Waiting longer than 14 days to perform cataract surgery on the second eye may be unnecessary, according to an analysis of more than 1.8 million participants, published in JAMA Ophthalmology. The retrospective cohort study evaluated population-based refractive outcome data from American Academy of Ophthalmology’s Intelligent Research in Sight (IRIS) Registry.

Three groups were studied: same-day immediate sequential bilateral cataract surgery (ISBCS), and two delayed sequential bilateral cataract surgery (DSBCS) cohorts — DSBCS from 1 to 14 days, or DSBCS 15 to 90 days. Baseline best-corrected visual acuity (BCVA) for the first surgical eye was better in the immediate than in both delayed groups. For the second eye, baseline BCVA was similar for all cohorts. Postoperatively — after correcting for age, race, comorbidities, and insurance status — uncorrected visual acuity (UCVA) and BCVA in the ISBCS set was lower than both delayed interval cohorts, first and second eyes.

Postoperative UCVA and BCVA in DSBCS-14 was significantly higher compared with patients in DSBCS-90. Prior studies have shown that in healthy eyes, refractive errors even out at about 1 week after surgery. In the current analysis, most patients in DSBCS-14 had their second operation more than 7 days later, at a mean interval of 11.4 days. In the DSBCS-90 cohort, mean time between procedures was 34.6 days.

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Of participants receiving ISBCS, 46.8% reached a BCVA of 20/20 in the first and second treated eyes. When comparing delayed surgery with the ISBCS cohort, 5.7% more in DSBCS-14 attained BCVA of 20/20 in the first eye, and 10.0% more in the second eye (both P <.001). Compared with ISBCS, 1.9% less in the 15-to-90-day group attained BCVA of 20/20 in the first eye, but 6.6% more in the second (both P <.001).

Researchers linked older age to slightly reduced UCVA and BCVA. Additional aspects had an impact. “Race other than White, Medicaid coverage, and comorbid eye disease were independently associated with worse outcomes regardless of (statistical) correction,” the investigation explains. Asian and Black participants lost 0.5 to 1.2 letters compared with White participants, despite adjustment for comorbidities and other factors.

Axial length and topography data was not included in IRIS. Another limitation is that patients were not randomly assigned to immediate or delayed sequential surgery, thus limiting generalizability. A strength of this research is that it is the first evaluation specific to a delayed 1-to-14-day cohort, although investigators caution overall differences between groups may not be clinically relevant due to the large sample.

Smaller studies have reported outcomes for immediate vs delayed second eye operations, and some research has excluded patients with unusually long axial length or sight-threatening conditions. Other papers have reported improved outcomes for ophthalmologists who have larger cataract practices. “However, the current results did not change when controlled for each surgeon’s surgical volume, indicating that our outcome differences, albeit small, are likely not associated with outcome differences among surgeons performing a high vs low volume of operations,” according to the analysis.

Disclosures: Some of the study authors have received grants from public and private research agencies and organizations, or have declared affiliations with biotech companies. Please see the original reference for a full list of authors’ disclosures.


Owen JP, Blazes M, Lacy M, et.al. Refractive outcomes after immediate sequential vs delayed sequential bilateral cataract surgery. JAMA Ophthalmol. Published online: July 1, 2021. doi:10.1001/jamaophthalmol.2021.2032