Benefits and risks of immediately sequential bilateral cataract surgery: a literature review

Low vision devices for age-related macular degeneration: a systematic review

PURPOSE

Age-related macular degeneration (AMD) is a degenerative condition impacting central vision. Evaluating the effectiveness of low vision devices provides empirical evidence on how devices can rehabilitate and overcome deficits caused by AMD. This evidence could help to facilitate discussion on necessary future improvements to vision enhancement technology.

METHODS

A systematic review of the literature was conducted on low vision device use in AMD populations. Relevant peer-reviewed research articles from six databases were screened.

RESULTS

The findings of thirty-five studies revealed a significant positive impact of low vision devices leading to improvements in visual acuity, reading performance, facial recognition, and more. While the studies were found to have moderate risks of bias, a GRADE assessment of the evidence suggested the certainty of the evidence was low-moderate.

DISCUSSION

Simple hand-held low vision devices (e.g., magnifiers) appear to currently have greater preferential support than newer visual enhancement technology (e.g., head mounted devices). Financial, comfort or usability reasons may influence preferences more than performance-based findings. However, there is a lack of studies examining newer technologies in AMD populations, which future research should address. Moreover, given the presence of bias across the studies and limited controlled experiments, confidence in the results may be low.

CONCLUSIONS

Most studies indicated that low vision devices have positive impacts on reading and visual performance. But, even though they are reported to be a valuable asset to AMD populations, more rigorous research is required to draw conclusive evidence. IMPLICATIONS FOR REHABILITATIONLow vision devices can improve patient outcomes (e.g., vision, reading ability) for age-related macular degeneration populations.A multidisciplinary combination of low vision devices and rehabilitative services (i.e., eccentric viewing training, counselling, education) may enhance quality of life.

Patient satisfaction and attitudes towards immediate sequential bilateral cataract surgery

PURPOSE

To investigate patients' first-hand experience, satisfaction and attitudes towards immediate sequential bilateral cataract surgery (ISBCS).

SETTING

Royal Bournemouth Hospital, University Hospitals Dorset NHS Foundation Trust, Castle Lane East, Bournemouth, UK.

DESIGN

Retrospective study using semi-structured phone interviews and qualitative content analysis.

METHODS

Semi-structured telephone interviews were conducted by an independent interviewer, to explore patients' experiences of ISBCS, at least four weeks postoperatively. The open-ended responses were analysed using qualitative content analysis. Categories and meaning units were tabulated, with the number and percentage of patients contributing to each category provided.

RESULTS

25 patients were included. All patients rated their overall satisfaction of ISBCS as 'very satisfied' and would opt again to have both eyes operated on the same day. 22 patients (88%) reported a 'very good/comfortable' surgery experience. After surgery, 24 patients (96%) felt completely safe going home, with most organizing for family or friends to drive them home. None of the patients experienced any complications in the postoperative period. 24 patients (96%) experienced only minimal reduction in accomplishing daily living activities after surgery and 24 patients (96%) said they would recommend ISBCS to family and friends.

CONCLUSION

The results support wider implementation of ISBCS from the patient's perspective and experience. Providing written information addressing common themes and concerns is recommended to increase patient acceptance and uptake of ISBCS preoperatively.

Immediate Sequential Bilateral Surgery in Refractive Lens Exchange Patients: Clinical Outcomes and Adverse Events

PURPOSE

To evaluate outcomes and the incidence of adverse events (AEs) in patients who underwent bilateral same-day refractive lens exchange (RLE).

DESIGN

Retrospective case series.

PARTICIPANTS

Patients of a private intraocular surgery provider in the United Kingdom who underwent RLE in both eyes on the same day with treatment dates between March 2018 and December 2021.

METHODS

Clinical outcomes and AEs were collected for a continuous cohort of patients undergoing bilateral same-day RLE (in the absence of visually significant cataracts) or had mild cataracts (corrected visual acuity ≥ 20/40). One-month clinical outcomes were analyzed.

MAIN OUTCOME MEASURES

Refractive outcomes and visual acuity, intraoperative and postoperative AEs, and secondary surgical interventions recorded within the first month after surgery.

RESULTS

A total of 17 330 patients (34 660 eyes) were included in the analysis. Of these, 28 827 eyes received a multifocal intraocular lens (IOL), and 5833 eyes had a monofocal IOL. The percentage of eyes within ±0.50 diopters (D) of intended refraction was 85.5% and 86.2% for monofocal and multifocal IOL eyes, respectively. There was a total of 55 intraoperative AEs recorded in 55 eyes of 54 patients (per-eye incidence: 0.159%). Posterior capsule tear was the most common intraoperative event occurring in 37 eyes (0.107%). The number of AEs recorded within the first postoperative month was 267, occurring in 263 eyes of 177 patients (per-eye incidence: 0.759%). These included cystoid macular edema (CME) (172 eyes; 0.496%), significant corneal edema (28 eyes; 0.081%), persistent inflammation (27 eyes; 0.078%), significantly raised intraocular pressure (27 eyes; 0.078%), toxic anterior segment syndrome (8 eyes; 0.023%), wound leak (3 eyes; 0.009%), retinal detachment (1 eye; 0.003%), and retinal tear (1 eye; 0.003%). There were 56 secondary surgical interventions recorded within the first month of surgery, occurring in 54 eyes of 47 patients (per-eye incidence: 0.156%). The most common secondary intervention was the rotation of a misaligned toric IOL (24 eyes; 0.069%).

CONCLUSIONS

Elective same-day bilateral RLE had a low incidence of serious AEs, and high refractive predictability.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Pros and Cons of Immediate Sequential Bilateral Cataract Surgery from a Patient Perspective: A Survey

The aim of the study was to analyze patients' experiences with immediate sequential bilateral cataract surgery (ISBCS). An anonymous survey was sent by post to patients who underwent ISBCS between 1 May 2020 and 30 April 2022. A total of 195 participants completed the survey. Specifically, 94.6% of the respondents were satisfied with the possibility of having both eyes treated during one surgical procedure, 89.7% would choose ISBCS again if offered a choice, and 89.2% would recommend this procedure to their family members. ISBCS provided a subjective benefit for 84.6% of the respondents. The most commonly reported ISBCS-related problems were the necessity to sleep in a supine position (32.8%), inability to read shortly after the surgery (27.7%), having both eyes protected with a dressing (24.6%), and application of eyedrops to both eyes at the same time (17.4%). All patients were able to identify some pros of ISBCS, with the most common being single stay in the operating room (82.6%), lower number of visits to the clinic (62.6%), quick normalization of eyesight (61%), time savings for family members (54.9%), quick adjustment of reading glasses (32.3%), and economical aspects (23.6%). The perception of difficulties associated with ISBCS and the benefits offered by this procedure differed depending on patients' gender, age, marital status, education, place of residence, occupational activity, level of care dependence, and everyday activities. Understanding patients' opinions about ISBCS provides insight into the advantages and disadvantages of this procedure from a broader perspective.

