Explicit criteria for prioritization of cataract surgery

BACKGROUND

Consensus techniques have been used previously to create explicit criteria to prioritize cataract extraction; however, the appropriateness of the intervention was not included explicitly in previous studies. We developed a prioritization tool for cataract extraction according to the RAND method.

METHODS

Criteria were developed using a modified Delphi panel judgment process. A panel of 11 ophthalmologists was assembled. Ratings were analyzed regarding the level of agreement among panelists. We studied the effect of all variables on the final panel score using general linear and logistic regression models. Priority scoring systems were developed by means of optimal scaling and general linear models. The explicit criteria developed were summarized by means of regression tree analysis.

RESULTS

Eight variables were considered to create the indications. Of the 310 indications that the panel evaluated, 22.6% were considered high priority, 52.3% intermediate priority, and 25.2% low priority. Agreement was reached for 31.9% of the indications and disagreement for 0.3%. Logistic regression and general linear models showed that the preoperative visual acuity of the cataractous eye, visual function, and anticipated visual acuity postoperatively were the most influential variables. Alternative and simple scoring systems were obtained by optimal scaling and general linear models where the previous variables were also the most important. The decision tree also shows the importance of the previous variables and the appropriateness of the intervention.

CONCLUSION

Our results showed acceptable validity as an evaluation and management tool for prioritizing cataract extraction. It also provides easy algorithms for use in clinical practice.

"Near misses" in a cataract theatre: how do we improve understanding and documentation?

AIM

Near miss event reporting is widely used in industry to highlight potentially unsafe areas or practice. The aim of this study was to see if a descriptive method of recording near misses was an appropriate method for use in an ophthalmic operating theatre and to quantify how many untoward events were recorded using this system.

METHODS

The study was wholly conducted in a cataract theatre in the United Kingdom. The theatre nurse assigned to the patient in their journey through the operating theatre was asked to note any untoward events. As, at present, there is no consensus definition of near misses in ophthalmology the nurses recorded, in free text, any events that they considered to be a deviation from the normal routine in that theatre.

RESULTS

Of the 500 cases randomly chosen, 96 "deviations from normal routine" were described in 93 patients-that is, 19% of cases. All forms distributed to the nurses were returned (100% response rate). The commonest abnormal events were intraoperative (69), with a lesser number being recorded preoperatively (27). When these events were further classified, it was thought that 25 could be classified as near misses. One true adverse event was recorded during the study.

CONCLUSIONS

The results suggest that experienced nursing staff in an ophthalmic theatre are a reliable source for collecting data regarding near misses. A consensus is now required to define near misses in ophthalmology and to devise a user friendly input system that can use these definitions to consistently record these potentially vital events.

Audit of exracapsular cataract extraction with posterior chamber intraocular lens implantation in a tertiary eye care center in Ethiopia

A retrospective audit of records of 370 eyes of 315 patients for whom extracapsular cataract extraction with posterior chamber intraocular lens implantation (ECCE-PC IOL) was performed between 1998 and 1999 was made to determine postoperative visual outcome and complications. One hundred and ninety three patients were males and one hundred and seventy seven were females making a male to female ratio of 1:0.9. At two months postoperatively 82 (30.4%) of eyes had uncorrected visual acuity of 6/18 or better; while 176 (53.7%) of eyes attained an uncorrected visual acuity between 6/18 and 6/60, and 31 (11.5%) had visual acuity between 3/60 and 6/60. 340 of 358 (94.9%) had a preoperative visual acuity of < 3/60. As a result of the surgery, the percentage of blind eyes dropped from 94.9% to 4.4%. The commonest intra operative and early postoperative complications encountered were posterior capsular tear with vitreous loss (5.7%) and striate keratopathy (11.1%) respectively. Posterior capsular opacity was documented in 17 (4.6%) eyes as a late postoperative complication. Routine biometry, to calculate Intra ocular Lens (IOL) power was not done and this was the major limitation of the study. In conclusion, the study increases awareness of cataract surgery outcomes and provides a feedback to achieve better results both in terms of quality and quantity in cataract surgery. Further study with biometric measurement is recommended.

