Reply: Immediately sequential bilateral cataract surgery (ISBCS): an Academic Teaching Center's experience

We read with interest the comments of Yusuf et al. on our manuscript and listened to the corresponding ESCRS journal club.1 We agree that patient selection is a key to achieving good outcomes in ISBCS. We focused on reporting the safety of ISBCS at our academic center. Safety is generally defined by absence of complications. This was previously studied, comparing delayed sequential bilateral cataract surgery (DSBCS) and ISBCS with similar outcomes.2 We, therefore, reported all intraoperative and postoperative complications recorded in patient charts, with no exclusions. Intraoperative complications included only posterior capsular rupture and zonulysis. Although our center performs approximately 10 000 cataract surgeries annually, 4006 ISBCS eyes were included in the study since others underwent DSBCS or unilateral surgery. Those that did not undergo ISBCS, for whatever reason, were not included. Case selection followed the iSBCS recommended guidelines, whereas specific inclusion and exclusion criteria were left to each surgeon's judgment. All active cataract surgeons at our institution participate in ISBCS with variable involvement; surgeons with more experience and/or subspecialty training (eg, cornea, advanced anterior segment, and retina) generally accept more complex cases for ISBCS. Surgeons offer patients DSBCS by default with ISBCS as an option to selected patients at the surgeon's discretion. Patients can change their mind at any time, although their reasons were not studied and are not easily traceable at this time. When a complication was noted in the first eye, the second eye is deferred if the complication cannot be treated at surgery. For example, second-eye surgery could be pursued after a small posterior capsular rupture if in-the-bag intraocular lens placement could be achieved. Again, this was performed on a case-by-case basis, depending on surgeon comfort and patient discussion. With a small number of intraoperative complications (n = 21, 0.5%), we can infer that the number of deferred second eyes was also small. Regarding postoperative complications, there were no cases of endophthalmitis. An internal retrospective review at our center had determined our endophthalmitis rate to be 1:14 000. Our study was, however, not designed to definitively assess endophthalmitis rates, which would require a very large number of patients undergoing ISBCS and DSBCS beyond the scope of this study. Cystoid macular edema (CME) was a more common postoperative complication. Since perioperative optical coherence tomography cannot be routinely performed for every patient at our center, we may have missed epiretinal membranes and vitreomacular tractions on examination, which can increase CME risk. However, after understanding CME as a problem from this study, instituting routine use of topical postoperative nonsteroidal anti-inflammatory drugs should help reduce this risk.3 Each surgeon handles Fuchs' dystrophy based on their own experience. Subspecialty-trained corneal transplant specialists operated 942 eyes (24%) in our cohort, explaining the 310 eyes (7.7%) with preexisting corneal dystrophies. Patients with bilateral Fuchs' dystrophy were cautioned against ISBCS. Choice of procedure was ultimately left to the patients after suitable warning by their surgeon and often required dissuasion from ISBCS in unsuitable candidates, who often lived remotely and were eager to reduce traveling and visits, which can be difficult during long, harsh Quebec winters.

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