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Inside Eyetube.net | Sep 2011

A Checklist for ISBCS

Success with immediate sequential bilateral cataract surgery is more dependent on avoiding bad outcomes than on achieving excellent results.

Immediate sequential bilateral cataract surgery (ISBCS) has recently attracted increased interest clinically and in peer-reviewed literature. According to some surgeons, the protocol for ISBCS is controversial. But, in my clinic, ISBCS was introduced as a routine practice in 1999, just after it had been used successfully in a multifocal IOL study.1 High patient satisfaction, logistical advantages, and encouraging results have motivated our continued use of this approach.2

Approximately 5% to 10% of our cataract patients underwent ISBCS in the first few years after we established our technique. The rate gradually increased, stabilizing at approximately 25% to 30%. Similarly, annual reports from the Swedish National Cataract Register show a slowly increasing rate that currently lies around 4% to 5% for the whole country (Figure 1). Internationally, ISBCS is in routine clinical use in many health care systems, but use varies between nations, clinics, and even between doctors within the same clinic. This is probably exactly how it should be.

ISBCS should be undertaken only when high-quality operating room (OR) standards and sterilization routines are met. The surgeon considering ISBCS must be confident that the balance of risks and benefits is to the patient’s advantage and that the rate of intra- and postoperative complications is on an acceptably low level. Benchmarking against the international peer-reviewed literature3-8 and/or national quality registry data is highly recommended. Additionally, the International Society for Bilateral Cataract Surgeons’ General Principles for Excellence in ISBCS, accessible on the society’s Web site (www.isbcs.org), provides further information to subscribing members. For more information on these guidelines, see the article by Steve A. Arshinoff, MD, FRCSC, on page 59.


When the safety record of a unit and/or surgeon is compatible with ISBCS, the next step is to select suitable patients. I have created a checklist for my clinic, primarily intended for use when patients are examined preoperatively by a beginning ISBCS surgeon or by another properly educated care provider (see Checklist for Immediate Sequential Bilateral Cataract Surgery).

Surgeons performing their first ISBCS cases (to whom this article is addressed) must balance indications and contraindications differently than experienced ISBCS surgeons. In fact, all contraindicating factors listed below can be regarded as relative. As the ISBCS surgeon gains experience, a patient’s total situation may motivate ISBCS even with contraindicating factors present to some degree; however, patient safety and benefit must always be paramount. Although refractive lens exchange is not specifically discussed in this article, the same reasoning is relevant for such cases.

Indications. First and foremost, cataract surgery should be indicated in both eyes. Therefore, a cataract judged as disturbing the quality of vision must be present in both eyes. Posterior subcapsular cataract, central cortical cataract, moderate to severe nuclear sclerosis, or other opacities producing glare are especially disturbing if one eye is left unoperated. For the surgeon’s first ISBCS cases, it is recommended to choose patients with similar degrees of cataract development in both eyes. This makes it easy to explain to the patient that there is a high probability for the second eye to cause problems if left unoperated. Candidates for ISBCS may be occupationally active people or may be in need of good vision to support and care for a sickly relative. Also, although this does not commonly occur, for patients who are afraid of surgery it may be preferable to have the cataract removed from both eyes during one hospital visit instead of having to plan and prepare for a second round.

Below is a list of clinical indications for ISBCS:

  • Patients with preoperative Snellen decimal visual acuity between 0.1 and 0.5 are particularly suitable for ISBCS because of the high probability of binocular problems if one cataract is left unoperated and because lower visual acuities may indicate more severe or dense cataracts with increased risk for prolonged surgery.
  • If there is significant ametropia, and unilateral cataract surgery with a goal of emmetropia would lead to anisometropia, this is also a reason to suggest ISBCS.
  • If a patient requests quick vision rehabilitation, optimal visual quality is achieved faster with ISBCS.


Contraindications. Awareness of contraindicating factors is mandatory to avoid unwanted surprises during the learning curve. The risk for bilateral complications, especially vision-threatening ones, must be minimized. Bilateral postoperative endophthalmitis is most often discussed;9-12 however, published clinical data suggest that prevention of other bilateral complications such as corneal edema and cystoid macular edema is equally important.13,14 Ongoing inflammatory or infectious processes are obvious contraindications for ISBCS, but it is important to rule out any patient with a condition that might prolong or make cataract surgery more cumbersome. In cases difficult to assess preoperatively such as extremely short or long eyes, eyes previously treated with corneal refractive surgery or laser, or eyes with previous trauma (injury or surgery), it is prudent to perform only one unilateral surgery and assess the result before planning second-eye surgery. If the surgeon is unsure about postoperative compliance, for instance in patients with dementia or a history of drug abuse, bilateral surgery is strongly contraindicated. Needless to say, unwilling patients shall under no circumstances undergo ISBCS.