A study of the safety of continued anticoagulation for cataract surgery patients

Cataract surgery is the most common procedure performed on Medicare recipients. Many of these patients have been on anticoagulation therapy (ACT) regimens, but no consistent standard currently governs the use or cessation of ACT prior to surgery. This study evaluated the safety of continuing ACT in cataract surgery patients (of ASA III physical status) at seven centers. There was a 53% incidence of previous ACT among the 1,842 individuals sampled. During 2,241 procedures, only two patients (one on ACT) experienced abnormal surgical bleeding, noted as hyphemas. Seventeen (0.9%), nine on ACT and eight not on it, had some type of bleeding related to regional anesthesia; of these, nine had bruising and eight had subconjunctival hemorrhage. No major complications were noted in the ACT group during surgery, or at visits 1 day and 1 week postoperatively.

Teaching and Assessing Surgical Competency in Ophthalmology Training Programs

BACKGROUND AND OBJECTIVE

The Accreditation Council for Graduate Medical Education (ACGME) has mandated implementation of six new competencies in resident training in the United States. An implementation strategy is proposed to teach and assess cataract surgical competence.

PATIENTS AND METHODS

An intradepartmental Task Force for the ACGME competencies reviewed the literature for assessment tools to develop an implementation matrix for assessing surgical competence.

RESULTS

"Good practices" (gleaned from the literature) were adapted for the institution's needs and tested, including (1) written and explicit goals or objectives for each stage of training; (2) substitution of a criterion-referenced (Dreyfus model) scoring rubric for a norm-referenced, peer-benchmarked global evaluation; (3) use of formative rather than summative feedback; (4) incorporation of deliberate practice (Ericsson model); and (5) portfolio-based documentation of sentinel event markers and remediation.

CONCLUSION

An implementation matrix for teaching and assessing surgical competence might be useful for local compliance with the ACGME mandate.

Cataract care is mobile

Is the direction correct?

Current trends in cataract surgery in Thailand--2004 survey

OBJECTIVES

To survey and investigate the current trend of cataract surgery in Thai ophthalmologists in 2004.

MATERIAL AND METHOD

Questionnaires were sent to 600 ophthalmologists who were the members of the Ophthalmological Society and Royal Colleges of Ophthalmologists of Thailand. Data received from 248 (41.3%) of the recipients were analyzed and compared with those from the previous survey.

RESULTS

The majority of respondents were male (63.3%) while 36.7% were female. In cataract surgery, 99.2% were still doing cataract surgery, the average number of cataract surgery procedures per surgeon per month was 25.6, 89.8% preferred phacoemulsification, and 42.5% preferred acrylic lens. The posterior capsular tear was the most common complication.

CONCLUSION

There are trends toward more cataract surgical procedures performed by a surgeon, increasing preference of topical anesthesia, small incision wound and foldable acrylic lenses which reflected the popularity of phacoemulsification.

Second eye cataract surgery: perceptions of a population assisted at a university hospital

OBJECTIVE

To identify daily life difficulties perceived by patients suffering from senile cataract before and after second eye cataract surgery.

METHODS

Longitudinal prospective study with 84 patients consecutively seen within the framework of the Cataract Project, with visual acuity equal to or higher than 20/30 in the pseudophakic eye, and equal to or lower than 20/40 with the best possible optical correction in the cataractous eye. A questionnaire was applied during an interview.

RESULTS

Before surgery, 60.7% complained about visual impairment (moderate or marked); after surgery, 92.8% had no difficulty. Routine activities, mobility, and leisure activities were significantly altered after surgery (P =.001).

CONCLUSION

According to the patients' perceptions, there was a significant reduction in visual difficulties after second eye cataract surgery.