Comparisons of outcomes and complications of immediate sequential bilateral cataract surgery and unilateral cataract surgery in a tertiary hospital in South Korea

We investigated the proportions of immediate sequential bilateral cataract surgery (ISBCS) and unilateral cataract surgery during the coronavirus disease 2019 pandemic and compared visual outcomes between the two groups in a tertiary hospital in South Korea. We reviewed 441 cataract surgeries performed between March 1, 2021, and October 31, 2021, at Korea University Guro Hospital by a single surgeon (J.S.S). Medical records of demographics, preoperative visual acuity, corneal astigmatism, axial length, preoperative spherical equivalent, preoperative target (using Barrett's Universal 2 formula), postoperative visual acuity, postoperative refractive error, and postoperative complications were evaluated. Among all patients, 322 (73.0%) eyes underwent ISBCS, and 119 (27.0%) eyes underwent unilateral cataract surgery. The preoperative corrective distance visual acuity (CDVA) was lower in the unilateral cataract surgery group (0.40 ± 0.45 logMAR) than the ISBCS group (0.28 ± 0.16 logMAR, P = 0.008), whereas there was no significant difference in postoperative CDVA between the two groups (0.06 ± 0.10 logMAR vs. 0.07 ± 0.16 logMAR, P = 0.63). There was also no difference in the absolute refractive error between the two groups (0.46 ± 0.37 diopters [D] vs. 0.42 ± 0.38 D, P = 0.63). The preoperative CDVA (P = 0.000) was the significant factor influencing absolute refractive error (r = 0.191, P < 0.001). There was no difference in complications between the two groups, although two patients in the ISBCS group complained of postoperative strabismus.

Immediate or Delayed Sequential Bilateral ICL Surgery: a Survey of Chinese Ophthalmologists

INTRODUCTION

In China, the demand for implantable collamer lens (ICL) surgery is booming. Immediate sequential bilateral ICL surgery (ISBICLS) benefits patients and clinics, but it remains controversial and lacks standardization. We aim to investigate the prevalence of, factors for, and surgeon attitudes toward ISBICLS.

METHODS

In this cross-sectional survey study, an electronic questionnaire about the practice and attitudes toward performing ISBICLS or delayed sequential bilateral ICL surgery (DSBICLS) was distributed to 792 qualified ICL surgeons in Mainland China, between 4 April and 22 April 2022.

RESULTS

A total of 531 surgeons (66.79%) from 30 provinces in Mainland China responded. Among them, 374 (67.23%) were currently performing ISBICLS. Fifty-two percent (277) of surgeons reported performing ISBICLS more than 50% of the time, while 85.05% of surgeons chose to perform the second eye surgery 1 day after the first eye surgery. Seventy percent (248) of surgeons performing ISBICLS chose to perform the second eye surgery less than 30 min after the first eye surgery. Surgeons who started ICL surgery earlier (before 2010, OR = 2.772, 95% CI = 1.290-5.957, P = 0.009; 2011-2013, OR = 2.479, 95% CI = 1.060-5.800, P = 0.036), completed one-eye ICL surgery faster (< 3 min, OR = 3.936, 95% CI = 1.505-10.293, P = 0.005) and modified the second eye ICL selection less frequently (1-25%, OR = 0.203, 95% CI = 0.054-0.771, P = 0.019; 26-50%, OR = 0.173, 95% CI = 0.041-0.726, P = 0.017; 51-75%, OR = 0.299, 95% CI = 0.041-0.726, P = 0.123; 76-100%, OR = 0.163, 95% CI = 0.039-0.688, P = 0.014) tended to perform ISBICLS. No significant association was found among clinical settings, preoperative measurement devices, and hospital policies with performing ISBICLS. Regarding their attitudes toward ISBICLS, 54.63% preferred ISBICLS and 45.37% preferred DSBICLS. The main supporting reasons were patient convenience (98.64%), faster vision rehabilitation (73.56%), and improved perioperative compliance (73.22%). The concerns regarding ISBICLS included the risk of endophthalmitis (62.22%), lack of recommendation in expert consensus (61.67%), and decreased vault predictability (60.93%). The most common desires for further adoption were expert consensus on surgical criteria and patient indicators for ISBICLS (82.3%).

CONCLUSIONS

ISBICLS has been gradually adopted in Mainland China, but has not been widely accepted as a routine procedure. Surgeons' experience and skills mainly influence whether ISBICLS is performed. Further research is needed to explore standardized protocols to prevent endophthalmitis, the appropriate time interval of two eye surgery, and requisitions for surgeon skills.

Visual recovery after immediate sequential bilateral cataract surgery at a veterans' hospital

PURPOSE

To answer patient questions about the expected timeline for recovery, the objective postoperative visual acuities were reviewed for patients undergoing immediate sequential bilateral cataract surgery (ISBCS).

SETTING

Harry S. Truman Memorial Veterans' Hospital, Columbia, Missouri.

DESIGN

Retrospective chart review.

METHODS

All patients who underwent ISBCS in 2019 were evaluated. A total of 116 patients (232 eyes) were studied. Uncorrected distance visual acuity (UDVA) for postoperative day 0 or 1 (POD0/1), postoperative week 1 (POW1), and postoperative month 1 (POM1) were required for study inclusion. Patients with ocular comorbidities were not excluded, although all patients passed an initial screening to qualify for ISBCS. The outcome measures included POD0/1, POW1, and POM1 UDVA.

RESULTS

Postoperative UDVA was stable or improved compared with preoperative corrected distance visual acuity (CDVA) for 48% (66/138) of eyes on POD0, 79% (74/94) of eyes on POD1, and 90% (209/232) of eyes on POW1. 83% of patients at POD1 and 90% of patients at POW1 had stable or improved visual acuity in at least 1 eye. 92% (214/232) of eyes had a POW1 UDVA of 20/40 or better. Of the 18 eyes with a postoperative POW1 UDVA of 20/50 or worse, 5 (28%) were known preoperatively to have limited visual potential. 99% (115/116) of patients had at least 1 eye 20/40 or better.

CONCLUSIONS

Most of the patients who underwent ISBCS demonstrated meaningful improvement in UDVA compared with preoperative CDVA as early as POD1. These results serve to guide discussion of postoperative expectations with patients interested in ISBCS.

