Evidence-based management of resident-performed cataract surgery: an investigation of compliance with a preferred practice pattern

PURPOSE

To evaluate compliance with the American Academy of Ophthalmology (AAO) Cataract in the Adult Eye Preferred Practice Pattern (PPP) in a resident ophthalmology clinic.

DESIGN

Retrospective chart review.

PARTICIPANTS

All patients undergoing first-eye cataract surgery by ophthalmology residents with attending supervision at a Veterans Affairs Medical Center between January 1, 2006, and July 31, 2007.

METHODS

Electronic medical records (EMRs) were reviewed for compliance with the AAO Cataract in the Adult Eye PPP.

MAIN OUTCOME MEASURES

Frequency of resident compliance with all 39 elements of the AAO Cataract in the Adult Eye PPP.

RESULTS

A total of 129 patients met the inclusion criteria. The mean compliance with the PPP was 81%, with 62% of the elements having 90% or greater compliance. Compliance was below the mean for those PPP elements requiring patient input or assessment, including 0% for considering patient preference in the determination of anesthesia management, 73% for patient assessment of preoperative functional status, and 66% for patient assessment of postoperative vision.

CONCLUSIONS

Compliance with the AAO Cataract in the Adult Eye PPP in this resident ophthalmology clinic can be improved by increasing the documentation of patient input about their visual function both preoperatively and postoperatively. Further study of compliance with evidence-based guidelines is needed in ophthalmology, particularly in teaching hospitals where new providers are developing their approach to care.

Geographical variations in the benefit of applying a prioritization system for cataract surgery in different regions of Spain

BACKGROUND

In Spain, there are substantial variations in the utilization of health resources among regions. Because the need for surgery differs in patients with appropriate surgical indication, introducing a prioritization system might be beneficial. Our objective was to assess geographical variations in the impact of applying a prioritization system in patients on the waiting list for cataract surgery in different regions of Spain by using a discrete-event simulation model.

METHODS

A discrete-event simulation model to evaluate demand and waiting time for cataract surgery was constructed. The model was reproduced and validated in five regions of Spain and was fed administrative data (population census, surgery rates, waiting list information) and data from research studies (incidence of cataract). The benefit of introducing a prioritization system was contrasted with the usual first-in, first-out (FIFO) discipline. The prioritization system included clinical, functional and social criteria. Priority scores ranged between 0 and 100, with greater values indicating higher priority. The measure of results was the waiting time weighted by the priority score of each patient who had passed through the waiting list. Benefit was calculated as the difference in time weighted by priority score between operating according to waiting time or to priority.

RESULTS

The mean waiting time for patients undergoing surgery according to the FIFO discipline varied from 1.97 months (95% CI 1.85; 2.09) in the Basque Country to 10.02 months (95% CI 9.91; 10.12) in the Canary Islands. When the prioritization system was applied, the mean waiting time was reduced to a minimum of 0.73 months weighted by priority score (95% CI 0.68; 0.78) in the Basque Country and a maximum of 5.63 months (95% CI 5.57; 5.69) in the Canary Islands. The waiting time weighted by priority score saved by the prioritization system varied from 1.12 months (95% CI 1.07; 1.16) in Andalusia to 2.73 months (95% CI 2.67; 2.80) in Aragon.

CONCLUSION

The prioritization system reduced the impact of the variations found among the regions studied, thus improving equity. Prioritization allocates the available resources within each region more efficiently and reduces the waiting time of patients with greater need. Prioritization was more beneficial than allocating surgery by waiting time alone.

A comparison of the efficacy of cataract surgery using Aqualase with phacoemulsification using MicroFlow system

Purpose

To compare the outcomes after phacoemulsification performed with the AquaLase® and phacoemulsification in MicroFlow® system, including surgically induced astigmatism (SIA), corneal endothelial cell damage and postoperative recovery of visual acuity.