The prioritization of patients on waiting lists for cataract surgery: validation of the Western Canada waiting list project cataract priority criteria tool

PURPOSE

To assess the validity of the Cataract Priority Criteria Score (PCS), developed by the Western Canada Waiting List (WCWL) Project to determine patient prioritization for cataract surgery.

METHODS

Ophthalmologists assessed consecutive patients with the PCS and a visual analogue scale of urgency (VAS Urgency). Patients were mailed questionnaires pre- and post-surgery. Outcome measures were the Visual Function Assessment (VFA), EuroQol (EQ-5D), and best-corrected visual acuity.

RESULTS

The sample of 253 patients was 58% female (mean age, 73.7 years); 166 completed pre-and post-surgery VFA. The correlation of the PCS and VAS Urgency was 0.65 (p = 0.000). Adjusting for age, first or second eye surgery, and post-operative complication, the PCS predicted improvement in the VFA and visual acuity (p < .05).

CONCLUSIONS

These data provide some evidence to support the convergent and predictive validity of the PCS. Multiple patient outcomes should be used in the evaluation of the validity of priority scores.

Reflective consideration of postoperative endophthalmitis as a quality marker

PURPOSE

To study the incidence of acute postoperative presumed infectious endophthalmitis (PIE) in a UK district general hospital over a 10-year period. Consideration of such departmental healthcare-associated infection frequency rates as part of reflective and comparative quality practice in the light of local concerns.

METHODS

Hospital-based retrospective case series: 12 831 cataract extraction operations from 01/01/1995 to 31/12/2004 were studied. All cases of PIE within 6 weeks of cataract surgery were ascertained and investigated in a standardised format. PIE incidence rate per 1000 cataract surgical procedures was contrasted with the existing literature.

RESULTS

Seven isolated PIE cases occurred following phacoemulsification. None followed extra-capsular extractions. The PIE rate was 0.55 [95% CI; 0.22 to 1.12] cases per 1000 cataract extractions, or one PIE case within 6 weeks of surgery in every 1833 [95% CI; 893 to 4545] cataract operations undertaken. Five cases were culture positive. Details of PIE cases are presented.

CONCLUSION

PIE incidence rates in our department are slightly lower than reported case series in similar settings. Whether this is due to a variety of preventive measures deployed locally and/or methods of case ascertainment in published studies is problematic and is discussed. Departmental benchmarking data is important in relation to rare, but critical, patient safety incidents. Collection and monitoring of endophthalmitis outcomes is of merit and may inform patient choice. Surgical site infection surveillance systems of relevance are discussed. Implications for making healthcare safer, including reflective practice are, discussed in relation to cataract care.

Rapid assessment of cataract surgical services in age group 50 years and above in Lower Dir District Malakand, Pakistan

OBJECTIVE

To assess the rapid assessment of cataract blindness and surgical services in age group 50 years and above.

DESIGN

A cross-sectional survey.

PLACE AND DURATION OF STUDY

This survey was conducted in District Lower Dir, Malakand Division, NWFP, Pakistan, from March 9-23, 2003.

PATIENTS AND METHODS

A community-based survey was carried out with systematic cluster random sampling. The survey was preceded by a pilot study in which the proforma and operational methods were field-tested and refined. One thousand, one hundred and fifty eligible adults of 50 years and older were selected by systematic random sampling from the whole lower Dir district of Malakand, Pakistan. A total of 1076 subjects (93.6%) were examined. The visual acuity of each eye was assessed using tumble Snellen's E Card method at 6 and 3 meters. Any subject having visual acuity <3/60 with or without obvious lens opacity or with aphakia (removal of lens) or pseudophakia (removal of cataract lens and implantation of artificial lens) was examined in detail. The surgical services were assessed by measuring the prevalence of pseudophakia, surgical outcome of visual acuity and also the effect of place of surgery on outcome.

