Is it time to consider how we approach bilateral same-day cataract surgery?

In this issue of CEO, Ng et al.¹ explore ophthalmologists' attitudes to performing immediate sequential bilateral cataract surgery (ISBCS) with a survey of ophthalmologists in Singapore. The study also looks at ophthalmologist's appetite for ISBCS around the world, from a low of 13.9% performing this type of surgery in the United Kingdom to a high of 86% among Kaiser Permanente ophthalmologists in an HMO model in the United States. In Singapore, 27.6% practise ISBCS, and the most commonly cited reason being convenience for patients and faster rehabilitation.

Well, why not?

Dr Michael Goggin² in an editorial on the same subject in 2015 concluded ‘when we are at a point where complication rates are as low as can be achieved, when we have access, for instance to a routinely commercially available prophylactic intracameral antibiotic, when surgeons learn that they can trust their biometers and IOL power formulas, then perhaps we may be persuaded to move to ISBCS’.

Is it reasonable for us, nearly a decade later, to consider whether that time has arrived?

The most recent data from Australia is a snapshot of current practice from a survey by Sutton and Hodge.³ The feedback on this survey was provided by 194 RANZCO Fellows. Only 4.1% of ophthalmologists offered ISBCS, and of those who did perform it, 69% offered it in 5%–10% of their patients. It would appear to be the lowest rate of ISBCS in the world!

The current RANCZO guidelines⁴ question the quality of evidence regarding ISBCS and leaves the decision with the surgeon and the patient without giving specific advice.

There are essentially three arguments against ISBCS. The first is the risk of bilateral simultaneous postoperative endophthalmitis, and the second is the risk of bilateral simultaneous toxic anterior segment syndrome. The third is possible inaccurate intraocular lens selection in the first eye, implying that lens selection in the second eye can be improved with knowledge of the result from the first eye. This could involve the power of the IOL (spherical and/or toric error) or the type of IOL, for example, is the patient going to tolerate a presbyopia correcting IOL with complex optics such as a trifocal or EDOF in the first eye before deciding whether to implant a similar or different IOL in the second eye. I argued that the IOL power issue could no longer be taken seriously in a chapter written in a textbook on ISBCS.⁶ If this was a serious argument, the time between surgeries would be a minimum of 6 weeks to be truly certain of the refractive result in the first eye. Even surgeons who are opposed to ISBCS do not argue for this time interval between surgeries. With modern formulae, tear film optimisation, and better surgical techniques for toric intraocular lens orientation, the delay on accuracy grounds, for the majority of routine eyes, is unsustainable. The question around IOL type is more nuanced. Despite careful patient selection, a small number of patients will require an IOL exchange because they cannot tolerate the compromise in quality that comes with anything other than an aspheric monofocal IOL. Even with this knowledge, it is common practice to perform presbyopia correcting IOL surgery on the second eye soon after the first eye, well before neuroadaptation has occurred.

Regarding the risk of endophthalmitis and TASS, it should be clear that strict protocols are required. The second eye is treated as a separate surgery, with time out and confirmation of intraocular lens, surgeon and nurse re-scrub, the patient re-prepped and re-draped, separate instruments are sterilised through a different cycle (with indicators) and all medicines, fluid, viscoelastic and tubing are from different batch and lot numbers.⁷ Despite the hopes expressed in the 2015 CEO editorial, commercially available prophylactic intracameral antibiotics are still not available in Australia. Ophthalmologists are practical people and use commercially available diluted intracameral antibiotics or rely on compounding pharmacies to provide this service.

I think the recent pandemic was a time for reflection among many ophthalmologists, questioning their patterns of practice and how they use resources. The increasing importance of carbon emissions in medicine is also relevant to this argument. ISBCS is clearly convenient for patients, for relatives and carers, and is cost effective for society. It also helps the planet by reducing postoperative visits and road traffic. It is inconvenient financially for those facilities that benefit from surgery on separate days, and currently there is a financial cost to surgeons who perform ISBCS.

The Singapore survey by Ng et al. and their assessment of worldwide attitudes is timely. I would suggest that the arguments sensibly raised by Dr Michael Goggin in 2015 have largely been addressed, and it is now a matter of altering the financial incentives to encourage rather than discourage ISBCS and developing consensus on the best protocols to guide us in how we practice this type of surgery for the benefit of patients and our wider society.

There were no funding sources for this editorial.

Dr Michael Lawless is a consultant to Carl Zeiss Meditec and to Alcon Laboratories and serves on the Medical Advisory Board of Vision Eye Institute, Australia.