Methods

The cataracts of Lens Opacities Classification System, version III (LOCS III) nuclear grade below 2 were subjected in this study. Nineteen eyes underwent cataract operation using AquaLase® (Alcon Laboratories, Fort Worth, Texas, U.S.A.). A control group (19 eyes) used the MicroFlow® system (Millenium, Stortz, U.S.A.) and was selected by matching age, sex, systemic disease, corneal astigmatism and corneal endothelial cell density. All the surgeries were performed by the same operator. SIA, corneal endothelial cell loss, visual acuity, and corneal thickness were evaluated postoperatively.

Results

SIA in the group using AquaLase® was less than that of the group using MicroFlow® system (P=0.022) at 2 months postoperatively. Evaluation of corneal endothelial cell loss, recovery of visual acuity and corneal thickness found no statistically significant differences between the two groups.

Conclusions

Cataract surgery using AquaLase® induces less surgically induced astigmatism in mild to moderate cataracts.

The effects of cataract stage, lens-induced uveitis and cataract removal on ERG in dogs with cataract

OBJECTIVE

The purpose of this study was to determine the effects of cataract stage, lens-induced uveitis and cataract removal on the electroretinogram (ERG) of dogs with cataract.

ANIMALS STUDIED

Fifty-seven dogs diagnosed with unilateral or bilateral cataract whose ERG was recorded at Rakuno Gakuen University Teaching Animal Hospital from 2001 to 2004.

PROCEDURES

Four responses were recorded during the ERG: rod ERG, standard combined ERG, single-flash cone ERG and 30-Hz flicker ERG. Cataracts were divided into four stages: incipient, immature, mature and hypermature, and with or without lens induced uveitis (LIU). Noncataractous eyes of dogs with unilateral cataract were used as the control. We compared ERG amplitude, implicit time, and the b- to a-wave amplitude ratio of cataractous vs. noncataractous eyes, preoperative vs. postoperative cataractous eyes, and cataractous eyes with and without LIU.

RESULTS

No significant difference was found in ERG amplitude between incipient, immature and hypermature cataractous eyes, while in mature cataractous eyes decreased amplitude was confirmed in all responses compared with control eyes. However, no significant difference in b/a ratio was found at any stage of cataract. In postoperative eyes, increased amplitude was recorded in all responses compared to preoperative values. In eyes with LIU a decreased amplitude in the rod ERG and b-wave of standard combined ERG was recorded and, furthermore, a significant decline was confirmed in b/a ratio.

CONCLUSION

ERG values were influenced by cataract stage and LIU. LIU was associated with a reduction in the b/a ratio.

Clinical evaluation of blue-light blocker foldable acrylic IOL (HMY)

Efficacy and safety of blue-light-filtering acrylic IOL (HMY) were assessed and proven from 3 months to 1 year of postoperative follow-up in a clinical study performed on 80 eyes of 45 patients. Postoperative corrected visual acuity of all the eyes was 6/12 or better and 78.8% of them achieved higher than 6/6. The rate of mean corneal endothelial cell density decrease stood at 5.0%. Mild complications were observed, but none were serious.

The surgical management of cataract: barriers, best practices and outcomes

Cataract is the leading cause of blindness in the world. Cataract surgery has been shown by multiple studies to be one of the most cost-effective health interventions, and leads to a dramatic increase in quality of life and productivity for many patients. Though there has been marked improvement in the last several decades, surgical delivery services in developing nations are still suboptimal, and a large backlog in cataract cases continues to grow. To decrease this backlog, barriers to surgery, such as direct and indirect patient costs, geographic access to surgical facilities and surgeons, cultural factors, and patient education, must be addressed. In particular, access to services by women and rural patients needs to be improved. It is clear that extracapsular techniques are cost-effective and lead to better post-operative outcomes than intracapsular cataract extraction with aphakic correction. In addition, monitoring surgical outcomes is essential for improving the quality of surgical services. However, other issues regarding the delivery of cataract surgical services, including the role of average power intraocular lenses and the role of non-physician surgeons, are yet unresolved. Information about the true cost of surgery, including costs of surgeon training, equipment, and patient outreach programs, is needed so that the goal of self-sustaining programs may be obtained.

