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Immediately Sequential Bilateral Cataract Surgery—A Global Perspective
Steve A Arshinoff, MD, FRCSC
Directing Partner, York Finch Eye Associates, Humber River Hospital, Toronto, Ontario, Canada; Assistant Professor, Department of Ophthalmology and Vision
Sciences, University of Toronto, Toronto, Ontario, Canada; Assistant Clinical Professor, Surgery (Adjunct), McMaster University, Hamilton, Ontario, Canada
Abstract By the mid 1990s, the evolution of progressively safe and predictable cataract surgery saw the resurgence of centuries of interest in
performing immediately sequential bilateral cataract surgery (ISBCS). Within 10 years ISBCS had become generally accepted and the
International Society of Bilateral Cataract Surgeons (iSBCS) was formed (September 2008) to “promote education, mutual cooperation, and
progress in simultaneous bilateral cataract surgery.” The first initiative of the society members was to create a document “iSBCS General
Principles for Excellence in ISBCS 2009,” which was intended to disseminate information about the best practices they had discovered
to assist novice ISBCS surgeons. Next, ISBCS needed to be studied. Soon, data began to clarify some advantages of ISBCS, and risks were
carefully evaluated. It soon became apparent that the main impediment to the performance of ISBCS, globally, was money, in that many
jurisdictions financially penalized surgeons who performed ISBCS. Presently, we know that ISBCS carries many benefits to the patient,
his/her family, the surgical facility, and society. The feared risks for simultaneous bilateral endophthalmitis, the requirement to adjust
intraocular lens (IOL) selection for second eyes, based on first eye results, and others, have simply not been borne out under scrutiny.
ISBCS is now rapidly increasing in its performance and acceptance globally, but the financial factors remain to be solved.
Keywords Bilateral cataract surgery, immediately sequential bilateral cataract surgery, cataract surgery, endophthalmitis, simultaneous
Disclosure: Steve A Arshinoff, MD, FRCSC, has no conflicts of interest to declare. No funding was received in the publication of this article.
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation,
and reproduction provided the original author(s) and source are given appropriate credit.
Received: January 12, 2015 Accepted: February 9, 2015 Citation: US Ophthalmic Review, 2015;8(1):14–8
Correspondence: Steve A Arshinoff, MD, FRCSC, York Finch Eye Associates, 2115 Finch Ave W #316, Toronto, Ontario, Canada M3N 2V6. E: email@example.com
“The argument of whether to operate bilateral cataracts in a single
session, or in two different sessions, is as old as the operation itself,
and the controversy between supporters of one option and the other
had already, in the Middle Ages, become fiercely heated. So it has
stayed, over the centuries, up to the present day.” 1 Few suggestions
of how to advance cataract surgery have given rise to as much heated
discussion, often without scientific backing for claims and accusations.
Taking a broader perspective, Robert Wright has written eloquently on
how everything tends to amalgamations and increasing complexity, as
long as the parties engaged in the effort experience a nonzero sum
of benefits. 2 It should follow from this that the ultimate acceptance of
a complication that was a result of the bilaterality of the procedure
(such as bilateral postoperative endophthalmitis, corneal edema,
etc.) I was, however, concerned about any possible increased risk for
the procedure compared with delayed sequential bilateral cataract
surgeries (DSBCS), and so I adopted a number of strict practices, which
I believe to be essential to the safe practice of ISBCS:
bilateral cataract surgery is inevitable.
3. I have been practicing fairly routine immediately sequential bilateral
cataract surgery (ISBCS) since 1996, when a 35-year-old, female, racing
car driver demanded that I perform her two cataract surgeries at the
same sitting. She informed me of her tight schedule, and stated that
she had researched cataract surgery and surgeons carefully, and
concluded that the risk was far lower than that of her usual occupation.
She was prepared to sign whatever consent I wanted to give her. Her
result was excellent and her joy at recovering bilateral excellent vision
in one day so dramatic that I decided to offer ISBCS to selected patients,
and soon after to all patients. To date I have performed over 9,000
phacoemulsification procedures as ISBCS, and have never encountered
Tou ch MEd ica l MEdia
4. Intracameral antibiotics are used in every case.
Complete sterile separation of the two procedures is critical, with
reprepping and redraping between eyes, the use of different sets
of instruments and different lots of balanced salt solution (BSS),
disposables, and ophthalmic viscosurgical devices (OVDs).
If any unmanaged complication occurs with the first eye, the
second eye is deferred. (This has been an extremely rare
occurrence—perhaps five in nearly 20 years, and most of those
due to nonocular issues: patient complaint of sore back, our
instructions to the patient not having been properly translated to
a non-English speaking patient by the family, etc.)
Information of right and left eye intraocular lens (IOL) and
astigmatism clearly marked on a board in the operating room (OR)
for all staff to see. OR nurses are trained to read and interpret
biometric data, which they read out loud as they pass the IOL from
the circulating table to the scrub nurse, confirming IOL choice. We
have had no IOL errors since adopting this policy.