Bilateral vision-threatening disease necessitating urgent surgery in both eyes is a challenging situation, especially in the case of vitreoretinal disorders, where bilateral morbidity is not uncommon, and where surgeries are often longer and carry a higher risk than other ocular disorders. Clinical conditions occurring in both eyes simultaneously that require urgent bilateral retinal surgery, include diabetic vitreous hemorrhage with or without accompanying tractional retinal detachment (RD), Terson's syndrome, bilateral ocular trauma (including pediatric abusive head trauma), bilateral rhegmatogenous detachments, and retinopathy of prematurity.
Bilateral same-day intraocular surgery is a controversial issue. Under most circumstances, surgeons prefer to stage surgery, intervening first in the eye in which visual potential is threatened more urgently, and postponing a separate surgical intervention days or weeks later in the second eye. In the context of cataract surgery, this issue has been widely debated and published, particularly due to concerns regarding potential bilateral complications such as endophthalmitis and toxic anterior segment syndrome.1–3 In some countries, bilateral cataract surgeries are common, whereas in others, they are limited to patients undergoing general anesthesia only, or not performed at all. This is due not only to concerns regarding safety, but also to limitations in insurance payment and coverage of simultaneous bilateral surgery.
Bilateral intravitreal injections, also commonly performed in many countries and medical centers, have also been widely published, with numerous reports showing that bilateral same-day injections can be delivered without major safety risks (such as bilateral infectious or noninfectious endophthalmitis).4 It should be noted that intravitreal injections have rates of endophthalmitis similar to cataract surgery.5,6
Immediate sequential bilateral vitreoretinal surgery (ISBVS) is defined as vitrectomy performed in both eyes sequentially during the same anesthesia session. According to our review of the literature, these surgeries have been discussed infrequently.7
Patients and Methods
We retrospectively reviewed patient and operating room reports from our medical center from January 2003 to May 2019, searching for patients who underwent ISBVS on the same day. Patients who underwent bilateral procedures without bilateral vitrectomies (such as vitrectomy in one eye, with intravitreal injections or indirect laser treatments in the other eye) were excluded.
Data collected included age at presentation, sex, systemic diseases, ocular history and diagnosis, duration of symptoms, presenting visual acuity (VA), and description of detachment if present, including the status of the macula. Management outcomes recorded included the method of repair; time under anesthesia; precautions taken against cross-contamination between eyes; VA measured at 7 days, 1 month, and 6 months postoperatively from the repair; and intra-operative and postoperative (≤ 30 days) ocular and systemic adverse events (AEs).
We searched the Cochrane Central Register of Controlled Trials, Medline, and Embase for articles on bilateral vitrectomy, bilateral retinal surgery of any kind, and bilateral retinal surgical disorders, such as detachments, retinopathy of prematurity, diabetic retinopathy (DR), and bilateral complications of retinal surgery. There were no language or data restrictions in the search for trials. The databases were last searched on May 1, 2019. Reference lists of included trials were searched.
The study was approved by the Meir Medical Center institutional review board (Helsinki Committee). Data were obtained retrospectively from patients' electronic health records with patient privacy protection.
During the 16-year period database search, we found 14 patients who underwent ISBVS on the same day in both eyes. The cases included eight men and six women, with a mean age of 42.88 years (range: 5 months to 69 years). Relevant patient data are summarized in Table 1. Sterility was carefully observed, with each eye performed as a separate surgery, with surgeon and assisting nurse re-scrubbing and redressing. The second eye was cleaned and draped separately, and all surgical equipment replaced with a new set of sterile instruments and disposable surgical items and fluids. This has also been our standard departmental policy when performing bilateral cataract surgeries for many years. No AEs or complications were documented. The following reports describe three representative cases.
