Immediate sequential bilateral cataract surgery: time for wider adoption : Journal of Cataract & Refractive Surgery

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Immediate sequential bilateral cataract surgery: time for wider adoption

Srinivasan, Sathish FRCSEd, FRCOphth, FACS

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Journal of Cataract & Refractive Surgery: November 2022 - Volume 48 - Issue 11 - p 1231-1232
doi: 10.1097/j.jcrs.0000000000001070
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Your assumptions are your windows on the world. Scrub them off every once in a while, or the light won't come in.

—Isaac Asimov

The World Health Organization estimates that the number of cases of blindness from cataract will increase to 40 million in 2025 because of the aging population and longer life expectancies.1 There is robust evidence to demonstrate that the cataract surgical rate uptake has been on an upward trend.2 Cataract surgery techniques are being constantly refined with the introduction of technological advancements.

Fundamental changes have been transitioning in, from intracapsular cataract extraction in the 1960s and 1970s, to extracapsular cataract extraction (ECCE) in the 1980s and 1990s, to the current technique of sutureless small-incision phacoemulsification surgery with injectable intraocular lens (IOL) implantation. These surgical transitions have had good scientific credibility, showing measurable improvements in visual outcomes and safety. The randomized Madurai IOL study showed for the first time the superiority of ECCE over ICCE with posterior chamber IOLs for visual acuity restoration and safety.3 Similarly, a randomized clinical trial comparing ECCE with phacoemulsification found phaco to be clinically superior and cost-effective.4

Currently, sutureless clear corneal incision, continuous curvilinear capsulorhexis, phacoemulsification, and in-the-bag placement of a foldable IOL represent the gold standard for routine cataract surgery. Technological advances and standardized surgical techniques have resulted in cataract surgery being extremely successful with low complication rates.

Simultaneous bilateral cataract surgery, now more accurately referred to as immediately sequential bilateral cataract surgery (ISBCS), is where both eye surgeries are performed in one operating session (without the patient leaving the operating room) in contrast to delayed sequential bilateral cataract surgery (DSBCS), where the second eye surgery is done days, weeks, or months later. The earliest report of ISBCS dates back to 1952 when Chan et al. reported bilateral intracapsular cataract surgery in “one sitting.”5 In Finland, routine ISBCS has been common since 1996.6 A review of ISBCS on the Canary Islands by the Spanish government recently concluded that “ISBCS, as a surgical alternative for cataract patients, is as safe and effective as conventional DSBCS.”7

The International Society of Bilateral Cataract Surgeons (iSBCS) was founded in September 2008 with the aim of promoting interest, research, education, mutual cooperation, and progress in simultaneous bilateral cataract surgery. The society membership included the majority of prominent bilateral cataract surgeons worldwide. From 2005 to 2020, members of iSBCS shared data and promoted best practice principles of ISBCS during the ESCRS and ASCRS annual meetings. In 2009, iSBCS published General Principles for Excellence, which detailed the safe practice of ISBCS. As of January 1, 2020, iSBCS ceased to exist as the society felt it had fulfilled its mandate of promoting ISBCS into mainstream cataract surgery practice.

In the past, cataract surgeons were hesitant to adopt ISBCS due to fear of bilateral endophthalmitis, macular edema, toxic anterior segment syndrome, and refractive surprise. A review of literature showed only 4 published cases of bilateral simultaneous endophthalmitis.8–11 Certainly the introduction of intracameral antibiotics during cataract surgery has been significant in reducing the incidence of postoperative endophthalmitis in different healthcare settings.12,13

In 2011, Arshinoff et al. very elegantly demonstrated that risk for postoperative endophthalmitis in ISBCS appears to be at least as low as and possibly lower than published rates for unilateral surgery, particularly when recommended precautions are taken.14 Moreover, 2 recent studies with large datasets from the Swedish National Cataract Register and from the American Academy of Ophthalmology Intelligent Research in Sight Registry Data clearly demonstrated that the risk of postoperative endophthalmitis was not statistically significantly different between patients who underwent ISBCS and DSBCS or unilateral cataract surgery.15,16

The COVID global pandemic has certainly resulted in a change of mindset in surgeons offering ISBCS and patient acceptance of this practice. Since 2020, there have been 9 peer-reviewed publications on the wider acceptance of ISBCS among various healthcare settings. In the United Kingdom, after the pandemic, the Royal College of Ophthalmologists and the UK and Ireland Society of Cataract and Refractive Surgery jointly recommended more ISBCS in suitable patients to streamline cataract services.17

In this issue, Kwedar et al. (page 1260), in a retrospective chart review, in a veterans' hospital setting in the United States, show that patients undergoing ISBCS had meaningful recovery of uncorrected distance visual acuity as early as postoperative day 1. There is now robust peer-reviewed data demonstrating that ISBCS is as safe as DSBCS when the recommended guidelines and aseptic precautions are adhered to.


