Prof Christopher Liu on Immediate Sequential Bilateral Cataract Surgery

Tariq Aslam: Thank you. Welcome everybody to this
year’s Eye News Symposium and I am delighted to see you all here. We’ve got a really good range
of lectures and lecturers. Our first speaker Professor Liu I first met when he was
examining me for my MD thesis so that takes us back. The second time we
have met and he’s well known. He’s a pioneer in the field of cornea
especially in carotid prosthesis and this is an interesting talk because
sometimes big changes, I think in ophthalmology, don’t necessarily come
from very clever inventions or biochemistry or from genetics. Sometimes
the big changes and the things that make a big influence and the things that have
the highest impact on patients are relatively simple ideas but express well
and so I’m delighted for Professor Liu to be talking today about the pros and
cons of sequential bilateral cataract surgeries. Thank you. Thank you. Well good
morning everybody and thank you for spending your Sunday here listening to
this talk. I’ll try and keep it interesting for you. Firstly I want to find
out who’s practicing and advocating bilateral same-day cataract surgery at
the moment. One. You see actually this is quite a rare phenomenon and for those of
us who are proponents of bilateral cataract surgery sometimes we can be
ostracized. So I will tell you the in statistics and the science behind it and
then you can judge for yourself, how you want to apply this in your own practice.
So hopefully after the next 40 minutes you’ll have a much better understanding
of bilateral cataract surgery. So I am aproponent of safe informed immediately
sequential bilateral and Eye News has paid for my travel, accommodation and also
they said they would support my promotion to become a knight. Anyway you know this magazine.
It’s really quite wonderful and it’s always current and topical and you can
see if you turn to this page here you can see this young man here, and I
did examine him for his doctor of medicine thesis at Oxford University. He’s forever
young, isn’t he. Anyway thanks very much for this. So a historical
note, I think that as ophthalmologist we’ve always been taught to operate
one eye at a time and the reason for that is because we’re so frightened of
causing blindness in both eyes. Which remains a possibility but cataract
surgery nowadays is really a lot safer. So if you look at traditionally what
kind of cases we’d be looking to do bilateral same day surgery. We’re looking at
cases which require general anesthesia especially high-risk anesthesia so we
don’t put them through two GA’s and also for cases when the vision
potential is unknown in either eye because, for example, the cataracts are so
dense that you can’t actually see what the macular optic disc looks like. Now
there is a very deep fear, which you know you feel in yourself, that you know, even
when I do it, that I know that one day somebody might go blind in both eyes as
a result of my practice. But it’s mostly irrational fear. Now I will explain why
its irrational. Now the fear can be transferred. So let’s say if I and my
patient agreed to do immediately sequential bilateral cataract surgery
somewhere along the line when they finally appeared on the operating list
on the day they may have changed their minds and that if I ask them sometimes
it could be a family member or you could even be one of the ward nurses who
frightened them and then they chicken out. However look there are
many other eye surgery that we do both eyes at the same time and they all have
site threatening complications. So why is cataract surgery different. Though
the climate is changing and if you look at the NICE guidance on adult
cataract surgery there are two subsections that you can be looking at.
So firstly, 1.6.3, it says considered bilateral simultaneous
cataract surgery for: firstly I must take issue with this nomenclature because
it’s not simultaneous, its one after the other. So it is actually sequential. Now
they’re saying, people who are at low risk of ocular complications during and
after surgery should be considered for bilateral same day surgery and also
people need to have general anesthesia for cataract surgery but for whom
general anesthesia carries an increased risk of complications or distress. So for
example, if you have a patient who’s demented and you have to kind of catch
them before you can put them to sleep to have surgery. It would be quite unkind to
have to do that twice to them if you can rehabilitate them in one go and often
actually dementia improves when patients see better. 1.6.4
discuss the potential gradient benefits of bilateral cataract surgery with people,
which should include: the potential of immediate visual improvements of both
eyes. In other words there is measurable advantage of doing both eyes at the same
sitting but they also say will not be possible to choose a different implant
based on the outcome of the first eye. Actually those are not very important
because with modern-day biometry I didn’t really get it wrong, very much,
very often at all and in 50,000 cases done in America, published, there has
been no case which required going back to readjust the biometry. We have to
explain the complications the recent complications in both eyes
during and after surgery that can cause long-term visual impairment.