Immediate Sequential Bilateral Cataract Surgery: Opinions among Refractive Surgeons in the United States and a Comparative Analysis with European Consultants

Purpose

To analyze the perspectives of practicing refractive surgeons regarding the implementation of Immediate Sequential Bilateral Cataract Surgery (ISBCS) in the United States (US) and to compare their perspectives with those of European colleagues. Setting. Online refractive surgery forum.

Design

A survey-based questionnaire.

Methods

An electronic survey was emailed to all surgeon members of the Refractive Surgery Alliance (RSA) in the US. Participants were prompted to score their impressions regarding various aspects regarding ISBCS. Responses were compared to published reports conducted among European surgeons.

Results

The electronic link to the survey was emailed to US-based surgeon members of the RSA, where 107 participated (44.6%). Twenty-seven (25.2%) reported that they currently perform ISBCS. Twenty-three (22.5%) of the respondents indicated they felt ISCBCS should be offered as a standard of care for routine cataract surgery. For surgeons that do not perform ISBCS, the most important factors were related to medicolegal issues and decreased reimbursement, whereas evidence of effectiveness and complications related to ISBCS were less important. Compared to practitioners abroad, 67.2% of European ophthalmic surgeons, compared to 25.2% of US surgeons, perform ISBCS (p < 0.0001).

Conclusions

While US refractive surgeons often perform bilateral corneal procedures, many significant barriers exist to the widespread adoption of ISBCS. Concerns reported by US surgeons mirror those reported by surgeons in Europe. The majority of the US refractive surgeons in this survey indicate that ISBCS should not be the standard of care in routine cases, with the prevailing reason being concerns about decreased physician reimbursement and potential medicolegal issues, not safety.

Immediate sequential bilateral surgery versus delayed sequential bilateral surgery for cataracts

BACKGROUND

Age-related cataract affects both eyes in most cases. Most people undergo cataract surgery in both eyes on separate days, referred to as delayed sequential bilateral cataract surgery (DSBCS). An alternative procedure involves operating on both eyes on the same day, but as two separate procedures, known as immediate sequential bilateral cataract surgery (ISBCS). Potential advantages of ISBCS include fewer hospital visits for the patient, faster visual recovery, and lower healthcare costs. Nevertheless, concerns exist about possible bilateral, postoperative, sight-threatening adverse effects with ISBCS. Therefore, there is a clear need for evaluating evidence regarding the safety, effectiveness, and cost-effectiveness of ISBCS versus DSBCS.

OBJECTIVES

To assess the safety of ISBCS compared to DSBCS in people with bilateral age-related cataracts and to summarise current evidence for the incremental resource use, utilities, costs, and cost-effectiveness associated with the use of ISBCS compared to DSBCS in people with bilateral age-related cataracts (primary objectives). The secondary objective was to assess visual and patient-reported outcomes of ISBCS compared to DSBCS in people with bilateral age-related cataracts.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 5); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov; the WHO ICTRP; and DARE and NHS EED on the CRD Database on 11 May 2021. There were no language restrictions. We limited the searches to a date range of 2007 onwards.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) to assess complications, refractive outcomes, best-corrected distance visual acuity (BCDVA) and patient-reported outcome measures (PROMs) with ISBCS compared to DSBCS. We included non-randomised (NRSs), prospective, and retrospective cohort studies comparing ISBCS and DSBCS for safety assessment, because of the rare incidence of important adverse events. To assess cost-effectiveness of ISBCS compared to DSBCS, we included both full and partial economic evaluations, and both trial-based and model-based economic evaluations.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures and assessed risk of bias for NRSs using the ROBINS-I tool. For cost-evaluations, we used the CHEC-list, the CHEERS-checklist, and the NICE-checklist to investigate risk of bias. We assessed the certainty of evidence with the GRADE tool. We reported results for economic evaluations narratively.

MAIN RESULTS

We included 14 studies in the review; two RCTs, seven NRSs, and six economic evaluations (one study was both an NRS and economic evaluation). The studies reported on 276,260 participants (7384 for ISBCS and 268,876 for DSBCS) and were conducted in Canada, the Czech Republic, Finland, Iran, (South) Korea, Spain (Canary Islands), Sweden, the UK, and the USA. Overall, we considered the included RCTs to be at 'high to some concerns' risk of bias for complications, 'some concerns' risk of bias for refractive outcomes and visual acuity, and 'high' risk of bias for PROMs. The overall risk of bias for NRSs was graded 'serious' regarding complications and 'serious to critical' regarding refractive outcomes.  With regard to endophthalmitis, we found that relative effects were estimated imprecisely and with low certainty, so that relative estimates were not reliable. Nonetheless, we found a very low risk of endophthalmitis in both ISBCS (1/14,076 participants) and DSBCS (55/556,246 participants) groups. Based on descriptive evidence and partially weak statistical evidence we found no evidence of an increased risk of endophthalmitis with ISBCS. Regarding refractive outcomes, we found moderate-certainty (RCTs) and low-certainty (NRSs) evidence there was no difference in the percentage of eyes that did not achieve refraction within 1.0 dioptre of target one to three months after surgery (RCTs: risk ratio (RR) 0.84, 95% confidence interval (CI) 0.57 to 1.26; NRSs: RR 1.02, 95% CI 0.60 to 1.75). Similarly, postoperative complications did not differ between groups (RCTs: RR 1.33, 95% CI 0.52 to 3.40; NRSs: 1.04, 95% CI 0.47 to 2.29), although the certainty of this evidence was very low for both RCTs and NRSs. Furthermore, we found low-certainty (RCTs) to very low-certainty (NRSs) evidence that total costs per participant were lower for ISBCS compared to DSBCS, although results of individual studies could not be pooled. Only one study reported on cost-effectiveness. This study found that ISBCS is cost-effective compared to DSBCS, but did not measure quality-adjusted life years using preferred methods and calculated costs erroneously. Finally, regarding secondary outcomes, we found limited evidence on BCDVA (data of two RCTs could not be pooled, although both studies individually found no difference between groups (very low-certainty evidence)). Regarding PROMs, we found moderate-certainty evidence (RCTs only) that there was no difference between groups one to three months after surgery (standardised mean difference -0.08, 95% CI -0.19 to 0.03).

AUTHORS' CONCLUSIONS

Current evidence supports there are probably no clinically important differences in outcomes between ISBCS and DSBCS, but with lower costs for ISBCS. However, the amount of evidence is limited, and the certainty of the evidence was graded moderate to very low. In addition, there is a need for well-designed cost-effectiveness studies.

Patient Attitudes and Desirability Regarding Immediate Sequential Bilateral Cataract Surgery

Purpose

To analyze patient attitudes and desirability regarding routine immediate sequential bilateral cataract surgery (ISBCS).

