Auckland Cataract Study III: Refining Preoperative Assessment With Cataract Risk Stratification to Reduce Intraoperative Complications

Ophthalmology Residents' Experience in Cataract Surgery: Preoperative Risk Factors, Intraoperative Complications, and Surgical Outcomes

INTRODUCTION

This retrospective study explores the connection between preoperative patient risk factors, the experience of ophthalmology residents, and the outcomes of cataract surgeries performed at Hadassah Medical Center. It is hypothesized that with increased experience, residents may demonstrate greater proficiency in handling surgeries on higher-risk patients, potentially leading to improved surgical outcomes overall.

METHODS

Data were examined from 691 consecutive cataract surgeries in 590 patients, conducted by ophthalmology residents at Hadassah Medical Center (January 2018 to February 2022). Demographics, surgeon experience, preoperative cataract risk assessment score, and pre- and postoperative corrected distance visual acuity (CDVA) were analyzed. The risk score was based on cataract density, previous vitrectomy, presence of phacodonesis, small pupil, extreme axial length (> 30 mm or < 21.5 mm) or abnormal axial length (26-30 mm), shallow anterior chamber (< 2.5 mm), poor patient cooperation, oral alpha-1 blocker use, diabetic retinopathy (DR), Fuchs endothelial dystrophy, and having one functioning eye. This study focused on the correlation of risk scores with residents' surgical experience and surgical outcomes.

RESULTS

As residents gained experience, surgeries on patients with at least one risk factor increased from 54% (first year) to 75% (second year; p < 0.001) and fluctuated between 75%, 82%, and 77% (third, fourth, and fifth years, respectively), with initial preoperative CDVA declining progressively. Despite handling more complex cases over time, the percentage of intraoperative complications per patient decreased with each year of residents' experience (17%, 13%, 11%, 17%, 6%; respectively). Patients without any risk factor had higher postoperative CDVA than those with one or more risk factors (mean ± standard deviation [SD] in logMAR, 0.16 ± 0.26 vs. 0.27 ± 0.35; p < 0.001) and a higher percentage of CDVA improvement (63% vs. 57%, p = 0.016).

CONCLUSIONS

The use of a preoperative risk assessment scoring system to allocate surgeries to residents at varying experience levels may reduce the risk for surgical complications, thereby ensuring patient safety and providing residents with a gradual learning experience.

The impact of case complexity in resident-performed cataract surgery

PURPOSE

To evaluate the association of capsular dye and/or a pupil expansion device (PED) usage on the rate of major complication in resident-performed cataract extraction.

METHODS

Resident cataract surgeries between 2016 and 2019 were included. The primary outcomes were anterior or posterior vitrectomy (AVx and PPVx). Cases were grouped by the use of a PED and/or capsular staining along with additional preoperative risk factors.

RESULTS

Of the 1,348 cases, 371 (27.5%) documented capsular staining ("Dye-only"), 91 (6.8%) required pupil expansion ("PED-only"), and 100 (7.4%) used both capsular stain and a PED ("Both"). The remainder of cases (n=786, 58.3%) were classified as "Routine." Compared to the "Routine" group, "PED-only" and "Both" had significantly higher odds of an AVx (OR=2.90, 95% CI 1.27-6.19, P=0.01) and/or a PPVx (OR=2.33, 95% CI 1.07-5.12, P=0.04). Among the PPVx cases, the "PED-only" group has significantly higher odds than "Routine" and "Dye-only" (OR=4.64, 95% CI 1.68-12.79, P=0.01; and OR=6.48, 95% CI 1.7-25.0, P=0.005, respectively). In case-control analysis, vision, intraocular pressure, anterior chamber depth, axial length, cataract type, or severity had no significant overall association with complication. When compared to nuclear sclerotic cataract, posterior subcapsular (OR=7.86, 95% CI 1.46-42.47, P=0.017) and white/mature cataracts (OR=3.05, 95% CI 1.1-8.43, P=0.032) had increased odds of complication.

CONCLUSION

Resident-performed cataract surgery frequently required capsular staining and/or a PED, and intuitively, these cases had a higher overall complication rate compared to routine cases. However, the use of a PED independently was associated with significantly higher odds of a major complication requiring an unplanned vitrectomy independent of predisposing factors.

Cataract surgery risk stratification in phacoemulsification and manual small incision cataract surgery in a teaching hospital

PURPOSE

To evaluate a system that objectively assesses the risk of cataract surgery complications performed with phacoemulsification and manual small incision cataract surgery (MSICS) techniques.

METHODS

The study was a retrospective comparative interventional case series. Electronic medical records of consecutive eyes that underwent cataract surgery from January 2019 to December 2019 were evaluated. Patient's demographic data and preoperative risk factors were identified, and cataract was categorized as per Lens Opacities Classification System (III). Cataract eyes were grouped into normal cataract cases (G1) and complex cataract cases (G2 and G3), based on the risk factors. The rate of complications in each group and the rate of each complication were calculated and compared.

RESULTS

The overall rate of anyone complication was 2.2% with 2.3% in G1, 1.0% in G2 and 3.9% in G3 (p < 0.001). MSICS technique, mostly used for complex cases (54.2%), reported a higher complication rate than the phacoemulsification technique (2.9% vs 1.4%, p < 0.001). However, the complication rates among the normal and complex cases were similar (2.3% vs 2.2%, p = 0.376). The total posterior capsular tear rate was 1.1% with no vitreous loss in nearly 1 in eight eyes.