So here we’re talking about endophthalmitis or internal infection of
the eye and cysts like macular edema. Which does not always completely recover
and also the likely need for additional supports because they are now recovering
from both eyes rather than just one at a time. So here’s the NICE guidance. So this talk we have five sections and
you can stop me anytime to ask questions Firstly we will cover the rationale for
the immediately sequential bilateral cataract surgery (ISBCS). The
prerequisites for offering this type of surgery. The measures that we can take to
reduce risk. Stakeholders perspectives from the patient’s point of view, from eye surgeons point of view, optom’s point of view etc and the ethical and medical
legal aspects business. Rationale for ISBCS So these are a two newer methods of
delivery of cataract surgery. The one on the right, we’re not really talking
about, except that they self prepare for surgery and they more or less go to
theatres directly, bypassing the ward and day case units and then they leave
immediately afterwards. So they’re just there for 40 minutes. This is what we’re
talking about bilateral surgery both eyes in the same admission and there is a lot
of convenience to patients and their relatives and carers and it has been
worked out that the second eye including re-scrubbing only adds 12 minutes to
your operating time. So obviously there’s reduced cost to hospital in society and
the question is whether it’s safe and we could be talking about the precautions
case selection and of course patient choice as well. We’ve already talked about this, however of course, two wrongs don’t make a right. These are some of the advantages to the
patient and the people looking after the patient by including ourselves.
So one referral is made and then refer when it comes to the hospital or to the
GP. We processe it the once rather than twice where they come for second eye
surgery. One pre-assessment, one admission and also when you do the second eye
because you’ve just done the first eye you’ve actually learnt about how the
first eye behaves. For example, how the capsule behaves or how the nucleus
behaves etc. You can apply that knowledge to the second eye.
If you require GA then only one is required. One post-op visit. One lot of
waiting for refractive stability, which could be up to six weeks for a corneal
wound. One sight test. One pair of new glasses and no period of binocular
imbalance. Now if you have a long waiting list you could be waiting for months for
your second eye and that’s really quite unkind, especially if there is any
ametropia. You say if you have a myope if you convert it to become a
emmetrope and the other eye is still very myopic and of course you can also save
money but the main thing is that it is actually a better method of delivery of
cataract surgery. It is not about saving money although that is the secondary
consideration. So what are the disadvantages. Well you are taking a
risk with both eyes at the same sitting and also there will be discomfort in both
eyes during a recovery period Any questions up to this point? Attendee: If you have got one eye where the vision is significantly down and the other eye is still reasonable Would you still consider that or what sort
of limit would you put on the good eye before doing the second cataract? Christopher Liu: Okay, well the guidance is also given in NICE in that your second eye surgery should have the same criteria for
listing as your first time. So if you’ve got a clear lens, then you wouldn’t do it,
if you’ve got a little cataract, then you wouldn’t do it. It has to be visually
significant. Tariq Aslam: Can I ask,
do you go onto the second eye, Is there a period where you reflect on how the first eye surgery went before
you go to the second eye? Are there ever times when the surgeon decides,
actually I’m just gonna do one as this is a bit tricky? Christopher Lui: Yes. Yes. We will come onto that. So now let’s have a look at the prerequisites Okay.There we go.
Of course we need bilaterally visually significant cataracts.
Now it may be that the milder cataract is not actually very bad but you look at
it and you know from the experience that after removing the worst cataracts. You
know that they will want the other eye done and you know from the experience don’t
you, that the patient will tell you “Oh don’t touch my good eye” and
then you know that when they come back after the first time and say well
it now this is the good eye and my good eye has become the bad eye and I really
don’t like it. So even if it’s a moderate cataract you know from the experience
that they will want second eye surgery. So you can list them for bilateral if you like.
The patient must have informed consent. It is actually quite difficult even to
get informed consent for one eye but getting informed consent for
bilateral surgery is more difficult. You need to have reliable biometry.
So nowadays we’re looking at partial coherence interferometry, like the IOLMaster.
You need to have a good surgeon track record. You need to have that
surgeon supported by an experienced and knowledgeable theatre team and we can’t
have a new person in the team when this sort of surgery is done because you’re
just inviting disaster. You need to have a good hospital track record of endophthalmitis.
