While the current sequential approach to cataract surgery is still the standard, the emergence of same-day, bilateral cataract surgery has sparked considerable interest, raising questions about its efficacy, safety and overall patient outcomes. There are a number of advantages associated with same-day, bilateral cataract surgery, also referred to as immediately sequential bilateral cataract surgery (ISBCS), including enhanced patient convenience, reduced health-care costs and expedited visual rehabilitation. Patients may experience shorter overall recovery times and decreased postoperative visits, leading to greater patient satisfaction. However, there are also potential concerns that may impact a surgeon’s decision when determining the best approach for their patients. These include surgical complications, refractive considerations and reimbursement challenges. 

Here, we’ll explore the pros and cons of same-day, bilateral cataract surgery, and engage in a nuanced discussion of the complexities surrounding this approach. Experienced surgeons offer their perspectives and advice to help their colleagues navigate this debate and make informed decisions that are in the best interest of their patients and practice. 

Figure 1. In addition to identifying good candidates for bilateral same day cataract surgery, surgeons may incorporate small changes to pre- and postop routines to help achieve successful outcomes for both the patient and surgeon, for example, using clear shields postoperatively. (Courtesy Derek DelMonte, MD)

Why ISBCS?

Proponents argue that same-day, bilateral cataract surgery offers advantages for patients, ophthalmologists and the health-care system as a whole. Quicker binocular vision recovery, increased surgeon efficiency, decreased postoperative visits and decreased patient time spent in a surgery center are all benefits of this approach, says Sloan Rush, MD, of Amarillo, Texas.

For patients with limited mobility, transportation challenges or busy schedules, the ability to undergo surgery on both eyes in a single day can significantly improve their overall experience. Additionally, this surgical option may alleviate anxiety and apprehension associated with multiple surgeries, which could benefit patient satisfaction and outcomes.

“With two separate surgery dates and associated postop visits, it can be upwards of eight or more trips to the doctor’s office. That number can be significantly reduced with bilateral same day surgery,” notes Derek DelMonte, MD, of Greensboro, North Carolina, who also highlights the potential burden of additional travel. “Many patients travel a good distance for this surgery, particularly those who live in more rural areas. The likelihood of a car accident/injury on the trips was higher than the likelihood of a complication from bilateral same day surgery.”

Faster visual recovery is another reason to consider ISBCS for eligible patients, some surgeons say. By performing surgery on both eyes on the same day, patients can achieve optimal visual acuity in a shorter timeframe. This improvement in vision enhances overall quality of life and enables patients to resume daily activities sooner, minimizing the disruption caused by prolonged recovery periods.

“For patients with high preop prescriptions, the time spent with anisometropia after one eye is operated on can be very bothersome,” says Dr. DelMonte. “Some patients experience dizziness/nausea due to the high level of anisometropia and many find it difficult to perform their daily tasks such as work and hobbies.”

The impact can be even greater for older patients with a higher risk of falls/instability, he adds, while noting that, “this time also delays the brain’s ability to learn how to adjust to the ‘new normal’ of their vision. This neuro-adaptation is much faster if both eyes are performed at the same time.”

The time spent with only one eye done can be frustrating for the patient and actually make it more difficult for some individuals to adjust to the final outcome once the second eye is complete, emphasizes Dr. DelMonte. 

ISBCS can reduce costs for patients (surgery cost, travel expenses, time out of work, etc.) and the health-care system (i.e., less OR time, fewer visits). “This cost savings can add up to large amounts for the overall health-care system considering the number of people undergoing cataract surgery in the U.S. (and world) yearly,” says Dr. DelMonte. “As many are still working, the overall saving to the general economy could also be taken into account as time away from work is lost productivity.”

Safety Considerations

Some surgeons may be hesitant to use this approach for several reasons, including safety and refractive concerns. One of the often-heard arguments against bilateral same-day surgery, notes Dr. DelMonte, is the risk of a bilateral infection (endophthalmitis).

“If a patient were to experience a bilateral complication on the same day, it could have a much more devastating impact on the patient than if only one eye had the complication and could be rehabilitated prior to the second eye surgery,” he notes. “This is perhaps more likely in the case of TASS (toxic anterior segment syndrome) which is an inflammatory complication after surgery that can look like endophthalmitis but happens in ‘outbreaks’ that can impact a whole day or part of a day of surgery.” 

There’s still some controversy regarding the most common cause of these outbreaks; however, many believe they are related to contaminants in the surgery pathway (instruments/cleaning supplies, etc.) that impact more than just one patient, says Dr. DelMonte. 

While potential risks should always be considered prior to any procedure, recent years have seen a significant decrease in the risks associated with same-day, bilateral cataract surgery. Advancements in incision size, equipment and infection prophylaxis have made the overall risk of complications very low, according to Dr. DelMonte. 

“The risk for bilateral blinding complication is still extremely low,” adds Dr. Rush. “Using intracameral antibiotics such as moxifloxacin (and not vancomycin due to risk for hemorrhagic occlusive retinal vasculitis [HORV]) decreases the risk for endophthalmitis to 1 in 10,000 or less. Therefore, this complication occurring consecutively is exceedingly rare.”

