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Debate continues over simultaneous bilateral cataract surgery

Issue: March 2015

ByDennis S.C. Lam, MD, FRCOphth

ByYizhi Liu, MD, PhD

ByAlex H. Fan, FRCS

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Simultaneous bilateral cataract surgery, mostly by phacoemulsification, continues to provoke hot debate among ophthalmologists. This is because there are pros and cons regarding a number of issues, including safety, efficacy, cost-effectiveness, and patient and surgeon perspectives. Before deciding whether simultaneous or sequential phaco is more suitable for a particular patient, one should carefully examine the different issues involved, preferably with active input from the patient.

Risk of bilateral endophthalmitis, CME

Endophthalmitis is the nightmare of every cataract surgeon, not to mention if it occurs in both eyes. In the past, this was the major hurdle for considering simultaneous bilateral cataract surgery (SBCS). However, with the introduction of small-incision phaco and the use of prophylactic intracameral antibiotics, the post-phaco endophthalmitis rate has dropped to a historically low level. By combining the strict practice of treating each eye as an independent case in terms of sterilization, instruments, consumables and even personnel, and using different lot numbers for consumables such as drapes, solutions, viscoelastics and tubing, the potential risk of bilateral endophthalmitis after SBCS should be low.

Besides endophthalmitis, cystoid macular edema (CME) is another safety issue that may need to be considered. Because CME is usually a delayed adverse event, sequential cataract surgery may give the surgeon a chance to delay surgery and/or employ preventive measures in the second eye. However, because clinically significant CME is rather uncommon nowadays and usually has a good response to topical NSAIDs, it is not a big concern. Moreover, many of the second eye phaco surgeries would have been done before the onset of clinically significant CME from the first eye phaco.

See sooner or see better?

SBCS has the advantage of prompt and balanced restoration of visual functions bilaterally and avoiding a period of uncomfortable postoperative anisometropia, especially in those who have significant preoperative refractive errors. On the other hand, SBCS also means that there will be no second chance to correct any refractive surprise arising from the first cataract surgery. Many surgeons value the refractive outcomes of the first eye and make corresponding adjustments, if necessary, for the second eye during subsequent surgery.

Lower cost but less income

SBCS usually means lower average calculated cost per eye. However, the revenue for the surgeon or the center may be less. Both insurance policies and government reimbursement schemes play a major role in this regard. In the U.S., for example, the government pays only half for the second eye during simultaneous surgery. Finland, on the other hand, has no financial penalty for SBCS and, therefore, has the highest rate of bilateral simultaneous cataract surgery in the world. It is obvious that the decision is more than a professional and medical decision.

Convenience vs. peace of mind

SBCS is usually more convenient for patients because it involves fewer medical visits, faster recovery, simpler postoperative medication regimens, and less sick leave or time off. However, many patients are also afraid of the rare but possible risks of bilateral loss of sight. They may not mind paying extra visits or scheduling a separate date for the second eye surgery in order to have peace of mind. This is particularly true in the retired population, which forms the main source of cataract surgery. On the other hand, if the above-mentioned preventive measures are properly taken, the theoretical risk of simultaneous bilateral endophthalmitis after SBCS would be very low indeed. Moreover, full awareness of such a condition and early recognition and prompt and timely management of endophthalmitis can yield a good final visual outcome.

An evolving scene

With the advancement of technologies such as intraoperative aberrometry, IOL calculators, newer and more accurate IOL formulae, and enhanced surgical instruments and procedures, it is certain that the debate will continue. The practice of choosing simultaneous or sequential cataract surgery is constantly evolving. One thing that should not change is that the patient should always be involved in the decision-making process. We should keep an open mind, and the preference of the individual surgeon should be well-respected. SBCS is always an option, provided that the surgeon is comfortable with it.

• References:
• Arshinoff SA. Surv Ophthalmol. 2012;doi:10.1016/j.survophthal.2012.05.002.
• Arshinoff SA, et al. J Cataract Refract Surg. 2011;doi:10.1016/j.jcrs.2011.06.036.
• Chang DF. Br J Ophthalmol. 2003;doi:10.1136/bjo.87.3.253.
• Henderson BA, et al. Surv Ophthalmol. 2012;doi:10.1016/j.survophthal.2012.05.001.

• For more information:
• Dennis S.C. Lam, MD, FRCOphth, can be reached at State Key Laboratory in Ophthalmology, Sun Yat-Yen University, 54 South Xianlie Road, Guangzhou 510060, People’s Republic of China; email: dennislam.gm@gmail.com.

Disclosure: The authors report no relevant financial disclosures.