CONCLUSION

A preoperative risk stratification system is crucial for obtaining informed consent and better allocation of cases to surgeons based on their expertise to minimize intraoperative complications.

Application of Artificial Intelligence in the Analysis of Features Affecting Cataract Surgery Complications in a Teaching Hospital

Aims: To evaluate the ocular and systemic factors involved in cataract surgery complications in a teaching hospital using artificial intelligence.

Methods: One eye of 1,229 patients with a mean age of 70.2 ± 10.3 years old that underwent cataract surgery was selected for this study. Ocular and systemic details of the patients were recorded and then analyzed by means of artificial intelligence. A total of 1.25 billion simulations of artificial intelligence learning and testing were conducted on several variables and a customized model of analysis was developed.

Results: A total of 73 complications were recorded in this study. According to the analysis performed, the main factors involved in cataract surgery complications were: a surgeon in training, axial length and intraocular lens power. The model predicted how long surgery would last with an error of <6 min compared to the effective time needed.

Conclusions: According to the data here obtained, artificial intelligence could be an interesting option to build customized models able to prevent complications and to predict actual surgery time. The customized algorithm option allows the development of better models adaptable to different units as well as the possibility to be calibrated for the same unit along time.

Can Applying a Risk Stratification System, Preoperatively, Reduce Intraoperative Complications during Phacoemulsification?

SIGNIFICANCE

Adopting a risk stratification system and appropriate listing of cases reduces the rates of intraoperative complications during phacoemulsification. Such listing would allow both safe surgery and enhance training, by ensuring an appropriately experienced surgeon is available to operate on a case or supervise and teach a junior surgeon.

PURPOSE

To assess if the application of a simple, robust, validated preoperative scoring system can reduce the rates of intraoperative complications if patients are assigned to the appropriately experienced surgeon's list and surgical time is modified accordingly.

METHODS

Prospective data collection. One thousand one hundred and thirty five (1135) consecutive patients undergoing phakoemulsification cataract surgery were assessed preoperatively according to weighted criteria. According to the points of risk they accumulated using this system, the patients were preoperatively allocated to one of the four risk groups. The total rate of intraoperative complications for each risk group as well as the rate of each reported complication for each risk group was calculated.

RESULTS

The rate of intraoperative complications through the risk groups was 1 = 0.62%, 2 = 0.44%, 3 = 0.18%, and 4 = 0% (P = .005). Thirty-seven per cent 37% (n = 420) of all operations were performed on eyes of patients carrying at least one risk factor for intraoperative complications. The overall rate of any intraoperative complication was 1.2% (n = 14). There was a 0.4% (n = 5) rate of a posterior capsule tear with 2 of these cases with vitreous loss.

CONCLUSIONS

Risk stratification, allowing adequate theatre time and appropriate surgical experience, can reduce the rates of intraoperative complications. The risk stratification system allows for better planning of surgical lists and could be used as a transition for those trainees deemed to have sufficient experience for the more 'challenging' cases under adequate supervision.

Auckland Cataract Study IV: Practical application of NZCRS cataract risk stratification to reduce phacoemulsification complications

IMPORTANCE

Reduction of intraoperative complications in phacoemulsification cataract surgery.

BACKGROUND

To assess practicability of a risk stratification system, the New Zealand Cataract Risk Stratification (NZCRS) system, in a major teaching hospital service, without investigator oversight, to ascertain whether benefits identified in research studies are maintained in busy clinical practice.

DESIGN

Prospective cohort study in a major public teaching hospital.

PARTICIPANTS

Five hundred cases of phacoemulsification cataract surgery.

METHODS

NZCRS system inserted into 621 consecutive preoperative cataract patient files. Recommendation to allocate higher-risk cases to experienced surgeons.

MAIN OUTCOME MEASURES

NZCRS system uptake and adherence, appropriate identification of high risk cases and intraoperative complication rates.

RESULTS

NZCRS scores calculated in 500 of 621 (80.5%) cases and 98 (19.6%) scored as "high risk." Cataract surgery (N = 500) performed by: 12 Registrars (20%), 4 Fellows (7.2%), 26 Consultants (72.8%). Risk scores adhered to in 99%. Overall intraoperative complications (3.0%) included iris prolapse 1.6% and posterior capsule tear 0.8%. No statistical difference in complication rates identified between surgeon grades. Mean best-corrected visual acuity was 6/10 (20/32). Postoperatively, cystoid macular oedema occurred in 3.2%. Rescoring by an experienced investigator noted a greater number of "high risk scores" (31.6% vs 19.6%) related to differences in subjective scoring of anterior chamber depth and cataract density.

CONCLUSIONS AND RELEVANCE

Practical uptake of cataract risk stratification was promising in this study with NZCRS calculated in 80.5% with 99% adherence to scoring recommendations. Compared to baseline studies, in the day-to-day clinical setting, a continued, decreasing trend in frequency and severity of intraoperative complications was noted. Subjective variability of risk scoring may be further improved by better, objective, standardization.