Same-day bilateral cataract surgery?
Increasing evidence for immediate sequence bilateral cataract surgery in selected cases
Performing bilateral cataract procedures in one surgical session appears to be as safe and effective as performing the procedures in two separate sessions on different days, provided that there is good patient selection and appropriate standardised precautions are taken, according to Rudy MMA Nuijts MD, Maastricht University Medical Centre.
“In today’s COVID-19 world, patients should be given an informed option between immediate and delayed-sequence bilateral cataract surgery,” Dr Nuijts told the 38th Congress of the ESCRS.
Proponents of immediate sequential bilateral cataract surgery (ISBCS) argue that it is less expensive for the health providers, is more efficient and provides patients with a faster visual recovery compared to delayed-sequence bilateral cataract surgery (DSBCS), he noted. Additional benefits it offers to patients include less costs for travel, less home care and decreased absence from work. However, there are also those who caution that bilateral cataract surgery could pose medico-legal risks in the event of serious, potentially blinding complications in both eyes.
The bulk of available data indicate that ISBCS poses no additional risk in terms of complications and is as effective in terms of visual outcome for both the first and second eye, Dr Nuijts said. However, he noted that in their responses to the 2019 ESCRS practice survey, 70% of respondents said they never perform ISCBCS, while 19% said they only do it when there are extenuating circumstances such as when general anaesthesia is required or in cases of mental retardation.
A similar survey of cataract surgeons in the Netherlands in 2020, during the COVID period, showed again that 70% of cataract surgeons do not perform ISBCS, and of the 26% who do perform ISBCS, 90% only do so in one-to-five cases per month. On the other hand, 45.6% said that they would consider performing ISBCS in the near future, Dr Nuijts noted.
Dr Nuijts noted that current guidelines in the Netherlands do not allow ISBCS to be performed and for that reason he and his associates, including Lindsay S. Spekreijse MD, have initiated the Bilateral Cataract Study in the Netherlands (BICAT-NL). The multi-centre randomised controlled trial will be conducted in 10 hospitals in the Netherlands and will include 858 patients who will undergo ISBCS or delayed sequence bilateral surgery (DSBCS).
The protocol in the ISBCS arm of the study will follow the 2009 General Principles for Excellence of the International Society of Bilateral Cataract surgeons. That is, in all cases there will be strict separation of instruments, and intraocular medication for the right and left eye. In addition, all eyes will receive standard administration of intracameral antibiotics and the routine in all cases will be to perform the surgery in the right eye first and the left eye second. Furthermore, all reusable surgical instruments will be sterilised using different autoclaves.
The exclusion criteria for the study include eyes with axial lengths less than 21mm or more than 27mm, eyes with previous ocular surgery and eyes with significant comorbidity. Based on these criteria, around 40% of cataract patients would be eligible for ISBCS, as would 25-to-35% of cataract patients at tertiary care centres such as the Maastricht University Hospital, Dr Nuijts noted.
Preliminary results in the 630 patients who have so far been included in the BICAT-NL study show that, when corrected for axial length and baseline visual acuity, there were no significant differences between the outcomes in the second eye in the two treatment groups in terms of subjective refraction and corrected or uncorrected visual acuity.
The proportion of eyes with a postoperative refraction within less than 1.0D of target in the ISBCS group and the DSBCS group was 96.2 % and 96.8%, respectively (p=0.689), and the proportion with a postoperative refraction within less than 0.5D of target refraction was 78.9% and 75.5% respectively (p=0.339).
The mean logMAR visual acuity of the second eye were also very similar in the two groups both for uncorrected (p=858) and best-corrected (p=0.913) visual acuity, the latter value being roughly zero in both groups. Moreover, the proportion with postoperative visual acuity of 0.1 logMAR or better in the ISBCS and DSCBS groups was 49.0% and 48.1%, respectively (p=0.820), without correction and 87.4% and 89.0%, respectively, with best correction.
Adverse events in the ISBCS group included one case of bilateral uveitis (0.0015%) developed at 10.5 weeks postoperatively. Adverse events in the DSBCS group included one case of bilateral corneal decompensation (0.0015%) which developed at six weeks postoperatively, and one case of bilateral macular oedema (0.0015%) which developed at 4.5 weeks postoperatively. There were no cases of endophthalmitis in either group. The two treatment groups had a comparable incidence of mild adverse events such as dry eye and dysphotopsias.
“The preliminary results of our study showed comparable safety and effectiveness for ISBCS and DSBCS. Potential hurdles include product availability, reimbursement issues for surgeons and training young ophthalmologists to perform the procedures,” Dr Nuijts concluded.