Abbreviations
- DSBCS
Delayed sequential bilateral cataract surgery
- EQ5D
EuroQOL Five Dimensions questionnaire
- HUI3
Health Utility Index Mark 3
- ISBCS
Immediately sequential bilateral cataract surgery
- NICE
National Institute for Health and Care Excellence
- NRS
Non-Randomized Study
- QOL
Quality of life
- RCT
Randomized Controlled Trial
- SR
Systematic review
- VF
Visual Function questionnaire
Context and Policy Issues
According to the Canadian Survey on Disabilities conducted in 2017, approximately 1.5 million Canadians were living with mild to very severe loss in vision.1 As one of the leading causes of blindness, cataracts affected approximately 3.5 million Canadians as per the Cost of Vision Loss Report published in 2009.1 Characterized by a loss in lens transparency due to breakdown of tissue and clumping of proteins, cataracts left untreated may lead to vision impairment and blindness.2 With age-related cataract being the most common type,2 cataract surgery utilization is anticipated to increase.3
By removing and replacing the cloudy lens with a prosthetic lens,2 cataract surgery in both eyes, if indicated, is most commonly performed on separate days and is known as delayed sequential bilateral cataract surgery (DSBCS).3 Alternatively, bilateral cataract surgery can also be performed on the same day, which is known as immediately sequential bilateral cataract surgery (ISBCS)3 or bilateral simultaneous cataract surgery.4
With potential benefits such as reduced turnover time between procedures, lower health care costs, less postoperative visits, and fewer patient and staff encounters,3,5 the use of ISBCS may help streamline health care delivery when faced with capacity challenges.6 However, potential safety concerns such as the development of complications (e.g., bilateral endophthalmitis, corneal edema) should be considered. The aim of this report is to summarize and critically appraise the relevant clinical evidence and evidence-based guidelines regarding the safety and use of ISBCS for the treatment of bilateral cataracts.
Research Questions
What is the clinical evidence regarding the safety of immediately sequential bilateral cataract surgery for the treatment of bilateral cataracts?
What are the evidence-based guidelines regarding the use of immediately sequential bilateral cataract surgery for the treatment of bilateral cataracts?
Key Findings
One systematic review with meta-analysis, three primary non-randomized studies, and one evidence-based guideline regarding the safety or use of immediately sequential bilateral cataract surgery (ISBCS) for the treatment of bilateral cataracts were included in this report. The identified literature revealed varied, but largely neutral, conclusions regarding the safety of ISBCS for the treatment of bilateral cataracts. Specifically, the systematic review with meta-analysis suggested that there were no significant differences in postoperative quality of life scores including Visual Function 7- and 14-item questionnaire, EuroQOL Five Dimensions questionnaire, and Health Utility Index Mark 3 score between those who underwent ISBCS versus delayed sequential bilateral cataract surgery (DSBCS). However, patients who underwent ISBCS exhibited significantly greater improvements in postoperative Catquest scores compared to those who underwent DSBCS.
Findings from a primary non-randomized study suggested that there were no significant differences in the rates of intraoperative complications including posterior capsular rupture and vitrectomy, while another non-randomized study observed numerically similar rates of posterior capsular rupture after adjustments for case complexity between ISBCS and DSBCS patients. One primary non-randomized study detected no significant differences in rates of postoperative endophthalmitis between ISBCS and DSBCS patients. However, patients who underwent ISBCS exhibited significantly lower rates of macular edema compared to those who underwent DSBCS.
Based on variable quality evidence, the NICE guideline recommends that patients need to be informed of the risks versus benefits of ISBCS (recommendation strength not assigned). In addition, ISBCS should be considered for patients with a low complication risk, or for those needing general anesthesia but anesthesia may increase their complication risk (evidence of benefit is less certain).
Overall, the body of evidence used to inform this report was limited in quantity and was largely low to moderate in quality. Additionally, the high degree of heterogeneity of studies in the systematic review and lack of randomization in the primary clinical studies should be taken into consideration when interpreting these results. Finally, since the sample populations consisted of patients living in the US, United Kingdom, Spain, New Zealand, Australia, Japan, Finland, Sweden, or Switzerland, these findings may not be generalizable to the Canadian setting.