Standards in consent for cataract surgery

Consent forms for cataract surgery performed at Burnley General Hospital (BGH) and Blackburn Royal Infirmary (BRI) from October 4 to December 7, 2004, were prospectively reviewed to ensure that the East Lancashire Hospital's National Health Service (NHS) Trust Policy on consent to treatment and Department of Health (DoH) guidelines were being followed when seeking consent for cataract surgery. A set of 22 criteria derived as standards were formulated from the reference guide published by the DoH and from the East Lancashire trust policy document for consent to treatment. Each consent form was measured against these standards. Cases were randomly selected between BRI and BGH prospectively. All consent forms completed by physicians involved in formulating the standards were excluded. The review showed the NHS Trust Policy and DoH guidelines were largely followed when seeking consent for cataract surgery. However, certain areas were found to be deficient. If a health professional fails to obtain proper consent and the patient suffers harm as a result of treatment, it may be a factor in a claim of negligence against that health professional. Subsequent recommendations may include simple solutions that can be implemented to improve clinical practice when obtaining informed consent.

[Assessment of clinical practice guidelines about cataract management]

PURPOSE

To evaluate the quality of clinical practice guidelines (CPG) about the management of cataract in adults.

MATERIAL AND METHOD

A bibliographic search was carried out selecting the CPG based on the evidence or on the expert consensus, published since the year 2000. The guidelines selected were assessed with the AGREE Instrument.

RESULTS

Six guidelines were assessed. Three were classified as "recommend with provisos or alterations" and the others "would not be recommended". In accordance with the AGREE Instrument criteria, no guidelines can be recommended for their use in the clinical practice if they were not modified previously.

Rapid assessment of avoidable blindness in Negros Island and Antique District, Philippines

OBJECTIVES

To conduct rapid assessments of avoidable blindness to estimate the magnitude and causes of blindness in people aged >/=50 years in Negros Island and Antique district, Philippines.

METHODS

Clusters of 50 people aged >/=50 years were sampled with probability proportionate to size. Households within clusters were selected through compact segment sampling. Visual acuity (VA) was measured with a tumbling "E" chart. Ophthalmologists examined people with VA<6/18 in either eye.

RESULTS

In Negros, 2774 of 3649 enumerated subjects were examined (76.0%) and 3177 of 3842 enumerated subjects in Antique (82.7%). The prevalence of blindness (presenting VA<3/60 in better eye) was 2.6% (95% CI = 2.0 to 3.2%) in Negros and 3.0% (2.4 to 3.6%) in Antique. The leading cause of blindness was untreated cataract, and was refractive error for visual impairment (VA<6/18 to >/=6/60). Most of the cases of blindness (67% in Negros, 82% in Antique) and visual impairment (94% in Negros, 95% in Antique) were avoidable (ie, operated and unoperated cataract, refractive error and corneal scar). In Negros, 23% of eyes had a poor outcome after cataract surgery, and 13% in Antique.

CONCLUSIONS

The prevalence of blindness in two areas in the Philippines was relatively low. Since most cases were avoidable, further reductions are possible.

Use of our existing eye care human resources: assessment of the productivity of cataract surgeons trained in eastern Africa

OBJECTIVES

To measure the productivity of cataract surgeons in Africa and assess the factors that predict high productivity.

METHODS

A questionnaire on productivity and working environments was sent to all cataract surgeons trained in Malawi, Uganda, Tanzania, and Kenya. In addition, 2 meetings and in-depth discussions were held to elicit information on strategies to improve productivity among surgeons in general.

RESULTS

More than 77 000 cataract surgeries were performed in the years 2000 through 2004, resulting in an annual productivity rate of 243 surgeries per surgeon. Higher productivity was associated with having 2 or more cataract surgical sets, a well-functioning operating microscope, 3 or more nursing support staff, and a community program that includes transporting patients to the hospital.

CONCLUSION

Strategies for training, supporting, and supervising cataract surgeons in Africa need to be revised to create conditions amenable to greater productivity.

A retrospective analysis to determine the effect of independent treatment centres on the case mix for microsurgical training

AIM

To determine the effect of Independent Sector Treatment Centres (ISTC) on microsurgical training.

