Cataract Surgery Volumes and Complications per Surgeon and Clinical Unit

Prioritizations in Swedish cataract surgery - when resources are limited-Exemplified by the COVID-19 pandemic

PURPOSE

To study the prioritization effects of the of COVID-19 pandemic on Swedish cataract surgery using a national healthcare registry with high coverage.

SETTING

A study from the Swedish National Cataract Register (NCR), involving all patients undergoing cataract surgery in Sweden during 2019-2022 - before, during and after the COVID-19 pandemic.

RESULTS

With the pandemic outbreak, the number of cataract surgeries fell by 22% in 2020 (15 369 procedures), albeit with large regional differences (-43% to +58%). The numbers recovered in 2021, and in 2022, a new top notation was seen (n = 149 952). On a national level, the patients were younger (-0.46 years, p < 0.001), with a larger proportion of less difficult cases (p < 0.001) and the proportion of males was higher (p < 0.001) during the pandemic, but all these variables also differed substantially between different regions and clinics.

CONCLUSION

A national registry with high coverage can map the consequences of an event disrupting elective surgery in detail. During the COVID-19 pandemic, the impact on Swedish cataract surgery varied largely between different regions, clinics, and healthcare providers, leading to inequality in the availability of surgery. These differences likely owed to variations in healthcare policy approaches in different parts of the country. The present study shows that outcomes at one clinic or region cannot be extrapolated to larger regions under these circumstances. It actualizes the need to aim for a healthcare on equal terms, but it also shows a system that delivers care to many despite difficult times.

Risk factors for complications in resident-performed cataract surgery: A systematic review

We assessed risk factors for complications associated with resident-performed cataract surgery. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we searched 4databases in September, 2023. We included peer-reviewed, full-text, English-language articles assessing risk factors for complications in resident performed cataract surgery. We excluded studies describing cataract surgeries performed by fellows, combined surgeries, and studies with insufficient information. Our initial search yielded 6244 articles; 15 articles were included after title/abstract and full-text review. Patient-related risk factors included older age, hypertension, prior vitrectomy, zonular pathology, pseudoexfoliation, poor preoperative visual acuity, small pupils, and selected types of cataracts. Surgeon-related risk factors included resident postgraduate year and surgeon right-handedness. Other risk factors included absence of supervision, long phacoemulsification time, and phacoemulsification with high power and torsion. The quality of the studies was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation; most studies graded as moderate, primarily due to risk of bias. When assigning cases to residents, graduate medical educators should consider general and resident-specific risk factors to facilitate teaching and preserve patient safety.

Ten-year trends of immediate sequential bilateral cataract surgery (ISBCS) as reflected in the Swedish National Cataract Register

PURPOSE

To analyse trends of ISBCS reported to the Swedish National Cataract Register (NCR) over a 10-year period.

METHODS

Since 2010 the NCR contains social security number of all individuals in the list of parameters reported to NCR after each cataract procedure. Bilateral surgeries were mapped out using social security numbers. When dates of both-eye surgeries are identical for an individual it is classified as an immediate sequential bilateral cataract surgery (ISBCS). This study includes all data reported during the period 1st of January 2010 to 31st of December 2019. During the study period 113 cataract surgery clinics affiliated to the NCR reported their data on consecutive cataract cases.

RESULTS

For the whole period 54 194 ISBCS were reported. The total number of bilateral cataract extractions was 422 300. There was a significant trend of increasing ISBCS over time with linear regression (Beta = 1.75, p < 0.001). In ISBCS the occurrence of an ocular comorbidity decreased over time. The use of a capsular tension ring was significantly more common in ISBCS than in delayed sequential bilateral cataract surgery (DSBCS). All other measures taken during surgery were more common in DSBCS. The use of multifocal IOL was significantly more frequent in ISBCS compared to DSBCS (p < 0.001).

CONCLUSIONS

The use of ISBCS has increased over the study period. The operated eyes have less risk factors than eyes going through a DSBCS, but both ocular comorbidities and surgical complications occur in ISBCS eyes.

Incidence, risk factors and outcomes of cataract surgery after plaque brachytherapy for posterior uveal melanoma

Purpose

To examine incidence, risk factors, and outcomes of cataract surgery after plaque brachytherapy for posterior uveal melanoma.

Design

Retrospective interventional cohort study contrasted with general population data.

Methods

All patients treated with plaque brachytherapy for a posterior uveal melanoma at Sweden's national referral center between 2010 and 2022 were included (n = 933). These patients were cross-referenced with data from the Swedish National Cataract Register. Competing risk incidences and outcomes of cataract surgery were compared with a random sample of 1000 individuals from the general population.