You need to have day one follow up of at least by telephone and there has to be a
hospital hotline. If there are any problems at all, redness and pain,
sensitivity to lights, straight away they go back to the
hospital to be looked at. So today the equipment and instruments
very important. Maintenance and renewal of equipments and theater air
conditioning and filtration. So your operating theater needs to be in tip-top
condition and the microbiologist should be coming in to check the air quality on
the regular basis and don’t have chop and change the machines and
implants too frequently. You know even these are just basic principles like if
you’re using the same implant for three to five years then it’s fine because
there’s initial learning curve and then you get good results. Once you changed to a
new implant, new injector, then the results immediately plummet for the
first few months. Centralised sterilisation, especially Phaco probe.
The Phaco probe is the most difficult thing to sterilise because it’s got a
long lumen. It’s got to be done properly and then increase the use of disposable
instruments but I mean I do have some issue with this because it’s not a very
sustainable solution and with the metallic ones you know you throw away
metal and there’s only so much metal and the in the earth so if you throw it away
then you’re not going to be getting more metal and if you throw away plastic
that’s not very good either. So Audit is very important. So we won’t go through
all the details except that it’s greatly enhanced by electronic patient of
medical records (EPR) and EMR and there is there has been a national audit: The
National Ophthalmic Data Set but unfortunately NOD is going to run out
of money from August this year and the ministers would not fund any more money.
We were just trying to get somewhere. Attendee: Can I ask you what you mean by
corneal decompensation? I am not sure what it is. Christopher Liu: Corneal decompensation
is when the cornea fails from, in these circumstances from cataract surgery that
maybe you use too much phaco power or fluid or you’re not careful with your
technique than the endothelial cells either drop off or die and the
cornea swells, gives you corneal edema.
Normally that doesn’t really happen with careful surgery however their
pre-existing conditions like Fuchs and etherial dystrophy which can predispose
to corneal edema. So the prerequisites any questions or
prerequisites? Attendee: You did mention that one eye might not
have a sufficentley dense cataract. What we find in practice, one might have had a
dominant and have an operation on a non-dominant eye that then sees better than the dominant eye and then that causes a lot of problems. So I can see why its a good idea to do sequential surgery as it maintains the dominance. Christopher Lui: Thats right, yeah, very
very true. Any other questions before we move on? So this is a very important
part. What measures you can take to reduce risk and there are basically
three strategies. Firstly there is the option not to
proceed with the second eye if the first one has not got completely well. So
already you know that therefore it is not a realisitic decision that you would
actually do both operations You’re planning to but if that doesn’t go well
you’re not going to do that one. So that has to be explained to the patient as
well. The second thing is to exclude high-risk eyes because you’re more
likely to go wrong and the third thing is some delicate downs in the operating
theaters to have two trolleys of instruments and we’ll go into the
details of that. Two trolleys for two operations. So let’s first look at the option not to proceed with the second eye. We all know
that the risk of endophthalmitis is related to vitreous loss and a length
of the operation. So therefore if you’ve lost vitreous
then you shouldn’t operate on the second eye and similarly if you’ve taken so
long, such a long time for your first operation let’s not put the patient
through the second one and similarly for cystoid macular oedema, retinal detachments,
the risk of those happening also increased by vitreous loss. So if you
have vitreous loss that’s just another reason for not proceeding with a second eye.
These are the things which would put me off doing the second eye. Posterior
capsular tear, zonular dehiscence, long operation, high phaco energy and any sight
of vitreous in the anterior chamber. So we’ve gone through that already. That’s
why it’s immediately sequential and not bilateral simultaneous. I don’t know
how that crept into NICE terminology. When excluding the high-risk eyes.
So you’re thinking of listing now. They’ve got bilateral cataracts but
these are the things which might put you off. At least discuss with them. Now blepharitis
can be treated with lid hygiene and chloramphenicol at bedtime
for one month. Blocked tear ducts that especially if there’s a mucus seal that
really needs to be sorted out even for unilateral cataract surgery, let alone
bilateral cataract surgery. Diabetics, especially if they have any diabetic
retinopathy at all. We don’t want to take that risk because we know that if there
is diabetic macular edema you do the operation and it can suddenly take off
and therefore nowadays there is a trend to do cataract surgery as well as an
intravitreal injection at the same time. Patients with low immunity and
patients who are allergic to iodine which is a very very good disinfectant.
