Defining the Costs of ISBCS

Immediate sequential bilateral cataract surgery (ISBCS) has the potential to reduce costs, lessen environmental impact, and improve healthcare efficiency, according to Steve A Arshinoff MD.

In his clinical practice in Canada, 90% of his cataract patients undergo bilateral surgery.

“I think that, historically, cataract surgery has inevitably evolved to become immediate, sequential, and bilateral,” Dr Arshinoff said. “It turns out that up until recently, cataract surgery before 1930 was done everywhere as a bilateral procedure.”

The trend changed owing to fear of infection and the absence of any infection prophylaxis, such as intracameral antibiotics. As a result, surgeons became reluctant to take risks, giving bilateral cataract surgery, and any bilateral surgery, a reputation for being too dangerous. The subsequent advent of effective intracameral antibiotics reduced the dreaded risk of bilateral simultaneous postoperative endophthalmitis (BSPOE) to about one in one hundred million. This risk is the same as getting instantly killed while driving one kilometre on an empty road in Europe, he pointed out.

ISBCS concerns include interprocedural IOL power adjustments for the second eye. However, the literature does not show any benefit for the refractive outcomes, which he said makes no difference with modern biometry.

There is also fear of litigation, but, as he observed, the bilateral procedure has never been the main culprit. The real outstanding problem is money.

It is possible to consistently save up to 33% of the cost of two separate procedures by doing ISBCS, Dr Arshinoff said. This is supported by numerous studies from the US, Finland, Canada, Sweden, and the UK, conducted in hospitals and private surgical centres, showing cost savings for the patients and their families, the surgical centres, and the payer.^1,2 Savings come from registering the patient only once, reducing office visits, and achieving a 10% improvement in patient turnover in the operating room. In addition, the second eye is always easier and a bit quicker, he observed.

The economic advantage for doctors heavily depends on the healthcare system. The Canadian province of Québec, for example, pays the same amount for both eyes, whereas the province of British Columbia applies a 50% fee reduction for the second eye when operated on the same day, Dr Arshinoff explained.

Current global trends show increasing cost per cataract procedure and in the number of surgeries performed annually. This growth is largely driven by the introduction of modern techniques and intraocular lenses that produce better surgical results.

Payers would like to have some control over this increase in expenses, and ISBCS could be a way to save money without limiting innovation, he noted. However, payers want surgeons to be responsible for the successful outcomes in every case, which Dr Arshinoff said has developed into a severe accountability obstacle, creating mistrust and limiting surgeons from taking on difficult cases.

Despite the current financial constraints, ISBCS is gaining acceptance as the preferred solution in many parts of the world.

“ISBCS has proven in many ways better than delayed sequential bilateral cataract surgery (DSBCS), and it is increasing globally. Patients love it and doctors also like it,” Dr Arshinoff said.

“We must try hard to convince the payers and the other groups we work with to cooperate with each other as much as possible. We should not wait to be told by government to do ISBCS so that government can save money. We should work on doing things well ourselves and try to develop systems that work. Surgeons should be the leaders.”

Dr Arshinoff spoke at the 2025 ESCRS Annual Congress in Copenhagen.

Steve A Arshinoff OC (Officer of the Order of Canada), MD, FRCSC is Professor of the Department of Ophthalmology and Vision Sciences, University of Toronto, Canada.

1. Lee F, Arshinoff SA, et al. Can J Ophthalmol, 2025 Jun 5: S0008-4182(25)00159-0. doi:10.1016/j.jcjo.2025.04.010.

2. Arshinoff SA, ed. “Immediately Sequential Bilateral Cataract Surgery (ISBCS),” Academic Press, 2022.