Chapter 2 Why did we not always do ISBCS? Obstacles overcome ∗

Cataract surgery has evolved tremendously in the past few decades leading up to our ability to consider returning to immediately sequential bilateral cataract surgery (ISBCS), which was done in simpler times, prior to World War 1, when surgical expectations were minimal. However, at the dawn of the 21st century, before ISBCS could be adopted by individual practitioners and become widespread, there were multiple obstacles that had to be addressed and then brought forward in academic discussions between the early adopters and those reluctant to perform same-day bilateral surgery. The initial important obstacles involved safety, specifically the risk of bilateral complications, which had been significantly reduced by the early 21st century with improved techniques and prophylactic regimens. Next, outcomes became the main concern. With better biometric equations, better management of astigmatism and more consistent, safe ISBCS protocols, and efficient surgical techniques, successful outcomes became quicker and more predictable allowing patients to benefit from faster recovery with ISBCS. Finally, the questions of third-party payment for same-day second-eye surgery and of ISBCS approval by ophthalmological societies and governing jurisdictions remain the two most important barriers, which still need to be addressed to convince all surgeons to adopt ISBCS. This chapter will discuss each of these obstacles and their solutions to date in greater detail.