Demographics and Clinical Data
Case 1. A 5-month-old infant with no significant medical history was diagnosed with abusive head trauma (previously known as shaken baby syndrome). He presented to the pediatric service in our hospital with convulsions, increased intracranial pressure, and apathy. The ophthalmic examination shortly after his arrival disclosed multiple pre- and intra-retinal hemorrhages throughout the posterior poles of both eyes, without papilledema. He was admitted to the pediatric intensive care unit for treatment, and 3 days after his admission, he had a follow-up eye examination. Gaze following was inconsistent. There were thick bilateral subhyaloid hemorrhages that completely covered both maculas. Because this condition has serious amblyogenic potential at this age, and because of his intracranial hemorrhages and convulsions that the anesthesiologists considered at moderate risk for general anesthesia, he was referred for bilateral vitrectomy at one session under general anesthesia, which included bilateral 27-gauge pars plana vitrectomy (PPV) with bilateral posterior hyaloid and internal limiting membrane peeling, as well as peripheral endolaser barrier application. There were no AEs or complications either during or after surgery.
Case 2. A 53-year-old woman with bilateral proliferative DR underwent surgery due to bilateral vitreous hemorrhages and tractional RDs. This patient had multiple systemic comorbidities including diabetes, a history of cerebrovascular accident, dyslipidemia, Hodgkin's lymphoma, and a complex cardiac history of congestive heart failure and severe ischemia, for which she had previously undergone 16 percutaneous coronary interventions with multiple stent placements. She was unable to cooperate with surgery under local anesthesia, due to severe anxiety and orthopnea. Therefore, we decided to operate on both eyes at one session under general anesthesia, as she was considered very high risk by the anesthesiologist. She underwent bilateral vitrectomy with no AEs or complications either during surgery or during postoperative follow-up.
Case 3. A 15-year-old boy with high myopia was diagnosed with a RD in his left eye by his primary ophthalmologist, who referred him to our service. His best-corrected VA in the left eye was 6/90, and ophthalmic examination revealed a macula-off RD in the left eye. However, a macula-on RD was also found in his right eye, as well as bilateral lattice degeneration, with numerous retinal holes in both peripheries. He was referred for bilateral vitrectomy, endolaser, and intravitreal tamponade, in one session under general anesthesia due to his young age and poor potential for cooperation with local anesthesia. There were no AEs, infections, or complications either during or after surgeries.
ISBVS surgeries have rarely been discussed in the literature. Niharika et al.8 reported the clinical characteristics and surgical outcomes of 84 consecutive patients with bilateral simultaneous RD. They looked at the impact of the time interval between surgeries on the visual and anatomical outcome and found no statistically significant differences in the outcomes of second eyes of a staged intervention. However, they did not consider the option of bilateral same-day vitreoretinal surgery.
Yoshihiro et al.9 studied the feasibility and safety of bilateral simultaneous vitreoretinal surgery in pediatric patients, mostly with retinopathy of prematurity (ROP). They endorsed ISBVS as a treatment option when staged bilateral surgery unduly increases the risk for vision loss, mortality, or both, and when repeated anesthesia is undesirable or impractical. Likewise, Shah et al.7 showed that simultaneous bilateral 25-gauge lens-sparing vitrectomy for stage 4 ROP is safe, effective, and with good outcomes, provided both eyes are treated as if they were the eyes of two different patients, with separate preparation and equipment, as is our policy.
Krohn and Seland10 examined the incidence, pre-operative findings, and surgical outcome of patients presenting with simultaneous bilateral RDs. Their management of all cases included two separate surgeries, with the interval between surgeries varying from 4 days to 28 weeks (mean: 4 weeks). Finger et al.11 also examined the incidence and surgical management of simultaneous bilateral RD but did not mention the interval between surgeries.
Finn et al.12 reported the clinical course and outcomes of simultaneous, bilateral RDs managed by vitrectomy. In their study, 11 patients underwent bilateral same-day repair, and 10 patients were treated sequentially with unilateral surgeries performed on different days. There was no difference in visual outcomes for the second eye of a staged intervention when compared to macula-off RDs with same-day bilateral surgery and there were no AEs such as infection in patients undergoing simultaneous surgery.