Methods
Literature Search Methods
A limited literature search was conducted by an information specialist on key resources including Ovid Medline, Embase, the Cochrane Library, the University of York Centre for Reviews and Dissemination (CRD) databases, the websites of Canadian and major international health technology agencies, as well as a focused internet search. The search strategy was comprised of both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. The main search concepts were sequential bilateral cataract surgery. No filters were applied to limit the retrieval by study type. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2010 and July 27, 2020.
Selection Criteria and Methods
One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in
Exclusion Criteria
Articles were excluded if they did not meet the selection criteria outlined in , they were duplicate publications, or were published prior to 2010. Studies involving patients with trauma-induced or congenital cataract, and those who underwent other forms of cataract surgery (e.g., femto laser-assisted cataract surgery were also excluded. Furthermore, systematic reviews in which all relevant studies were captured in other more recent or more comprehensive systematic reviews were excluded. Primary studies retrieved by the search were excluded if they were captured in one or more included systematic reviews. Guidelines with unclear methodology were also excluded.
Critical Appraisal of Individual Studies
The included publications were critically appraised by one reviewer using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2)7 for systematic reviews, the Downs and Black checklist8 for non-randomized studies, and the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument9 for guidelines. Summary scores were not calculated for the included studies; rather, the strengths and limitations of each included publication were described narratively.
Summary of Evidence
Quantity of Research Available
A total of 95 citations were identified in the literature search. Following screening of titles and abstracts, 78 citations were excluded and 17 potentially relevant reports from the electronic search were retrieved for full-text review. Six potentially relevant publications were retrieved from the grey literature search for full-text review. Of these potentially relevant articles, 18 publications were excluded for various reasons, and five publications met the inclusion criteria and were included in this report. These comprised one systematic review (SR),10 three non-randomized studies (NRSs),11–13 and one evidence-based guideline.4
Appendix 1 presents the PRISMA14 flowchart of the study selection. Additional references of potential interest are provided in Appendix 5.
Summary of Study Characteristics
One SR with meta-analysis,10 three NRSs,11–13 and one evidence-based guideline4 were identified for inclusion in this review. Additional details regarding the characteristics of included publications are provided in Appendix 2.
Study Design
The included SR with meta-analysis10 consisted of English-language studies published from January 2000 to May 2014. With study designs restricted to SRs, meta-analyses, randomized controlled trials (RCTs), NRSs, and cost-effectiveness analyses, Malvankar-Mehta et al. (2015) included a total of 11 studies which all had relevant outcomes for this report.10
Three primary studies were included in this report.11–13 Buchan et al. (2020)13 and Herrinton et al. (2017) conducted non-randomized retrospective comparative studies, while Guber et al. (2015) conducted a retrospective single-arm study.
The included evidence-based guideline4 was developed by the National Institute for Health and Care Excellence (NICE) and was published in 2017. This guideline was informed by systematic searches conducted on February 18, 2016 and screened for RCTs.4 The NICE guideline development group used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the quality of the evidence and graded the quality of evidence from very low to high.4 The strength of recommendations were reflected in the wording (i.e., “offer/advise” was used for strong recommendations with clear evidence of benefit, while “consider” was used if the evidence was less certain).4 The rating systems for quality of evidence and strength of recommendations are reported in Appendix 2. Decisions on the recommendations were reached through consensus.4
Country of Origin
The first author of the included SR10 was from Canada. The authors of the three primary studies were from the United Kingdom,13 US,11 and Switzerland,12 respectively. The NICE guideline is meant to apply to the United Kingdom.4
Patient Population
The identified SR included studies involving adult patients (≥ 19 years old) with bilateral cataracts.10 The total number of participants included in this SR was 3,657.10 The mean age of participants across the included primary studies within the SR ranged from 65.32 to 77.9 years old.10
The three included primary studies involved 249,414,13 24,615,11 and 11012 adult patients with bilateral cataracts, respectively. While one primary study specified adults to be ≥ 18 years old,13 the two other primary studies did not specify an age cutoff.11,12 The mean ages for the three primary studies were 75.5 years old,13 79.0 years old,12 and not reported.11
The target population covered by the NICE guideline was adult patients (≥ 18 years old) with cataracts.4 The intended users of this guideline are health care professionals, commissioners and providers, and people living with cataracts.4
Interventions and Comparators
The SR with meta-analysis10 included primary studies that compared ISBCS and DSBCS using phacoemulsification for bilateral cataracts with no requirement for a specific follow-up duration. While two primary studies11,13 compared ISBCS and DSBCS using phacoemulsification, one primary study only evaluated ISBCS using phacoemulsification.12 The follow-up durations for the three primary studies were 120 days after surgery,11 one month after surgery,12 and not reported,13 respectively.
