Joel Hunter, MD Refractive Surgeon, Hunter Vision Updated 10/31/18 11:27 AM
There are a lot of parts of medical dramas on TV that are exaggerated for effect. One example would be how much romance exists within the hospital during medical training. In real life, everyone is so busy or sleep-deprived that romance never gets a passing thought. You know what, it wasn’t until I just wrote this out that I realized for the first time maybe that was only true for me. And now I’ve accidentally made myself sad.
Never matter, there are dramatic lines of dialogue in hospital dramas that are thought-provoking, but not uttered in real-world medicine. The big exception to this would be the primary rule of medical treatment: “First do no harm.” That specific idea is one of the fundamentals that really gets drilled in throughout medical training. As a matter of fact, more than once I had an attending physician say casually, in Latin, “primum non nocere.” And everyone knew what it meant. That’s how significant the concept stands as a core, guiding principle.
Unilateral vs. bilateral RLE
There’s a reason for pointing all that out in a blog about fixing one lens at a time (unilateral RLE) vs. doing refractive lens exchange on both eyes on the same day (bilateral RLE). I’d like to address the concern for most people leading to this question about unilateral vs. bilateral: is it about money in some way? Honestly, the decision is made one way or the other based on the best interpretation possible of the data available to the surgeon. I’d like to believe it is exceptionally rare for doctors to make major practice decisions based on financial incentive for one or the other.
And for the financial aspect, the knife (or laser) cuts both ways. In the most cynical interpretation possible, unilateral surgery is based on the fact that insurance pays less if you do both eyes at once instead of on separate days. Since a practice has to be intentional about being set up for bilateral surgery, they choose to do RLE unilaterally because that’s how they do cataracts. The other interpretation is that bilateral RLE is more cost efficient and helps sales, so the decision must be based on those stats.
Great! Now since we have that out of the way, we can move on the real reasons. It is about surgeon comfort and complication risk. For surgeon comfort, I mean intellectually, and below the (brain) waves, emotionally. Take, for example, a doctor who’s done unilateral surgery for 25 years, and had good results with only a handful of complications. It’s really unlikely they’ll decide to change their practice model no matter how many PowerPoint presentations you force them to watch. The idea of “my personal experience is more relevant than these statistics” is a pretty unassailable stronghold. And that’s okay, because—one eye at a time—these are docs who get great results! And if they aren’t, then we probably don’t want them doing bilateral surgery anyway.
Benefits of bilateral RLE
The idea of surgeon comfort, while I believe it to ultimately be emotional, stems from the idea of increasing risk. I’m 100% in agreement with not increasing risk of complications. Primum non nocere. As a matter of fact, this is the reason I am a proponent of bilateral RLE and cataract surgery for good candidates. The protocol set for the International Society of Bilateral Cataract Surgeons (ISBCS)—and yes, there really is a society for everything—has been based on multiple studies on huge numbers of cataract surgeries (in the millions).
After all the data is parsed, analyzed, and interpreted, it becomes clear that the risk of a sight-threatening complication is unimaginably low. How low, you may ask? Low enough that when using statistical analysis of actual data, it turns out your chance is higher of dying in a car accident on your drive to your second eye’s surgery than of losing your vision from bilateral RLE. The only extrapolation necessary in figuring those stats is about losing vision. Fatal car accidents have happened, but no one has ever lost their vision from bilateral RLE. The statistics are so favorable for bilateral RLE that “first do no harm” can be put into a larger frame of overall daily risks of life and come out on top.
When you add the other benefits of bilateral RLE—surgery is over in one clinic visit, no doubling of post op visits, less drops to figure out for less time, etc.—the “pro” list starts to dominate on the pros and cons chart. It isn’t the only correct way to do RLE, but it is a really great option for candidates. Surgeons who do one eye at a time for all patients are doing what’s best in their hands and in their practice. And we’re all doing our best to respect the principle of primum non nocere. I think that in this case, though, we can do even better than that.