Immediately Sequential Bilateral Pediatric Cataract Surgery
Rupal H. Trivedi
M. Edward Wilson
Surgery on both eyes during one trip to the operating room has been performed on muscles, on lids, and in refractive laser surgery. However, surgical management of bilateral intraocular pathology (e.g., cataract, glaucoma) has generally been performed during separate sessions at different intervals depending on surgeon’s preference, patient’s/parent’s preference, and the outcome of the first procedure. The terminology used to describe the practice of bilateral cataract surgery done on the same day has been confusing. It has been referred to as same-day sequential, immediately consecutive, simultaneous bilateral, or immediately sequential bilateral surgery.1 “Immediately sequential bilateral cataract surgery” (ISBCS) is the currently preferred title, contrasting it with “delayed sequential bilateral cataract surgeries” (DSBCS), where the two procedures are performed as totally separate operations on different days.2
By any name, bilateral intraocular surgery not performed as totally separate operations on different days remains controversial. The risks of bilateral infection or toxic anterior segment syndrome (TASS) are weighed against the benefits of surgery under a single general anesthesia (GA). The latter reduces the travel time for the family and eliminates the risk of amblyopia due to delay between surgery on the first eye and the second eye. Cost considerations may favor the immediate sequential approach, but as Kushner3 warned in his 2010 editorial, allowing those in charge of health care dollars to influence practice patterns may introduce devastating potential risks. As with many debates in health care, the best management of risk and resources requires an assessment of the surgical setting and the health of the patient.
The use of ISBCS has been reported at least as far back as the early 1950s.4,5 An international society of bilateral cataract surgeons has now been founded (www.isbcs.org). However, ISBCS remains a hotly debated topic where almost every discussion either starts or ends with a comment on the disagreement surrounding its use. Peer-reviewed publications on ISBCS often have an accompanying editorial or letter to the editor reflecting the controversial nature of the subject.3,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21
The historical reluctance to perform ISBCS stems, in major part, from the potentially devastating consequences of a severe complication when it occurs bilaterally and the difficulty we have in quantitating how often such a rare complication would affect both eyes simultaneously if both eyes were put at risk at the same time. Can the benefits of ISBCS justify even the smallest risk of bilateral blindness? The important question here is not “Can it be done?” but, more properly, “Should it be done?” Although ISBCS remains controversial, for children with health problems, the risks of GA should be weighed against the risks of ISBCS. Many surgeons agree that there is a place for the ISBCS approach in patients for whom GA poses more than average risks.22,23,24,25 Several authors have proposed that ISBCS is a feasible and recommendable approach in selected pediatric cataract patients.22,23,24,26,27 We have used this approach in about 5% of infants operated for bilateral visually significant cataract, mainly because of higher risk of anesthesia, however, we have also used it (rarely) when we knew that the family would have difficulty getting back to us for the surgery on the second eye.
PROS
Medical
It may be logical to believe that performing ISBCS in the very young reduces the risk to the patient incurred from GA by exposing them to only one extended anesthesia episode rather than two separate episodes. Although we are not aware of a published study comparing the risk of more than one GA with that of prolonged anesthesia time, it is commonly accepted that induction, tracheal intubation, and emergence are high-risk periods of anesthesia.28 However, a longer procedure may also tend to increase the risk of anesthetic mortality in infants, and one should
weigh the risk of 1 longer operation versus 2 shorter ones.3 Anesthetic agents could adversely affect neurologic, cognitive, and social development of neonates and young children. One cohort study found an association between the development of reading, written language, and mathematics learning disabilities and two or more anesthesia episodes as well as longer cumulative duration of anesthesia in children younger than the age of 4 years.29 Later, Rappaport et al.30 noted that there is not enough information to draw any firm conclusions regarding an association between anesthetic exposure and subsequent learning disabilities. Nallasamy et al.28 recommended ISBCS in infants with bilateral congenital cataracts who are rated with an American Society of Anesthesiologists physical status >2 or generally those who are at higher risk for anesthesia-related complications. The systemic diseases associated with congenital/infantile cataracts in which anesthetic difficulties are higher than average are described by Zwaan24: rubella syndrome (congenital heart defects), Lowe syndrome (hypocalcemia, acidosis, renal failure), homocystinuria (thromboembolic episodes), prematurity (respiratory problems), Marfan syndrome (cardiovascular and respiratory problems), and craniosynostoses (difficult intubation, increased intracranial pressure, associated heart defects, respiratory problems), among others. Although Marfan syndrome and homocystinuria are included in the above list, eyes with subluxated lens are complicated to operate, and most physicians would avoid performing ISBCS for such cases. Also, for each child, the risk of anesthesia is best determined in consultation with an experienced pediatric anesthesiologist and with the physicians caring week to week for the child.
weigh the risk of 1 longer operation versus 2 shorter ones.3 Anesthetic agents could adversely affect neurologic, cognitive, and social development of neonates and young children. One cohort study found an association between the development of reading, written language, and mathematics learning disabilities and two or more anesthesia episodes as well as longer cumulative duration of anesthesia in children younger than the age of 4 years.29 Later, Rappaport et al.30 noted that there is not enough information to draw any firm conclusions regarding an association between anesthetic exposure and subsequent learning disabilities. Nallasamy et al.28 recommended ISBCS in infants with bilateral congenital cataracts who are rated with an American Society of Anesthesiologists physical status >2 or generally those who are at higher risk for anesthesia-related complications. The systemic diseases associated with congenital/infantile cataracts in which anesthetic difficulties are higher than average are described by Zwaan24: rubella syndrome (congenital heart defects), Lowe syndrome (hypocalcemia, acidosis, renal failure), homocystinuria (thromboembolic episodes), prematurity (respiratory problems), Marfan syndrome (cardiovascular and respiratory problems), and craniosynostoses (difficult intubation, increased intracranial pressure, associated heart defects, respiratory problems), among others. Although Marfan syndrome and homocystinuria are included in the above list, eyes with subluxated lens are complicated to operate, and most physicians would avoid performing ISBCS for such cases. Also, for each child, the risk of anesthesia is best determined in consultation with an experienced pediatric anesthesiologist and with the physicians caring week to week for the child.
Social
Social benefits of ISBCS include less anxiety for parents because their infant will undergo GA only once. This saves time for the caregiver who may have to travel far distances to the hospital and may have to arrange for the care of other children in the family. One of the relative indications of ISBCS is when follow-up care and travel are significant hardships for the parents. Sarikkola et al.31 reported ISBCS in adults was positively received by patients. It improved patient satisfaction, and 91% of patients who underwent ISBCS reported that they would recommend it to relatives or friends. Chung et al.32 also noted a high degree of patient satisfaction in a prospective controlled trial. These adult studies may lead us to think that ISBCS could produce higher satisfaction for the parents of our pediatric patients, too.
