Written by George A. Dumas, MD
Since cataract surgery is the most commonly performed operation in the geriatric population, it shouldn’t come as a surprise that this would be a target for payors of medical care. Most notably, health insurer Anthem has recently stated that it is unnecessary to have an anesthesiologist or nurse anesthetist to administer and monitor sedation in most of these cases.1 Let’s take a look at aspects of this procedure that have led us to this point. The American College of Cardiology and the American Heart Association have categorized cataract surgery as a very low-risk procedure.2 Cataract surgery is an avascular procedure and considered very low-risk for bleeding complication. Regional needle blocks during routine use of antithrombotic therapies are generally safe provided that levels are in the usual therapeutic window.3 Most modern day cataract surgeries are performed under topical/intracameral local anesthesia with sedation. Routine preoperative testing is unnecessary4 and the chance of dying from cataract surgery is estimated to be 0.014%.5
It can be argued that the involvement of the anesthesia team has led to much of the perceived safety and low mortality rate in cataract surgery. Many ophthalmologists still utilize needle blocks and sub-Tenon’s blocks for cataract surgery. Complications may include brainstem anesthesia which will require immediate intubation and resuscitation of the patient. Patient expectations are high and anxiety, pain, and fear during cataract surgery produce lower patient satisfaction scores.6 Sedation and analgesia are often used to supplement suboptimal local anesthesia. Patient movement and eye block complications account for most of the closed claims for monitored anesthesia care during ophthalmic surgery.7
In a discussion on this topic in Kaiser Health News, Dr. David Glasser, an ophthalmologist stated: “An ophthalmologist cannot administer conscious sedation and monitor the patient and do cataract surgery at the same time.”1 Anthem states that anesthesia services may be covered for cases of medical necessity which includes: patients <18 years old, patients unable to cooperate or communicate, patients unable to lie flat, and complex surgery. It should be noted that anesthesia services for cataract surgery are covered by Medicare. An ophthalmologist will most likely be focused on the eye, not necessarily the patient’s vital signs, respiratory signs, and sedation. Patient safety experts are concerned. Leah Binder, president and CEO of the Leapfrog Group, stated that there are better ways for Anthem to save money than keeping anesthesiologists and nurse anesthethetists out of the OR.1 Her suggestion: “How about identifying surgeons who have the highest complication rates, and letting patients know about them?”1 This is sure to be a hot-button topic moving forward but as a wise anesthesiologists once told me, just because you can doesn’t mean that you should.
References
1. Andrews, M. Anthem Calls On Eye Surgeons To Monitor Anesthesia During Cataract Surgery. Kaiser Health News. Feb. 20, 2018. https://khn.org/news/anthem-calls-on-eye-surgeons-to-monitor-anesthesia-during-cataract-surgery/
2. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64:e77-137.
3. Katz J, Feldman MA, Bass EB, et al. Risks and benefits of anticoagulant and antiplatelet medication use before cataract surgery. Ophthalmology. 2003;110(9):1784-8.
4. Schein OD, Katz J, Bass EB, et al. Study of Medical Testing for Cataract Surgery. The value of routine preoperative medical testing before cataract surgery. N Engl J Med. 2000;342(3):168-75.
5. Keay L, Lindsley K, Tielsch, et al. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev. 2012;3:CD007293.
6. Fung D, Cohen MM, Stewart S, Davies A. What determines patient satisfaction with cataract care under topical local anesthesia and monitored sedation in a community hospital setting? Anesth Analg. 2005;100:1644-50.
7. Bhananker SM, Posner KL, Cheney FW, et al. Injury and liability associated with monitored anesthesia care: A closed claims analysis. Anesthesiology. 2006;104:228-34.
