Issues around same day bilateral cataract surgery

Cataracts are the commonest operation in the world. With modern day surgical techniques, it’s also the safest. And better yet, advances in lens technology mean some patients may enjoy the best vision of their entire life post-surgery.

This technological revolution has meant cataract surgery is more than avoiding blindness – rather, in many ways it’s about optimising vision.

Today, we aim to deliver patients crystal clear vision in the activities they enjoy most, and some may even be totally free from glasses altogether. As such, many opt for surgery earlier so they can enjoy improved quality of life, younger and for longer.

If we’re moving towards optimising quality of life, doesn’t it make sense to offer same day bilateral cataract surgery? It is much more convenient for patients, with less time off work, only a single trip to hospital, is often more cost effective and has a faster time course to full recovery.

The main arguments against same day surgery focus on the risk of infection, but that risk has been effectively mitigated by using completely separate equipment between eyes.

Well, we finally have a good answer to this question, and it’s got nothing to do with infection. It’s all about vision.

Data from the IRIS Registry, a huge multicentre eye disease clinical registry based in America with over 3 million patients recruited, has shone a light on this controversy.¹ In their report of 1.8 million patients split between immediate sequential bilateral cataract surgery (ISBCS) and delayed sequential bilateral cataract surgery (DSBCS), ISBCS or same day bilateral cataract surgery was associated with worse visual outcomes.

Let’s drill into this. The authors broke the DSBCS group into an early group, where the second eye was operated within 14 days, and a late group, where the second eye was operated within three months. After adjusting for confounders, the best performing group was the early delayed, followed by the late delayed, while the same day bilateral surgery group came in last.

It should be noted the size of the difference was small. On average the same day group performed worse by three to four letters in uncorrected vision, despite having better pre-surgical vision, compared to the delayed groups.

Further, the proportion who achieved uncorrected 6/6 vision in the second eye was worse in the same day group (21%) compared to the delayed group (24.2%).

What does this mean? Delaying surgery between eyes, even by a couple of weeks, on average gave better outcomes than having both cataracts operated on the same day.

The likely reason is the delay allows the surgeon the opportunity to check the performance of the first eye, and if necessary, adjust the second eye for better results. The differences are small, but when it comes to vision we are aiming for better and better outcomes, and it is these incremental small improvements that add up to make sizable differences over time. If your vision is 6/5, the difference is probably not overly noticeable. However, if your vision is 6/12, this small difference affects your ability to drive without glasses.

Saying that, I do believe there is a role for same day cataract surgery. In cases where anaesthetic may be risky, or intellectual disability where the goal is to reduce the number of trips to hospital, it makes sense.

Some healthy patients may choose to have same day cataract surgery because it fits with their life and requirements better. However, these patients should have a thorough informed consent so they understand what they are choosing, and a proper understanding of both options available.

We should take a step back and put it all in perspective. Ultimately, much of this refractive error is correctable with glasses, contact lenses or laser eye surgery, so all is not lost. However, many patients are opting for early cataract surgery to get the best vision they can at an earlier age and enduring extra procedures is not ideal.

In my mind, this is good evidence that modern day routine practice should be delayed sequential cataract surgery.

Ultimately our goal as ophthalmologists should be to offer our patients the best vision they can achieve, and sometimes that may involve telling them not to rush things.

Reference 

1. Owen JP, Blazes M, Lacy M, et al. Refractive Outcomes After Immediate Sequential vs Delayed Sequential Bilateral Cataract Surgery. JAMA Ophthalmol 2021;139(8):876-85.

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