RESULTS

Prevalence of total bilateral blindness was 2.6%, and unilateral blindness 2.46%. Total prevalence of aphakia was 2.4%, which was almost equal in both sexes, male 2.3% and female 2.4%. Prevalence of unilateral aphakia was 0.3 % in females being slightly higher than males, 0.16 %. The prevalence of bilateral aphakia was 2.2% and 2% in males and females respectively. Prevalence of total pseudophakic eyes was 2.74%. Surgical outcome showed good, borderline and poor visual acuity of 40.5%, 22% and 14.3% respectively. Surgical outcome was also seemed to be better in private hospitals as compared to field camps.

CONCLUSION

It is concluded that to reduce the prevalence of blindness there was a need to improve the quality of services in mobile camps and fixed facilities. At the same time the visual outcome of surgery could be improved by expanding the number of Intraocular lens procedures and routine monitoring of cataract outcome.

[Predictive value of preoperative fasting glucose test of diabetic patients regarding surgical outcome in cataract surgery]

OBJECTIVE

To determinate the predictive value of preoperative glucose test of diabetic patients, with age above 40 years, for visual acuity outcome and clinical perioperative complications, in cataract surgery with local anesthesia, in an academical medical center.

METHODS

Type 2 diabetic patients, above 40 years of age, indicated for cataract surgery between February 10, 2000 and January 10, 2001, at the State University of Campinas, São Paulo, Brazil. All patients had a preoperative medical assessment by a physician one week before surgery, and were submitted to serum fasting glucose test and 12-lead electrocardiogram. There was no delay in the surgeries of patients with abnormal serum glucose test results, so, the result of the test alone was not a reason to cancel the surgery. According to the glucose test, the patients were assigned to one of two groups: Normal Glucose Test Group (60-115 mg/dL) or Abnormal Glucose Test Group (>115 mg/dL). Postoperative best-corrected visual acuity and clinical perioperative complications were recorded on a standardized form.

RESULTS

The sample consisted of 193 patients. 67 (34.7%) had a serum glucose test within normal limits (normal glucose test group) and 126 (65.3%) outside normal limits (abnormal glucose test group). The mean result of the "normal glucose test group" was 98.5+/-17.3 mg/dL and 166.5+/-48.9 mg/dL for the "abnormal glucose test group" (p<0.001). We observed perioperative complications in 21 (10.7%) patients, all arterial hypertension cases; 7 (10.5%) of these in patients with normal glucose test result and 14 (11.1%) in patients with abnormal result (p<0.888). The postoperative best-corrected visual acuity was similar in both groups.

CONCLUSION

There was no influence of the preoperative serum glucose level on perioperative clinical complications or visual acuity outcome.

Searching the way out for posterior capsule opacification

Searching the way out for posterior capsule opacification was one of our goals in improving current cataract surgery techniques. The second goals was restoring accommodation but this goal prooved to remain unsolved. The bag-in-the-lens concept of IOL and implantation technique has been used in 271 patients of which 15 children. These patients have a follow-up of one month to 5 years. The optical axis of all these patients remained crystal clear, which allows us to conclude that the problem of PCO is solved by the bag-in-the-lens implantation concept. These very encouraging results inspired us to new ideas, which will receive priority in our research: accommodation and optimising the quality of vision by compensating for the ocular aberrations.

Pilot National Electronic Cataract Surgery Survey: I. Method, descriptive, and process features

AIM

The primary aim of this large pilot survey was to demonstrate the use and benefits of electronic data collection with respect to rapidly monitoring the access, delivery, and outcome of cataract surgery in the NHS and to update benchmark standards for these parameters of care.

METHOD

Eight NHS departments that currently use specialty-specific electronic clinical systems or Electronic Patient Records (EPR) to collect a minimum preoperative, operative, and anaesthetic data set for cataract surgery agreed to pool their data.

