Immediate Sequential Bilateral Surgery Versus Delayed Sequential Bilateral Surgery for Cataracts – Review

Author: Dickman MM, Spekreijse LS, Winkens B, Schouten JS, Simons RW, Dirksen CD, Nuijts RM.

Geographical coverage: Canada, the Czech Republic, Finland, Iran, South Korea, Spain (Canary Islands), Sweden, the UK and the USA.

Sector: Cataract surgery

Sub-sector: Treatment comparison

Equity focus: Not reported

Study population: Patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Not applicable

Background: Age-related cataract is the leading cause of preventable blindness and commonly affects both eyes, markedly diminishing quality of life in older adults. Most patients currently undergo delayed sequential bilateral cataract surgery (DSBCS), with each eye operated on different days. Immediate sequential bilateral cataract surgery (ISBCS) treats both eyes on the same day—still as two separate procedures—thereby reducing hospital visits, accelerating visual recovery, and lowering healthcare costs. Concerns about bilateral complications, notably endophthalmitis, have restricted routine use; for example, US and Canadian guidelines limit ISBCS to exceptional cases, whereas NICE guidance supports it for low-risk patients in the UK. Rising surgical demand from an ageing population makes it timely to reassess the safety and efficiency of ISBCS.

Objective:

Primary objectives were to compare the safety of ISBCS with DSBCS in adults with bilateral age-related cataract and to summarise evidence on incremental resource use, utilities, costs, and cost-effectiveness. A secondary objective was to compare visual and patient-reported outcomes.

Main findings:

Fourteen studies met the inclusion criteria: two randomised controlled trials (RCTs), seven non-randomised studies (NRSs), and six economic evaluations (one study contributed to both categories). Collectively they involved 276 260 participants (7 384 ISBCS; 268 876 DSBCS) from Canada, the Czech Republic, Finland, Iran, South Korea, Spain (Canary Islands), Sweden, the UK and the USA.

Risk of bias for RCTs ranged from high to some concerns for complications, refractive outcomes and visual acuity, and was high for patient-reported outcome measures (PROMs). For NRSs it was serious for complications and serious to critical for refractive outcomes.

Endophthalmitis was exceptionally rare in both groups (ISBCS 1/14 076; DSBCS 55/556 246). No reliable evidence indicated an excess risk with ISBCS (low-certainty).

Refractive accuracy (failure to achieve ±1.0 dioptre of target) did not differ significantly (RCTs: RR 0.84, 95 % CI 0.57–1.26; NRSs: RR 1.02, 95 % CI 0.60–1.75). Post-operative complications were similarly comparable (RCTs: RR 1.33, 95 % CI 0.52–3.40; NRSs: RR 1.04, 95 % CI 0.47–2.29), but certainty was very low.

Limited but consistent evidence suggested lower total costs per participant for ISBCS; one economic evaluation reported ISBCS as cost-effective, though methodological limitations were noted.

Secondary outcomes showed no clinically important differences in best-corrected distance visual acuity or PROMs one to three months after surgery.

Methodology:

Comprehensive searches (CENTRAL, MEDLINE, Embase, ISRCTN, ClinicalTrials.gov, WHO ICTRP, DARE, NHS EED) from 2007 onwards, without language restrictions, identified RCTs, non-RCTs, cohort studies and cost-effectiveness studies comparing ISBCS with DSBCS using phacoemulsification and intra-ocular-lens implantation. Two reviewers independently screened records, extracted data, and assessed quality (ROB-2, ROBINS-I, CHEC/CHEERS/NICE checklists). Random-effects meta-analysis was applied; heterogeneity was explored with χ² and I² statistics. Publication bias was not assessed owing to <10 studies per meta-analysis. Certainty of evidence was judged with GRADE.

Applicability / external validity:

Most studies were conducted in high-income settings using standardised protocols and excluded high-risk patients, limiting generalisability to low-resource environments or complex cases. Variation in surgical technique, antibiotic prophylaxis and follow-up schedules may further influence external validity. More research in low- and middle-income countries is required to confirm safety and cost-effectiveness across diverse contexts.

Geographic focus:

Canada, the Czech Republic, Finland, Iran, South Korea, Spain (Canary Islands), Sweden, the UK and the USA.

Summary of quality assessment:

Overall confidence in the review’s conclusions is high. Searches were exhaustive; eligibility criteria were explicit; data extraction and quality appraisal were conducted independently by two reviewers using validated tools; study characteristics were thoroughly reported; and appropriate meta-analytic methods were employed with due consideration of heterogeneity.