Second-eye surgery

Quality statement 6 - Cataract Clinical Care Standard

Options for a patient with bilateral cataract are discussed when the decision about first-eye surgery is being made. Second-eye surgery is offered using similar criteria as for the first eye, but the potential benefits and harms of a delay in second-eye surgery are also considered, leading to a shared decision about second-eye surgery and its timing.

Purpose

To ensure that patients with bilateral cataract who have a higher risk of poorer visual function after first-eye surgery are identified, the options for surgery are discussed, and a decision about timing is made, appropriate to their individual clinical circumstances and personal preferences.

For patients

If you have cataract in both eyes, your eye surgeon will discuss whether you would benefit from having surgery in both eyes. For many people, having cataract surgery in one eye is enough to improve vision. If your eye surgeon thinks you may need operations on both eyes, the options include:

  • Having surgery on the second eye weeks or months after the first eye has recovered from surgery
     
  • Having surgery on the second eye on the same day as the first eye or the day afterwards.
    The option most suitable for you will depend on a number of factors. Some of the factors you should take into account include:
     
  • How your overall vision is expected to change after surgery in the first eye – if one eye is very different from the other (for example, much more short-sighted), it may be hard to see clearly
     
  • The risks of an infection or another complication. Although the risk of complications is small, having complications in both eyes could be very serious. If you are at high risk of complications or have other eye problems, having operations on both eyes at the same time may not be recommended
     
  • Your general health, any other eye problems, and your personal circumstances and preferences.

Discussing these issues with your eye surgeon, and understanding the potential harms and benefits will help you decide if and when you want to arrange surgery for your second eye, and how to go about doing so.

For clinicians

Discuss second-eye surgery and its timing when first-eye surgery is being planned. Similar criteria apply when assessing the need for second-eye surgery as for the first eye63 (clinically significant visual impairment, vision-related activity limitations and comorbidities – see quality statements 4 and 5). In addition, consider existing or anticipated anisemotropia (a significant difference in refractive error between the two eyes) after first-eye surgery, and its impact on vision and visual function, including stereopsis (depth perception), stereoacuity and falls risk.

Advise patients of the options available and appropriate in their clinical circumstances. This may include no surgery, surgery on two separate days some time apart or second-eye surgery on the same or next day. Explain to patients what they can expect from having, or not having, second-eye surgery, and discuss the benefits and potential harms with them to help decide between options.

Having second-eye surgery later allows complete postoperative recovery (and, if needed, treatment of postoperative complications) from first-eye surgery, and the opportunity to assess and plan surgery based on the results of first-eye surgery. Make arrangements for second-eye surgery as soon as it is appropriate for the patient’s preferences and circumstances.

There is limited evidence to support second-eye surgery on the same or next day.64 It may be considered for patients4,8:

  • At low risk of complications during and after surgery, or at risk from delayed second eye surgery
     
  • To avoid a second general anaesthetic, when general anaesthetic is required
     
  • For whom distance and travel are considerable barriers, such as in remote and very remote areas.

Ensure that patients are informed of the consequences of complications, including the risk of potentially blinding complications in both eyes, such as endophthalmitis or toxic anterior segment syndrome.4 Second-eye surgery may not be appropriate for some patients. As well as individual preference, some patients may have another eye condition that makes it too risky for them, or makes an improvement in vision less likely.

For health service organisations

Provide access to current evidence-based guideline recommendations for second-eye surgery and support use of these recommendations by clinicians. Ensure the availability of protocols relating to decisions about second-eye surgery and its timing. For patients having delayed second-eye surgery, prioritise surgery according to clinical need.

If second-eye surgery on the same or next day is carried out in the health service, ensure that facilities are appropriately equipped, and that local protocols are in place to minimise the risk of complications and manage them should they occur.4

For patients

If you have cataract in both eyes, your eye surgeon will discuss whether you would benefit from having surgery in both eyes. For many people, having cataract surgery in one eye is enough to improve vision. If your eye surgeon thinks you may need operations on both eyes, the options include:

  • Having surgery on the second eye weeks or months after the first eye has recovered from surgery
     
  • Having surgery on the second eye on the same day as the first eye or the day afterwards.
    The option most suitable for you will depend on a number of factors. Some of the factors you should take into account include:
     
  • How your overall vision is expected to change after surgery in the first eye – if one eye is very different from the other (for example, much more short-sighted), it may be hard to see clearly
     
  • The risks of an infection or another complication. Although the risk of complications is small, having complications in both eyes could be very serious. If you are at high risk of complications or have other eye problems, having operations on both eyes at the same time may not be recommended
     
  • Your general health, any other eye problems, and your personal circumstances and preferences.

Discussing these issues with your eye surgeon, and understanding the potential harms and benefits will help you decide if and when you want to arrange surgery for your second eye, and how to go about doing so.

For clinicians

Discuss second-eye surgery and its timing when first-eye surgery is being planned. Similar criteria apply when assessing the need for second-eye surgery as for the first eye63 (clinically significant visual impairment, vision-related activity limitations and comorbidities – see quality statements 4 and 5). In addition, consider existing or anticipated anisemotropia (a significant difference in refractive error between the two eyes) after first-eye surgery, and its impact on vision and visual function, including stereopsis (depth perception), stereoacuity and falls risk.

Advise patients of the options available and appropriate in their clinical circumstances. This may include no surgery, surgery on two separate days some time apart or second-eye surgery on the same or next day. Explain to patients what they can expect from having, or not having, second-eye surgery, and discuss the benefits and potential harms with them to help decide between options.

Having second-eye surgery later allows complete postoperative recovery (and, if needed, treatment of postoperative complications) from first-eye surgery, and the opportunity to assess and plan surgery based on the results of first-eye surgery. Make arrangements for second-eye surgery as soon as it is appropriate for the patient’s preferences and circumstances.

There is limited evidence to support second-eye surgery on the same or next day.64 It may be considered for patients4,8:

  • At low risk of complications during and after surgery, or at risk from delayed second eye surgery
     
  • To avoid a second general anaesthetic, when general anaesthetic is required
     
  • For whom distance and travel are considerable barriers, such as in remote and very remote areas.

Ensure that patients are informed of the consequences of complications, including the risk of potentially blinding complications in both eyes, such as endophthalmitis or toxic anterior segment syndrome.4 Second-eye surgery may not be appropriate for some patients. As well as individual preference, some patients may have another eye condition that makes it too risky for them, or makes an improvement in vision less likely.

For health service organisations

Provide access to current evidence-based guideline recommendations for second-eye surgery and support use of these recommendations by clinicians. Ensure the availability of protocols relating to decisions about second-eye surgery and its timing. For patients having delayed second-eye surgery, prioritise surgery according to clinical need.

If second-eye surgery on the same or next day is carried out in the health service, ensure that facilities are appropriately equipped, and that local protocols are in place to minimise the risk of complications and manage them should they occur.4

Read quality statement 7 - Preventive eye medicines