If they have low immunity or if they have iodine allergy than maybe bilateral is not
for them. We’ve talked about corneal decompensation. So patients with fuchs and a
endothelial dystrophy for example. Lenticular abnormalities, pseudoexfoliation, subluxation of the lens, wobbly lens and previous trauma probably one eye at a time. Risk of glaucoma, so
patients who have already had a trabeculectomy, bilateral trabeculectomy for
example, you go in there with phaco there is a one-fifth chance of blocking up
their functioning clip. So probably in these cases, one eye at a time and where
there is a personal and family history of retinal detachments or if they are
really high myopes and if they have the risk of biometry error, being short eyes,
long eyes and previous laser refractive surgery and also patients with iritis.
These are probably best avoided. So here are examples of the
not routine and routine cataracts, also the exfoliation or really dense cataract,
small pupil and dense cataract requiring iris hooks etc. So now in terms of sterility
this slide will tell you how seriously we take sterility in Brighton and Sussex
Eye Hospital. So they are completely separate operations. We will reglove, rescrub,
regown, redrape and we always drade so that the lashes are out
of the way and then also the drape would stick here nicely as well. So that
there’s no communication between the eye and the nostrils because that’s what
bugs are as well. We will use a different trolley of instruments and for
one of the two sets of instruments one would have been held back from the
previous week so you know that’s of proven sterility because you already
from that sterilisation batch you’ve already operated on dozens of
patients and if there was a problem then you’ve already you already know that
that’s a bad batch. We will use some implants of slightly different powers or
different batch numbers and anything entering the eye and we will reduce the
number of things entering the eye. Now entering the eye, we have your irrigating
solution, your ophthalmic viscosurgical device and the intracameral anesthetic
intracameral antibiotic etc. They will bear different batch numbers or have
come from different manufacturers Now my practice, actually nowadays, is to use
subconjunctival cerfuroxime with one of the two eyes. So as to not put the cerfuroxime in
the other way. Which eye to operate on first?
Well if you’re a surgeon you will ask. Well usually of course, the one with
more severe cataract but if you have got extremely asymmetry, so that the
dense cataract is actually a little bit risky but the other one is easier you
might do the easier one first and you’ve completed that and then you can do the
slightly riskier one and you give the patient a better chance
of having both eyes completed. Choice of anesthesia
GA is possible but actually nowadays it’s mostly topical and subtenons. Now these
are to be avoided if you can sharp needle techniques and also intracameral
anesthetic in both eyes. one eye is okay. Here’s a scleral tunnel
wound which adds a couple of minutes to the operation but you can see that it’s
much longer and much more secure both to physical trauma and also potential entry
of bugs so a scleral tunnel wound is stronger physically and also gives you a
lower risk of endophthalmitis. Let’s have a look at the catastrophic
complications of cataract surgery. Expulsive haemorrhage, when the whole
contents of the eye come through your wound and mushroom out. Now that is very
unlikely nowadays with keyhole surgery because when the intraocular pressure
goes up the keyhole seals itself and then it tamponades it and, it doesn’t, it
cannot lead or come out any more. Bacterial and fungal endophthalmitis, we
know that with antibiotics and good draping and sterilisation the risk of
endophthalmitis is under one in a thousand However that’s not to say that the risk of both eyes developing endophthalmitis will be
one in a million and I’ll explain why later on. It’s because of this concept of
conditional probability that the two eyes are actually not independent so if one eye
is it develops one particular complication the other eye because it’s
come from the same person, being operated on the same day, the other eye is likely
to develop the same complication as well. So we don’t really know, what, how big the
risk is of that bilateral endophthalmitis and it’s the same for cystoid macular oedema
as well. You can do perfect surgery and you can still have cystoid macular oedema but
we’ll go into that in a moment. So my current surgical pracitce is once we’ve discussed and had informed consent then the first time will be done under topical and intracameral anesthesia through clear temporal cornea wound and then have intracameral
cefuroxime for protection from endophthalmitis and then they wear a clear
shield day and night for one week to stop them touching the eye and for the second
eye they will receive some subtenon anesthesia because patients always feel
the second eye more than the first eye whether they’re done on the same day or
separate days it’s always like that and I have this theory that when they first
come for the first time they have no idea what’s going to hit them so they
really really well-prepared and is less than what they expect. So they
think now its a doddle. So the second time around they think it’s a doddle and then
