dr. Chynn on same day bilateral cataract surgery

Q:

Was a bit surprised that OMIC has granted liability coverage for same day bilateral cataract surgery. They have suggestions but not underwriter requirements/ restrictions. Certainly a refusal to cover this could have discouraged ophthalmology from going further in that direction. I know same day cataract surgery has been discussed on kera–net with proponents for it. I guess all the OMIC insured ultimately take the pooled financial risk of this. Certainly hope OMIC has thought this through and feels that a case of bilateral endophthalmitis secondary to an elective surgery is defensible…..

A:

I know this may not exactly help in a court of law, like if you were sued for a bilat complication from doing bilat CE

I personally would not do that, as the worst-case scenario of bilat endophtalmitis is so bad. However, i did my cornea fellowship under Doyle Stulting, Past President of ASCRS, who is a MD and PhD so very precise. I remember when i did this fellowship in the early days of laser vision correction (1996), we were just transitioning from unilat to bilat refractive surgery, so we had the same question of whether or not we should do bilat surgery. Well, Doyle is one of the most meticulously quantitative doctors whom i have ever met, and while my refractive fellowship preceptor (George Waring) was too, we were debating this issue in a somewhat qualitative way, and also leaving out other important considerations (because they were not eye-related).

Doyle asked one of the outgoing fellows (?maybe Keith Walter?) to help calculate the risk of being severely injured or killed in a car accident on the drive to and from Emory Eye Clinic, taking into account such factors as the average length of commute (quite far for our catchment area), and the average fatality rate on Georgia highways using public data, and they actually concluded that the “risk savings” that you would gain from doing LASIK on different days was more than counterbalanced by the additional risk you would have from doubling the number of commutes in and out for op and postops!:) there is also the consideration from a statistical POV that, although you are taking the risk of a bilat complication down to almost zero by doing the 2 eyes on different days, you are in some ways doubling the risk of having a complication in 1 eye (because you are undergoing 2 procedures, not 1). this is analogous to very conservative parents who take separate planes when flying when they have young children, while they are basically taking the risk of them both dying and leaving their kids orphans and putting it down to zero, what they often don’t think about is that they are also effectively doubling the chance that 1 of them will die in a plane crash (bc they are now taking 2 flights, not 1) so those are 2 logical arguments that are quantitative and may be used in a court of law. more practically, i do use these when discussing the pros and cons of doing bilat LASEK surgery with patients (along with the concept that if you do unilat surgery you can use data from over/undercorrections to try to prevent that in the 2nd eye) i don’t know exactly what the odds are of bad complications for refractive surgery vs modern CE, but again, am unscientifically shying away from bilat CE, just bc the downside of an infection after CE is usually worse than after refractive surgery, particularly surface ablation (bc it’s easier to treat surface infections than those underneath a flap)

hope this helps

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