Complication rates of resident-performed cataract surgery: Impact of early introduction of cataract surgery training

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.

Resident involvement in cataract surgery at the Veterans Health Administration: complications, case complexity, and the role of experience

PURPOSE

To characterize intraoperative complications, case complexity, and changes in complication rates with surgical experience for cataract surgeries involving residents at the Veterans Health Administration (VHA).

SETTING

All VHA facilities where cataract surgery was performed.

DESIGN

Multicenter, retrospective cohort study.

METHODS

A retrospective review of all cataract surgeries within the VHA between July 2010 and June 2021 was conducted. Several parameters, including resident involvement, intraoperative complications, and case complexity as determined by Current Procedural Terminology codes, and use of pupil expansion or capsular support devices, were collected. Complication rates were compared between residents and attendings.

RESULTS

Of 392 428 cataract surgeries completed across 108 VHA facilities, 90 504 were performed by attendings alone, while 301 924 involved a resident. Of these, 10 244 (11.3%) of attending cases were complex compared with 32 446 (10.7%) of resident cases. Pupil expansion devices were required in 8191 of attending cases (9.05%) and 31 659 (10.5%) of cases involving residents ( P < .001). Similarly, cases involving residents were more likely than attending-only cases to require a capsular support device (0.835% vs 0.586%, P < .001). Cases involving residents were more likely to have posterior capsular rupture (4.75% vs 2.58%, P < .001) and dropped nucleus (0.338% vs 0.198%, P < .001). Higher resident case volumes were associated with significantly lower complication rates for posterior capsular rupture, dropped nucleus, zonular loss, and suprachoroidal hemorrhage.

CONCLUSIONS

Although residents had higher intraoperative complication rates than attendings, these rates were reduced with surgical experience. Residents were involved in a similar number of complex surgical cases as attendings.

Intraoperative Complication Rates in Cataract Surgery After Resuming Surgery Following the COVID-19 Shutdown

Purpose

To evaluate surgeon performance and intraoperative complication rates of cataract surgery after resumption of elective surgeries following the operating room (OR) shutdown from the coronavirus disease 2019 (COVID-19) pandemic. Subjective surgical experience is also evaluated.

Methods

This is a retrospective comparative study which analyzes cataract surgeries performed at an inner city, tertiary academic center. Cataract surgeries were categorized into Pre-Shutdown (January 1-March 18, 2020), and Post-Shutdown, for all cases which occurred after surgeries resumed (May 11-July 31, 2020). No cases were performed between March 19 and May 10, 2020. Patients undergoing combined cataract and minimally invasive glaucoma surgery (MIGS) were included, but MIGS complications were not counted as cataract complications. No other combined cataract-other ophthalmic surgeries were included. A survey was used to gather subjective surgeon experience.

Results

A total of 480 cases (n=306 Pre-Shutdown and n=174 Post-Shutdown) were analyzed. Although there was a higher frequency of complex cataract surgeries performed Post-Shutdown (5.2% vs 21.3%; p<0.00001), complication rates before versus after the shutdown were not statistically significant (9.2% vs 10.3%; p=0.75). Phacoemulsification was the step of cataract surgery in which residents were most concerned about when returning to the OR.

Conclusion

After the surgical hiatus due to COVID-19, significantly more complex cataract surgeries were reported and surgeons reported higher general anxiety level when first returning to the OR. Increased anxiety did not lead to higher surgical complications. This study provides a framework to understand surgical expectations and outcomes for patients whose surgeons faced a prolonged two-month hiatus from cataract surgery.

Resident-Performed Phacoemulsification Cataract Surgery: Impact of Resident-Level Characteristics

Purpose

To evaluate the rate of complications in resident-performed phacoemulsification and influencing factors.

Methods

In this retrospective cohort study, the outcomes of cataract surgeries performed by 18 ophthalmology residents were analyzed. The outcome of first 80 phacoemulsification cataract surgeries (1440 cataract surgeries) performed by each resident were analyzed. Outcome measures included the rate of intraoperative capsular rupture requiring anterior vitrectomy, nucleus drop, and incomplete attempts at uncomplicated procedures. Changes in the rate of complications over the surgical training course were also assessed.