METHODS

A novel scoring protocol for stratification of cases suitable for microsurgical training was devised. This scoring protocol was applied to all patients who underwent cataract surgery on a single consultant dedicated training list between September and November 2004. These patients are representative of patients remaining on the waiting list after ISTC selection, that is, the residual case mix. Patients who underwent cataract surgery on the same consultant list in the same period in 2003 were also analysed when there was no ISTC or other waiting list initiative in operation.

RESULTS

Data was available for 129 patients. Seventy three patients underwent cataract surgery between September and November 2003 and 56 patients underwent cataract surgery in the same period in 2004. Using the devised scoring protocol, the mean score in the 2003 group was 1.08 +/-1.75 (range, 0.0-10.5) and for the 2004 group the mean score was 2.31 +/-2.65 (range, 0.0-4.5). A Mann-Whitney test showed that there was a statistically significant difference between the scores in the two groups (P=0.0009). With Independent Sector Treatment Centre implementation the percentage of cases suitable only for consultants increased fourfold.

CONCLUSION

The decrease in suitable cases for training as shown in this study is likely to have serious consequences on microsurgical training in the UK. We recommend that the results of this study are considered in any current or future plans for ISTC continuation and expansion.

Redesign and modernisation of an NHS cataract service (Fife 1997-2004): multifaceted approach

PROBLEM

A Scottish national health service ophthalmic facility was unable to cope with increasing demand for cataract surgery.

DESIGN

Multifaceted approach to redesign hospital space to accommodate a cataract unit; to invest in cataract nursing staff to allow more operations under local anaesthesia and as day cases; and to enhance input by general practitioners and optometrists to streamline and reduce false positive cataract referrals. A prospective audit for productivity was undertaken in 2004 (two years after the redesign) and compared against the national cataract surgery audit data for Fife from 1997.

SETTING

District general hospital serving a population of 400,000 in south east Scotland.

KEY MEASURES FOR IMPROVEMENT

Increasing throughput of cataract surgery while assessing quality of care provided against predefined evidence and Royal College of Ophthalmologists' guidelines, and evaluating training standards for ophthalmic surgical trainees against higher surgical training requirements.

STRATEGIES FOR CHANGE

Cataract services were redesigned to increase throughput and to reduce waiting times while preserving the quality of patient care. A secondary end point was to maintain surgical case load mix thus allowing trainees to continue to fulfil the number of operations required to acquire higher surgical training standards.

EFFECTS OF CHANGE

In the same three month period 237 cataract operations were carried out in 1997 and 374 in 2004, representing an increase of productivity by 60%. The waiting time for surgery decreased from more than one year to three months. The redesign resulted in almost complete preoperative and postoperative assessment by nursing staff, thus freeing medical time and allowing for more operations. Optometrists' referrals with reports increased significantly (P<0.0001). The number of operations carried out as day cases under local anaesthesia increased, with fewer intraoperative complications and postoperative visits (P<0.0001). The number of operations carried out by trainees more than doubled, from 43 to 100 cases, thus improving training opportunities.

LESSONS LEARNT

Modest capital investment in rebuilding space and in staff for cataract services can improve the quality and volume of cataract surgery. Enhancing existing NHS services provides for future need while maintaining training standards, thus potentially obviating the need for independent treatment centres. This model could be used throughout the United Kingdom.

Surgery for cataract

Reorganisation of in-house services is an efficient way to improve quality and increase volume

Outcomes of cataract surgery in Pakistan: results from The Pakistan National Blindness and Visual Impairment Survey

AIM

To evaluate the outcomes of cataract surgery in Pakistan.

METHODS

Cross-sectional, nationally representative sample of 16 507 adults (aged >or=30 years). Each underwent interview, logarithm of the minimum angle of resolution visual acuity (VA), autorefraction, examination of optic disc. Those with <6/12 VA on presentation underwent best-corrected VA and dilated biomicroscopic ocular examination.

