Simultaneous Bilateral Cataract Surgery (SBCS) is also commonly called Immediately Sequential Bilateral Cataract Surgery (ISBCS). It is a procedure in which cataract extraction and intraocular lens insertion are performed sequentially as independent surgeries on both eyes during the same visit.
In contrast, performing surgery on the second eye on a different day (several days to weeks to months later) is called Delayed Sequential Bilateral Cataract Surgery (DSBCS)2).
The history of ISBCS is long; Chan and De la Paz reported the first same-day bilateral cataract surgery in 1952. In Finland, it has been actively adopted since 1996, and currently about 40% of all cataract surgeries in Finland and Sweden are performed as ISBCS3). In the United States, however, it remains less than 1%, showing significant regional variation.
ISBCS is indicated for patients with decreased visual acuity due to bilateral cataract. When surgery is performed on one eye at a time, anisometropia occurs during the period between the first eye surgery and the second eye surgery. Anisometropia during this period can cause double vision, eye strain, and increased risk of falls. ISBCS eliminates this period and enables early recovery of binocular vision 2).
In candidates for ISBCS, the following are confirmed:
Points for evaluating ISBCS suitability
Confirmation of bilateral cataract: Presence of cataracts in both eyes that are indicated for surgery
Refractive status: If there is high refractive error before surgery, the impairment due to anisometropia is significant, and the benefit of ISBCS is greater
General condition: Patients at high risk for general anesthesia, or those who wish to avoid repeated general anesthesia
Presence of ocular complications: Evaluate for factors that increase the risk of endophthalmitis or toxic anterior segment syndrome (TASS)
Corneal risk: Risk of corneal decompensation due to endothelial dystrophy, cornea guttata, etc.
Decreased reliability of biometry: Axial length >26 mm (high myopia), <21 mm (high hyperopia), after laser refractive surgery
Lens/angle issues: Lens subluxation, pseudoexfoliation syndrome, history of glaucoma
QIs the surgical outcome (visual recovery) of ISBCS inferior to that of DSBCS?
A
No. Regarding corrected distance visual acuity (CDVA) outcomes, there is no significant difference between ISBCS and DSBCS (evidence level low to very low) 2). When antimicrobial prophylaxis is performed according to guidelines, no significant differences are observed in the risks of major complications such as endophthalmitis, wound dehiscence, macular edema, and corneal edema2).
Down syndrome (Trisomy 21) occurs in more than 1 in 1000 births, and 60% have ophthalmic problems 3). The rate of cataract comorbidity increases with age. In such patients, airway management is difficult due to multiple craniofacial abnormalities, short neck, obesity, and cognitive impairment, and the risk of multiple general anesthesia sessions is high 3). Therefore, ISBCS is often indicated.
Adequate informed consent from the patient is essential. Explain the benefits, risks, and alternatives (DSBCS) of ISBCS and obtain consent 1).
QWhat are the contraindications that require special attention before performing ISBCS?
A
The main contraindications are as follows: ① Untreated blepharitis or dacryocystitis (risk of endophthalmitis), ② Diabetes or immunosuppression (increased infection risk), ③ Corneal endothelial dystrophy or cornea guttata (risk of corneal decompensation), ④ Reduced reliability of biometry (high myopia/high hyperopia, post-refractive surgery), ⑤ Lens subluxation or pseudoexfoliation syndrome. If complications occur during the first eye surgery, consider canceling the second eye 2).
The most important principle for safe ISBCS is to “perform the two eye surgeries as completely independent separate surgeries” 2). Specifically, adhere to the following:
Complete separate sterilization of instruments: Instruments used for the first eye must be sterilized in a completely separate cycle before the second eye surgery 2)
Prohibition of sharing medications and devices: Do not share medications, eye drops, instruments, or infusion bags between the first and second eye 2)
Reprep and redrape the patient: After completing the first eye, disinfect again with 5–10% povidone-iodine for at least 3 minutes and apply a new drape
Intracameral antibiotic administration: It is strongly recommended to administer intracameral antibiotics at the end of surgery 1)2)
If an unexpected complication (e.g., posterior capsule rupture) occurs during surgery on the first eye, resolve the complication before proceeding to the second eye. In some cases, consider postponing the second eye 2).
Because both eyes have been operated on, no eye patch is used. Instead, start potent antibiotic eye drops early, immediately after surgery 4).
QIs ISBCS particularly beneficial for pediatric patients who require general anesthesia?
