Immediate Sequential vs. Delayed Sequential Bilateral Cataract Surgery

Abstract

Purpose We conducted a retrospective comparative-effectiveness study of best-corrected visual acuity (BCVA) and refractive error (RE) following immediate sequential (ISBCS) and delayed sequential (DSBCS) bilateral cataract surgery. We tested two hypotheses: (1) among DSBCS patients, 2nd eye outcomes were no different than 1st eye outcomes; (2) averaged between each patient’s two eyes, outcomes did not differ between ISBCS and DSBCS patients. Design Retrospective comparative-effectiveness study. Subjects Kaiser Permanente Northern California members who underwent non-complex bilateral cataract surgery during 2013 through June 30, 2015. Methods We performed an intention-to-treat analysis comparing ISBCS to DSBCS using conditional logistic regression analysis, accounting for surgeon and patient-level factors. Main Outcome Measures BCVA, RE. Results The analysis of visual outcomes included both eyes of 13,711 DSBCS and 3,561 ISBCS patients. Because of the large sample size, some statistical differences lacked clinical significance. Ocular comorbidities were slightly more prevalent in DSBCS patients. Postoperative BCVA was 20/20 or better in 48% of DSBCS 1st eyes, 49% of DSBCS 2nd eyes, 53% of ISBCS right eyes, and 51% of ISBCS left eyes. The within-person difference in postoperative BCVA averaged zero (0.00) between the 1st and 2nd DSBCS eyes, and between the ISBCS right and left eyes. After adjustment, average postoperative BCVA was better in ISBCS patients, although the difference was not statistically significant. (compared with 20/20 or better: odds ratio for worse than 20/20 was 0.91, 95% confidence interval 0.83–1.01). Emmetropia (spherical equivalent −0.5 to 0 D) was achieved in 61% of 1st DSBCS eyes, 61% of 2nd DSBCS eyes, 63% of ISBCS right eyes, and 62% of ISBCS left eyes. After adjustment, average postoperative RE was no different in ISBCS compared with DSBCS patients (compared with emmetropia: odds ratio for ametropia was 1.02, confidence interval 0.92–1.12). We confirmed one case of postoperative endophthalmitis in 10,494 ISBCS eyes (1.0 per 10,000 eyes), two cases in 38,736 DSBCS eyes (0.5 per 10,000 eyes) (p=0.6), and no patient had bilateral endophthalmitis. Conclusion Compared with DSBCS cataract surgery, we found no evidence that ISBCS surgery was associated with worse postoperative BCVA or RE, or with an increased complication risk.

The Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: Report 7, immediate sequential bilateral cataract surgery in the UK: Current practice and patient selection

“…The loss of ability to alter refractive aim of the second eye is mentioned in the 2017 NICE cataract guidelines as something that needs to be told to patients opting for ISBCS. Despite this, superiority of refractive outcomes of DSBCS over ISBCS in large case series has not been demonstrated [ 20 ]. We also felt it unhelpful to deal with the issue of refractive outcomes here, as the patient group being operated for ISBCS, as indicated by the high GA rate, is not representative of the population that might in theory be offered ISBCS should this practice go to scale within in the NHS.…”

<p>Outcomes and Adverse Events of Sub-Tenon’s Anesthesia with the Use of a Flexible Cannula in 35,850 Refractive Lens Exchange/Cataract Procedures</p>

“…26 In this study, sub-Tenon's anesthesia achieved great results with complete akinesia and we highlighted some advantages of this technique over cataract/refractive lens exchange performed with topical anesthesia only. There is a new challenge in intraocular surgery at the moment with the advent of immediate sequential bilateral cataract surgery (ISBCS) and its progressive acceptance in modern ophthalmic practice, 28 our clinics including. With this approach, full sub-Tenon's block is not practical, as it would result in postoperative diplopia and therefore topical anesthesia is often the preferred choice.…”

Cataract service redesign in the post-COVID-19 era

“…Immediate sequential bilateral cataract surgery (ISBCS) has been shown to be as safe and effective to conventional delayed sequential bilateral cataract surgery. 47 Its advantages include decreased wait time for surgery, reduced clinical visits, convenience for patients and overall saving for healthcare systems. 48 Currently, ISBCS in the UK is offered to limited patients who require general anaesthesia for social reasons, for example, patients with learning difficulty.…”