Dear Editor

Dr Johansson's thorough and well-written article concerning 'same day' bilateral cataract surgery brought home keen memories and stirred up thoughts of my own experience with this approach to certain patients legally blind due to cataracts.

Periodically from 1951 through 1968, I was the Eye Surgeon-in-Charge of the then modern one hundred bed Kurji (Patna, Bihar, India) Holy Family Hospital Eye Clinic and Eye Hospital on the banks of the Ganges - 350 miles northwest of Calcutta. During the 1951 through 1952 operating season (the winter months), my schedule averaged twenty cataract operations daily. At that time my cataract surgery involved using either the erisiphake or Smith Indian technique . During that period I performed several dozen 'same day' - I prefer 'simultaneous' - bilateral cataract operations. The cataracts were primarily Morgagnian or cataracta nigra in type. The patients were legally blind with light perception only. They were primarily rural patients who in many cases had traveled - many times walked - with attending family members from distant villages, 'Same day' bilateral cataract surgery was frequently offered them - a golden opportunity for patients who might never again have access to surgery in a hospital under the aegis of the dedicated and skilled Medical Mission Sisters of Philadelphia. Most patients - and the burdened relatives - readily accepted the offer of 'same day' bilateral cataract surgery. For the patient, it was a matter of convenience; for the relatives, it was matter of expediency. I also realized that with vision restoration in one eye, the patient - or perhaps more so, the relatives - might not be interested in returning for surgery on the second eye. A prevalent philosophy was: "Two eyes are a luxury , one eye is a necessity". As a result, the patient frequently would develop the complications of a leaking hypermature (Morgagnian) cataract - phacolytic glaucoma. Such a painful glaucoma - a medical emergency - in a patient distant from acceptable medical care is a horrendous problem for the patient - and the family .

In spite of my own successful results with 'same day' bilateral cataract surgery in rural India , even there I was very selective - just as Dr Johansson has been - in offering this procedure to patients. In fact, during the eye clinic sessions subsequent to that of 1951-1952, I did not perform 'same day' bilateral cataract surgery but separated the two operations by at least a few days. I felt that the risk to the patient and to the reputation of the hospital was unacceptable. There is a basic rule in cataract surgery: "The second eye frequently behaves like the first eye." A complication in the first eye - often a delayed one - may presage a similar complication in the second when that eye is subjected to the same surgical procedure. This is particularly devastating in cases of endophthalmitis - more so in purulent panophthalmitis. Dr Johansson was fortunate in that it was the second, not the first eye, of his patient that developed the endophthalmitis. One can imagine the potentiality for infection of the second eye in cases where the first eye developed endophthalmitis in a 'same day' bilateral cataract operation.

In America (USA), 'same day' bilateral cataract surgery with rare exception cannot be advisable. With a sufficient number of qualified cataract surgeons with access to readily available ambulatory facilities and with scheduling of cataract surgery - on the first eye and subsequently on the second - at the convenience of the patient, Dr Johansson's standards for 'same day' bilateral cataract surgery would rarely if ever be met.

In addition, that ever-threatening incubus - the legal profession - hovers constantly above the American surgeon. 'Same day' bilateral cataract surgery is simply a bete noir for the American surgeon to avoid.

After completing the 1951-1952 cataract operating season in India, I returned to my private eye practice in Rochester , New York. There I was asked by a leading eye surgeon in the area if I would testify in court in his behalf. He had performed 'same day' bilateral cataract surgery on an older patient in an attempt to save her the expense of a second hospital stay. Unfortunately, postoperatively the patient developed diffuse retinal hemorrhaging bilaterally and was permanently blind with vaguest light perception. I informed the surgeon - a good friend - that I could not testify favorably for him, because I felt that he had demonstrated poor judgment in performing 'same day' bilateral cataract surgery in America (USA). In court, the eye surgeon was found guilty of malpractice. From that day he never again performed surgery of any type.

Dr Johansson's criteria in his country and my criteria in India cannot normally be met in contemporary America (USA).

Cataract surgeon, beware!