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Immediate versus delayed sequential bilateral cataract surgery in children: a cost-effectiveness analysis
  1. Alexandra Cernat1,2,
  2. Margaret Jamieson1,
  3. RuthAnne Kavelaars1,
  4. Sina Khalili3,
  5. Vishaal Bhambhwani3,4,5,
  6. Kamiar Mireskandari3,5,
  7. Myla E Moretti1,6
  1. 1Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
  2. 2Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Ontario, Canada
  3. 3Ophthalmology and Vision Sciences, Hospital for Sick Children, Toronto, Ontario, Canada
  4. 4Ophthalmology Services, Department of Surgery, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
  5. 5Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
  6. 6Ontario Child Health Support Unit, Clinical Trials Unit, Hospital for Sick Children, Toronto, Ontario, Canada
  1. Correspondence to Dr Myla E Moretti, Ontario Child Health Support Unit, Clinical Trials Unit, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; myla.moretti{at}


Background/aims Children with bilateral cataracts may undergo immediate sequential bilateral cataract surgery (ISBCS), which involves surgery on both eyes during the same general anaesthesia, or delayed sequential bilateral cataract surgery (DSBCS), which involves operating on each eye on separate days and requires a second anaesthesia. ISBCS is viewed with caution because of the risk of bilateral endophthalmitis. Proponents of ISBCS emphasise that the incidence of serious complications is low and is outweighed by benefits such as avoidance of multiple anaesthesia, faster visual rehabilitation and potential for decreased costs. However, there is a paucity of literature regarding the cost-effectiveness of ISBCS in children. We conducted a cost-effectiveness analysis to determine whether ISBCS is more cost-effective than DSBCS from the societal and health system perspectives in Ontario, Canada, which has a universal, single-payer system.

Methods A retrospective analysis of children who underwent ISBCS or DSBCS at a tertiary referral paediatric hospital was conducted. A decision tree was constructed using TreeAge Pro 2018 software. Clear visual axis was the measure of effectiveness. A time horizon of 8 weeks postoperatively was adopted. Both direct and indirect costs were included.

Results Fifty-three children were included, 37 in the ISBCS group and 16 in the DSBCS group. ISBCS and DSBCS were equally effective. ISBCS resulted in cost-savings of $3,776 (95% CI:−$4,641 to $12,578) CAD, per patient, from the societal perspective and $2,200 (95% CI:−$5,615 to $10,373) CAD per patient from the health system perspective.

Conclusion ISBCS was less costly than DSBCS from both societal and health system perspectives while being equally effective.

  • child health (paediatrics)
  • treatment surgery

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  • Contributors AC, MJ, RAK, VB, KM and MEM developed the study design. AC, MJ, RK and MEM developed the decision model, guided by VB’s and KM’s clinical expertise. SK and VB performed data collection, while AC, MJ, RK and MEM led the interpretation and analysis of the data. AC led the writing of the manuscript. All authors contributed to critically revising the article for important intellectual content and final approval of the version to be published.

  • Funding AC is generously supported by the Hospital for Sick Children’s Research Training Centre through the Restracomp Master’s Scholarship, as well as by a Canada Graduate Scholarships Master’s Award (CGS-M) awarded by the Canadian Institutes of Health Research (CIHR). This economic evaluation was conducted as part of an academic training programme.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study has received ethics approval from the Research Ethics Board at the Hospital for Sick Children in Toronto, Ontario.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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