they feel everything, every single bit. So if you give them subtenons it is kinder
to them because they don’t feel quite so much for the second eye. I will use a
scleral tunnel and I will use subconjunctival cefuroxime mixed with
dexamethasone and lidocaine as well to take away all the discomfort and then I
will be padded till the following day, but they will see through the first eye
through the clear shield till the following day. Any questions on precautions? Attendee: Would tamsulosin be a precaution
for doing two eyes at once? Christofer Lui: Okay, you know they were
asking me an advanced level question I’m just talking about GCSEs for the moment. Myself
I’m not too worried because I will use intracameral phenylephrine to combat the
possible floppy iris syndrome and it was really bad that I would just don’t do
the other eye. So it kind of depends on how confident you are and
how good you are. As you get better and better
and the hospital is really good you can actually work with lower, lower your
safety threshold because you know under your hands it will be safe. So I’m happy
to try. I would say to the patient if this is really what you want, I mean
it’s not that I would particularly recommend it but if you really want it.
I will do it for you but if the first one doesn’t go completey well then we will not
go ahead with the second. Attendee: When you’re doing bilateral surgery is it
done, I mean, the amount of general anesthesia which is used on operation is
quite small amount, isn’t it. Christopher Liu: Nowadays very small. First eye topical and second eye sudtenon. Attendee: Yeah, but most patients have topical whether
its unilateral cataract surgery or bilateral. Is bilateral also topical or
is it general anesthetic? Christopher Liu: We don’t really use general anesthesia very much in bilateral and not because, if they would have a general anesthetic
not because it’s bilateral is because they’re very anxious or they’re
claustrophobic and if it is local then the first one will be topical the second
eye will be subtenon. So that they feel less. Okay, let’s carry on. Now this is
actually a very short section. Stakeholders perspectives
These are the stakeholders and that may not be complete. Patients and their carers.
Surgeons, Optoms, Ward nurses, Theatre nurses. Hospital and Trust. Commissioners.
The health care economy, society in general and sustainability.
So we will just look at the first three in a tiny little bit of detail and then the rest
we will cover in the final section of the talk Patient
Pros: Simplified journey. Rapid and full visual rehabilitation, undoubtedly, and people
have been through this, they are very happy. How about the Cons: well they are taking a risk with both eyes at the same
sitting and bilateral recovery may be more arduous especially if bilateral cystoid macular oedema happens and of course they will probably around the same time
in both eyes as well and they will have to go through a period whilst the cystoid
macular oedema recovers under treatment it will also have a fear of
bilateral blindness of course. So it’s really important that they go in with
open eyes. That they have had informed consent and they understand everything. So surgeons and optometrists, well the Pros: you are providing, if you believe
in this, the best care for patients and I think there is evidence
to say that this is the best care and if you do this carefully it will enhance your
reputation. However if something goes drastically
wrong then you have a reputational risk. So you do need to bare
this in consideration, bare this in mind and of course you also have the fear of
bilateral blindness happening to your patients So any questions on
stakeholders perspectives? Attendee: Everywhere a group of hospital mangers would probably go “Yipee yipee, we’ll save lots of money” and then presumably will put pressure on surgeons in the whole wide department to say “Yes that’s a great idea, we can do bilateral surgery
and save X amounts of money” The surgeons will be going “Hang on a minute”
and how do you stop this dynamic from happening? Christopher Liu: I thinks thats why we have to be very careful and that’s like when I say, you know, when I declared my interest, I didn’t just say I’m a proponent of bilateral cataract surgery. I also said that a careful and informed and that’s
really important. You know that when people come in with really really thick
documents. Most people just read the executive summary or even a summary of
the executive summary. So the messaging has to be clear that it is not for
everybody. Not everybody and every hospital can do it. It’s certainly not
for every patient and you will see we were going to go into this in
much more detail in the ethical part of it which is the final
part in the moment. Attendee: So is corneal decompensation almost a certainty with fuchs dystrophy? Christopher Liu: Well not at all, not at all,
you know I know that a reasonable surgeon, actually I’m all right. That I
have never decompensated a fuchs patient because there are
precautions that you can do so a scleral tunnel wound, which is further
away from the cornea and using a dispersive viscoelastic
device like HPMC, using low phaco energy and just being very careful with
the maneuver so it’s very unlikely. However, now we are actually doing
corneal transplantation for fuchs dystrophy a lot earlier and why is that then.