Methods

This study was conducted as a prospective, consecutive survey-based case series from a single private practice institution serving a mostly rural population. A standardized phone survey assessing patient perspectives on ISBCS was administered to patients before and after routine delayed sequential bilateral cataract surgery (DSBCS) was performed. Subject responses were analyzed, including a subset analysis on patient responses under a variety of circumstances.

Results

There were 61 patients enrolled into the study and 47 completed the surveys before and after routine DSBCS (77.0% completion rate). Thirty-nine (83.0%) of respondents had a favorable outlook of ISBCS preoperatively, whereas 36 (76.6%) had a favorable outlook of ISBCS postoperatively (p>0.05). On the postoperative questionnaire, twenty-five (53.2%) of respondents were willing to accept additional surgical risk if necessary to receive ISBCS, and this finding was significant between the subgroup of patients with systemic health co-morbidities compared to those without systemic health co-morbidities (p=0.05).

Conclusion

Most patients had a favorable outlook of ISBCS before and after undergoing DSBCS. Patients with underlying systemic health co-morbidities were most likely to accept additional surgical risk if necessary to receive ISBCS. From a patient’s perspective, ISBCS may be an acceptable option to routinely implement when cataract surgery is required for both eyes.

Endophthalmitis Rate in Immediately Sequential versus Delayed Sequential Bilateral Cataract Surgery within the Intelligent Research in Sight (IRIS®) Registry Data

PURPOSE

To compare the rate of postoperative endophthalmitis after immediately sequential bilateral cataract surgery (ISBCS) versus delayed sequential bilateral cataract surgery (DSBCS) using the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry database.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients in the IRIS Registry who underwent cataract surgery from 2013 through 2018.

METHODS

Patients who underwent cataract surgery were divided into 2 groups: (1) ISBCS and (2) DSBCS (second-eye surgery ≥1 day after the first-eye surgery) or unilateral surgery. Postoperative endophthalmitis was defined as endophthalmitis occurring within 4 weeks of surgery by International Classification of Diseases (ICD) code and ICD code with additional clinical criteria.

MAIN OUTCOME MEASURES

Rate of postoperative endophthalmitis.

RESULTS

Of 5 573 639 IRIS Registry patients who underwent cataract extraction, 165 609 underwent ISBCS, and 5 408 030 underwent DSBCS or unilateral surgery (3 695 440 DSBCS, 1 712 590 unilateral surgery only). A total of 3102 participants (0.056%) met study criteria of postoperative endophthalmitis with supporting clinical findings. The rates of endophthalmitis in either surgery eye between the 2 surgery groups were similar (0.059% in the ISBCS group vs. 0.056% in the DSBCS or unilateral group; P = 0.53). Although the incidence of endophthalmitis was slightly higher in the ISBCS group compared with the DSBCS or unilateral group, the odds ratio did not reach statistical significance (1.08; 95% confidence interval, 0.87-1.31; P = 0.47) after adjusting for age, sex, race, insurance status, and comorbid eye disease. Seven cases of bilateral endophthalmitis with supporting clinical data in the DSBCS group and no cases in the ISBCS group were identified.

CONCLUSIONS

Risk of postoperative endophthalmitis was not statistically significantly different between patients who underwent ISBCS and DSBCS or unilateral cataract surgery.

Trends, Factors, and Outcomes Associated with Immediate Sequential Bilateral Cataract Surgery (ISBCS) Among Medicare Beneficiaries

PURPOSE

To report the incidence of immediate (ISBCS) and delayed sequential bilateral cataract surgery (DSBCS) and identify factors associated with undergoing ISBCS.

DESIGN

Retrospective cohort study.

SUBJECTS

Medicare beneficiaries aged ≥65 who underwent ISBCS and DSBCS from 2011 to 2019.

METHODS

Population-based analysis of the 100% Medicare fee-for-service carrier claims data. Logistic regression models were performed to evaluate factors associated with ISBCS.

MAIN OUTCOME MEASURES

1) Incidence of ISBCS and DSBCS, 2) demographic, ocular and medical characteristics associated with receipt of ISBCS, and 3) rates of endophthalmitis and cystoid macular edema (CME) after ISBCS or DSBCS.

RESULTS

A total of 4,014 (0.2%) ISBCS and 1,944,979 (99.8%) DSBCS patients were identified. Black (OR:2.31, 95%CI: 2.06-2.59), Asian (OR:1.82, 95%CI: 1.51-2.12), or Native American (OR:2.42, 95%CI: 1.81-3.23) patients were more likely to receive ISBCS compared to White patients. Patients residing in rural areas had higher likelihood of ISBCS (OR:1.26, 95%CI: 1.17-1.35) compared to metropolitan areas. Patients operated at a hospital compared to ambulatory setting (OR:2.71, 95%CI: 2.53-2.89) were more likely to receive ISBCS. Patients with bilateral complex vs. non-complex cataract (OR:3.23, 95%CI: 2.95-3.53) were more likely to receive ISBCS. Patients with a Charlson comorbidity index (CCI) of 1-2 (OR:1.45, 95%CI: 1.29-1.62), 3-4 (OR:1.70, 95%CI: 1.47-1.97), 5-6 (OR:1.97, 95%CI: 1.62-2.39), and CCI≥7 (OR:1.97, 95%CI: 1.55-2.50) were all more likely to receive ISBCS compared to those with CCI=0. In contrast, patients with glaucoma (OR:0.82, 95%CI: 0.76-0.89), macular degeneration (OR:0.75, 95%CI: 0.68-0.82), and macular hole/epiretinal membrane (OR:0.55, 95%CI: 0.48-0.65) were less likely to undergo ISBCS compared to those without. Cumulatively, there was no significant difference in endophthalmitis rate within 42 days between ISBCS (1.74 per 1,000 ISBCS) and DSBCS (1.01 per 1,000 DSBCS; p=0.15). Similarly, there was no significant cumulative difference between ISBCS (1.79 per 100 ISBCS) and DSBCS (1.96 per 100 DSBCS) CME rates (p=0.48).

CONCLUSION

Overall utilization of ISBCS among Medicare beneficiaries remains low over the past decade, though rates of endophthalmitis and CME were comparable to DSBCS. Race, geography, systemic and ocular comorbidities were associated with receiving ISBCS. ISBCS represents a potential opportunity to improve access to cataract surgery.

