Following the presentation of data at the 43rd European Society of Cataract and Refractive Surgeons Congress (Copenhagen, September 12–16), which suggested that patients undergoing same-day cataract surgery (immediate sequential bilateral cataract surgery, ISBCS) achieved visual outcomes comparable to those treated on separate occasions (delayed sequential bilateral cataract surgery, DSBCS), The Ophthalmologist caught up with study authors — Vincenzo Maurino, Consultant Ophthalmic Surgeon at Moorfields NHS Foundation Trust and Moorfields Private, London, UK, and Gabriele Gallo Afflitto, Cataract Fellow at Moorfields Eye Hospital NHS Foundation Trust — to discuss their findings.
What initially inspired you to investigate immediate sequential bilateral cataract surgery (ISBCS) versus delayed sequential surgery (DSBCS)?
Vincenzo Maurino: There has been a growing trend since COVID-19 pandemic to optimize surgical efficiency in cataract surgery. We have long known that bilateral simultaneous cataract surgery is feasible – there was even a Society of Immediate Sequential Bilateral Cataract Surgery –, and, during the pandemic, the Royal College of Ophthalmologists (UK) reinforced national guidelines to ensure that ISBCS could be safely performed in the country.
The advantages are clear: for patients, ISBCS allows faster visual recovery, smoother adaptation, and a quicker return to normal daily activities. It also benefits the healthcare system by reducing both procedural time and overall costs compared with DSBCS.
Naturally, as surgeons, our priority is to ensure that patient safety is never compromised. For this reason, ISBCS must adhere to strict selection criteria, with careful assessment of risks and benefits, and rigorous protocols for sterility and surgical technique to minimize any potential complications.
Can you talk me through the main findings of your study?
Gabriele Gallo Afflitto: We compared the visual and refractive outcomes of monofocal and multifocal intraocular lens (IOL) implantation in immediate versus delayed bilateral cataract surgery.
Our analysis showed that multifocal IOL implantation achieved results that were at least comparable to those obtained with monofocal IOLs in both surgical settings. Specifically, multifocal IOL implantation in the context of ISBCS resulted in uncorrected visual acuity of 20/20 in 85% of cases, compared with about 75–80% across the other groups. Postoperative refractive spherical equivalent was close to zero in all four groups, with only minimal — statistically significant but clinically negligible — differences in both refractive sphere and cylinder. Multifocal IOL implantation demonstrated slightly greater refractive precision, reflected in lower mean and median refractive errors.
Vincenzo Maurino: The main concerns with ISBCS are two-fold. The first is safety — particularly the risk of infection affecting both eyes. Numerous studies have now demonstrated that the procedure is safe, provided that strict protocols are followed — standards that every cataract surgeon must be familiar with today.
The second concern relates to refractive accuracy. During cataract surgery, we implant a lens inside the capsular bag, but its final position can vary slightly, leading to potential refractive surprises. In DSBCS, we can use the refractive result from the first eye to fine-tune the lens power for the second eye. For example, if we notice an unexpected deviation from the target after four weeks, we can adjust accordingly when operating on the fellow eye.
This refinement is not possible with ISBCS, as both eyes are treated on the same day. However, our study shows that even with visually demanding multifocal lenses — which require particularly high precision — outcomes remain excellent. This reflects the remarkable advances in intraocular lens design, biometry, and the overall precision of modern cataract surgery.
Our analysis showed that multifocal IOL implantation achieved results that were at least comparable to those obtained with monofocal IOLs in both surgical settings. Specifically, multifocal IOL implantation in the context of ISBCS resulted in uncorrected visual acuity of 20/20 in 85% of cases, compared with about 75–80% across the other groups. Postoperative refractive spherical equivalent was close to zero in all four groups, with only minimal — statistically significant but clinically negligible — differences in both refractive sphere and cylinder. Multifocal IOL implantation demonstrated slightly greater refractive precision, reflected in lower mean and median refractive errors.
Vincenzo Maurino: The main concerns with ISBCS are two-fold. The first is safety — particularly the risk of infection affecting both eyes. Numerous studies have now demonstrated that the procedure is safe, provided that strict protocols are followed — standards that every cataract surgeon must be familiar with today.
