Immediate sequential bilateral cataract surgery shows worse visual outcomes than delayed surgery: JAMA
Cataract is the leading cause of visual impairment in the US, affecting an estimated 24 million people. In the US, cataract surgery is usually performed with 1 to 2 weeks or more between eyes. Conflicting literature exists about whether visual outcomes are better with delayed sequential bilateral cataract surgery (DSBCS) or immediate sequential bilateral cataract surgery (ISBCS), in which the surgeon operates on both eyes on the same day as separate procedures. DSBCS has been preferred historically because it allows for adjustment of the intraocular lens power in the second eye in case of refractive surprise and provides time to monitor for endophthalmitis or other complications that can cause severe vision loss.
ISBCS is the preferred approach in several countries outside the US. Potential advantages of ISBCS include immediately improved bilateral vision, fewer follow-up visits, improved efficiency, and potential for reduced costs. In addition, studies from countries where ISBCS is routine suggest that risk of bilateral endophthalmitis is low with the use of intracameral antibiotics and strict aseptic separation between operations.
The goal of cataract surgery is to improve vision and quality of life. In recent years, ISBCS has gained favor among US ophthalmologists. However, the question of whether unexpected refractive outcome occurs more often with ISBCS remains unanswered and is likely an important consideration. Furthermore, knowledge of any additional factors associated with worse visual outcome after cataract surgery is critical for practitioners and patients who need to be counseled appropriately.
The American Academy of Ophthalmology Intelligent Research in Sight (IRIS) Registry includes electronic health record data from more than 50 million unique patient visits, including demographic and clinical information. Owen and team aimed to analyze this large data set to evaluate any potential disparity in refractive outcomes among ISBCS, short-interval (within 1-14 days between 2 operations) DSBCS (DSBCS-14), and long-interval (15-90 days apart) DSBCS (DSBCS-90). They also aimed to identify any factors associated with worse visual outcome.
This retrospective cohort study used population-based data from the American Academy of Ophthalmology Intelligent Research in Sight (IRIS) Registry. A total of 18,24,196 IRIS Registry participants with bilateral visual acuity measurements who underwent bilateral cataract surgery were assessed. Participants were divided into 3 groups (DSBCS-90, DSBCS-14, and ISBCS groups) based on the timing of the second eye surgery. Univariable and multivariable linear regression models were used to analyze the refractive outcomes of the first and second surgery eye. Outcomes included mean postoperative uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA) after cataract surgery.
- The BCVA was higher by 0.89 (P < .001) letters in the DSBCS-14 group, whereas in the ISBCS group, the UCVA was lower by 2.79 (P < .001) letters and the BCVA by 1.64 (P < .001) letters.
- Similarly, compared with the DSBCS-90 group for the second eye, in the DSBCS-14 group, the UCVA was higher by 0.79 (P < .001) letters and the BCVA by 0.48 (P < .001) letters.
- In the ISBCS group, the UCVA was lower by −1.67 (P < .001) letters and the BCVA by −1.88 (P < .001) letters.
This cohort study analyzed data from 44,525 patients who underwent ISBCS, 8,97,469 patients who underwent DSBCS14, and 8,82,202 patients who underwent DSBCS-90. The study found that the ISBCS group had statistically significantly worse UCVA (2.8 fewer letters in first eyes and 1.7 fewer letters in second eyes) compared with the DSBCS-90 group, despite having better presurgical BCVA. Unexpectedly, the DSBCS-14 group had similar but better VA outcomes that were statistically significant compared with the DSBCS-90 group.
The current study also found that race, insurance type, and comorbid eye disease were associated with worse outcomes, suggesting that other factors may have influenced visual outcomes among surgery groups.
The current analysis found similar outcomes between DSBCS-14 and DSBCS-90. In fact, the DSBCS-14 group performed slightly better than the DSBCS-90 group, although the difference was fairly small (0.4-0.9 letters). This finding may be attributable to successful adjustment for any refractive surprise in the DSBCS-14 group between procedures, suggesting that a longer waiting period may be unnecessary.
On the basis of data from the clinical practice setting of nearly 2 million bilateral cataract surgery patients, this study found that ICBCS was associated with worse visual outcomes when compared with DSBCS-90 or DSBCS-14, although the difference may not be clinically relevant. Race other than White, Medicaid coverage, and comorbid eye disease were independently associated with worse outcomes regardless of correction. Although these factors should be considered when counseling patients preoperatively, further studies to evaluate other potential confounders are warranted because they may explain the small outcome differences found between the surgery groups.
Source: Owen et al; JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2021.2032