Results

The most common surgical complications were capsular rupture (7.5%), followed by incomplete attempt(s) (5.9%), and nucleus drop (1.1%). Comparing the first 40 and second 40 surgeries, the rate of complications decreased as a function of surgeon experience in all resident cohorts. Greater theoretical skills and younger surgeon age were associated with a lower rate of intraoperative capsular rupture (hazard ratios = 1.421 and 1.481, respectively; P = 0.047 and P = 0.041, respectively). The use of antianxiety drugs and number of surgeries in the first 6 months demonstrated no predictive value for a lower rate of intraoperative complications (hazard ratios = 0.929 and 1.002; P = 0.711 and P = 0.745, respectively).

Conclusion

The use of antianxiety medication and more surgeries in the first 6 months did not decrease the rate of intraoperative complications of phacoemulsification, while improvement of theoretical skills may have increased the safety of resident-performed cataract surgery.

To study the learning curve of capsulorhexis in manual small incision cataract surgery among postgraduate residents in central India

PURPOSE

To evaluate the learning curve of continuous curvilinear capsulorhexis (CCC) and to assess the number of surgeries required to master it among residents in a postgraduate teaching institute.

METHODS

The present prospective observational study was based on the completion time and complication rates related to CCC performed using various techniques by 10 students in the 2^nd (JR2) and 3^rd-year (JR3) of residency. CCC was performed either by a cystotome or capsulorhexis forceps or by a combined method in 253 eyes, of which 160 eyes (63.2%) were operated by JR3 and 93 (36.8%) by JR2. The complication rates were studied with respect to the number of capsular extensions, posterior capsular rent (PCR), zonular dehiscence, need for senior surgical assistance, and nucleus drop.

RESULTS

The average time required for the completion of CCC was 412 ± 90.5 s. The average number of times residents required to fill the anterior chamber with viscoelastic was 6.9 ± 1.4. The average size of CCC was 7 ± 0.66 mm. Extended CCC was the most common complication. JR2 required assistance from a senior surgeon in 47 eyes (50.5%), whereas JR3 required assistance in 39 eyes (24.4%) (P = 0.0001). The rate of PCR was not significantly different in JR2 (7.5%) and JR3 (8.8%).

CONCLUSION

CCC is a difficult step to master in the trainee. Focusing and practicing on this step will help to reduce the complications and maximize proficiency. Approximately 6-eight surgeries are required to master CCC.

Trends in Ophthalmology Resident Operative Experience and the Early Impact of the COVID-19 Pandemic

Purpose This study aimed to evaluate trends in ophthalmology resident operative experience and the early impact of the novel coronavirus disease 2019 (COVID-19) pandemic.

Design Present study is a retrospective analysis of the Accreditation Council for Graduate Medical Education (ACGME) Case Log System.

Participants Anonymized graduating resident case logs from 2011 to 2020 academic years (AYs) were examined for this study.

Methods Regression analysis for each procedure category was performed to identify trends between 2011 and 2019 AYs. Unpaired two-tailed t-test compared 2018 to 2019 and 2019 to 2020 AY's for each category surgeon (S) and as surgeon and assistant (S + A).

Main Outcome Measures Mean and median cases as (S) and (S + A) during 2011 to 2019 AYs. Comparison between 2018 to 2019 and 2019 to 2020 AY's for each category as (S) and (S + A) to evaluate the impact of the COVID-19 pandemic.

Results Total ophthalmology procedures as (S) rose from a mean of 479.6 to 601.3 (p < 0.001; R 2 = 0.96; Δ/year = 16.9) and a median of 444 to 537 (p < 0.001; R 2 = 0.97; Δ/year = 13.1). Total procedures as (S + A) rose from a mean of 698.1 to 768 (p < 0.01; R 2 = 0.83; Δ/year = 9.07) and a median of 677 to 734 (p < 0.05; R 2 = 0.61; Δ/year = 6.64). Cataract procedures as (S) rose from a mean of 152.8 to 208 (p < 0.001; R 2 = 0.99; Δ/year = 7.98) and a median of 146 to 197 (p < 0.001; R 2 = 0.97; Δ/year = 7.87). Cataract procedures as both (S + A) rose from a mean 231.4 to 268.7 (p < 0.001; R 2 = 0.95; Δ/year = 5.5) and a median of 213 to 254 (p < 0.001; R 2 = 0.93; Δ/year = 5.33). Between 2018 to 2019 and 2019 to 2020 AYs, the first pandemic year was associated with significant reductions in total procedures (601.3–533.7 [p < 0.0001]) as (S) and 768.0 to 694.4 (p < 0.0001) as (S + A), cataract surgery (208–162.2 [p < 0.0001]) as (S) and 268.7 to 219.1 (p < 0.0001) as (S + A), and glaucoma surgery (16.3–14.2 [p = 0.0068]) as (S) and 25.6 to 22.6 (p = 0.0063) as (S + A).