Thats because we know that even with mild corneal edema before they really
decompensate with those guttata, the excrescences, the contrast sensitivity
for the eye after cataract surgery, is not that great. So nowadays we are doing
combined DMEK and phaco, even in the relatively early stage of fuchs because
we know that gives them much better vision especially in low contrast
situations. Any other questions? Okay. Well let’s have a look at
the ethical and medical legal aspects of this practice. It is a relatively long
section of about 10 minutes. Hopefully I will not just have too many of you. We
know about the advantages their well rehearsed and the strategies we
just discussed. Now encouraged by people I organised an ethical workshop
in London which took place on the 8th of June and yesterday I managed to upload
part 2 on to YouTube so you can watch that if you want but somehow I have not
managed to go through the first half which is a two-hour part
so all in all we set there for three and a half hours after two hours we took a
tea break and look at the people that we’ve had 30 people, 3 ethicists,
religious persons from the major religions of the land, 2 lawyers,
1 health economist, the chair of NICE guidance, who happens to be the president,
current president of the Royal College of Ophthalmology, college officers,
surgeons for and against, one optometrist sent by the College of optometrists and
a number of patients who have had bilateral and unilateral cataract surgey,
and 1 layperson. So I’ve distilled the essence of all that
into the next ten or so slides. Let me try not to lose you, okay. Patient
choice is really important and it is said that bilateral surgery should or
must be considered and if the patient is not suitable then you can dismiss it but
it ought to be offered to suitable patients. So even if you personally don’t
believe in this, as a surgeon or as an and optom, it should be discussed and if
the patient wants it. Then if you don’t want to do it yourself, you should send
the patient to somebody else who can do this. Consent, a very difficult issue
and as you know consent really starts from the patient being
referred and the consultation and the letter the clinic letter you dictate,
hopefully in front of them, and they get a copy of it and then a consent form but
actually most lawyers will say that consent form by itself is just a piece
of paper it doesn’t really hold up to the law and one of the two lawyers
there said well maybe we can develop an app which takes them through everything
and then finally it’s certified that they’ve really understood. Bilateral cataract surgery can be done
because there is already a substantial number of people doing it and not only
in this country but also in parts of Spain, in Scandinavia and other countries.
So it is an established practice however you have to make sure that you don’t put
in one step wrong and all your documentation has to be perfect because
if something should go wrong, they will ask you, the lawyers will ask a lot of
questions and you should be able to answer them.
No surgeon can be forced to perform any surgery that they don’t want
to do, however, it is their responsibility to discuss all options including
bilateral surgery We as doctors the direct responsibility is to the
patient in front of us but we also have a duty to a higher duty to society to
conserve resources. There’s only a limited amount of money to go around but
if you save money by doing bilateral then don’t expect the money to appear
back in ophthalmology or your departments. It will be spent on some of
the things, like paediatrics or cancer or what have you. The priest sent by Vincent Nichols,
who is the highest Catholic person in the land explained to us in
the Catholic faith that we should give preference to the poor and helpless and
this includes conserving funds because the poor and helpless are the first to
suffer when services go down to a lower level. Think of the common
footprints of doing everything one after the other when it can be all done in one
go. People have been worried about creating two queues. We already have a
problem not being able to do the first eyes of patients how can we morally
justify giving people the faster queue to get both eyes done but there are
people not having that the first item. So it goes like that they’re actually two
separate queues so what you do is because you can actually fit you can fit
fewer patients onto each operating list but more eyes but operating this so
initially you will have a longer waiting list but once that hump is over people
are not coming back for the second eyes quite so much and therefore your queue
will actually shorten. So it’s a good thing.
