Worldwide, retinal surgery is most often performed by a single surgeon who performs both the cataract and retinal surgery. In the United States, retinal surgery is most often performed by a retina surgeon, with sequential cataract surgery occurring either before or after the procedure, performed by a cataract surgeon. Why the difference in practice patterns? Why not do both surgeries on the same day? There is not an easy answer to these questions.

Proponents of combined surgery argue that a single surgery reduces the risk of anesthesia, complications, and time away from work, and it may actually result in better visual outcomes. Opponents of it argue that you cannot choose the correct lens in the setting of macular pathology and that there are longer surgical times, lens problems after surgery, and other challenges. But the unwritten reason in the United States is very different — the almighty dollar.

For most US retina specialists, keeping referring doctors happy is at the top of the to-do list. Taking referring cataract surgeons’ bread-and-butter phacoemulsification away would be practice suicide. So, in some cases, the retina surgeon will bring the cataract surgeon to their OR. However, the logistics of getting the cataract surgeon to the OR with the retina surgeon in some hospitals would be very difficult. Considering also that Medicare Section 40.8 reduces reimbursement when 2 surgeons perform 1 surgery on the same day, it is not hard to see why combined procedures are rarely performed in the United States. So, is this a good thing or not?

In this issue, Victor M. Villegas, MD, and Timothy G. Murray, MD, MBA, summarize the techniques and more importantly the outcomes for combined macular surgery. At the Cole Eye Institute, we have also been performing combined retinal procedures for years largely due to the fact that our staff are salaried. This means my cataract surgeon will not have their fees reduced. Whether the retina surgeon is doing both surgeries or bring in a cataract surgeon to your OR, the tips and tricks in this article will be surely be helpful.

This brings us back to the first question about practice patterns. Changing billing and referral patterns will take a phase change in how we look at ophthalmic surgery in the United States. Whether this is the appropriate course of action will depend on well-performed clinical studies. RP