Conclusion During 2011 to 2019 AYs, cataract, intravitreal injections, glaucoma, and total procedures increased significantly. During the early period of the COVID-19 pandemic (2019–2020 AY), national halting of elective procedures had a precipitous effect on resident cataract surgery experience to volumes similar to 2013 to 2014 AY where the mean was twice the current required minimum number. With few exceptions, other procedure volumes remained stable.

Confidence of UK Ophthalmology Registrars in Managing Posterior Capsular Rupture: Results from a National Trainee Survey

Introduction

To establish the level of confidence amongst UK ophthalmology specialist registrars (residents) in managing posterior capsule rupture (PCR) during cataract surgery.

Methods

An online nine-item questionnaire was distributed to all registrars, recruited nationwide via regional representatives. Data collected included stage of training, number of completed cataract operations, cumulative PCR rate, number of PCRs independently managed, understanding of vitrectomy settings and fluidic parameters and access to simulation. Respondents self-evaluated their confidence in managing PCR with vitreous loss.

Results

Complete responses were obtained from 248 registrars (35% response rate). Mean number of phacoemulsification procedures performed was 386. For senior registrars (OST 6–7), 35 out of 70 (50%) felt confident to manage PCR independently and 55 out of 70 (78.6%) were either quite confident or very confident at deciding when to implant an intraocular lens during PCR management. Lower confidence levels were noted for junior trainees (OST 1–2). Over 65% of survey respondents had access to relevant simulation.

Conclusions

Our results represent the largest UK survey analysing the confidence of PCR management amongst registrars. Confidence improves with duration of training and increased exposure to management of PCR. However, 50% of senior registrars still lacked confidence to independently manage PCR and vitreous loss. A specific competency-based framework, potentially using a simulator or simulating a PCR event, incorporated into the curriculum may be desirable.

Defining the surgical footprint in cataract surgery: patient-related outcomes dependent on the experience of the surgeon

PURPOSE

To investigate which patient-related outcomes are dependent on the experience of the cataract surgeon.

METHODS

The study was designed as a prospective observational study. Novice (<150 surgeries performed) and experienced (>1000 surgeries performed) cataract surgeons from the Department of Ophthalmology, Rigshospitalet - Glostrup and Nordsjaellands Hospital - Hillerød were included in the study. Patients operated by the included surgeons were examined preoperatively, 1 day, 3 days, and 3 weeks after standard, noncomplicated cataract surgery. Primary outcomes were change in central corneal thickness and endothelial cell loss. Secondary outcomes were best-corrected visual acuity, intraocular pressure, aqueous flare, central macular thickness, and surgical complications.

RESULTS

Surgery performed by novice surgeons resulted in significantly lower visual acuity (mean -3.6 letters (Early Treatment Diabetic Retinopathy Study (ETDRS)); 95% CI: -7.3; -0.4, p = 0.03) and greater corneal thickness (mean 26.7 µm; 95% CI: 6.8; 46.6, p = 0.01) on the first day postoperative than surgery performed by experienced surgeons.

CONCLUSION

The experience of the cataract surgeon affected visual acuity and central corneal thickness in the immediate postoperative period. In the future, these patient-related outcomes may be used to assess the technical proficiency of surgical trainees and investigate the effect of different training programs.

Application of evidence-based nursing in patients after cataract surgery and its impacts on visual acuity recovery and psychological status

OBJECTIVE

To probe into the evidence-based nursing in patients after cataract surgery and its impact on their visual acuity recovery and psychological status.