The second concern relates to refractive accuracy. During cataract surgery, we implant a lens inside the capsular bag, but its final position can vary slightly, leading to potential refractive surprises. In DSBCS, we can use the refractive result from the first eye to fine-tune the lens power for the second eye. For example, if we notice an unexpected deviation from the target after four weeks, we can adjust accordingly when operating on the fellow eye.
This refinement is not possible with ISBCS, as both eyes are treated on the same day. However, our study shows that even with visually demanding multifocal lenses — which require particularly high precision — outcomes remain excellent. This reflects the remarkable advances in intraocular lens design, biometry, and the overall precision of modern cataract surgery.
Do you see ISBCS becoming standard practice in the UK?
Vincenzo Maurino: ISBCS is already widely performed across Scandinavia and much of Europe. Back in the 1990s, when we first began performing laser vision correction, patients would often leave with a patch after PRK and return months later for surgery on the second eye. Today, that approach would be unthinkable — both eyes are routinely treated together because the risk is so low.
I believe the same evolution will occur with ISBCS. As we continue to select suitable patients, exclude those at higher risk of infection or complications, and refine our sterility and surgical techniques, ISBCS will become the standard approach — not for everyone, but for the vast majority of patients.
Gabriele Gallo Afflitto: By 2019, one in five bilateral cataract surgery extraction procedures performed in Sweden were carried out as immediate sequential bilateral cataract surgery. In other words, ISBCS has already become part of routine clinical practice in several countries.
Survey data indicate that, in most countries — particularly in the United States — adoption remains limited. The main reason appears to be not only concerns about potential complications, but also financial disincentives, as reimbursement for bilateral procedures is typically lower than for two separate operations on the same patient.
I believe the same evolution will occur with ISBCS. As we continue to select suitable patients, exclude those at higher risk of infection or complications, and refine our sterility and surgical techniques, ISBCS will become the standard approach — not for everyone, but for the vast majority of patients.
Gabriele Gallo Afflitto: By 2019, one in five bilateral cataract surgery extraction procedures performed in Sweden were carried out as immediate sequential bilateral cataract surgery. In other words, ISBCS has already become part of routine clinical practice in several countries.
Survey data indicate that, in most countries — particularly in the United States — adoption remains limited. The main reason appears to be not only concerns about potential complications, but also financial disincentives, as reimbursement for bilateral procedures is typically lower than for two separate operations on the same patient.
How would ISBCS impact the UK healthcare system – specifically the NHS – if it did become standard practice?
Vincenzo Maurino: The potential impact could be tremendous in reducing patient waiting times and improved health economics. In a busy, publicly funded healthcare system like the NHS, improving efficiency is essential. If implemented appropriately and in line with existing regulations, ISBCS could greatly streamline care pathways — shortening recovery times, enhancing the patient experience, and ultimately improving quality of life, which is what matters most.
Is there anything else you would like to add?
Gabriele Gallo Afflitto: Although the study included a relatively large sample, it was conducted at a single center, and further multicenter research will be essential to confirm these findings.
Future work should also aim to expand the study population, particularly within the multifocal IOL subgroups. It is important to acknowledge that patient characteristics may not have been evenly distributed across our groups, as ISBCS was primarily offered to those considered strong candidates for it — a factor that may have contributed to the more favorable outcomes observed in the multifocal ISBCS group.
Vincenzo Maurino: In the UK, multifocal IOL implantation is offered in the context of private practice only. As such, the results may be somewhat skewed in favor of this group, since the procedures were carried out by highly experienced surgeons with substantial expertise in complex lens implantation.
Nevertheless, I believe this represents just the beginning. Over the next decade, ISBCS is likely to become the standard approach — except in selected high-risk cases where it may not be appropriate to proceed in this way.
Future work should also aim to expand the study population, particularly within the multifocal IOL subgroups. It is important to acknowledge that patient characteristics may not have been evenly distributed across our groups, as ISBCS was primarily offered to those considered strong candidates for it — a factor that may have contributed to the more favorable outcomes observed in the multifocal ISBCS group.
Vincenzo Maurino: In the UK, multifocal IOL implantation is offered in the context of private practice only. As such, the results may be somewhat skewed in favor of this group, since the procedures were carried out by highly experienced surgeons with substantial expertise in complex lens implantation.
Nevertheless, I believe this represents just the beginning. Over the next decade, ISBCS is likely to become the standard approach — except in selected high-risk cases where it may not be appropriate to proceed in this way.