RESULTS

A total of 162 surgeons from 50 consultant teams and eight NHS Trusts agreed to submit their data on a total of 16,541 operations for age-related cataract. This report describes the age, sex, and ethnic profiles of the patients, waiting time for surgery, ocular copathology causing a reason for a guarded visual prognosis, visual impairment on admission, visual acuity in the operated eye, and the characteristics of the anaesthetic and surgical procedures.

CONCLUSIONS

This survey has raised the benchmark standards established by the last National Survey in 1997. There has been a near universal switch to day case, phacosurgery under local anaesthesia (all used in > or =99.1% of cases compared with 70, 77, and 86%, respectively in 1997). The visual impairment in the operated eye is lower with 45% having 6 / 12 or better compared with 27% in 1997. Waiting times and visual impairment in the fellow eye have probably improved although data collection for these variables was incomplete. All departments require specialty-specific clinical systems to efficiently collect and analyse these data and this survey proves their potential to form the basis for national electronic surveys in the future.

[European Cataract Outcome Study--results of five years of participation]

GOAL

To inform about European Cataract Outcome Study and to publish results from the Department of Ophthalmology, Faculty Hospital in Hradec Králové achieved during the five years' participation. METHOD, GROUPS: European Cataract Outcome Study is an international multicentric study pursuing quality of cataract surgery in individual departments of European countries. Its goal is to monitor the development of new trends and to be helpful in setting standards using the collected data. The Study evaluates results of all surgeries performed during one month. Our department participated in it in the years 1998-2002. In the first part of the trial the basic demographic data as well as the course of the surgeries were followed, in the second part results of examination during the first six months after the surgery were collected.

RESULTS

Operations are mostly performed by means of the facoemulsification method in local anesthesia (subconjunctival or parabulbar), the stay in hospital varies in individual years between 35.1% and 56%, the percentage of implanted foldable (soft) intraocular lenses rises every year, in 2002 up to 61.5% (average of the whole study was 78.2% in 2002), the percentage of posterior lens capsule rupture during the procedure during the five year period in our department descends (range 3.7% to 1.2%). In the referred groups, 40.4% to 50.5% of eyes suffered from still another disease. The best corrected visual acuity 0.6 or better after the surgery achieved in individual years 64% to 78%. The deviation from planed refraction is between 0.69 to 0.88 diopters. The induced postoperative astigmatism varied in followed periods from 0.49 to 0.69 cylindrical diopters.

CONCLUSION

The results of the study shows that the quality of surgeries performed in the department is on the high level and is fully comparable with contemporary European standard.

Risk management strategies following analysis of cataract negligence claims

INTRODUCTION

Clinical governance and risk management is very important in today's clinical practice. Cataract surgery is one of the most common procedures performed in the NHS, with around 200,000 operations per year. In order to help minimise the frequency of negligence claims, we performed a collaborative study to analyse claims relating to cataract surgery, dealt with by the defence organisations of England, Scotland, Wales, and Northern Ireland.

MATERIALS AND METHODS

All claims dealt with by the Medical Defence Union, the Medical Protection Society, and the Medical and Dental Defence Union of Scotland from January 1990 to December 1999, were analysed by three ophthalmologists with at least 5 years' speciality experience. Recurrent themes were identified and claims were grouped by major causative factor. The findings were discussed by a panel compromising the authors in conjunction with the defence unions and risk management strategies were designed.

RESULTS

There were 96 claims within the 10- year period analysed. Of these, the largest group (52) pertained to claims that related to accepted complications of cataract surgery. The remainder comprised two groups: 'Medical Errors' (anaesthetic, surgeon, and biometry) and 'Other Claims' comprising subjective complaints, pain and poor visual outcome. A total of 16 claims had been settled by May 2002, 45 are ongoing and 35 have closed without settlement.

CONCLUSIONS

The majority of claims pertained to well-recognised complications of cataract surgery. If these risks are adequately explained to the patient before surgery and if the care provided reaches a standard acceptable to a responsible body of professional opinion, all such claims should be defensible. Good visual outcome does not protect against litigation.