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EDITORIALS: C S Gray, H L Crabtree, J E O'Connell, and E D Allen Waiting in the dark: cataract surgery in older people BMJ 1999; 318: 1367-1368 [Full text]

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Avoiding waiting in the dark: simultaneous bilateral cataract extraction?

Andrew Coombes   (24 June 1999)

Avoiding waiting in the dark: simultaneous bilateral cataract extraction? 24 June 1999
Andrew Coombes Send response to journal: Re: Avoiding waiting in the dark: simultaneous bilateral cataract extraction?	EDITOR In their recent editorial, Gray et al highlighted the benefit of bilateral cataract surgery, particularly if the second eye receives surgery within six weeks of the first1. We agree with their view that surgery should be directed towards those with most need. Nevertheless Gray et al also recognise that an increase in the availability of cataract surgery would help to satisfying increased demand. A step towards achieving this and accomplishing surgery in both eyes is simultaneous bilateral cataract extraction (SBCE). While this does not dramatically reduce operating time, it halves the number of required outpatient visits. However, SBCE is a particularly controversial issue. This is apparent from the range of opinions expressed when SBCE was raised in the consultation section of the Journal of Cataract and Refractive Surgery in 19972 and in subsequent letters to the same journal on this subject3. The majority of conservative surgeons agree that SBCE is only appropriate in unusual circumstances, for example, when the surgery requires general anaesthesia (GA) and repeated GA represents a risk to the patient. The principle concern which prevents many surgeons adopting SBCE is the risk of potentially blinding bilateral post-operative infection: endophthalmitis. A study of 316 cases of SBCE indicated a low incidence of complications and although endophthalmitis occurred in one case, it was unilateral4. Despite this, the majority of cataract extractions in the UK are performed on one eye at a time with a gap of many weeks or months until the second eye receives surgery. Endophthalmitis has a low incidence, estimated as 0.1% and, although it may occur at any stage following surgery, serious infection involving pathogenic bacteria usually occurs within 48 hours5. A further concern about SBCE is the inability to alter the choice of intraocular lens implant power placed in the second eye based on experience with the first. Within the Eye Department at St George's Hospital, patients presenting with visual loss due to bilateral cataract are offered surgery one eye at a time, but on consecutive operating lists forty-eight hours apart. We feel that this avoids or reduces the perceived risks and problems of SBCE. At the same time it achieves the benefits of halving outpatient visits and performing surgery to both eyes in close succession. To date, we have not experienced any cases of endophthalmitis in this group of patients. Adam Booth, Senior House Officer in ophthalmology Andrew Coombes, Specialist Registrar in ophthalmology Chad Rostron, Consultant ophthalmologist Department of Ophthalmology St Georges Hospital London SW17 0QT 1 Gray CS, Crabtree HL, O'Connell JE, Allen ED. Waiting in the dark: cataract surgery in older people. BMJ 1999;7195:1367-8. 2 Masket S, ed. Consultation section. J Cataract Refract Surg 1997;23:1437 -41. 3 Responses to Consultation section (letters). J Cataract Refract Surg 1998;24:430-1. 4 Beatty S, Aggarwal RK, David DB, Guarro M, Jones H, Pearce JL. Bilateral simultaneous cataract surgery in the UK. Br J Ophthalmol 1995;79:111-4 5 Kressloff MS, Castellarin AA, Zarbin MA. Endophthalmitis. Surv Ophthalmol 1998;43:193-224