Visual acuity and quality of life in heavy visual workload patients with bilateral cataract before and after phacoemulsification

BACKGROUND: To date, there is a number of debatable aspects of cataract phacoemulsification in the literature, one of which is the investigation of features of the surgery in patients with visually stressful work. AIM: The aim is to investigate the dynamics of the best corrected distance visual acuity and quality of life in heavy visual workload patients with bilateral cataract before and after phacoemulsification. MATERIALS AND METHODS: We observed 32 heavy visual workload patients with binocular cataracts. All patients underwent standard phacoemulsification using Infiniti (Alcon, USA) or Constellation (Alcon, USA) devices according to the standard technique. The quality of life was assessed using the tested in refractive surgery QOL-25 questionnaire. RESULTS: The high efficiency of phacoemulsification surgery was established, which is confirmed (14 days after the second procedure) by an increase in best corrected distance visual acuity to an average value of 0.920.95 relative units. Along with this, a certain quality of life dynamics of was revealed, which is manifested by a statistically significant deterioration (by 2.34.7%, p = 0.020.008) in the index in 14 and 21 days after the first surgical procedure compared to the data obtained at 7 days after first operation. CONCLUSION: Surgical treatment of binocular cataracts in heavy visual workload patients is based on earlier (in 710 days) surgery on the second eye or performing an immediately sequential bilateral cataract surgery.

Immediate Sequential Bilateral Vitrectomy Surgery for Retinopathy of Prematurity: A Single Surgeon Experience

Objectives:

We report the safety and efficacy of simultaneous bilateral vitrectomy for stage 4 and stage 5 retinopathy of prematurity (ROP).

Materials and Methods:

Babies who had immediate sequential bilateral vitrectomy surgery for stage 4 or stage 5 ROP were included in this retrospective study. Clinical history, demographic characteristics of the patients, surgical procedure details, perioperative and postoperative ophthalmic and systemic complications, and postoperative anatomical success rates were evaluated. General anesthesia features were also recorded.

Results:

Seventy eyes of 35 babies who had immediate sequential bilateral vitrectomy surgery for stage 4 or stage 5 ROP were reviewed. At the time of surgery, the mean age was 41.4±4.9 weeks. There was preoperative plus disease in 58.6% of the eyes. The mean surgery/eye ratio was 1.2. Mean anesthesia time was 95±64 minutes. The mean follow-up was 28.1 months (3 to 84 months). Anatomical success was 95.7% for stage 4A (44/46 eyes), 83.3% for stage 4B (15/18 eyes), and 50% for stage 5 (3/6 eyes) ROP. Patients with stage 5 ROP had significantly less anatomical success than stage 4A and 4B (p=0.004). None of the patients had endophthalmitis and anesthesiarelated severe complications.

Conclusion:

Immediate sequential bilateral vitrectomy surgery can be considered an option for patients with active bilateral stage 4 and stage 5 ROP. The risk of endophthalmitis should be weighed against the risks of disease progression and anesthesia-related complications.

Use of Simultaneous Bilateral Cataract Surgery (SBCS) to Optimize Parameters Affecting the Subjective Perception of the Procedure

Introduction

Simultaneous Bilateral Cataract Surgery (SBCS) is still a relatively controversial procedure. The main objection is the risk of bilateral endophthalmitis or bilateral refractive error. However, SBCS has also some advantages (faster visual rehabilitation, lower risk of nosocomial infection, and lower cost). Performing surgery on both eyes in one session has one additional advantage which has not yet been described in the literature (according to the information available to authors). It allows surgeons to distinguish the effect of minor differences in the surgical protocol on the subjective perception of the procedure more accurately, which is a more suitable method than comparing two independent groups of patients.

Purpose

To compare the effect of minor changes in the surgical protocol during SBCS on intraindividual subjective perception of surgery (pain, pressure, glare, and perception of the duration of the surgery).

Methods

During the surgery of the right and left eyes of one patient, we randomly changed one surgical parameter (use of intracameral anesthesia, light intensity of the operating microscope, type of eyelid speculum, creation of the posterior circular capsulorhexis, and communication with the patient during surgery). Patients immediately after both surgeries subjectively evaluated the perception of pain (on the scale 0–10), pressure, and glare (on the scale 0–5) and estimated the duration of the surgery, separately for each eye. Each change was evaluated in a group of 50 patients.

Results

In the control group with no parameters changed, we noted no difference in subjective perception of the first and second surgery. In subgroups, where we changed the protocol, we detected only minor differences in subjective perception of pain, pressure, glare, and duration of the surgery. Only one statistically significant difference in subjective pain perception was in the subgroup where we used eye intracameral anesthesia (0.34 eyes with intracameral anesthesia, 0.44 eyes with only topical anesthesia). We did not note any statistically significant differences in the perception of the time of surgery.

Conclusion

SBCS can be used to optimize the parameters of cataract surgery. In our study, we noted a positive effect of intracameral anesthesia on subjective perception of surgery.

Immediate versus delayed sequential bilateral cataract surgery in children: a cost-effectiveness analysis

BACKGROUND/AIMS

Children with bilateral cataracts may undergo immediate sequential bilateral cataract surgery (ISBCS), which involves surgery on both eyes during the same general anaesthesia, or delayed sequential bilateral cataract surgery (DSBCS), which involves operating on each eye on separate days and requires a second anaesthesia. ISBCS is viewed with caution because of the risk of bilateral endophthalmitis. Proponents of ISBCS emphasise that the incidence of serious complications is low and is outweighed by benefits such as avoidance of multiple anaesthesia, faster visual rehabilitation and potential for decreased costs. However, there is a paucity of literature regarding the cost-effectiveness of ISBCS in children. We conducted a cost-effectiveness analysis to determine whether ISBCS is more cost-effective than DSBCS from the societal and health system perspectives in Ontario, Canada, which has a universal, single-payer system.

METHODS

A retrospective analysis of children who underwent ISBCS or DSBCS at a tertiary referral paediatric hospital was conducted. A decision tree was constructed using TreeAge Pro 2018 software. Clear visual axis was the measure of effectiveness. A time horizon of 8 weeks postoperatively was adopted. Both direct and indirect costs were included.

RESULTS

Fifty-three children were included, 37 in the ISBCS group and 16 in the DSBCS group. ISBCS and DSBCS were equally effective. ISBCS resulted in cost-savings of $3,776 (95% CI:-$4,641 to $12,578) CAD, per patient, from the societal perspective and $2,200 (95% CI:-$5,615 to $10,373) CAD per patient from the health system perspective.

CONCLUSION

ISBCS was less costly than DSBCS from both societal and health system perspectives while being equally effective.