It is important to keep in mind that the checklist presented here is primarily suggested for use by surgeons selecting their first ISBCS cases. Once experience is gathered, contraindications can be balanced more relatively. Patient safety must, however, always be paramount in every case.

It could be argued that the success of an ISBCS surgeon is more dependent on avoiding bad outcomes than achieving excellent results. Careful preoperative evaluation of indications and contraindications is therefore necessary in each case.

Björn Johansson, MD, PhD, practices in the Department of Ophthalmology, Linköping University Hospital, Sweden, and is the Secretary of the Swedish Ophthalmological Society. Dr. Johansson states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +46 10 1033068; fax: +46 10 1033065; e-mail: bjorn.johansson@lio.se.

  1. Lundh BL,Lundh U,Pecshegyi T,Petrelius A,Philipson B,Rube H,Setterquist H,Åhlin G.Swedish multicentre study of Allergan’s SA40 AMO Array multifocal IOL – 2 years’follow-up.Acta Ophthalmol Scan.2000;79:638.
  2. Johansson BA,Lundh BL.Bilateral same day phacoemulsification:220 cases retrospectively reviewed.Br J Ophthalmol.2003;87(3):285-290.
  3. Barry P,Seal DV,Gettinby G,Lees F,Peterson M,Revie CW.ESCRS Endophthalmitis Study Group.ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery:Preliminary report of principal results from a European multicenter study.J Cataract Refract Surg.2006;32(3):407-410.
  4. Kelly SP,Mathews D,Mathews J,Vail A.Reflective consideration of postoperative endophthalmitis as a quality marker.Eye (Lond).2007;21(11):1419-1426.
  5. Artzén D,Lundström M,Behndig A,Stenevi U,Lydahl E,Montan P.Capsule complication during cataract surgery: Case-control study of preoperative and intraoperative risk factors:Swedish Capsule Rupture Study Group report 2.J Cataract Refract Surg.2009;35(10):1688-1693.
  6. Behndig A,Montan P,Stenevi U,Kugelberg M,Lundstrom M.One million cataract surgeries:Swedish National Cataract Register 1992–2009.J Cataract Refract Surg.2011;37:1539–1545.
  7. Murphy C,Tuft SJ,Minassian DC.Refractive error and visual outcome after cataract extraction.J Cataract Refract Surg.2002;28(1):62-66.
  8. Gale RP,Saldana M,Johnston RL,Zuberbuhler B,McKibbin M.Benchmark standards for refractive outcomes after NHS cataract surgery.Eye (Lond).2009;23(1):149-152
  9. Ozdek SC,Onaran Z,Gürelik G,Konuk O,Tekinflen A,Hasanreiso lu B.Bilateral endophthalmitis after simultaneous bilateral cataract surgery.J Cataract Refract Surg.2005;31(6):1261-1262.
  10. Kashkouli MB,Salimi S,Aghaee H,Naseripour M.Bilateral Pseudomonas aeruginosa endophthalmitis following bilateral simultaneous cataract surgery.Indian J Ophthalmol.2007;55(5):374-375.
  11. Puvanachandra N,Humphry RC.Bilateral endophthalmitis after bilateral sequential phacoemulsification.J Cataract Refract Surg.2008;34(6):1036-1037.
  12. Arshinoff S.Bilateral endophthalmitis after simultaneous bilateral cataract surgery.J Cataract Refract Surg. 2008;34(12):2006-8;author reply 2008.
  13. Tyagi AK,Mcdonnell PJ.Visual impairment due to bilateral corneal endothelial failure following simultaneous bilateral cataract surgery.Br J Ophthalmol. 1998;82(11):1341-1342.
  14. Chalioulias K,Tsaloumas M.Bilateral cystoid macular edema after phacoemulsification in post-laser in situ keratomileusis eyes.J Cataract Refract Surg.2007;33(6):1101-1103.


• The surgeon considering ISBCS must be confident that the balance of risks and benefits is to the patient’s advantage.

• For the surgeon’s first ISBCS cases, it is recommended to choose patients with similar degrees of cataract development in both eyes.