Simultaneous Bilateral Cataract Surgery

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 by Derek W DelMonte, MD on September 29, 2021.


Surgical Therapy

Simultaneous Bilateral Cataract Surgery

The procedure is also known by the following names: Immediately sequential bilateral cataract surgery

Background

Simultaneous bilateral cataract surgery (SBCS) remains a controversial topic in most developed countries despite studies which have shown that it is both safe and effective.[1]

As with many controversial medical procedures, there are clear advantages and disadvantages of performing simultaneous bilateral cataract surgery.

Advantages:

  • Minimizing patient visits to the surgical facility and doctor's office
  • Faster recovery to binocular vision particularly seen in patient's with high refractive errors
  • Decreased cost to patient
  • Decreased cost to the health system


Disadvantages:

  • Risk of bilateral endophthalmitis
  • Risk of bilateral toxic anterior shock syndrome (TASS)
  • Unable to gain refractive insight from first eye[2]
  • Decreased reimbursement for physicians (in certain health systems)


Recent improvements in cataract surgery technology and techniques have improved the complication rate of cataract surgery to the point that even the risk of bilateral same-day surgery is exceedingly low. This has led to more surgeons offering this option to their patients.

There are regional variations in how this procedure is viewed, which can be seen in the number/percentage of patients undergoing SBCS. For example, in Sweden as many as 40 percent of patients undergo SBCS, where that number is less than 1% in the United States.[3]

Patient Selection

Despite the known risks, many doctors have historically performed this procedure on select patients, including those with serious co-morbidities who have significant trouble getting to the operating room and/or undergoing anesthesia. (example, Downs Syndrome patients)

Today, doctors are offering this to many routine, healthy patients as a convenience and cost saving measure.

Indications

Bilateral Cataracts

Contraindications[4]

Any factors that create risk of surgical complications

Any factors that create risk of endophthalmitis or TASS

Increased risk of infection from untreated blepharitis and mucocele; diabetes mellitus; immunosuppression and immunodeficiency, including systemic steroids

Leukemia or lymphoma

Iodine allergy

Increased risk of corneal decompensation, including endothelial dystrophy and guttata

Increased risk of inaccurate biometry, with high myopia of approximately greater than 26 mm of axial length, high hyperopia of approximately less than 21 mm of axial length and previous laser refractive surgery[5]

Lenticular abnormalities such as history of ocular trauma, lens subluxation, phacodonesis or pseudoexfoliation

Increased risk of high IOP with glaucoma, trabeculectomy and previous iritis

(There is the option not to proceed if the first eye operation has not gone completely well.)

Surgical Technique

The term is generally applied to the act of performing bilateral cataract extraction with intra-ocular lens placement as independent operations sequentially on the same visit. This includes re-preping and draping the patient between eyes.

Outcomes

Recent outcome studies have not shown any significant difference in outcomes from traditional sequential cataract surgery.

Complications

Bilateral endophthalmitis

Bilateral TASS

Bilateral refractive surprise

References

  1. Arshinoff S, Bastianelli P. Incidence of postoperative endophthalmitis after immediate sequential bilateral cataract surgery. J Cataract Refract Surg 2011;37:2105-2114.
  2. Olsen T. Use of fellow eye data in the calculation of intraocular lens power for the second eye. Ophthalmology 2011;118:9:1710.
  3. Kessel L, Andresen J, Emgaard D, Flesner P, Tendal B, Hjordal J. Immediate Sequential Bilateral Cataract Surgery: A Systemi Review and Meta-Analysis. J Ophthalmol 2015;
  4. Krüger, J. and Liu, C., 2022. In what situations should simultaneous bilateral cataract surgery not be performed?. [online] Healio.com. Available at: <https://www.healio.com/news/ophthalmology/20120331/in-what-situations-should-simultaneous-bilateral-cataract-surgery-not-be-performed> [Accessed 9 January 2022].
  5. Covert DJ, Henry CR, Koenig SB. Intraocular lens power selection in the second eye of patients undergoing bilateral, sequential cataract extraction. Ophthalmology 2010;117:1:49-54.
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