RESULTS

1317 subjects (633 men) had undergone surgery in one or both eyes. Of the 1788 operated eyes, 1099 (61%) had undergone intracapsular cataract extraction (ICCE) and 607 (34%) extracapsular surgery with an intraocular lens (ECCE+IOL). Presenting VA: 275 (15.4%) eyes: 6/12 or better; 253 (14.1) <6/12 >or=6/18; 632 (35.3%) 6/18 to 6/60; 85 (4.8%): 6/60 to 3/60; 528 (29.5%): <3/60. With "best" refractive correction, these values were: 563 (31.5%), 332 (18.6%), 492 (27.5%), 61 (3.4%), 334 (18.7%), respectively. Of the 1498 eyes with VA <or=6/12 on presentation, 352 (23.5%) were the result of coincident disease, 800 (53.4%) refractive error and 320 (21.4%) operative complications. Eye camp surgery (OR 1.72, p = 0.002), ICCE (OR 3.78; p<0.001), rural residence (OR 1.36, p = 0.01), female gender (OR 1.55, p<0.001) and illiteracy (OR 2.44, p<0.001) were associated with VA of <6/18. More recent ICCE surgeries were associated with a poorer outcome. The ratio of ECCE+IOL:ICCE in the last 3 years was 1.2:1, compared with 1:3.3 >or=4 years before the survey.

CONCLUSION

Almost a third of cataract operations result in a presenting VA of <6/60, which could be halved by appropriate refractive correction. This study highlights the need for an improvement in quality of surgery with a more balanced distribution of services.

Rapid assessment of avoidable blindness in Nakuru district, Kenya

OBJECTIVES

To estimate the prevalence of avoidable blindness in > or =50-year-olds in Nakuru district, Kenya, and to evaluate the Rapid Assessment for Avoidable Blindness (RAAB), a new methodology to measure the magnitude and causes of blindness.

DESIGN

Cross-sectional population-based survey.

PARTICIPANTS

Seventy-six clusters of 50 people 50 years or older were selected by probability proportionate to size sampling of clusters. Households within clusters were selected through compact segment sampling. Three thousand seven hundred eighty-four eligible subjects were selected, of whom 3503 (92.6%) were examined.

METHODS

Participants underwent a comprehensive ophthalmic examination in their homes by an ophthalmologist, including measurement of visual acuity (VA) with a tumbling-E chart and the diagnosis of the principal cause of visual impairment. Those who had undergone cataract surgery were questioned about the details of the operation and their satisfaction with surgery. Those who were visually impaired from cataract were asked why they had not gone for surgery.

MAIN OUTCOME MEASURES

Visual acuity and principal cause of VA<6/18.

RESULTS

The prevalence of bilateral blindness (presenting VA < 3/60) was 2.0% (95% confidence interval [CI], 1.5%-2.4%), and prevalence of bilateral visual impairment (VA of <6/18-> or =6/60) was 5.8% (95% CI, 4.8%-6.8%) in the sample. Definite avoidable causes of blindness (i.e., cataract, refractive error, trachoma, and corneal scarring) were responsible for 69.6% of bilateral blindness and 74.9% of bilateral visual impairment. Cataract was the major cause of blindness (42.0%) and visual impairment (36.0%). The cataract surgical coverage was high, with 78% of those with bilateral cataract who needed surgery having had surgery at VA<3/60. The quality of surgery was of concern because 22% of the 222 eyes that had undergone cataract surgery had VA<6/60 with best correction. The main barriers to surgery were lack of awareness and cost. The RAAB methodology was easy to use, and each team could visit one cluster per day.

CONCLUSIONS

The prevalence of blindness in > or =50-year-olds in Nakuru district was low, in part due to the high cataract surgical coverage. The RAAB is easy to use and inexpensive and provides information about the magnitude and causes of avoidable blindness that can be used for planning and monitoring eye care services.

Patient safety in cataract surgery

PURPOSE

The recent focus on healthcare errors and safety suggest that practitioners and policy makers might appraise their cataract surgical care from a patient safety perspective. This paper reviews patient safety issues relevant to cataract care. Causation and consequences of incidents in cataract surgery, with implications for policy, are discussed.