It’s also important to note that most surgeons, including Dr. DelMonte, advocate for a completely separate procedure from start to finish with the exception of the patient not leaving the operating room between surgeries. 

Figure 2. When performing same-day, bilateral cataract surgery, or ISBCS, all equipment should be separated and each eye should be treated as an individual procedure.

“This means after the completion of the first eye, the patient’s drapes are removed, the eye is cleaned and when the patient would normally be leaving the room, the whole OR team prepares for a completely new procedure with new equipment, new drapes, new preop prep, etc.,” he explains. “No steps should be skipped to maintain a low risk of bilateral complications. It should also be noted that if a complication occurs during the first eye, the second is postponed to a different day.”

Vallejo, California, surgeon James Carolan reiterated the rarity of these complications when guidelines are followed and appropriate safety measures are taken. “Yes, there are risks but if you’re fastidious about working with reliable vendors, separating by lot number and following the principles put forth by the International Society of Bilateral Cataract Surgeons, that risk is very small,” he says. “Cases of TASS or bilateral infection are more likely to occur when the workflow is changed, vendors change or something else out of the ordinary happens.”

There are also refractive considerations to take into account before making a decision on the best surgical approach. “While our ability to hit a refractive target with surgery is remarkably good, there are still cases that end up more myopic or hyperopic than anticipated,” says Dr. DelMonte. 

If this happens in the first eye, ophthalmologists can adjust their approach prior to performing surgery on the second eye. “In patients in whom certainty with lens selection is challenging, for example post-radial keratotomy patients, it can make sense to avoid same-day surgery to better help us with the second eye,” says Dr. DelMonte.

Another case where same-day surgery may not be the best option is in patients who are contact lens dependent, such as those with corneal ectasia. “These patients will often need to be re-fitted with a new contact lens prescription prior to gaining visual improvement from cataract surgery,” explains Dr. DelMonte, who recommends waiting for full rehabilitation of the first eye before proceeding with the second eye’s surgery. This can help avoid bilateral visual impairment for a period of time between surgery and contact lens refit.

The risk of a postoperative surprise in refraction is improving as the newest formulas continue to better estimate effective lens position and account for posterior corneal contributions to refraction, he notes. 

Since the vast majority of surgeons perform surgery within the postop healing period of the first eye, they’ll rarely get a final refraction from the first eye before operating on the second eye. “The question then becomes, when would you adjust the second eye based on incomplete data from the first eye? The answer is really only if there is a very large error, which is exceedingly rare,” says Dr. DelMonte. 

“Some may argue that the risk of having to do a bilateral lens replacement (or laser refractive enhancement) is enough to avoid bilateral surgery; however, the number of times this may be needed does not necessarily outweigh the benefits to so many,” he argues. “By simply avoiding patients at the highest risk for refractive surprise, we may be able to minimize this risk significantly.”

Dr. Carolan underscores the importance of patient selection for successful same-day, bilateral cataract surgery. “Not every patient will be the right fit, and not just because of health-related issues,” he notes. “You also need to consider a patient’s social situation and support system. Ask them about their occupation and home life.”

“How are they going to do during those first few days when both eyes are blurry? Do they have the necessary support? Will they have difficulty with postoperative compliance? The entire patient must be considered when determining if they’re right for same-day, bilateral cataract surgery,” Dr. Carolan emphasizes. 

There is also the possibility for lens errors with ISBCS; however, simple changes to time-out and preparation for bilateral same-day surgery can help mitigate this risk, according to Dr. DelMonte. 

“For example, most will perform two separate time-outs, one prior to each case. Leaving only the IOL for the current surgery in the room and having color-coded IOL selection sheets (Blue for right eyes, Green for left eye or similar) which indicate the eye I am working on at the time all help,” he says. “With these adjustments, I haven’t found an increased risk of wrong-IOL implantation in these cases.”

Reimbursement Challenges

Despite the potential benefits, reimbursement remains a significant barrier to the widespread implementation of same-day, bilateral cataract surgery. In fact, Drs. Carolan,
DelMonte and Rush agree that this is the main reason why it hasn’t been more fully adopted by practices. 

“I believe the decrease in reimbursement is the largest inhibitor to widespread adoption,” says Dr. Rush. “The bilateral modifier 50 indicator from Medicare and other insurances dates back to the 1970s and only permits for 50 percent of the allowable for the fellow side of any body part operated on, regardless of if it being an ear, an eye or a knee. 

“This decrease in reimbursement generally results in a net loss of revenue for the second eye for the surgery center, making it financially unviable,” he continues. “Further, the advances in surgical techniques make this reimbursement ruling obsolete. When adhering to published guidelines for ISBCS, the safety of ISBCS is comparable to delayed sequential bilateral cataract surgery.”

Dr. Rush’s practice routinely performs next-day sequential bilateral cataract surgery (NDSBCS) on almost all patients that don’t have a contraindication (80+ percent of all cataract patients), which allows for full reimbursement and confers some (but not all) of the advantages of ISBCS, he explains.