A
Yes. In patients with pediatric cataracts, intellectual disabilities, or systemic diseases, general anesthesia is required for all cataract surgeries 5). Repeated general anesthesia accumulates cardiopulmonary and airway risks. ISBCS allows both eyes to be operated on under a single general anesthesia, providing significant benefits for this patient group. It is considered particularly beneficial in patients with difficult airways, such as those with Down syndrome3).
The advantages of ISBCS are mainly due to the following mechanisms.
Avoidance of anisometropia: During the period between the first and second eye surgeries, the patient experiences a large difference in refractive power between the two eyes (anisometropia). This anisometropia hinders binocular fusion and increases the risk of falls and accidents. ISBCS eliminates this period 2).
Efficient use of medical resources: Operating room time, patient visits, and medical costs are reduced 2).
Minimization of general anesthesia risk: Especially in patient groups requiring general anesthesia, halving the number of anesthesia sessions can reduce risks 2)3).
Mechanisms of Disadvantages and Risks
Bilateral endophthalmitis: If bacterial endophthalmitis occurs simultaneously in both eyes, it can lead to bilateral blindness in the worst case. This is the greatest concern with ISBCS.
Bilateral toxic anterior segment syndrome: Risk of non-infectious anterior segment inflammation occurring simultaneously in both eyes.
Bilateral refractive surprise: Biometric errors occur in the same direction in both eyes, and the opportunity to adjust the power of the second eye based on the result of the first eye is lost.
In cases of bilateral postoperative endophthalmitis caused by protocol violations, pathogens are transmitted to both eyes when instruments contaminated during the first eye surgery are used for the second eye without re-sterilization 4).
Typical course (from the case of Kogawa et al. 2023) 4)
A 75-year-old woman undergoing chemotherapy for lung cancer (immunosuppressed state) with a history of bilateral uveitis and secondary glaucoma. At the hospital where ISBCS was performed, after intracameral moxifloxacin administration, the same instruments were used for both eyes without re-sterilization. On the morning of the first postoperative day, visual acuity was 20/50 to 20/60 in both eyes with no inflammatory findings. From the evening of the same day, visual acuity decreased in both eyes. On the second postoperative day, bilateral conjunctival injection, hypopyon, and corneal edema were observed, visual acuity dropped to light perception, and intraocular pressure was 39–40 mmHg. Emergency vitrectomy was performed on the same day. Six months after vitrectomy, visual acuity recovered to 20/30 in both eyes.
The ESCRS Cataract Guidelines and the AAO Preferred Practice Pattern (PPP) state that when recommended surgical guidelines are followed, ISBCS shows no significant difference in the risk of endophthalmitis, toxic anterior segment syndrome, or other major complications compared to DSBCS 1)2). However, because the absolute number of endophthalmitis cases is very small, further data accumulation is needed to draw definitive conclusions 2).
A retrospective cohort study using the AAO IRIS Registry (Intelligent Research in Sight) found no statistically significant difference in the incidence of postoperative endophthalmitis after ISBCS compared to DSBCS 1).
Application to children and adults with cognitive/intellectual disabilities
In a study of cataract surgery outcomes in 54 eyes (30 patients) of children with systemic diseases or cognitive disabilities, preoperative visual acuity of 1.4 logMAR (mean) improved to 1.0 logMAR at 2 years postoperatively, and approximately 70% of parents reported improvement in their child’s psychomotor skills 5). In such patients, the risk of repeated general anesthesia is high (lack of anesthesia services accounted for 78% of referral delays) 5), and the ability to complete bilateral surgery under a single anesthesia via ISBCS is highly significant.
Application to multifocal intraocular lenses and presbyopia correction
When implanting multifocal intraocular lenses (MFIOLs) in both eyes, ISBCS is considered advantageous because neuroadaptation can begin simultaneously in both eyes.
American Academy of Ophthalmology. Cataract in the Adult Eye: Preferred Practice Pattern. San Francisco: AAO; 2021.
Spekreijse LS, et al. European Society of Cataract and Refractive Surgeons (ESCRS) Cataract Guidelines. J Cataract Refract Surg. 2023.
Sharma R, Shankar S, Kumar N, Vichhare N. Immediately sequential bilateral cataract surgery in Down syndrome. Indian J Ophthalmol. 2022;70:4089-91.
Kogawa S, Suzuki Y, Furukawa A, et al. Bilateral simultaneous endophthalmitis after immediately sequential bilateral cataract surgery. Am J Ophthalmol Case Rep. 2023;32:101886.
Mandal S, Maharana PK, Nagpal R, et al. Cataract surgery outcomes in pediatric patients with systemic comorbidities. Indian J Ophthalmol. 2023;71:125-37.
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