Evolution of and developments in simultaneous bilateral cataract surgery. Update 2020

The debate on role of ‘simultaneous bilateral cataract surgery’ (SBCS) continues. The world population has exponentially increased during last fifty years and average human lifespan has increased by a decade during the last century. This translates to ever increasing geriatric population with its inherent problem of preventable blindness because of cataract formation in the elderly. We are adding to the backlog of cataract surgeries not only in the ‘developing world’ but also in the ‘developed world.’ Times demand that we reconsider our old fashioned approach of staggering bilateral cataract surgeries. Serious, but a potential, risk of simultaneous bilateral infection/endophthalmitis has been the biggest deterrent in acceptance of SBCS as a routine procedure. The opponents of SBCS strongly believe in this argument that has not been documented when strictly followed the recommendations regarding separate procedures of each eye. The advantages of reducing the ever-increasing backlog of preventable/treatable blindness, faster visual recovery, economic benefits to patients as well as health care providers, lesser risk of amblyopia in pediatric population, and decreased risk of as serious a complication as death by exposure to general anesthesia in pediatric and adult population, etc. outweigh the disadvantages of SBCS when compared with ‘delayed bilateral cataract surgery’ (DBCS). SBCS is favored over DBCS in pediatric population and in uncooperative, mentally retarded and physically disabled adults needing general anesthesia to reduce the risks and complications of general anesthesia. Considering such factors and review of available literature strongly support that SBCS has a definite role where indicated, under certain circumstances, and in certain select group of patients in both developing as well as developed countries.

Correlation of binocular refractive error and calculation of intraocular Lens power for the second eye

Background

Reducing refractive error has always been a tricky problem. The aim of this study was to verify the correlation between binocular refractive error (RE) after sequential cataract surgery and explore an individualized calculation method of intraocular lens (IOL) for the second eye.

Methods

This was a prospective study. One hundred eighty-eight affected eyes in 94 age-related cataract patients who underwent sequential cataract surgery in the Department of Ophthalmology, Tangdu Hospital, China, were recruited. Complete case data were included for a correlation analysis of binocular RE. Data obtained in patients with RE values greater than 0.50 diopters (D) in the first eye were extracted and the patients divided randomly into two groups: Group A and B. In the adjustment group, group A, we modified the IOL power for the second eyes as 50% of the RE of the first eye. In group B, the control group, there was no modification. The mean absolute refractive error (MARE) values of the second eyes were evaluated one month after surgery.

Results

The correlation coefficient of the binocular RE after sequential cataract surgery was 0.760 (P < 0.001). After the IOL power of the second eyes was adjusted, the MARE of the second eyes was 0.57 ± 0.41 D, while the MARE of the first eyes was 1.18 ± 0.85 D, and the difference was statistically significant (P < 0.001).

Conclusions

Binocular REs were positively correlated after sequential cataract surgery. The RE of the second eye can be reduced by adjusting the IOL power based on 50% of the postoperative RE of the first eye.

A survey exploring ophthalmologists' attitudes and beliefs in performing Immediately Sequential Bilateral Cataract Surgery in the United Kingdom

BACKGROUND

The standard approach to treat cataracts is Delayed Sequential Bilateral Cataract Surgery (DSBCS), during which patients have a separate operation date for each eye. An alternative method of delivery is Immediately Sequential Bilateral Cataract Surgery (ISBCS). The aim of this project was to examine the attitudes and beliefs of UK ophthalmologists towards ISBCS, explore their reasons to either practise or not practise ISBCS and identify barriers hindering its implementation in the UK.

METHODS

A questionnaire was distributed to consultant members of The Royal College of Ophthalmologists (RCOphth, UK) and collected electronically. An initial screening question in regards to prior experience with ISBCS directed the rest of the survey; participants were asked to rate the importance of several factors with regards to performing ISBCS. Free text options were also available. Descriptive analysis was subsequently performed.

RESULTS

Of the 1357 recipients, 130 (9.6%) ophthalmologists completed the survey. Of those, 13.9% were currently performing ISBCS, 83.1% had never performed, and 3.1% had previously done so but since stopped. The main factors that acted as barriers were lack of: (1) College approval (20.5%); (2) medico-legal approval (20.2%); (3) evidence to support the use of ISBCS (16.0%); and (4) hospital approval (13.3%). Additionally, the perceived risk of complications for patients played an important role when considering ISBCS, with the risk of endophthalmitis being most feared.

CONCLUSIONS

This survey demonstrates some of the barriers that prevent ophthalmologist's performing ISBCS in the UK. There is a need for further exploration in this field to evaluate the effect of addressing any of these concerns on the implementation of ISBCS.

Simultaneous Bilateral Pediatric and Juvenile Cataract Surgery Under General Anesthesia: Outcomes and Safety

PURPOSE

To evaluate the surgical approach, outcome, and safety of bilateral simultaneous cataract surgery (BS-Cat) compared with unilateral cataract surgery (US-Cat) and bilateral 2-timed cataract surgery (BT-Cat) in children.

DESIGN

Retrospective, interventional case series.

METHODS

Setting: Department of Ophthalmology, Medical University, Vienna, Austria.

PARTICIPANTS

Children aged 0-18 years who received cataract extraction owing to a unilateral or bilateral cataract between January 2003 and December 2018 were included. Main Outcomes and Measures: Information regarding the type and duration of surgery and total anesthesia time were recorded. Additionally, intraoperative and postoperative complications including retreatments were evaluated.

RESULTS

A total of 220 eyes of 147 patients were included in this analysis (US-Cat: n = 74 patients; BS-Cat: n = 63 patients; BT-Cat: n = 10 patients). The mean age at surgery was 15.94 ± 27.10 months in the US-Cat group, 33.47 ± 58.20 months in the BS-Cat group, and 41.91 ± 55.09 months in the BT-Cat group. The main surgical approach was lensectomy combined with anterior vitrectomy ± IOL implantation (US-Cat: 98.65%; BS-Cat: 95.24%; BT-Cat: 100%; P = .08). Initial intraocular lens implantation was not commonly performed in all groups (US-Cat: 27.03%; BS-Cat: 23.02%; BT-Cat: 50.00%). The mean anesthesia time was shortest in the US-Cat (91.62 ± 26.12 min), followed by the BS-Cat (123.81 ± 30.11 min) and BT-Cat groups (186.00 ± 42.34 min; P < .001), contrary to the duration of surgery (US-Cat: 37.56 ± 15.69 min; BS-Cat: 32.33 ± 17.31 min; BT-Cat: 37.50 ± 18.67; P = .087). An accidental oxygen decrease below 93% was rare in all groups (US-Cat: 6.76%; BS-Cat: 17.46%; BT-Cat: 10.00%). Intraoperative surgical complications occurred rarely (P = .95) and involved mainly the iris. The number of postoperative complications (P = .17) and interventions (P = .10) was similar in all groups. Visual axis obscuration (US-Cat: 28.38%; BS-Cat: 23.81%; BT-Cat: 20.00%; P = .67) and glaucoma (US-Cat: 6.76%; BS-Cat: 15.87%; BT-Cat: 15.00%; P = .20) showed no difference between the groups. However, nystagmus was more pronounced in the BS-Cat group (US-Cat: 12.16%; BS-Cat: 49.21%; BT-Cat: 20.00%; P < .001), whereas strabismus was more pronounced in the US-Cat group (US-Cat: 68.92%; BS-Cat: 33.33%; BT-Cat: 40.00%; P < .001).