Bodanowitz et al.13 retrospectively investigated the clinical course and risk factors of simultaneous bilateral RDs and operated on 10 of 11 patients in one session bilaterally. However, only two eyes underwent vitrectomy, the others undergoing other procedures such as scleral buckling.
Benmerzouga Mahfoudi et al.14 studied the incidence, management, and postoperative results of nine patients with bilateral RDs. However, only three cases were simultaneous, and none were operated upon in one session.
During the 16-year study period, of approximately 5,000 PPV surgeries performed in our service, a total of 14 ISBVS were documented. Accordingly, we do not recommend ISBVS as a standard of care, but suggest considering it under certain conditions, such as for patients unable to undergo surgery under local anesthesia, who definitely require urgent or semi-urgent bilateral, vitreoretinal surgery, that would necessitate a second general anesthesia in the near future if performed separately.
We recommend considering this option especially in cases where general anesthesia is considered high risk. In our opinion, there is little if any benefit in delaying treatment of a second eye, if it is clear in advance that both eyes require surgery. Furthermore, in cases of sight-threatening diseases requiring surgery (eg, bilateral RD, bilateral endophthalmitis, bilateral tractional detachment, etc.) even surgical failure or a complication in the first eye would not contraindicate or prevent the need for urgent surgery in the second eye. Avoiding repeat general anesthesia, especially in cases of comorbidities with increased risk, is another factor to be considered. In our opinion, ISBVS has additional advantages in the management of these conditions including reduced peri-operative hospitalization and recovery time, as well as reduced burden to the patients and their families.
Obviously, the overall safety of the patient, especially with the need for repeated high-risk general anesthesia must be weighed against the added risks of bilateral surgeries. However, even though small case series such as ours cannot attest to the overall safety of the procedure, we believe that in cases where it is definitely known in advance that both eyes require urgent or semi-urgent surgeries, there is little to be gained in terms of ocular safety (and possibly much to be lost in terms of patient systemic safety with repeated risky general anesthesia) by waiting a few days in between surgeries, provided the techniques described above for complete separation of the two surgeries are observed. Furthermore, in cases where the indication in both eyes requires gas tamponade (eg, bilateral RDs requiring general anesthesia or bilateral macular holes requiring general anesthesia), the surgeon must discuss the complex postoperative course with the patient, as vision will be decreased bilaterally while there is gas in both eyes, and may elect to use silicone oil tamponade in one or both eyes as a consequence.
- Schachat AP. Simultaneous bilateral endophthalmitis after immediate sequential bilateral cataract surgery: what's the risk of functional blindness?Am J Ophthalmol. 2014;158(2):410–411. doi:10.1016/j.ajo.2014.05.008 [CrossRef] PMID:25085107
- Li O, Kapetanakis V, Claoué C. Simultaneous bilateral endophthalmitis after immediate sequential bilateral cataract surgery: what's the risk of functional blindness?Am J Ophthalmol. 2014;157(4):749–751.e1. doi:10.1016/j.ajo.2014.01.002 [CrossRef] PMID:24630205