1. Bourne RR, Stevens G, White RA, Flaxman S, Mascarenhas M, Price H, Leasher J, Pesudovs KI, Taylor HR; GBD Study Vision Loss Expert Group. The global burden of disease study: the impact of vision loss: prevalence and trends of blindness and visual impairment over the past 28 years. Presented at the annual meeting of the Association for Vision and Research in Ophthalmology, Fort Lauderdale, Florida, May 2012. Abstract available at: Accessed October 12, 2022
2. Wang W, Yan W, Fotis K, Prasad NM, Lansingh VC, Taylor HR, Finger RP, Facciolo D, He M. Cataract surgical rate and socioeconomics: a global study. Invest Ophthalmol Vis Sci 2017;57:5872–5881
3. Prajna NV, Chandrakanth KS, Kim R, Narendran V, Selvakumar S, Rohini G, Manoharan N, Bangdiwala SI, Ellwein LB, Kupfer C. The Madurai Intraocular Lens Study. II: Clinical outcomes. Am J Ophthalmol 1998;125:14–25
4. Minassian DC, Rosen P, Dart JKG, Reidy A, Desai P, Sidhu M. Extracapsular cataract extraction compared with small incision surgery by phacoemulsification: a randomised trial. Br J Ophthalmol 2001;85:822–829
5. Chan JO, De la Paz P. Bilateral cataract extraction in one sitting. J Philipp Med Assoc 1952;28:700–705
6. Serrano Aguilar PG, Ramallo Fariña Y, López Bastida J, Cabrera Hernández JM, García Pavillard A, Goás Iglesias de Ussel J, Pérez Silguero MA, Pérez Silguero D, Henríquez de la Fé F, Carreras Díaz H, Duque González B, González Marrero J. Safety, effectiveness and cost-effectiveness of bilateral and simultaneous cataract surgery versus two-stage bilateral cataract surgery. Health Technology Assessment Reports SESCS No. 2006/05. Canary Islands Health Service, Ministry of Health of the Government of the Canary Islands. Available at: Accessed October 12, 2022
7. Kaipiainen S. Simultaneous Bilateral Cataract Surgery (SBCS) in Finland. Presented at the ASCRS course on simultaneous bilateral cataract surgery: myth, monster, or magic? ASCRS Symposium on Cataract, IOL and Refractive Surgery, Chicago, Illinois, April 2008
8. BenEzra D, Chirambo MC. Bilateral versus unilateral cataract extraction: advantages and complications. Br J Ophthalmol 1978;62:770–773
9. Kashkouli MB, Salimi S, Aghaee H, Naseripour M. Bilateral pseudomonas aeruginosa endophthalmitis following bilateral simultaneous cataract surgery. Indian J Ophthalmol 2007;55:374–375
10. Ozdek SC, Onaran Z, Gurelik G, Konuk O, Tekinsen A, Hasanreisoglu B. Bilateral endophthalmitis after simultaneous bilateral cataract surgery. J Cataract Refract Surg 2005;31:1261–1262
11. Puvanachandra N, Humphry RC. Bilateral endophthalmitis after bilateral sequential phacoemulsification. J Cataract Refract Surg 2008;34:1036–1037
12. Arshinoff SA, Bastianelli PA. Incidence of postoperative endophthalmitis after immediate sequential bilateral cataract surgery. J Cataract Refract Surg 2011;37:2105–2114
13. Herrinton LJ, Shorstein NH, Paschal JF, Liu L, Contreras R, Winthrop KL, Chang WJ, Melles RB, Fong DS. Comparative effectiveness of antibiotic prophylaxis in cataract surgery. Ophthalmology 2016;123:287–294
14. Haripriya A, Chang DF, Namburar S, Smita A, Ravindran RD. Efficacy of intracameral moxifloxacin endophthalmitis prophylaxis at Aravind Eye Hospital. Ophthalmology 2016;123:302–308
15. Friling E, Johansson B, Lundström M, Montan P. Postoperative endophthalmitis in immediate sequential bilateral cataract surgery. A nationwide registry study. Ophthalmology 2022;129:26–34
16. Lacy M, Kung TPH, Owen JP, Yanagihara RT. Endophthalmitis rate in immediately sequential versus delayed sequential bilateral cataract surgery within the Intelligent Research in Sight (IRIS) Registry Data. Ophthalmology 2022;129:129–138
17. Immediate sequential bilateral cataract surgery (ISBCS) during COVID recovery: RCOphth/UKISCRS rapid advice document. Available at: Accessed October 12, 2022
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