Bilateral Same Day Cataract Surgery: An Idea Whose Time Has
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COVID-19 shut down the world with that, the delivery of healthcare dramatically changed, perhaps forever. Cataract surgeons have instituted many changes in practice during COVID-19. The move to more digitized and virtual healthcare delivery, online education tools, electronic intake, consolidating in-person visits, and increased spacing between cases have become the norm for cataract surgery. The one change in practice that could have the most significant benefit in reducing infection exposure risk is immediate sequential bilateral cataract surgery (ISBCS). Furthermore, ISBCS is less expensive, reduces PPE burn, is more efficient, and provides faster binocular recovery of vision for the patient.

ISBCS has been debated for years, while the evidence in its support has grown over time. Hospitals achieve higher productivity and cost savings of over 30% when performing ISBCS instead of delayed sequential bilateral cataracts surgery (DSBCS). The new normal of the COVID-19 era requires extra spacing, cleaning, and time between cases, resulting in increased costs. When considering the additional patient costs for travel, family/caregiver time, and absence from work with the extra postoperative visits and recovery requirements of DSBCS, the cost efficiency is even greater with ISBCS.

The principles of safe ISBCS have been laid out by the International Society of Bilateral Cataract Surgeons. They include treating each eye as a separate independent procedure with new instruments, packs, gloves, gowns, drapes, and different lot numbers for pharmaceuticals and viscoelastics. Intracameral antibiotics are recommended. Caution is suggested in those eyes with a higher risk of refractive surprises (prior refractive surgery, extreme axial lengths), and increased risk of complications due to ocular co-morbidities. If there is a complication in the first eye of a planned ISBCS unresolved at the time of surgery, it is advised to defer the second eye.

Opponents who argue against ISBCS argue on two clinical points: the risk of bilateral postoperative endophthalmitis or TASS, and second eye refractive planning. However, there is no evidence to substantiate these fears. There have been no cases of bilateral endophthalmitis where the proper aseptic technique had been followed, nor has there been any cases of bilateral TASS reported with ISBCS. In a series of 95,606 ISBCS surgeries, there were no bilateral endophthalmitis cases. The overall infection rate was 1 in 16,890 (0.006%) with the use of intracameral antibiotics.7 The theoretical risk of simultaneous bilateral postoperative endophthalmitis with proper aseptic technique is estimated to be less than 1 in 100,000,000.

Ocular risks must be compared with systemic risks, as rare as either may be. Anesthesia and traveling risks are doubled with DSBCS versus ISCBS. Currently, the most feared and substantial systemic risk during the pandemic era is COVID-19 exposure. After the initial consultation and diagnostic testing, ISBCS reduces the number of patient visits (including waiting), and contact exposures by half. Exposure to other patients is critical for our elderly cataract population, whose risk of dying is higher with COVID-19 infection. In support of ISBCS, a recent sizeable comparative study found that ISBCS performed no worse than DSBCS for postoperative BCVA, refractive error, or complications.