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Original Investigation
July 1, 2021

Refractive Outcomes After Immediate Sequential vs Delayed Sequential Bilateral Cataract Surgery

Author Affiliations
  • 1Department of Ophthalmology, University of Washington, Seattle
  • 2Karalis Johnson Retina Center, Seattle, Washington
JAMA Ophthalmol. Published online July 1, 2021. doi:10.1001/jamaophthalmol.2021.2032
Key Points

Question  Are refractive outcomes similar between immediate sequential bilateral cataract surgery (ISBCS), short-interval (1-14 days) delayed sequential bilateral cataract surgery (DSBCS-14), and long-interval (15-90 days) delayed sequential bilateral cataract surgery (DSBCS-90)?

Findings  In this cohort study of 1 824 196 patients from the Intelligent Research in Sight Registry, uncorrected and best-corrected visual acuities were lower for patients undergoing ISBCS by 2.79 and 1.64 letters, respectively, and higher for patients undergoing DSBCS-14 by 0.41 and 0.89 letters, respectively, compared with those undergoing DSBCS-90.

Meaning  This study found that ISBCS was associated with worse outcomes than DSBCS, although the small but statistically significant differences may not be clinically relevant.


Importance  Approximately 2 million cataract operations are performed annually in the US, and patterns of cataract surgery delivery are changing to meet the increasing demand. Therefore, a comparative analysis of visual acuity outcomes after immediate sequential bilateral cataract surgery (ISBCS) vs delayed sequential bilateral cataract surgery (DSBCS) is important for informing future best practices.

Objective  To compare refractive outcomes of patients who underwent ISBCS, short-interval (1-14 days between operations) DSBCS (DSBCS-14), and long-interval (15-90 days) DSBCS (DSBCS-90) procedures.

Design, Setting, and Participants  This retrospective cohort study used population-based data from the American Academy of Ophthalmology Intelligent Research in Sight (IRIS) Registry. A total of 1 824 196 IRIS Registry participants with bilateral visual acuity measurements who underwent bilateral cataract surgery were assessed.

Exposures  Participants were divided into 3 groups (DSBCS-90, DSBCS-14, and ISBCS groups) based on the timing of the second eye surgery. Univariable and multivariable linear regression models were used to analyze the refractive outcomes of the first and second surgery eye.

Main Outcomes and Measures  Mean postoperative uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA) after cataract surgery.

Results  This study analyzed data from 1 824 196 patients undergoing bilateral cataract surgery (mean [SD] age for those <87 years, 70.03 [7.77]; 684 916 [37.5%] male). Compared with the DSBCS-90 group, after age, self-reported race, insurance status, history of age-related macular degeneration, diabetic retinopathy, and glaucoma were controlled for, the UCVA of the first surgical eye was higher by 0.41 (95% CI, 0.36-0.45; P < .001) letters, and the BCVA was higher by 0.89 (95% CI, 0.86-0.92; P < .001) letters in the DSBCS-14 group, whereas in the ISBCS group, the UCVA was lower by 2.79 (95% CI, −2.95 to −2.63; P < .001) letters and the BCVA by 1.64 (95% CI, −1.74 to −1.53; P < .001) letters. Similarly, compared with the DSBCS-90 group for the second eye, in the DSBCS-14 group, the UCVA was higher by 0.79 (95% CI, 0.74-0.83; P < .001) letters and the BCVA by 0.48 (95% CI, 0.45-0.51; P < .001) letters, whereas in the ISBCS group, the UCVA was lower by −1.67 (95% CI, −1.83 to −1.51; P < .001) letters and the BCVA by −1.88 (95% CI, −1.98 to −1.78; P < .001) letters.

Conclusions and Relevance  The results of this cohort study of patients in the IRIS Registry suggest that compared with DSBCS-14 or DSBCS-90, ISBCS is associated with worse visual outcomes, which may or may not be clinically relevant, depending on patients’ additional risk factors. Nonrandom surgery group assignment, confounding factors, and large sample size could account for the small but statistically significant differences noted. Further studies are warranted to determine whether these factors should be considered clinically relevant when counseling patients before cataract surgery.

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