Editor—Gray et al highlighted the benefit of bilateral cataract surgery, particularly if the second eye is operated on within six weeks of the first.1
We agree with their view that surgery should be directed at those with most need. Nevertheless, Gray et al also recognise that an increase in the availability of cataract surgery would help to satisfy increased demand. A step towards achieving this and accomplishing surgery in both eyes is simultaneous bilateral cataract extraction. Although this does not greatly reduce operating time, it halves the number of outpatient visits required. However, simultaneous bilateral extraction is controversial, as shown when the issue was raised in the Journal of Cataract and Refractive Surgery in 1997.2,3
Most conservative surgeons agree that simultaneous extraction is appropriate only in unusual circumstances—for example, when the surgery requires general anaesthesia and repeated general anaesthesia represents a risk to the patient. The principal concern which prevents many surgeons adopting simultaneous extraction is the risk of potentially blinding bilateral postoperative infection: endophthalmitis.
A study of 316 cases of simultaneous bilateral extraction indicated a low incidence of complications, and although endophthalmitis occurred in one case, it was unilateral.4 Despite this, most cataract extractions in the United Kingdom 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 after surgery, serious infection with pathogenic bacteria usually occurs within 48 hours.5
A further concern about simultaneous extraction is the inability to alter the choice of power of intraocular lens placed in the second eye based on experience with the first. Our eye department offers patients presenting with bilateral cataracts surgery on one eye at a time but on consecutive operating lists 48 hours apart. We feel that this avoids or reduces the perceived risks and problems of simultaneous extraction. At the same time it achieves the benefits of halving outpatient visits and performing surgery on both eyes in close succession. To date, we have not experienced any cases of endophthalmitis in this group of patients.
References
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