The NICE guideline considered the overall management of cataracts at various stages (i.e., before, during, and after cataract surgery).4 Specifically, this guideline made recommendations on the use of phacoemulsification or femtosecond laser-assisted cataract surgery.4 Recommendations relevant for this report pertained to ISBCS using phacoemulsification.4
Outcomes
The authors of the SR with meta-analysis investigated effectiveness and safety outcomes for ISBCS and DSBCS using phacoemulsification.10 Safety outcomes relevant for this report included quality of life (QOL) scores as measured by the Visual Function Questionnaire (VF-7, VF-14), EuroQOL Five Dimensions Questionnaire (EQ5D), Health Utility Index Mark 3 (HUI3), and Catquest Questionnaire.10 Furthermore, the authors of the SR also qualitatively described postoperative complications associated with ISBCS and DSBCS.10 Complete definitions of QOL scores are described in Appendix 2.
Authors of all three primary studies evaluated intraoperative and postoperative complications associated with ISBCS and/or DSBCS using phacoemulsification.11–13 However, in the primary study authored by Buchan et al.,13 the assessment and reporting of postoperative complications was limited to rates of endophthalmitis.
The NICE guideline made various recommendations regarding the management of cataracts before (i.e., referral), during, and after surgery. However, the outcomes relevant for this report were the appropriateness, risks, and benefits of ISBCS.4
Summary of Critical Appraisal
Additional details regarding the strengths and limitations of included publications are provided in Appendix 3.
Systematic Review and Meta-Analysis
As per AMSTAR II criteria,7 the included SR10 with meta-analysis was generally well conducted with clearly stated objectives, inclusion criteria, stated key search terms, provided search strategies, searched multiple databases, provided a list of included studies, and evaluated the risk of bias in included primary studies with appropriate techniques. Furthermore, details of study selection were explicitly stated, and data extraction was conducted in duplicate, which decreases the risk for inconsistencies.10 Grey literature searches were conducted, which decreases the risk of missing relevant, non-indexed studies.10 Finally, the SR authors disclosed their funding source to be the Canadian National Institute for the Blind and that there are no potential conflicts of interest.10
In terms of methodological limitations, the exclusion criteria were not explicitly stated, the exclusion of non-English publications was not justified, a list of excluded studies was not provided, and the use of an a priori study protocol was not reported.10 The authors used I2 statistics and χ2 test to assess for heterogeneity, which was rated as high.10 Although the authors assessed the risk of publication bias using funnel plots, they were unable to rule out publication bias due partially to the small number of studies.10 Additionally, albeit the authors conducted fixed-effect and random-effect meta-analysis for outcomes related to QOL, outcomes related to postoperative complications were described qualitatively due to the limited availability of safety data10 Finally, since the primary studies were conducted in the US, Spain, New Zealand, Australia, Japan, Finland, and Sweden, the findings may not be generalizable to the Canadian setting.10
Non-Randomized Studies
The three NRS11–13 shared some methodological strengths such as clearly stated objectives, methodology and time period for participant enrollment, interventions, outcome measures, and main findings. Buchan et al. disclosed that there were no conflicts of interest and no funding support was provided for their study.13
Nonetheless, these three NRS11–13 also had some methodological limitations such as lack of reporting of characteristics of patients lost to follow-up and lack of sample size calculation a priori. The two comparative studies11,13 lacked randomization, and patient and clinician blinding, which may result in selection bias. Specifically, baseline patient characteristics such as mean age varied between the ISBCS (71.5 years old) and DSBCS (75.6 years old) group in one comparative study,13 while the mean age was not reported for the second comparative study.11 Additionally, these two comparative studies contained unbalanced sample sizes with considerably fewer number of patients in the ISBCS compared to DSBCS groups (1,073 versus 248,34113 and 5,247 versus 19,36811). Since the three NRS11–13 did not report sample size calculations and the single-arm study12 contained a relatively small sample size (N = 110), these studies may have been underpowered. Although the inclusion and exclusion criteria were clearly described in the study authored by Herrinton et al.,11 Buchan et al.13 only stated the inclusion criteria and Guber et al.12 did not establish the inclusion and exclusion criteria. Statistical tests used to assess the main outcomes were described and estimates of random variability were reported in two studies,11,13 but not in the third study.12 Furthermore, statistical analysis was not reported for postoperative endophthalmitis rates in the study authored by Buchan et al.13 The authors of the three NRS did not specify primary versus secondary outcomes and did not report on adjustment of multiplicity.11–13 Finally, listing Kaiser Permanente as their funding source, Herrinton et al.11 disclosed a potential conflict of interest in that Kaiser Permanente benefits from the implementation of ISBCS. Guber et al.12 disclosed that there were no conflicts of interest but did not disclose their funding source.