CONCLUSION

Simultaneous removal of bilateral cataract in children showed no statistically significant differences regarding intraoperative and postoperative complications when compared to unilateral and 2-timed bilateral cataract surgery. Anesthesia time was longer in simultaneous bilateral than in unilateral cataract surgery, but only by the surgery time of the second eye. However, prolonged anesthesia time was not accompanied by a decrease of oxygen saturation.

Ginsenosides induce extensive changes in gene expression and inhibit oxidative stress-induced apoptosis in human lens epithelial cells

Background

The effect of ginsenosides on the growth and apoptosis of human lens epithelial (HLE) B3 cells exposed to H₂O₂ was investigated. In addition, the effect of ginsenosides on gene expression in HLE-B3 cells was analyzed using microarray assays to determine its molecular mechanism.

Methods

HLE-B3 cells were treated with 1.75 M H₂O₂ in the presence or absence of 5, 10 or 20 μM ginsenosides. Cell viability and apoptosis were examined by MTT assays and flow cytometry, respectively, at 24 to 120 h after the treatment. Furthermore, HLE-B3 cells were treated with 20 μM ginsenosides for 8 days and total RNA was isolated and analyzed using the Affymetrix GeneChip Array. Principal component analysis was performed to visualize the microarray data.

Results

Addition of ginsenosides significantly alleviated the growth inhibitory effect of H₂O₂ on HLE-B3 cells and the percentage of viable cells was increased by more than 3 folds. Flow cytometric analysis showed that 6.16 ± 0.29% of H₂O₂-treated HLE-B3 cells were early apoptotic cells, and the percentage was reduced to 4.78 ± 0.16% (P < 0.05) in the presence of 20 μM ginsenosides. Principal component analysis revealed that ginsenoside caused extensive changes in gene expression in HLE-B3 cells. A total of 6219 genes showed significant differential expression in HLE-B3 cells treated with ginsenoside; among them, 2552 (41.0%) genes were significantly upregulated, whereas 3667 (59.0%) genes were significantly downregulated. FOXN2, APP and RAD23B were the top three upregulated genes while WSB1, PSME4 and DCAF7 were the top three downregulated genes in HLE-B3 cells treated with ginsenosides.

Conclusion

Ginsenosides induce extensive changes in the expression of genes involved in multiple signaling pathways, including apoptotic signaling pathway and DNA damage response signaling pathway. Ginsenosides alleviate H₂O₂-induced suppression of the growth of HLB cells and inhibit H₂O₂-induced apoptosis of HLB cells.

Surgical outcomes of immediate sequential bilateral vitreoretinal surgery for advancing retinopathy of prematurity

Purpose:

Bilateral eye surgery in the same session may be required for advancing stage 4 retinopathy of prematurity (ROP). The purpose of this study was to evaluate the outcomes of immediate sequential bilateral vitreoretinal surgery (ISBVS) in stage 4 ROP.

Methods:

In a retrospective interventional study at a tertiary care center, 60 eyes of 30 infants who underwent ISBVS for stage 4 ROP between December 2015 and May 2017 were studied. In cases with clear retrolental access, 25G or 27G lens sparing vitrectomy (LSV) was performed and in the rest 25G lensectomy with vitrectomy (LV) was performed through clear corneal entries. The final anatomical outcome measures were the status of tractional retinal detachment (TRD) and macular status.

Results:

The mean gestational age was 28.4 ± 2.0 weeks and birth weight was 1214.5 ± 329.7gms. The mean postconceptional age at surgery was 40.8 ± 2.2 weeks. Stages 4a and 4b were present in 86.7% and 13.3% eyes respectively. LSV was performed in 95% eyes whereas LV was performed in the rest. None of the eyes developed lens touch, choroidal hemorrhage, postoperative hypotony, corneal decompensation, or endophthalmitis. At last follow-up (mean 45 weeks, range 20–68 weeks), macula was attached in 90% eyes with the TRD resolved completely in 61.7% eyes and significantly decreased in another 25% eyes. Sequalae included macular drag, epiretinal membrane, and progression to fibrotic stage 5 disease.

Conclusion:

ISBVS is safe and effective for bilateral stage 4 ROP and should be recommended in rapidly progressive cases.

Re-engineering the Hong Kong Quality of Life Questionnaire to Assess Cataract Surgery Outcomes

PURPOSE

To assess psychometric properties of the Hong Kong Quality of Life Questionnaire (HKQ) using Rasch analysis and use it to assess cataract surgery outcomes.

METHODS

The HKQ was interviewer administered to participants at baseline (preoperative) and 12 months of follow-up (postoperative). Rasch analysis was used to assess and improve psychometric properties of the HKQ using the preoperative data. The responsiveness of the HKQ was assessed on the stacked preoperative and postoperative data, reported with the effect size.

RESULTS

One hundred ninety-nine participants (median age: 72 years; interquartile range: 65 to 78 years) with cataract completed the HKQ at the preoperative assessment. There were more women (58%) and most of the participants had bilateral cataract (83.9%). Nearly half of the participants had undergone surgery in one eye (45.2%) followed by bilateral surgery (38.7%). Psychometric assessment guided by Rasch analysis resulted into a 15-item HKQ with promising psychometric properties including adequate measurement precision (2.09), no misfitting items, near perfect targeting (-0.05), unidimensionality, and with no evidence of item bias. For those who completed the HKQ (n = 82, 41.2%) at the 12-month follow-up visit, all groups demonstrated statistically significant gains in the HKQ scores, with the highest gain in participants who had undergone bilateral surgery (effect size: 2.61).

CONCLUSIONS

The 15-item HKQ was valid and psychometrically sound and might be a highly responsive instrument to measure cataract surgery outcomes in China. This study demonstrated that cataract surgery significantly improves quality of life in the Chinese population. [J Refract Surg. 2018;34(6):413-418.].

Cataracts

An estimated 95 million people worldwide are affected by cataract. Cataract still remains the leading cause of blindness in middle-income and low-income countries. With the advancement of surgical technology and techniques, cataract surgery has evolved to small-incisional surgery with rapid visual recovery, good visual outcomes, and minimal complications in most patients. With the development of advanced technology in intraocular lenses, the combined treatment of cataract and astigmatism or presbyopia, or both, is possible. Paediatric cataracts have a different pathogenesis, surgical concerns, and postoperative clinical course from those of age-related cataracts, and the visual outcome is multifactorial and dependent on postoperative visual rehabilitation. New developments in cataract surgery will continue to improve the visual, anatomical, and patient-reported outcomes. Future work should focus on promoting the accessibility and quality of cataract surgery in developing countries.