People have also been worried that trainees will not have second eyes to
operate on because obviously when you do both eyes at the same time they gotta be
senior surgeon consultant etc but actually that’s not true if a consultant
or really senior person otherwise has done the first I successfully the second
eye can be done by a trainee there’s no reason why not. Ward nurses are quite happy because
instead of processing six or seven patients, for six or seven eyes, they are
processing three or four patients, for six to eight eyes. So they have less work
to do on the ward but in theaters because of all the delicate balance of
the instruments and so on, the theater nurses really hate this because they
have to spend so much more time preparing the instruments however if
bilateral surgery should become mainstream then the manufacturers will
put together left eye packs and right eye packs and you just pull them off
from the shelves and that will become a lot easier. We’ve talked about this
already. The prerequisites. How safe does it have to be before it can be offered.
The thing is to demonstrate safety you need to do a study which involves maybe
10 million cataract operations because the risk of bilateral blindness is
exceedingly rare. Therefore the consensus in this meeting,
in this ethical workshop, is that well, it seems to be save enough so let’s just
tread cautiously and then modify our practice as years goes on, when we gather
more evidence one way or the other. We’ve talked about fear. Let’s try not to
frighten ourselves and patients. We’ve talked about this as well, after both
eyes have been done it is a more arduous time because both eyes are somewhat
uncomfortable and certainly if they’re so unlucky to develop bilateral cystolic
macular edema then there will be a period when they need to be supported
because they will have coefficient for a small number of weeks. There’s also
concern that we might be doing unnecessary second eye operations
because if the patient had been offered just one eye and even though they might
have a visually significant cataract on the other eye
they might say “Oh, I’m all right for the moment and I won’t have this
done yet” and it could be months or years or they may never come back. So they’re
worry by some surgeons is that we might be doing some unnecessary
operations. So this is actually a risk we have to discuss with patients and also
make sure that they really are bilaterally visually significant before
we offer bilateral surgery. Uncertainties. Well I’ve explained the conditional,
concept of conditional probability, where we don’t really know what the risk is. We
know statistically it probably is about 1 in 250,000 and maybe 1 in a million
but for any particular individual patient we don’t know what their
individual risk is. So it has to be discussed with the patient that we don’t
really know what the risk is for you. Statistically it’s very very small. So any questions? Attendee: What are the chances of if the biometric measurements not, were in error. What are the chances of a person developing ametropia
supposing he was long sighted in both eyes pre-op and post-op who became
short sighted in one eye and long sighted in the other and then well the problems of ametropia. What would the problems be? Christopher Liu: I think the biometry error
is not very likely nowadays also if there is a biometry error in one eye which, for example, if they were plus 5, plus 5,
and then you got it wrong then both eyes are likely be either
plus 1 or minus 1 together. I don’t think it’s likely that one become minus 1 and the
other still plus 2. It’s just very unlikely and also
Attendee: What could cause that effect if that was the case? Christopher Liu: If that was the case, then you have the same things that you can do, either glasses, contact lenses, piggyback implants, laser
refractive surgery or exchange of implant. Those are the possibilities but
very unlikely. Attendee: The patient might say that
“Oh, look there was an error made, either biometric or surgeons error to induce this ametropia. Christopher Liu: Okay. Well first
thing is very unlikely that ametropia would be induced but it’s down
to your having communicated with the patient’s through your discussions and
informed consent. Attendee: Can that happen?
And should the patient be or should it be made aware that this is
a possibility that can happen. That you can become short sighted in one eye and long sighted in the other Christopher Liu: Well the problem is when it comes to informed consent, if you want to discuss all the possible things that can go right or go wrong.
It’s gonna take you a long, long time. Now thats not to say you shouldn’t do that, but I think in
practice, we can’t actually do that. So that’s why we give patient information
leaflets, to help them understand things, and also communication and trust is
really important. That you need to show that you we care for them, because we do,
but they also need to understand that we we do have their best interest in the
heart. Attendee: Obviously with the promotion of litigation etc on television. People when they find that they were long sighted will become a
short sighted in one eye and long sighted So there is legal issues. So
they can say “look I shall get compensation” Christopher Liu: In practice when optometry or ophthalmology, every second that we have for
dealing with a patient, we are at risk. That you know, this is the
difference. Any other questions? Attendee: So is the high refractive error
the indication that bilateral surgery? Christopher Liu: Well it is and it isn’t.