Evidence-Based Guidelines
The NICE guideline provided a clear description of their objectives, specified the target populations and users, sought the views and preferences of the target population, provided unambiguous and easily identifiable recommendations, presented monitoring criteria for the recommendations, described facilitators or barriers to their application, provided tools for putting recommendations into practice, and explicitly described procedures for guideline updates.4 The guideline development group was comprised of experts from multidisciplinary areas and the views of the funding sources did not appear to have influenced the guidelines’ contents.4 The supporting evidence, along with the quality of evidence, used to inform the recommendations were provided.4 However, details of external review was not reported.4
Summary of Findings
The overall findings of the included studies and guideline are highlighted below. One SR with meta-analysis,10 three primary studies,11–13 and one evidence-based guideline4 met the inclusion criteria for this report. Detailed summaries of the main findings and authors’ conclusions are available in Appendix 4.
Clinical Evidence Regarding the Safety of ISBCS for the Treatment of Bilateral Cataracts
Evidence regarding the safety of ISBCS for the treatment of bilateral cataracts was available from one SR with meta-analysis10 and three primary studies.11–13 Full definitions of QOL scores are described in Appendix 2.
Quality of Life Scores
In the SR with meta-analysis that compared ISBCS and DSBCS using phacoemulsification for bilateral cataract surgery, pooled estimates on postoperative QOL scores relevant for this report included Visual Function questionnaire (VF-7 and VF-14), EuroQOL Five Dimensions Questionnaire (EQ5D), Health Utility Index Mark 3 (HUI3), and Catquest questionnaire.10
In patients who underwent ISBCS, although there were significant postoperative improvements in VF-7, VF-14, EQ5D, and HUI3 scores compared to before the surgery, there were no significant differences in postoperative Catquest scores compared to before the surgery 10 However, patients who underwent ISBCS exhibited significant improvements in postoperative Catquest scores compared to those who underwent DSBCS.10 Finally, there were no significant differences in postoperative VF-7, VF-14, EQ5D, and HUI3 scores in patients who underwent ISBCS compared to those that underwent DSBCS.10
Intraoperative Complications
Clinical evidence regarding intraoperative complications were available from three primary studies.11–13 According to one primary comparative study, there was a significantly greater risk of intraoperative complications (3.5% versus 2.6% of eyes) and posterior capsular rupture rates (PCR) (1.9% versus 1.2% of eyes) in ISBCS compared to DSBCS eyes.13 However, after adjustments for case complexity, PCR rates were numerically similar between ISBCS (0.98%) and DSBCS (0.78%) eyes (statistical comparison not performed and complexity adjustment details not available).13 The case complexity was adjusted using variables such as surgeon grade, patient age, inability to lay flat during surgery, and diabetic retinopathy.13
Findings from another primary comparative study suggested that there were no significant differences in PCR (0.84% versus 0.67% of patients) or vitrectomy (0.42% versus 0.45% of patients) rates between patients undergoing ISBCS and DSBCS.11 Lastly, in the primary single-arm study involving patients who underwent ISBCS, observed intraoperative complications included intraoperative floppy-iris syndrome (9% of eyes), intraoperative conversion to intracapsular cataract extraction (1% of eyes), accidental sulcus implantation (0.5% of eyes), and intraocular lens implant breakage (0.5% of eyes).12
Postoperative Complications
Clinical evidence regarding postoperative complications were available from one SR10 with meta-analysis and three primary studies.11–13 The authors of the SR10 with meta-analysis narratively described the data (i.e., not pooled analysis) regarding postoperative complications from four clinical studies (statistical analyses not reported)15–18 In ISBCS eyes, complications with rates ≥ 5% included central corneal edema and intraocular pressure > 30 mmHg.10 In DSBCS eyes, complications with rates ≥ 5% included posterior capsule fibrosis and intraocular pressure > 30 mmHg.10 The authors did not report if there were cases of endophthalmitis.10
