We thank Dr Schachat for his interest in our editorial on (same-day) immediate sequential bilateral cataract surgery. We had hoped that non–cataract specialists such as Dr Schachat, who is a renowned retinal surgeon, would be interested in the subject.

Dr Schachat is concerned that he might have to face a blind patient; he is under no obligation to undertake any procedure that he does not wish to. Furthermore, such a blind patient is at least 26 times (perhaps over 2000 times) rarer than death from elective general anesthesia, which is widely accepted practice. The validity of the assumption of independence between eyes (as described ) might be challenged, and indeed we address this in our editorial, but there is no evidence that the risk of bilateral endophthalmitis is greater than the risk of death after general anesthesia. In 95 606 cases of immediate sequential bilateral cataract surgeries reported recently, there was no simultaneous bilateral endophthalmitis. The 4 cases of simultaneous bilateral endophthalmitis in the literature violated accepted protocols.

Schachat suggests that surgeons may not follow segregation protocols. This would constitute medical negligence in the United Kingdom. We believe that practitioners who elect to offer suitable patients all the advantages of immediate sequential bilateral cataract surgery will adhere carefully to protocols. Those who do not will place themselves in a legally indefensible position. We again highlight the recommendations of the International Society of Bilateral Cataract Surgeons, which is the internationally accepted standard of care for bilateral cataract surgeries.

The concept that using first eye refractive data can improve fellow eye outcome remains controversial, with limited evidence on which patients with normal biometric parameters this might significantly benefit, and how best to refine intraocular lens selection for the fellow eye. Patients with eyes outside of normal parameters (extreme myopia, hypermetropia, and post–refractive surgery eyes) would be poor candidates for same-day bilateral surgeries, but they are not typical. With the development of intraoperative aberrometry, as well as improved biometry, we may soon be able to offer our patients enhanced refractive outcomes for both eyes, regardless.

We wished to highlight the extremely small risk of bilateral blindness from infection following immediate sequential bilateral cataract surgeries; but the risk remains even when fellow-eye surgery is delayed. Most patients and most ophthalmologists choose same-day refractive surgery and cosmetic blepharoplasties. We believe surgeons who undertake lens-based surgery for refractive or cataract surgery should consider offering bilateral cataract surgeries to appropriate patients. Given the potential savings, where there are financial discouragements, these should be drawn to the attention of health care funding agencies and reconsidered. Finally, we echo Dr Schachat’s sentiments on applauding those seeking to develop better data, so we can make decisions on that basis, and not on fear.