Sir,

We were pleased that the Scientific Journal of the Royal College of Ophthalmologists recognizes that immediate sequential bilateral cataract surgery (ISBCS) now merits open discussion in the pages of the August 2012 edition of your journal.

We read with interest the submission by Tatham and Brookes,1 but could not follow their logic. Their paragraph 1 seems to summarize all the published peer-reviewed evidence in favor of ISBCS. However they state that the interest in ISBCS is fueled by economic benefits. In fact, many jurisdictions financially penalize bilateral cataract surgery, and in many countries it is a money-losing proposition for the surgeon. Almost all the articles referenced by Tatham and Brookes discuss the medical benefits to the patients, which are considerable, but not economic benefits.2 We would also like to encourage health care providers/financing bodies to take in account patient benefits and logistical and economic effects for the social system as a whole when deciding upon the reimbursement of ISBCS.

Paragraph 2 waves the shroud of ‘bilateral blindness’, but omits that bilateral simultaneous ophthalmic surgery is common, and the risk of bilateral infection has been shown to be extremely small in bilateral cataract surgery.3 LASIK, blepharoplasties, ptosis, and squint surgery are all commonly performed bilaterally, and bilateral simultaneous retinal surgery is not that rare.

In paragraphs 3 and 4, they effectively summarize the recommendations of our Society (see www.isbcs.org), for which we thank them, as good advice deserves repetition. However, in paragraph 5, they state that ISBCS may be ‘logistically difficult’. We disagree; if ISBCS is a regular event, then there are no logistical problems. Setting up for cases of ISBCS is much easier than for double the number of single eye cases. They then turn to the question of endophthalmitis, stating that diabetes is a risk factor. This does not appear to be the opinion of The Royal College of Ophthalmologists, who do not mention it in their document ‘Cataract Surgery Guidelines’ published September 2012. Curiously, they also state that if one eye develops endophthalmitis, there is less chance of both being involved by deferring second eye surgery. We know of no evidence to support this statement. As it is known that most cases of endophthalmitis emanate from the patient’s own flora, it is questionable whether delaying the second eye reduces the risk for that eye. Furthermore, they refer to diabetes and blepharitis as risk factors, and while we agree that this is widely believed, and many increase precautions in the presence of these conditions, we again know of no published data on which to base these suppositions.

In paragraph 6, the authors turn to economics and turnover. Our experience is the reverse of their suppositions; we can easily add one or two eyes to a 4-h operating list when the majority of cases are ISBCS as opposed to unilateral surgery. The time saved is in moving patients in and out of theater and redundant paperwork. The comments on time from listing to surgery, and time from first to second eye surgery is likely to be very variable for multiple reasons. However, we are aware that within 16 miles of the authors’ hospital the current waiting time for cataract surgery routinely exceeds 6 months.

In the final two paragraphs, the authors equate bilateral endophthalmitis with bilateral blindness. This extraordinary assumption would imply no treatment of this complication, which seems unlikely. Our experience is that the modern management of endophthalmitis leaves many eyes with useful, (and often excellent) vision, and to assume blindness shows a rather alarmist approach. In these closing paragraphs, the authors muse on ‘Should bilateral same day cataract surgery routinely be offered to all?’ We accept that they may have been asked to opine on this specific question, and may indeed have used the narrowness of the question to reply. We believe that ISBCS should be offered routinely to all appropriate patients, and that full consent and explanation of options should be offered. We believe that there are patients who should not have such surgery, but with increasing experience with ISBCS, as with any other procedure, the surgeon discovers that fewer and fewer patients fall into the routine exclusion group. However, ISBCS is currently routinely NOT offered to appropriate patients in the UK, and many other countries, despite peer-reviewed published evidence of effectiveness, economy, and very low risk. We would suggest that many patients would benefit if more ophthalmologists would remember to consider this option when listing patients for surgery.