In the primary comparative study authored by Buchan et al., endophthalmitis rates of 0% and 0.01% were observed in patients who underwent ISBCS and DSBSC, respectively (statistical analysis not reported).13 Postoperative complications other than endophthalmitis were not reported in this study.13 In the primary comparative study authored by Herrinton et al., no significant differences were observed in endophthalmitis rates between patients who underwent ISBCS (1 per 10,000 eyes) and DSBCS (0.5 per 10,000 eyes), with no cases of bilateral endophthalmitis in either group.11 However, there was a significantly greater rate of macular edema in patients who underwent DSBCS (0.85%) compared to ISBCS (0.55%).11 Lastly, in the primary single-arm study involving patients who underwent ISBCS, observed postoperative complications included hypertony (1% of eyes), corneal decompensation (1% of eyes), wound dehiscence with iris incarceration (0.5% of eyes), conversion from dry to wet age-related macular degeneration (0.5% of eyes), herpes keratitis reactivation (0.5% of eyes), and prolonged anterior chamber inflammation (0.5% of eyes).12 The authors of this single-arm study did not report if there were cases of endophthalmitis.12
Guidelines Regarding the Use of ISBCS for the Treatment of Bilateral Cataracts
One identified evidence-based guideline provided recommendations regarding the use of ISBCS for the treatment of bilateral cataracts.4 The recommendations in the NICE guideline were based on very low to high quality evidence.4 This guideline recommends using the same criteria as the first eye when offering cataract surgery for the second eye (strong recommendation).4 Furthermore, this guideline recommends that ISBCS should be considered for patients with a low risk of ocular complications, or for patients requiring general anesthesia but for whom anesthesia would increase their risk of distress or complications (evidence of benefit is less certain).4 Patients should be informed of the risks and benefits of ISBCS including the potential immediate bilateral visual improvement or impairment, the need for additional postoperative support, and the inability to select an alternate intraocular lens based on first-eye outcomes (recommendation strength not assigned).4
Limitations
Limitations were identified in the critical appraisal (details in Appendix 3); however, additional limitations exist.
Although the included SR10 with meta-analysis was generally well-conducted, the authors rated the underlying evidence from relevant primary studies as being poor to high in quality. Additionally, there was a high degree of between-study heterogeneity with I2 index as high as 97.1%.10 Due to limited clinical evidence regarding safety, outcomes related to postoperative complications were presented narratively and not included in the meta-analysis.10
The lack of primary RCTs not included in the aforementioned SR10 and the small sample size (N = 110) in the single-arm study12 should be considered when interpreting the findings of this report. Since two relevant primary studies involved patients from surgical sites within the Kaiser Permanente Northern California system11 or from one specific hospital in Switzerland,12 these sample populations may not represent the population of interest in those respective countries and may limit the external validity of the study findings. Additionally, since the three primary studies were conducted in the United Kingdom,13 US,11 or Switzerland,12 the findings may not be generalizable to the Canadian setting.
The NICE guideline was developed for use in the United Kingdom; therefore, the generalizability of the recommendations to the Canadian context is unclear.4 Overall, considering the limitations mentioned, the findings and recommendations summarized in this report need to be interpreted with caution.
Conclusions and Implications for Decision or Policy Making
This review was comprised of one SR10 with meta-analysis and three NRS11–13 regarding the safety of ISBCS for the treatment of bilateral cataracts. Furthermore, one evidence-based guideline was identified regarding the use of ISBCS for the treatment of bilateral cataracts.4 Due to unclear methodology, guidance documents published by the Canadian Ophthalmological Society,5 and jointly by the Royal College of Ophthalmologists and United Kingdom and Ireland Society of Cataract and Refractive Surgery6 were excluded from this report and allocated to Appendix 5.