- Henderson BA, Schneider J. Same-day cataract surgery should not be the standard of care for patients with bilateral visually significant cataract. Surv Ophthalmol. 2012;57(6):580–583. doi:10.1016/j.survophthal.2012.05.001 [CrossRef] PMID:22995968
- Chao DL, Gregori NZ, Khandji J, Goldhardt R. Safety of bilateral intravitreal injections delivered in a teaching institution. Expert Opin Drug Deliv. 2014;11(7):991–993. doi:10.1517/17425247.2014.909806 [CrossRef] PMID:24815986
- Fileta JB, Scott IU, Flynn HW Jr, . Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. Ophthalmic Surg Lasers Imaging Retina. 2014;45(2):143–149. doi:10.3928/23258160-20140306-08 [CrossRef] PMID:24635156
- VanderBeek BL, Bonaffini SG, Ma L. The association between intravitreal steroids and postinjection endophthalmitis rates. Ophthalmology. 2015;122(11):2311–2315.e1. doi:10.1016/j.ophtha.2015.07.005 [CrossRef] PMID:26281823
- Shah PK, Narendran V, Kalpana N. Safety and efficacy of simultaneous bilateral 25-gauge lens-sparing vitrectomy for vascularly active stage 4 retinopathy of prematurity. Eye (Lond). 2015;29(8):1046–1050. doi:10.1038/eye.2015.78 [CrossRef] PMID:25998945
- Singh N, Jain M, Jaisankar D, et al. Bilateral simultaneous rhegmatogenous retinal detachment: Clinical characteristics and surgical outcome. Retina. 2019;39(8):1504–1509. doi:10.1097/IAE.0000000000002208 [CrossRef] PMID:30028409
- Yonekawa Y, Wu WC, Kusaka S, et al. Immediate sequential bilateral pediatric vitreoretinal surgery: An International Multicenter Study. Ophthalmology. 2016;123(8):1802–1808. doi:10.1016/j.ophtha.2016.04.033 [CrossRef] PMID:27221737
- Krohn J, Seland JH. Simultaneous, bilateral rhegmatogenous retinal detachment. Acta Ophthalmol Scand. 2000;78(3):354–358. doi:10.1034/j.1600-0420.2000.078003354.x [CrossRef] PMID:10893072
- Finger ML, Bovey E, Wolfensberger TJ. Incidence and Surgical Management of Simultaneous Bilateral Retinal Detachment. Klin Monatsbl Augenheilkd. 2016;233(4):478–481. doi:10.1055/s-0041-111827 [CrossRef] PMID:27116513
- Finn AP, Eliott D, Kim LA, et al. Characteristics and Outcomes of Simultaneous Bilateral Rhegmatogenous Retinal Detachments. Ophthalmic Surg Lasers Imaging Retina. 2016;47(9):840–845. doi:10.3928/23258160-20160901-07 [CrossRef] PMID:27631480
- Bodanowitz S, Hesse L, Kroll P. [Simultaneous bilateral rhegmatogenous retinal detachment]. Klin Monatsbl Augenheilkd. 1995;206(3):148–151. doi:10.1055/s-2008-1035419 [CrossRef] PMID:7616721
- Benmerzouga Mahfoudi N, Chaker Harbi M, Boulaneb Beddiar F, Chachoua L. [Bilateral retinal detachment and high myopia: report of nine cases]. J Fr Ophtalmol. 2015;38(2):141–145. doi:10.1016/j.jfo.2014.12.001 [CrossRef] PMID:25648067
Demographics and Clinical Data
|Patient||Age (Years)||Sex||Preoperative Visual Acuity OS/OD||Postoperative Visual Acuity OS/OD||Anesthesia Typ e||Indications for Bilateral Operation||Operation Type||Duration of Anesthesia (Hours)||Postoperative Complications|
|1||0.5||Male||ND||ND||20/1200||20/1200||General||Bilateral dense pre-retinal hemorrhages covering macula||Vitrectomy||2:02||None|
|3||66||Female||1/24||1/36||1/24||1/24||General||Bilateral VH, ERM and cataract, OS MH||Vitrectomy||2:17||None|
|5||51||Female||HM||1/36||HM||6/15||General||Bilateral TRD, OD VH||Vitrectomy||ND||None|
|6||3||Female||0.5/36||LP||LP||CF||General||OS total hyphema and PVR, OD TRD||Vitrectomy||3:09||None|
|8||56||Male||6/30||CF||1/24||CF||General||Bilateral TRD and cataract||Vitrectomy||2:58||None|
|11||58||Male||6/12||6/60||6/30||6/60||General||OS TRD, OD VH, subhyaloid hemorrhage and bilateral cataract||Vitrectomy||1:24||None|
|13||55||Male||HM||HM||6/12||6/12||General||Bilateral Terson syndrome and VH||Vitrectomy||1:37||None|