METHODS

Ninety-seven patients with cataract who underwent surgery in our hospital were randomly divided into control group (n=48, receiving conventional nursing) and observation group (n=49, receiving evidence-based nursing) for a prospective study. Postoperative visual acuity recovery, incidence of complications, recurrence rate within 1 year, psychological status before and after surgery and quality of life were compared between the two groups.

RESULTS

The best corrected visual acuity of the affected eye of patients at 3 and 6 months after surgery in both groups was significantly higher than that before surgery, with the best corrected visual acuity of the same period in the observation group higher than that in the control group (all P<0.05). The incidence of postoperative complications and recurrence rate within 1 year in the observation group were lower than those in the control group (all P<0.05). Three months after operation, the scores of Hamilton Anxiety Scale and Hamilton Depression Scale in the two groups were lower than those before operation, with the scores in the observation group lower than those in the control group (all P<0.05); and the scores of all items in Generic Quality of Life Inventory in the two groups were higher than those before operation, with the scores in the observation group higher than those in the control group (all P<0.05).

CONCLUSION

Evidence-based nursing for patients after cataract surgery can significantly improve the recovery of patients' postoperative visual acuity, reduce the incidence of postoperative complications as well as the recurrence rate. It also helps to improve the adverse psychological status of patients and their postoperative quality of life.

Imaging of the post-operative orbit and associated complications

Dedicated post-operative radiological evaluation following ophthalmologic procedures is relatively uncommon. However, given the ever-growing ophthalmologic procedural advancements and the increasing utilization of neuroimaging for myriad indications, the orbits are often imaged incidentally in a delayed post-procedural state. Regardless of the clinical scenario, it is important for neuroradiologists and other specialists commonly exposed to orbital imaging to be aware of both expected and abnormal post-operative imaging findings because misinterpreted normal features or unrecognized complications can result in vision-threatening delays in treatment or mismanagement. In this review article, we discuss many common ophthalmologic procedures, their indications, and most likely complications. We also provide illustrative operative photographs and radiological imaging examples. By understanding the surgical intent, recognizing the devices that are commonly used, and developing familiarity with the appearance of post-operative complications, pitfalls in interpretation can be avoided and patient outcomes ultimately improved.

Impact of surgical experience on early post-operative regional corneal thickness after phacoemulsification

Background: Currently, phacoemulsification is a very common cataract surgical procedure in which the lens is emulsified and aspirated from the eye through a small corneal incision.Aim: To compare early regional corneal thickness changes following phacoemulsification done by experienced surgeons versus trainee surgeons.Setting: A prospective cohort study was done at Ibn Al Haitham tertiary eye hospital in Baghdad, Iraq.Methods: The data were collected for 5 months, from 01 March 2018 until 31 July 2018. Adult patients undergoing phacoemulsification and intraocular lens surgery were prospectively evaluated and divided into two groups. Group 1 comprised those operated by experienced surgeons, whilst Group 2 patients were operated by trainee surgeons. Slit lamp examination and endothelial specular microscopy were assessed with the measurement of central corneal thickness (CCT) and peripheral corneal thickness (PCT), using Scheimpflug imaging (Pentacam).Results: There was a significant statistical difference in post-operative CCT between Groups 1 and 2, being 596.72 ± 50.69 µm compared to 631.54 ± 67.84 µm in Groups 1 and 2, respectively, with a mean difference of 34.82 µm (p = 0.000). More difference was observed in post-operative PCT (148.38 µm) as it was 734.8 ± 88.55 µm in the experienced group, compared to 883.18 ± 128.43 µm in the trainee group (p = 0.005).Conclusion: Phacoemulsification done by trainee surgeons was associated with higher CCT and PCT.

Operative Time and Complication Rates of Resident Phacoemulsification Surgeries in a National University Hospital: A Five-Year Review

Purpose

To determine the operative time and complication rates of resident phacoemulsification surgeries at different time points in training.

Methods

Retrospective cross-sectional study at the Department of Ophthalmology of the Philippine General Hospital. All resident-performed elective adult phacoemulsification surgeries from January 1, 2014, to December 31, 2018, were included, while operations with planned anterior or posterior procedures were excluded. Cases were arranged chronologically and divided into time points with 25 cases each. Operative time and complication rates were computed for each time point. As defined by the ICO Ophthalmology Surgical Competency Assessment Rubric (OSCAR), 30 minutes was used to gauge competency based on operative time, while complications were compared to published rates for residents. Results for the first 50 cases, the minimum number required by graduation, were also compared with succeeding cases.