Immediate Sequential vs. Delayed Sequential Bilateral Cataract Surgery: Retrospective Comparison of Postoperative Visual Outcomes

OBJECTIVE

We conducted a retrospective comparative-effectiveness study of best-corrected visual acuity (BCVA) and refractive error (RE) after immediate sequential (ISBCS) and delayed sequential (DSBCS) bilateral cataract surgery. We tested 2 hypotheses: (1) among DSBCS patients, second-eye outcomes were no different than first-eye outcomes; (2) averaged between each patient's 2 eyes, outcomes did not differ between ISBCS and DSBCS patients.

DESIGN

Retrospective comparative-effectiveness study.

PARTICIPANTS

Kaiser Permanente Northern California members who underwent noncomplex bilateral cataract surgery from January 1, 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 3561 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 first eyes, 49% of DSBCS second 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 first and second 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 diopter) was achieved in 61% of first DSBCS eyes, 61% of second DSBCS eyes, 63% of ISBCS right eyes, and 63% 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 1 case of postoperative endophthalmitis in 10 494 ISBCS eyes (1.0 per 10 000 eyes) and 2 cases in 38 736 DSBCS eyes (0.5 per 10 000 eyes) (P = 0.6), and no patient had bilateral endophthalmitis.

CONCLUSIONS

Compared with DSBCS, we found no evidence that ISBCS was associated with worse postoperative BCVA or RE, or with an increased complication risk.

Simultaneous Bilateral Cataract Surgery in Outreach Surgical Camps

OBJECTIVES

The aim of this study was to evaluate the safety and visual outcomes of simultaneous bilateral cataract surgery (SBCS) with intraocular lens implantation performed in outreach surgical eye camps.

METHODS

The medical records of 47 consecutive patients who underwent simultaneous bilateral small-incision cataract surgery between January 2010 and December 2015 in outreach surgical camps in rural Cameroon were reviewed. The measures included postoperative visual outcomes and intraoperative and postoperative complications.

RESULTS

Data from 94 eyes of 47 participants (30 men, 17 women; mean age: 60.93 ± 13.58 years, range: 45–80 years) were included in this study. The presented best visual acuity (VA) was less than 3/60 in 100% of the eyes. At the 4-week follow-up, 84.04% of the eyes showed increased VA of 1 line or more (P = .001). Of these, 71 (75.53%) achieved good VA (greater than 6/18). Intraoperative or postoperative complications occurred in 19 (20.21%) eyes. The most serious intraoperative complication was a posterior capsule rupture and vitreous loss (2 patients, 2 eyes). The postoperative complications included a transient elevation in the intraocular pressure (6 eyes), chronic corneal oedema (5 eyes), iris capture (3 eyes), lens decentration (2 eyes), and hyphema (1 eye). No cases of postoperative endophthalmitis were recorded.

CONCLUSIONS

Under the strict observation of endophthalmitis prophylaxis, SBCS is an option to reduce the cataract blindness backlog in rural areas of developing countries.

Pros and cons of immediately sequential bilateral cataract surgery (ISBCS)

Immediately sequential bilateral cataract surgery (ISBCS) is currently a "hot topic" in ophthalmology. There are well-documented advantages in terms of quicker visual rehabilitation and reduced costs. The risk of bilateral simultaneous endophthalmitis and bilateral blindness is now recognized to be minuscule with the advent of intracameral antibiotics and modern management of endophthalmitis. Refractive surprises are rare for normal eyes and with the use of optical biometry. Where a general anesthetic is indicated for cataract surgery, the risk of death from a second anesthetic is much higher than the risk of blindness. A widely recognized protocol from the International Society of Bilateral Cataract Surgeons needs to be adhered to if surgeons wish to start practicing ISBCS.

Immediate Sequential Bilateral Pediatric Vitreoretinal Surgery: An International Multicenter Study

PURPOSE

To determine the feasibility and safety of bilateral simultaneous vitreoretinal surgery in pediatric patients.

DESIGN

International, multicenter, interventional, retrospective case series.

PARTICIPANTS

Patients 17 years of age or younger from 24 centers worldwide who underwent immediate sequential bilateral vitreoretinal surgery (ISBVS)-defined as vitrectomy, scleral buckle, or lensectomy using the vitreous cutter-performed in both eyes sequentially during the same anesthesia session.

METHODS

Clinical history, surgical details and indications, time under anesthesia, and intraoperative and postoperative ophthalmic and systemic adverse events were reviewed.

MAIN OUTCOME MEASURES

Ocular and systemic adverse events.

RESULTS

A total of 344 surgeries from 172 ISBVS procedures in 167 patients were included in the study. The mean age of the cohort was 1.3±2.6 years. Nonexclusive indications for ISBVS were rapidly progressive disease (74.6%), systemic morbidity placing the child at high anesthesia risk (76.0%), and residence remote from surgery location (30.2%). The most common diagnoses were retinopathy of prematurity (ROP; 72.7% [P < 0.01]; stage 3, 4.8%; stage 4A, 44.4%; stage 4B, 22.4%; stage 5, 26.4%), familial exudative vitreoretinopathy (7.0%), abusive head trauma (4.1%), persistent fetal vasculature (3.5%), congenital cataract (1.7%), posterior capsular opacification (1.7%), rhegmatogenous retinal detachment (1.7%), congenital X-linked retinoschisis (1.2%), Norrie disease (2.3%), and viral retinitis (1.2%). Mean surgical time was 143±59 minutes for both eyes. Higher ROP stage correlated with longer surgical time (P = 0.02). There were no reported intraoperative ocular complications. During the immediate postoperative period, 2 eyes from different patients demonstrated unilateral vitreous hemorrhage (0.6%). No cases of endophthalmitis, choroidal hemorrhage, or hypotony occurred. Mean total anesthesia time was 203±87 minutes. There were no cases of anesthesia-related death, malignant hyperthermia, anaphylaxis, or cardiac event. There was 1 case of reintubation (0.6%) and 1 case of prolonged oxygen desaturation (0.6%). Mean follow-up after surgery was 103 weeks, and anatomic success and globe salvage rates were 89.8% and 98.0%, respectively.

CONCLUSIONS

This study found ISBVS to be a feasible and safe treatment paradigm for pediatric patients with bilateral vitreoretinal pathologic features when repeated general anesthesia is undesirable or impractical.