It is because if you’re doing one you are bound to cause an ametropia but
on the other hand if you have a high bio when the biometry error can be high and
also there’s a risk of retinal detachments then maybe not. So
it’s a balance and the thing about retinal detachment is actually not
everybody believes that cataract surgery can precipitate the retinal detachment
and even if it does it could be months or years later. So what do you do, you do
one and wait a few years, is just not possible. So it’s balanced it’s a real
life situation not black and white. Attendee: Would your main concern be the effects of
bilateral cystoid macular oedema post-surgery in this sort of procedures given
that it’s a lot more common than endophthalmitis? Christopher Liu: You are absolute right. I think
of course everybody is worried about bilateral endophthalmitis but it’s going
to be very rare if you follow the protocol and you do things very very
carefully. However, if it does happen absolutely awful isn’t it. On the other
hand with bilateral cystoid macular oedema it’s not guaranteed that they will
actually recover their full vision because some CMO do not fully recover
or can go on forever. So yes you’re right one is absolutely devastating and
rarer the other is likely to be a little bit more common. So also I’m worried
about it because it’s going to be more common than the other one but it’s not going
as devastating as the other one, when both eyes go dark right. Attendee: So you have a patient that is plus 5 right and left pre-op and one eye has cataract and the other has no visually significant cataract. Would you still be justified going ahead on the basis ametropic Christopher Liu: I think that’s an
ethical question isn’t it. You’re right. I think I would
offer it because based on the fact that this patient has a cataract. Am I going
to make him plus 5 now if he’s accepting of that, that’s fine, but if he really
want zero I can give that to him but I would be committing into second eye
surgery unless he can wear a contact lense. Again it’s a matter of discussion and
nowadays it’s not as though nobody does clear lens extraction, you know in middle
age to help people with PRK So if you were to ask me that question thirty
years ago there would be a different answer but now it’s kind of normalised,
refractive lense surgery has been normalised. The other thing about the plus 5 is that there may be that there
will be a very low risk of retinal detachment in in a high myobe and
also there may be some problems with very narrow anterior chambers as well. As
some pressure problem or risk of angle closure, so that, you know that, kind of
makes it more ethical. Any other questions So if not, then I will make some announcements. Yours truly is going to be
engaged in the great debates at the Royal College of Ophthalmology right here
and Glasgow again on the 22nd May Please come and support me. This is going
to be available part two is already loaded part one outside of this evening
you can go and watch study if you want to watch three and a half hours again and the Brighton corneal course
registration is open that is a very cause that Eye News has just tweeted on my behalf.
So obviously I’ve great got support for my family and I just want to show
you a photo of them when I was at Buckingham Palace getting my OBE.
So when I get my knighthood, I will invite you back. If you have any questions or you can’t find
somebody to do your bilateral patient. You don’t want to do yourself. You know
what you’d refer to then I’m here thank you. Tariq Aslam: It was a really interesting talk.
It reminds me a lot of some of the processes we’ve been through with intravitreal
injections. We’ve started off draping up and taking patients to theatres and
after the injection looking with an indirect and checking the central artery
and now it’s sort of we’re getting patients in we’re doing
sequential individual injections even more recently, we were giving topical
antibiotic drops after the injections for quite a while and none of us
actually thought it was doing any good but nobody wants to be the first person
because we so those fear of stopping it what we all believed in.
Christopher Liu: I think nowadays is just one drop of coral there’s no more drops put in. Tariq Aslam: Its taken time, even though people thought it was acceptable it takes somebody like you I think to actually say yeah I’m gonna put my head
above the carpet and do i. Can I just ask very quickly into the audience who amongst this crowd having listening to now that talk, would be happy to refer a
patient if they thought they were appropriate for bilateral sequential
surgery. Attendee: I’m not sure it’s that straight forward, it would deend on our local ophthalmologists. Tariq Aslam: Just in terms of you, in terms of
your own feelings, yeah so it seems like it’s from the show of hands there is a positive idea about it. Christopher Liu: We didn’t ask the question before my talk but I can ask a supplementary question? Has the talk being useful?
Thank you. Thank you very much.

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