Results

A total of 4635 cases were included. Residents performed an average of 115.9 ± 30.4 cases, with no significant difference among residents (F(4,35)=2.64, p=0.12). Overall complication rate was 6% (n=276), similar to those reported internationally. Both median operative time and complication rates decreased significantly for every time point in training (p<0.001). After 50 cases, only 40% (n=16) of residents reached the operative time of 30 minutes. Median operative time is significantly lower when comparing the first 50 surgeries with the succeeding cases (37 minutes vs 29 minutes, p<0.001). Likewise, complication rate is also significantly lower (9.3% vs 3.5%, Χ² (1, N=4635) = 68.481, p<0.001), with an odds ratio of 2.85 (p<0.001, 95% CI [2.2, 3.7]).

Conclusion

There are significant improvements in both operative time and complication rates as more surgeries are performed. However, the minimum required 50 cases is not enough for resident competency based on operative time and complication rates.

Cataract complications study: an analysis of adverse effects among 14,520 eyes in relation to surgical experience

Background

To evaluate the learning-curve in performing cataract surgery with respect to developments in technology and different teaching strategies by comparing the incidence of capsular bag-related complications to operator experience.

Methods

A review of the registry of 14,520 cataract surgeries carried out at the Ophthalmology Unit of Kymenlaakso Central Hospital, Kotka, Finland, from August 8, 2009 to July 31, 2017.

Results

We identified 144 cases with posterior capsule rupture and/or loss of capsular bag support (incidence 0.99% of all surgeries). The mean age of patients was 76.9±9.1 years and gender distribution ratio 29:71 male:female. Pseudoexfoliation syndrome (PXF; incidence 21%) and small pupil (incidence 14%) were over-represented in complication eyes, especially at the beginning of the study. Capsular bag-related complication rates were reported in 0.36% of surgeries for senior and 7.03% for resident surgeons at the beginning of the study, compared to 0.32% and 1.32%, respectively, at the end of the study. Best-corrected visual acuity at the final post-operative visit was 0.61±0.16 decimals at the beginning of the study, and 0.81±0.19 decimals at the end of the study. The mean number of post-operative visits was 4.3±2.7 and did not show trend over the study period.

Conclusions

Real-world evidence suggests PXF and small pupil as significant risk factors in cataract surgery. A gradual decline in the rate complications was noted with increasing surgical experience, also among residents over the follow-up period.

Cataract phacoemulsification performed by resident trainees and staff surgeons: intraoperative complications and early postoperative intraocular pressure elevation

PURPOSE

To determine the incidence of intraoperative complications of phacoemulsification cataract surgery in a teaching hospital and to compare the intraoperative complication rate between resident trainees and staff ophthalmologists, to ascertain the overall rate of intraocular pressure (IOP) elevation on postoperative day 1 (POD1), and, again, to compare this value between resident trainees and staff surgeons.

SETTING

Centro Hospitalar São João, Oporto, Portugal.

DESIGN

Retrospective study.

METHODS

This study included eyes submitted for phacoemulsification cataract surgery from January 1, 2017, to December 31, 2017. There were no exclusion criteria. Data collected included the type of surgeon, level of resident training, case complexity, and intraoperative complications. From all noncomplicated surgeries, preoperative IOP and IOP-POD1 were collected.

RESULTS

A total of 2937 surgeries were included; 25.6% were performed by resident trainees. The complication rate was 6.3% with resident trainees and statistically significantly lower (3.3%) in staff surgeons. The complication rate of resident trainees did not differ according to their level of residency. There was a significantly increased incidence of IOP-POD1 elevation in the resident trainee group compared with the staff surgeon group. Surgeries performed by resident trainees, a preexisting history of glaucoma, and pseudoexfoliation were significant risk factors for IOP elevation.

CONCLUSIONS

To our knowledge, this is the first European study comparing the incidence of intraoperative and postoperative complications in cataract surgery performed by resident trainees and staff surgeons. We report a significantly higher rate of intraoperative complications and IOP elevation on POD1 in resident trainees vs staff surgeons.