Findings from the SR10 with meta-analysis suggested that, compared to those who received DSBCS, patients who underwent ISBCS experienced significantly greater improvements in postoperative Catquest scores. However, no significant differences were detected in other QOL scores including VF-7, VF-14, EQ5D, and HUI3 between the ISBCS and DSBCS group.10 Furthermore, postoperative complications with rates ≥ 5% included central corneal edema and intraocular pressure > 30 mmHg in ISBCS eyes and posterior capsule fibrosis and intraocular pressure > 30 mmHg in DSBCS eyes (statistical analysis not reported).10
Findings from three primary NRS11–13 evaluating intraoperative and postoperative complications varied, but mostly suggested no significant difference between those undergoing ISBCS versus DSBCS when statistical analysis was reported. Specifically, rates of intraoperative PCR were comparable between ISBCS and DSBCS eyes after adjustment for case complexity based on factors such as patient age and comorbidities.13 Additionally, no significant differences were detected in intraoperative PCR or vitrectomy rates between ISBCS and DSBCS patients in another study.11 Postoperative endophthalmitis rates of 0% and 0.01% were observed in patients who underwent ISBCS and DSBSC, respectively (statistical analysis not reported).13 Additionally, no significant differences were observed in endophthalmitis rates between ISBCS and DSBCS eyes in another study.11 However, rates of macular edema were significantly less in ISBCS versus DSBCS patients.11 Lastly, in the primary single-arm study with only ISBCS patients, intraoperative complications such as intraoperative floppy-iris syndrome (9% of eyes) and conversion to intracapsular cataract extraction (1% of eyes), and postoperative complications such as hypertony (1% of eyes) and corneal decompensation (1% of eyes) were observed.12
The identified NICE guideline recommends that ISBCS should be considered for those with a low risk of complications, or for those needing general anesthesia but anesthesia may increase their risk of distress or complications (evidence of benefit is less certain).4 Furthermore, clinicians should inform patients of the risks and benefits of ISBCS (recommendation strength not assigned).4 These recommendations were based on evidence that ranged in quality from very low to high.4
Overall, the body of evidence used to inform the included SR with meta-analysis ranged in quality from poor to high, and had a high degree of heterogeneity.10 The three primary studies11–13 ranged in quality from low to moderate. Furthermore, the two comparative studies11,13 lacked randomization, which may result in selection bias. Additionally, since the studies within the SR10 with meta-analysis and the three primary NRS11–13 were conducted in the US, United Kingdom, Spain, New Zealand, Australia, Japan, Finland, Sweden, or Switzerland, the findings may not be generalizable to the Canadian setting.
Further research investigating the safety of ISBCS, especially with large multinational clinical trials with Canadian representation, would provide additional knowledge base for clinicians providing care to adults living with bilateral cataracts. Additionally, guidelines developed with rigorous methodology that are specific to the Canadian context would provide additional guidance for bilateral cataract surgery during times with capacity challenges.
References
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Appendix 1. Selection of Included Studies
Appendix 5. Further Information
Health Technology Assessment – Alternative Intervention (DSBCS)
Systematic Review – Full Overlap with Other Systematic Review
Non-Randomized Study – Mixed Population (Pediatric and Adult)
Clinical Practice Guidelines – Unclear Methodology
Lundström
M, Barry
P, Henry
Y, Rosen
P, Stenevi
U. Evidence-based guidelines for cataract surgery: guidelines based on data in the European Registry of Quality Outcomes for Cataract and Refractive Surgery database.
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Jun;38(6):1086–1093.
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Additional References
Protocol for Systematic Review
Dickman
MM, Spekreijse
LS, Winkens
B, et al. Immediate sequential bilateral surgery versus delayed sequential bilateral surgery for cataracts.
Cochrane Database Syst Rev. 2019
19
Feb;2019 (2) (no pagination)(CD013270).
PubMed: PMPMC6380770
Accreditation Standards
Non-Hospital Medical and Surgical Facilities Accreditation Program
Accreditation Standards. Immediately sequential bilateral cataract surgery. Vancouver (BC): College of Physicians and Surgeons of British Columbia; 2018:
https://www.cpsbc.ca/files/pdf/NHMSFAP-AS-ISBCS.pdf. Accessed 2020 Aug 24
About the Series
CADTH Rapid Response Report: Summary with Critical Appraisal
Funding: CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.
Suggested citation:
Immediately Sequential Bilateral Cataract Surgery for the Treatment of Bilateral Cataracts: A Review of Safety and Guidelines. Ottawa: CADTH; 2020 August. (CADTH rapid response report: summary with critical appraisal).
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