Can I have both my cataracts done on the same day?

This has been a topic of controversy for eye surgeons in recent years. There are a few patients who ask whether they can have both their cataracts removed on the same day. This approach is called immediate sequential bilateral cataract surgery (ISBCS).

I will run through the benefits and risks of immediate sequential bilateral cataract surgery below when compared to the standard first eye cataract operation followed by the second eye 4 weeks later that I offer privately.

Benefits

1. The cataract patient saves time

You have one pre-assessment date, one surgical date for both eyes, and fewer post-operative visits

2. It saves the surgeon time

This is especially useful if there are longer waiting lists for second eye surgery sometimes seen on the NHS

3. It may save money

This is most valid on the NHS where there is a high volume of cataract surgery performed

4. Immediate benefits of both eyes

The patient has the immediate benefits of both eyes working together rather than having to be imbalanced for 4 to 6 weeks waiting for the other eye to be done

5. Less risks associated with anaesthesia

If you require a general anaesthetic for cataract surgery, then you will only need one general anaesthetic and have less risks associated with anaesthesia

Risks

1. Risk of post-operative infection

The risk of post-operative infection inside the eye is known as endophthalmitis. With immediate sequential bilateral cataract surgery, there is a theoretical risk of post-operative infection in both eyes after surgery – this would be catastrophic and could lead to poor vision in both eyes.

The studies have shown that the risk of infection inside one eye after cataract surgery is approximately 1 in 1000.

The theoretical risk of infection inside both eyes after immediate sequential bilateral cataract surgery has been quoted as 1 in 1 million. There are also no reported cases of infection in both eyes when modern techniques and best practice is employed. Injecting preventative antibiotics at the end of cataract surgery has drastically cut the rate of endophthalmitis.

2. Risk of a severe bleed behind the eye

The risk of a severe bleed behind the eye during cataract surgery is known as a suprachoroidal haemorrhage. The quoted risks of this complication are around 1 in 10000. There have been no reports of this type of bleed occurring in both eyes when both eyes have cataract surgery at the same time probably because the risk is very small in the first place.

3. Refractive surprise

Refractive surprise refers to an unexpected glasses prescription following cataract surgery despite the correct eye measurements and calculations before cataract surgery. The chance of refractive surprise in cataract surgery is increased in eyes that are very short or long-sighted (high refractive error) before the operation.

There are no reported cases of refractive surprise occurring in both eyes with immediate sequential bilateral cataract surgery.

It would seem logical to avoid immediate sequential bilateral cataract surgery in patients who are deemed high-risk patients due to high refractive error and those who have other co-existent eye conditions that make cataract surgery more difficult.

4. Swelling, retinal detachment and corneal swelling

Cataract surgery has other risks of complications such as swelling in the central part of the retina (cystoid macular oedema), retinal detachment and corneal swelling. When researchers have compared two groups of patients – one who had conventional cataract surgery performed on both eyes on different days versus patients who had cataract surgery on both eyes on the same day, they did not find any difference in risk of complications between the two groups.

So why don’t most eye surgeons feel comfortable performing immediate sequential bilateral cataract surgery?

Well, its biggest appeal is cost saving and this is most apparent in the NHS where we perform high volume cataract surgery – the change of practice amongst eye surgeons can take time especially in those surgeons who have experienced higher complications in the early days of modern cataract surgery. There is still a fear of complications occurring in both eyes at the same time, which would obviously be catastrophic. Interestingly the evidence shows that this risk is incredibly small but this fact has not shifted the mass attitude to avoiding immediate sequential bilateral cataract surgery.

Immediate sequential bilateral cataract surgery has its place when there is no other option but to perform one operation. Patients who need general anaesthesia and are at risk of complications of general anaesthesia such as patients with Down’s Syndrome often undergo immediate sequential bilateral cataract surgery often with no reported catastrophic complications.

Why do I suggest that you don’t undergo immediate sequential bilateral cataract surgery in the private sector?

Well, the wait time to have your second eye cataract surgery privately is very short and I can often perform your second eye surgery 3 weeks after your first.

Most, if not all of my private cataract surgery patients in London choose to have their bilateral cataract surgery done on different days in the conventional way. They too, are put off by the risk of catastrophic vision loss if a complication occurs in both eyes, no matter how small that risk actually is. Taking one eye at a time seems safer to patients.

It seems that no matter what the evidence, if it doesn’t feel right, patients will choose what feels comfortable for them in the end.

References

1. Sarikkola A-U, Uusitalo RJ, Hellstedt T, Ess S,Leivo T, Kivelä T. Simultaneous bilateral versus sequential bilateral cataract surgery: Helsinki Simultaneous Bilateral Cataract Surgery Study Report 1.J Cataract Refract Surg.2011;37(6):992-1002
2. Arshinoff SA,Strube YNJ,Yagev R.Simultaneous bilateral cataract surgery. J Cataract Refract Surg.2003;29:1282-1291
3. Johansson BA, Lundh BL Bilateral same day phacoemulsification:220 cases retrospectively reviewed.Br J Ophthalmol.2003;87:285- 290
4. Beatty S, Aggarwal RK, David DB, Guarro M, Jones H, Pearce JL. Simultaneous bilateral cataract extraction in the UK.Br J Ophthalmol.1995;79:1111-1114
5. Ramsay AL, Diaper CJM, Saba SN, Beirouty ZAY, Rawzi HH. Simultaneous bilateral cataract extraction. J Cataract Refract Surg. 1999;25:753-762
6. Sharma TK, Worstmann. Simultaneous bilateral cataract extraction. J Refract Surg.2001;27:741-744
7. Sarikkola A-U, Kontkanen M, Kivelä T, Laatikainen Simultaneous bilateral cataract surgery: a retrospective study. J Cataract Refract Surg.2004;30:1335-1341
8. Arshinoff SA,Odorcic S. Same-day sequential cataract surgery. Curr Opin Ophthalmol.2009;20:3-12
9. Chung JK, Park SH, Lee WJ, Lee SJ. Bilateral cataract surgery:a controlled clinical trial.J pn J Ophthalmol. 2009; 53:107-113
10. Serrano-Aguilar, Pedro et al. Immediately sequential versus delayed sequential bilateral cataract surgery: Safety and effectiveness Journal of Cataract & Refractive Surgery , Volume 38 , Issue 10 , 1734 – 1742