METHODS

Models of accident causation from other domains were drawn on and empirically applied to cataract care. Consultation was undertaken with experts in cataract surgery, patient safety, and in risk management. Feedback on patient safety was included from presentations made to staff and patients and from personal insights.

RESULTS

Ophthalmology teams should embrace steps to improve patient safety. The role of incident reporting is advanced, including the provision of a prompt menu of cataract patient safety incidents as suggested by the Royal College of Ophthalmologists.

CONCLUSIONS

Strict attention to detail, risk assessment, and careful consideration of the patient pathway is needed to enhance cataract care. Clinical errors, near misses and complications happen, and may provide an opportunity for learning to reduce the risk of similar events in the future. Investment in staffing and training, appropriate equipment, and development of a safety culture with patient involvement are key elements of safe cataract surgical care. Patients and the public expect that safe cataract care should be commissioned for them. Critical patient safety incidents, including incidents that have led to permanent harm, require careful analysis of underlying systems and/or root causes.

NIKE: a new clinical tool for establishing levels of indications for cataract surgery

PURPOSE

The purpose of this study was to construct a new clinical tool for establishing levels of indications for cataract surgery, and to validate this tool.

METHODS

Teams from nine eye clinics reached an agreement about the need to develop a clinical tool for setting levels of indications for cataract surgery and about the items that should be included in the tool. The tool was to be called 'NIKE' (Nationell Indikationsmodell för Kataraktextraktion). The Canadian Cataract Priority Criteria Tool served as a model for the NIKE tool, which was modified for Swedish conditions. Items included in the tool were visual acuity of both eyes, patients' perceived difficulties in day-to-day life, cataract symptoms, the ability to live independently, and medical/ophthalmic reasons for surgery. The tool was validated and tested in 343 cataract surgery patients. Validity, stability and reliability were tested and the outcome of surgery was studied in relation to the indication setting.

RESULTS

Four indication groups (IGs) were suggested. The group with the greatest indications for surgery was named group 1 and that with the lowest, group 4. Validity was proved to be good. Surgery had the greatest impact on the group with the highest indications for surgery. Test-retest reliability test and interexaminer tests of indication settings showed statistically significant intraclass correlations (intraclass correlation coefficients [ICCs] 0.526 and 0.923, respectively).

CONCLUSIONS

A new clinical tool for indication setting in cataract surgery is presented. This tool, the NIKE, takes into account both visual acuity and the patient's perceived problems in day-to-day life because of cataract. The tool seems to be stable and reliable and neutral towards different examiners.

'Fast-track' cataract services and diagnostic and treatment centre: impact on surgical training

AIMS

To evaluate the impact of 'Action on Cataracts' and the development of Diagnostic and Treatment Centre (DTC) on cataract surgery training in the Central Manchester and Manchester Children's University Hospital's Trust.

METHODS

We compared all cataract extractions undertaken from April to September 2005 with the same 6-month time period over the preceding 5 years. Surgery was performed on one of four types of lists: Manchester Royal Eye Hospital standard lists (MREH), Cataract Services list, Waiting List Initiative list (WLI), and Diagnostic and Treatment Centre list (DTC). Surgeons were identified by their specific codes and divided into grades.

RESULTS

The total number of cataract operations undertaken on the standard MREH lists has declined significantly over the years (P<0.001 chi(2) test for trend). The number of cataract operations performed by both Specialist Registrars (SpRs) and Senior House Officers (SHOs) demonstrated a statistically significant decline over the years (P<0.001 for both cases, chi(2) test for trend), with the SHOs number dropping dramatically over the last 2 years. When comparing the number of operations performed by junior SpRs and senior SpRs, shift in the balance can be seen towards the senior surgeons. The proportion of operations performed by junior SpRs declined from 50% in 2000 to 28.2% in 2005.

CONCLUSION

Recent changes in cataract care provision have had a significant impact on training. Our results document for the first time that both higher and basic surgical trainees were affected. Future care of our patients could be comprised owing to lack of training.