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Editor,—Although present day cataract surgery has a high success rate, simultaneous bilateral cataract surgery is not routinely performed.1 The main cause for concern in patients undergoing simultaneous bilateral surgery is the possibility of visual impairment due to serious complications affecting both eyes. The potential problem that is most frequently highlighted in the literature is the risk of bilateral endophthalmitis.1 2We report a case of bilateral poor vision following simultaneous bilateral phacoemulsification and intraocular lens implant due to secondary corneal endothelial failure. To our knowledge this has not been previously reported.
A 76 year old white woman was referred to our cornea clinic with complaint of poor vision. She had undergone an uncomplicated simultaneous bilateral phacoemulsification with posterior chamber intraocular lens implant in March 1995 at another hospital. A few months before her surgery the visual acuity had been noted to be 6/24 in either eye. She had bilateral cataracts and the corneas were reported as normal. Following the surgery her vision gradually deteriorated in both eyes over 6 months to 3/60 right and hand movements left. This was due to bilateral diffuse corneal oedema secondary to endothelial failure. She underwent a left penetrating keratoplasty in September 1995 and subsequently the same operation was performed in her right eye in August 1996. Unfortunately the right corneal graft failed in the postoperative period.
On presentation to us in September 1997 her vision was 1/60 right eye and 6/36 left. Examination revealed a right failed corneal graft with vascularisation in one quadrant and a clear corneal graft in the left eye (Fig 1). Intraocular lens implants were in situ. The fundus appeared grossly normal in the right eye. Early retinal pigment epithelial changes were noted at the left macula. She was offered a repeat right corneal graft with a guarded prognosis but she decided against it.
Previous studies of patients undergoing simultaneous, bilateral modern cataract surgery have reported no bilateral, vision threatening postoperative complications.1 3 Even so the possibility of rendering the patient temporarily or permanently blind cannot be completely ruled out. In a recent consultation section on simultaneous bilateral cataract surgery2 the main cause of concern among surgeons was the possibility of bilateral endophthalmitis. There was, however, no mention of bilateral secondary endothelial failure resulting in poor vision. Secondary endothelial failure accounts for approximately 25% of patients requiring corneal grafts4and they have a higher rate of graft failure and rejection.5 6 The visual prognosis is also poorer in this group of patients and it can take up to a year to reach an optimum level.7 8 Therefore, patients requiring corneal grafts for bilateral secondary endothelial failure following simultaneous bilateral cataract surgery can potentially be rendered visually handicapped for a long time.
We are not aware of the reasons for our patient having simultaneous bilateral cataract surgery. Unfortunately, despite an apparently normal corneal examination she still developed bilateral secondary endothelial failure resulting in severe visual impairment for a long time.
This case therefore demonstrates that the possibility of bilateral visual loss due to secondary endothelial failure is another strong argument against routine simultaneous bilateral cataract surgery. We suggest that patients who are being offered this surgery should be made aware of the risks and consequences of secondary endothelial failure. Preoperatively, a meticulous examination of their corneal endothelium should be undertaken. If significant corneal endothelial pathology is noted, than only unilateral cataract surgery should be performed. The second eye should have the cataract surgery only after the first eye has been successfully rehabilitated.