“More individuals are being trained in this approach; however, when entering practice they’re faced with a reimbursement structure that won’t allow them to perform the procedure, unless they’re working in the VA or a capitated system,” notes Dr. Carolan. “The time is coming for this idea to become more widespread, but the main issue holding us back is reimbursement.”

Patient Experiences

A cross-sectional study—conducted at Kaiser Permanente—evaluated patient experience and satisfaction with same-day bilateral cataract surgery versus DSBCS.¹ Study authors, including Dr. Carolan, sent a survey to patients who received immediate sequential bilateral cataract surgery (ISBCS) (n=1,818) and DSBCS (n=1,818) between 2017 and 2019. 

The research showed that patients who opted for ISBCS were more likely to choose this approach again and recommend it to a family member or friend. While convenience was the leading reason patients chose ISBCS (65 percent), surgeon recommendation was the primary reason patients elected for DSBCS (68 percent). 

From his own clinical experience, Dr. Carolan finds that the majority of his patients are glad they had same-day, bilateral cataract surgery. “Where you run into trouble is poor patient selection,” he says. “I’ve been doing this long enough that I have a good idea who would benefit from the ISBCS option and are most likely to have a positive overall experience.” He notes that he’s currently performing ISBCS in approximately 30 percent of his patients. “I could do more, but I choose not to because I feel it’s the right approach for my patients and practice,” he adds.

Dr. Rush has also found that most of the patients at his practice who undergo ISBCS are pleased with the simplicity of only going to a surgery center once, the decrease in visits associated with postoperative care and the quicker bilateral vision recovery. “Most of these patients assume that everyone gets ISBCS as they did and are even surprised to learn that the majority have delayed sequential bilateral cataract surgery,” he says. 

“Those of my patients who have undergone bilateral same-day surgery are generally some of my most happy patients,” adds Dr. DelMonte. “I do inform all up-front that this isn’t necessarily what most of their friends/relatives may choose or qualify for, but for select patients it’s a safe and effective procedure. I do spend a bit of time with the reason this isn’t always offered, to fully inform them of the risks associated with this method, however most are very happy to be given this choice and gladly accept the offer.”

Key Takeaways

Same-day, bilateral cataract surgery is a compelling option, offering a range of potential benefits alongside certain considerations. The convenience, faster visual recovery and potential cost-effectiveness of this approach make it an attractive choice for certain patients; however, it’s essential that ophthalmologists weigh the advantages against potential drawbacks and individual patient factors. 

“I recommend ISBCS for all routine, healthy patients in which there is both no financial reimbursementbarrier and no medical contraindication,” says Dr. Rush. “Otherwise, we offer NDSBCS. The most common ISBCS candidates in our practice are patients seeking elective vision correction procedure with refractive lens exchange. These eyes are usually healthy, and the patient is paying out of pocket which eliminates all reimbursement barriers.

“In addition, the advent of office-based surgery (OBS) allows for an advanced beneficiary notice which allows for the center to compensate for the relative loss in revenue due to the bilateral modifier 50 ruling,” he adds, while noting that patients with existing severe ocular co-morbidities should avoid ISBCS.

When asked what advice he would give to surgeons interested in trying this approach for the first time, Dr. Rush says they should be familiar with the published guidelines for excellence with ISBCS and start slowly with uncomplicated cases. Once confidence is gained, then it can be offered more routinely in select cases.

Dr. DelMonte emphasizes the importance of patient communication. “Have a good discussion about bilateral same day surgery with the patient and their family so they know the reasons to consider this, as well as reasons to decline if desired,” he says. “And remember that just because you plan for bilateral same day surgery, doesn’t mean you must proceed that way—know that plans can be changed if any difficulty arises during the day, and plan to discuss that possibility with the patient beforehand.”

Same-day, bilateral cataract surgery can be a very safe and effective procedure for the majority of patients who have bilateral cataracts, according to Dr. DelMonte; however, the important thing to keep in mind is that it may not be best for everyone. 

“Identifying those who may benefit the most while avoiding those at the highest risk is the true challenge,” he says. “Additionally, surgeons must be honest with themselves about their personal complication rates (particularly beginning surgeons) and may elect to offer or not offer based on their comfort level with postoperative complication risks.”

Dr. DelMonte believes that this approach will continue to gain favor over time. “I think fewer young surgeons are as familiar with the higher rates of complications cataract surgery had just a few years ago, and so are less gun-shy about trying this technique,” he notes. “In order for more surgeons to adopt it in this country, however, the reimbursement issue will have to be fixed. The most common place to see bilateral same day surgery in the U.S. are in health systems that don’t penalize the reimbursement, such as the Kaiser system, or the VA, and they’ve had great success with it.”

“The increasing utilization of premium IOLs, self-pay and OBS will eventually make ISBCS the most common method of cataract surgery,” predicts Dr. Rush. “But it may take another decade or more."

Drs. Carolan, DelMonte and Rush report no relevant disclosures. 

^{1. Carolan JA, Amsden LB, Lin A, et al. Patient experience and satisfaction with immediate sequential and delayed sequential bilateral cataract surgery. Am J Ophthalmol 2022;235:241-8.}