Update on Sequential Bilateral Cataract Surgery

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An analysis of refractive outcomes after se­quential bilateral cataract surgery revealed that surgery performed on both eyes on the same day was associated with worse visual acuity than was delayed sequential surgery.¹ While differences between cohorts were small, they may take on clinical relevance in the presence of additional variables such as age, ethnicity, and selected ocular comorbidities.

The findings are based on electronic medical records of nearly two million patients who underwent sequential bilateral cataract surgery, as reported in the Academy’s IRIS Registry.

Better to delay? The researchers analyzed visual out-comes following immediate and delayed sequential bilateral surgery. The latter category was further divided into two groups of patients: 1) those who had surgery in the second eye one to 14 days after the first surgery and 2) those who had the second surgery 15 to 90 days after the first.

After the researchers controlled for variables, im­mediate sequential surgery was associated with lower uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA) by 2.79 and 1.64 letters, respective­ly, when compared with delayed surgery.

Unexpectedly, patients who had the second surgery within 14 days of the first had better outcomes than did those who waited up to 90 days (0.41 and 0.89 letters, respectively; p < .001 for both).

Confounding variables. Older age, Black and Asian ethnicity, Medicaid coverage, previous history of glau­coma, and the presence of diabetic retinopathy (DR) or age-related macular degeneration were independently associated with worse visual outcomes.

“The associations between non-White race and Medicaid coverage were somewhat unexpected,” said Cecilia S. Lee, MD, MS, at the University of Washington in Seattle. Specifically, Medicaid beneficiaries had worse outcomes than those on Medicare, and Asian and Black patients had worse VA by approximately 1 letter and 0.5 letter, respectively, than did the White patients.

Controlling for surgical volume did not affect the current results, although other studies have found that visual outcomes are associated with the surgical vol­umes of the cataract surgeons.

Limited clinical impact? Although statistically signifi­cant, the findings were deemed not clinically relevant, as 1 or 2 letters do not mean much clinically. “Ophthal­mologists need to keep this in mind when interpreting our study results and considering them for clinical deci­sion-making,” Dr. Lee said.

But having said that, she also noted that a patient with several risk factors may be more likely to have worse visual outcomes that could be clinically significant after immediate sequential surgery.

As an example, she said, an older Asian patient with DR and Medicaid coverage could be expected to see approx­imately 1 Snellen line less than a younger White patient who has no DR and is covered by Medicare.

Looking ahead. Further re­search—including investigations of other potential confounders—may reveal ways to improve refractive outcomes in high-risk groups, Dr. Lee said. For now, given the min­imal difference in VA associated with timing of the second sur­gery, both same-day and delayed approaches are acceptable for most patients, she said. “Howev­er, if a patient has multiple risk factors for worse visual outcomes, a delayed approach may be con­sidered.” (For more, see “Sequential Bilateral Cataract Surgery and Refractive Outcomes.”)

—Miriam Karmel

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1 Owen JP et al. JAMA Ophthalmol. Published online July 1, 2021.

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Relevant financial disclosures—Dr. Lee: Klorfine Family Endowed Chair: S; National Institute on Aging: S; Research to Prevent Blindness: S.

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