In the UK, ISBCS is not widely adopted, which might explain the relatively low respondent rate for our survey. However, it is important that the themes addressed as a result of this questionnaire are explored. From our data, it is also evident that a large proportion of our respondents do not perform ISBCS. Moreover, it was confirmed that some respondents who previously performed ISBCS had stopped, mainly due to financial issues or lack of evidence supporting its use. Less emphasis was put on hospital policy or a lack of College approval. The fact that no respondents reported peer pressure as a barrier might reflect positive attitudes amongst ophthalmologists towards ISBCS.
In regards to specific cases in which ophthalmologists would consider the use of ISBCS, the majority of our participants still reported they would not perform ISBCS under any circumstances, demonstrating a strong resistance towards incorporating it into their clinical practice. However, some stated that they would consider its use. In particular, the use of ISBCS was favoured in the case of patients who required a general anaesthetic as it only requires one episode of anaesthesia. Additionally, it was found that the potential risk of endophthalmitis was the most important factor for participants not to perform ISBCS. This finding was in line with existing literature on reasons for not performing ISBCS.3,6 Other complications of ISBCS, such as risk of cystoid macular oedema and risk of an incorrect IOL power were also considered to be important in their decision to practise. Alongside the risk of endophthalmitis, medico-legal issues were feared. Interestingly, a lack of training to perform ISBCS or greater familiarity with single eye surgery was not deemed to be important; the risk of retinal detachment was also not considered to be important. This may suggest that ophthalmologists place a greater emphasis on potential penalties rather than lack of experience.
For those who previously performed ISBCS, a lack of supporting evidence was a significant factor in their decision to stop performing ISBCS. However, it did not impact on the decision to potentially start performing ISBCS for those who had not previously done so.
Several factors that may influence an ophthalmologist’s decision to offer ISBCS have been identified. Patient convenience seems to play a crucial role when considering ISBCS. Many participants reported that they would offer ISBCS as it reduces hospital visits and saves time for travel, as well as providing more convenience and quicker rehabilitation for patients. Some deemed improved visual outcomes for patients to be important. This is importance to note, as it appears that the fears of ophthalmologists may be overshadowing potential benefits for patients.
Looking at our data, it is clear that many ophthalmologists may not perform ISBCS or are reluctant to perform ISBCS in their clinical practice. Despite comparable outcomes to DSBCS demonstrated by high-quality evidence 7,8, ISBCS is still not adopted as a standard of care to this date.
Previous literature has found that the absence of postoperative refractive outcome from the first eye to guide the lens selection for the second eye, and the risk of bilateral vision loss were among the top concerns.9 In contrast, our study shows that financial reasons and the risk of complications are the most significant factors for not performing ISBCS (Table 3). To address these issues, policies need to be examined and adjusted if necessary, to increase the safe practice of ISBCS.6 In terms of financial barriers, it is unlikely that ophthalmologists would consider ISBCS with less financial incentive, considering the increased responsibility and tasks to all involved when compared to traditional DSBCS.3 However, a global solution cannot easily be resolved by changing financial policy. In some settings, the routine practice of ISBCS may not be feasible due to limited resources, especially in developing countries. For example, the use of intracameral antibiotic prophylaxis to prevent the complication of ISBCS may be limited alongside with a lack of hygiene and operating room protocol among other factors, in which case the risks may outweigh the benefits.10 Additionally, the risk of complications, especially endophthalmitis, along with other complications was the single most feared factor for our participants, which has been previously noted.6,11
Indeed, the majority of complications that are associated with ISBCS are manageable and should not cause unnecessary concern among ophthalmologists. There are published international guidelinesB from the International Society of Bilateral Cataract Surgeons, which aim to a minimise the incidence of complications. To our knowledge, the literature to date provides only a small number of case reports of bilateral endophthalmitis following ISBCS, in which none strictly followed the aforementioned guidelines.12,13,14 Strict adherence to the protocol should reduce the risk of complications.15 Within the NHS, clear procedural guidelines should be adopted in addition to hospital approval, to change the current culture of resistance towards ISBCS.
During delayed sequential cataract surgery, the second eye is compromised in visual acuity and colour vision whilst waiting for the next operation 16,17. Therefore, it may be prudent to operate bilaterally in the first instance in all patients with bilateral cataract 16,17. ISBCS could potentially provide a better standard of care than DSBCS in cataract operations. Faster rehabilitation, improved quality of life and less travel time would provide additional benefit to patients.18 Other advantages for society includes less time off work, reduced hospital resource consumption and efficient use of clinic/operation room time(3). Patients who are at a high risk of death due to undergoing a second general anaesthetic may also benefit from ISBCS.18 More research and training is also needed to improve the level of evidence to support the use of ISBCS and to allow ophthalmologists to make a better clinical decision for patients after close examination of its advantages and disadvantages.18
Our survey has allowed ophthalmologists to express their views and concerns related to the practice of ISBCS in the UK. Our study also highlights some of the negative factors that need to be overcome for ISBCS to become adopted more widely. Importantly, it provides a basis for which the moral and ethical debates for ISBCS can be discussed. We did not formally statistically analyse our results as it was not within the remit of this survey-based study to explore beliefs and attitudes. Demographics of the participants were not collected and could be incorporated in future surveys to determine whether the age, gender, and professional progression of the participants affect attitudes towards practising ISBCS. Our study provides a foundation for which we can explore the cultures and practices in other health systems regarding ISBCS. The basis of this survey has already been used to inform a subsequent project to explore the European view on ISBCS19 and we hope work within this area will broaden into the USA and Asia.
In conclusion, ISBCS has remained a controversial subject and there has been resistance towards its implementation in the clinical practice. From our study, it was evident that a large proportion of ophthalmologists would still not consider practising ISBCS, except in the cases in which patients are at a high risk of complications following a second general anaesthetic. Improved awareness of the practice of ISBCS and college and hospital approval is needed to change the resistant culture of unsubstantiated beliefs towards ISBCS in the world of ophthalmology, especially as it can provide additional benefits to both patients and practitioners compared to DSBCS.