George Hogarth
Introduction
Simultaneous bilateral cataract surgery or Immediately sequential bilateral cataract surgery (ISBCS) involves performing phacoemulsification and intraocular lens implantation in both eyes in the same sitting. One of the earliest reports of simultaneous surgery dates back to 1952. This was an ICCE operation. Over time it has grown in popularity due to the advent of phacoemulsification however, it should be noted that it is still carried out with manual small incision cataract surgery (MSICS) as well. Finland is the leading country for the proportion of simultaneous surgeries done. It has been carried out routinely there since 1996 and roughly 40% to 60% of cataract patients undergo simultaneous surgery (1). Literature approximates that between one-half and two-thirds of cataract patients may be eligible for bilateral cataract surgery (2).
Patient selection and precautions
In order to reduce the risk of any potential complications it is important that ophthalmologists stick to strict criteria.
Absolute contra-indications vary between surgeon and unit but may include:
- Concomitant surgery for glaucoma, corneal or retinal disease
- Previous significant eye surgery or significant eye injury, lens luxation or phacodonesis
- Increased risk of post-operative corneal failure (e.g. Fuchs’ dystrophy)
- Increased risk of infection (e.g. chalazion, active blepharitis)
- Ocular co-morbidity (e.g. recurrent uveitis, pseudoexfoliation, active or significant diabetic retinopathy)
- Previous refractive surgery, especially if the patient still prefers spectacle independence
- Concomitant glaucoma which is uncontrolled either eye
- Allergy to Povidone-Iodine (uncertainty could be addressed with patch testing) (3)
It is important to manage ocular comorbidities prior to surgery.
A fundamental principle that should always be followed is to treat each eye as individual. This is recommended by the International Society of Bilateral Cataract Surgeons. There are no reports of bilateral simultaneous endophthalmitis if these recommendations are followed. For each eye there should be a change of drape, gloves, gowns and instruments. Some ophthalmologists advocate that the instruments should come from different sterilisation cycles along with using viscoelastics from different companies or different lots.
The prevention of infection is a very important requirement in successful ISBCS as the risk of bilateral simultaneous endophthalmitis is the most feared complication and the main reason against undertaking ISBCS. Intracameral antibiotic prophylaxis is advised and reduces the rate of endophthalmitis, along with a well-sealed incision. If there are any complications with the first eye it is advisable to perform surgery on the second eye at a later date.
Advantages
There are numerous benefits to ISBCS. These include quick rehabilitation, fewer hospital/clinic visits, faster recovery to binocular vision (especially in patients with high refractive errors) and only one general anaesthetic for those requiring it (4). Patient satisfaction is also initially higher with ISBCS however at 1-year follow-up there was no difference in patient satisfaction between patients receiving ISBCS and those receiving DSBCS (delayed sequential bilateral cataract surgery).
Simultaneous binocular surgery can mean minor errors in overall refractive outcome occur however they are almost always symmetrical and hence do not cause problems such as anisometropia. Because stereoscopic vision is restored immediately small refractive errors are not generally a problem.
Risks and disadvantages
Objections against ISBCS appear to be primarily based on anecdotes rather than published data. It should be noted however that carrying out a double-masked trial of ISBCS versus DSBCS would be near impossible.
There are some claims that obtaining the refraction from the first eye allows improved outcome for second eye surgery, however this claim has not been supported by prospective trials. Optical biometry has drastically improved the predicted refractive outcome for normal eyes and following the guidelines of the International Society of Bilateral Cataract Surgeons means that the risk of refractive surprises are very small. None the less it is still important to consent patients about this risk.
One of the biggest arguments deployed against ISBCS is the risk of potential bilateral vision loss as a result of endophthalmitis, CMO (cystoid Macular Oedema) or TASS (Toxic Anterior Segment Syndrome). Other risks include corneal decompensation and retinal detachment (5). 7 cases of simultaneous bilateral endophthalmitis have been reported in the world literature, in all of these cases the surgical protocol recommended by the International Society of Bilateral Cataract Surgeons was breached or was uncertain in practice, meaning that aseptic rules were not adhered to. It cannot be said for absolute certainty if bilateral endophthalmitis would have occurred in these eyes had the protocols been adhered to but it can be said that no reports of bilateral simultaneous endophthalmitis exist when these recommendations have been followed.
According to the ESCRS prophylactic intracameral cephalosporin studies, the incidence of postoperative endophthalmitis after unilateral cataract surgery decreased from 1 in 331 cases (0.3%) without prophylactic intracameral antibiotics to 1 in 1,977 cases (0.05%) with prophylactic intracameral antibiotic prophylaxis. The overall rate of postoperative endophthalmitis after ISBCS was 1 in 5759. The risk of postoperative endophthalmitis is significantly reduced with the use of intracameral antibiotics. It should also be noted that bilateral endophthalmitis does not always mean bilateral blindness with vision being regained in around a third of eyes.
Conclusion
Advances in surgical techniques, intraocular lens calculations, infection prevention protocols, and patient selection mean reduced risks when performing bilateral cataract surgery on the same day. Advantages include faster visual rehabilitation, improved patient convenience, potential economic benefits through reduced healthcare costs and fewer hospital visits. There needs to be strict adherence to established safety guidelines however, including complete aseptic separation of procedures for each eye to minimise the risk of rare but potentially sight-threatening complications. It is likely that evidence supporting ISBCS will increase over time and with the anticipated rise in cataract surgery demand the adoption of ISBCS is likely to increase.
References
- Grzybowski A, Wasinska-Borowiec W, Claoué C. Pros and cons of immediately sequential bilateral cataract surgery (ISBCS). Saudi Journal of Ophthalmology [Internet]. 2016;30(4):244–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5161806/
- Malcolm J, Leak C, Day AC, Baker H, Buchan JC. Immediate sequential bilateral cataract surgery: patient perceptions and preferences. Eye (Lond). 2023 May;37(7):1509-1514.
- Immediate Sequential Bilateral Cataract Surgery (ISBCS) during COVID recovery: RCOphth/UKISCRS rapid advice document [Internet]. Available from: https://www.rcophth.ac.uk/wp-content/uploads/2020/09/Immediate-Sequential-Bilateral-Cataract-Surgery-Guidance.pdf
- Bhalla JS, Zakai MU, Mehtani A. Immediate sequential bilateral cataract surgery and its relevance in COVID-19 era. Indian J Ophthalmol. 2021 Jun;69(6):1587-1591.
- Arshinoff, Steve A. MD, FRCSC∗; Bastianelli, Paul A. BSc. Incidence of postoperative endophthalmitis after immediate sequential bilateral cataract surgery. Journal of Cataract & Refractive Surgery 37(12):p 2105-2114, December 2011. | DOI: 10.1016/j.jcrs.2011.06.036