Results

The 12-year incidence of cataract surgery after plaque brachytherapy was 27 % (95 % CI 23-31 %), which markedly exceeded the incidence of 16 % in the general population (95 % CI 13-18 %, Gray's P < 0.001). Patients treated with Iodine-125 had significantly higher incidence than patients treated with Ruthenium-106, and the latter had greater incidence than the general population (P < 0.001). In univariate competing risk regressions, older patients, female sex, thick tumors, and Iodine-125 were associated with cataract surgery. In multivariate analysis, older patients and Iodine-125 retained their significance. Outcomes of cataract surgery were overall similar in the plaque brachytherapy and general population, but the general population more often received post op. topical NSAID.

Conclusions

In this study, plaque brachytherapy for posterior uveal melanoma was associated with a significantly increased incidence of cataract surgery. Treatment with the gamma emitting isotope iodine-125 and older patient age at the time of brachytherapy emerged as the major risk factors. Outcomes of cataract surgery were comparable to the general population.

Time Savings Using a Digital Workflow versus a Conventional for Intraocular Lens Implantation in a Corporate Chain Hospital Setting

Purpose

To evaluate and compare the digital cataract workflow with the existing conventional workflow in terms of time savings for overall diagnostic procedures from preoperative measurements, data transfer, intraocular lens (IOL) power calculation, and axis marking for cataract surgery in a corporate hospital chain setting.

Patients and Methods

This prospective non-clinical study assessed the mean procedural times for preoperative assessments, calculation of IOL power, data transfer to operating devices, and total surgery for both digital and existing conventional workflows.

Results

Overall, 430 workflows (digital cataract workflow: 227; existing conventional workflow: 203) were included for time measurements. The digital cataract workflow resulted in shorter mean (± standard deviation [SD]) preoperative assessments with lesser variability among individual assessments than the existing workflow (14.15 ± 1.86 vs 21.41 ± 1.18 min, respectively); with a time saving of 35%. Similarly, the mean (± SD) time required for the subsequent assessment steps such as IOL calculation (2.19 ± 1.23 vs 3.17± 2.29 min; 30%), data transfer (0 vs 1.33 ± 0.25 min; 100%), IOL axis marking and alignment (0 vs 3.07 ± 0.53 min; 100%) were shorter with digital cataract workflow versus existing conventional cataract workflow. Briefly, the overall mean time from preoperative assessments to final surgery was 16.48 min with digital cataract workflow and 30.58 min with existing conventional workflow; resulting in a time saving of 46%.

Conclusion

The Zeiss digital cataract workflow demonstrated greater time savings at each step of the cataract surgery workflow compared to the existing conventional workflow. In addition, digitalization can lead to a more streamlined cataract surgery workflow that is more convenient and cost-effective than the existing conventional practices in a corporate chain hospital setting.

Experimental study comparing 2 different phacoemulsification systems with intraocular pressure control during steady-state flow and occlusion break surge events

PURPOSE

To compare peak surge and surge duration time after occlusion break, incision leakage compensation, and passive vacuum for 2 phacoemulsification systems.

SETTING

Carl Zeiss Meditec AG, Oberkochen, Germany.

DESIGN

Laboratory study.

METHODS

A spring-eye model was used to test Alcon Centurion Vision and Zeiss Quatera 700 systems. Peak surge and duration was measured after an occlusion break. Quatera tested in flow and vacuum priority modes. Vacuum limits ranged from 300 to 700 mm Hg with intraocular pressure (IOP) set at 30 mm Hg, 55 mm Hg, and 80 mm Hg. IOP vs incision leakage rates of 0 to 15 cc/min and passive vacuum were measured.

RESULTS

At 30 mm Hg IOP set point and vacuum limits ranging 300 to 700 mm Hg, the surge duration time after occlusion break ranged 419 to 1740 milliseconds (ms) for Centurion, 284 to 408 ms for Quatera in the flow mode, and 282 to 354 ms for Quatera in the vacuum mode. At 55 mm Hg, values ranged 268 to 1590 ms for Centurion, 258 to 471 ms for Quatera in the flow mode, and 239 to 284 ms for Quatera in the vacuum mode. At 80 mm Hg, values were 243 to 1520 ms for Centurion, 238 to 314 ms for Quatera in the flow mode, and 221 to 279 ms in the vacuum mode. Centurion exhibited slightly less peak surge than the Quatera. At 55 mm Hg: incision leakage rates 0 to 15 cc/min, Quatera held the IOP within ±2 mm Hg of target; Centurion was unable to hold IOP target allowing a 11.7 mm Hg decrease with 32% higher passive vacuum.

CONCLUSIONS

Quatera demonstrated slightly higher surge peak values and notably shorter surge duration times after occlusion break than Centurion. Quatera demonstrated better incision leakage compensation and lower passive vacuum than Centurion.

Analysis of vitreoretinal surgery activity in metropolitan France in 2016: impact on training capacities

PURPOSE

The purpose of the study was to describe vitreoretinal surgery activity and vitreoretinal surgeons in private or public practice in metropolitan France over the year 2016 to anticipate surgical training needs.

METHODS

Patients aged ≥20 years who had undergone vitreoretinal surgery, alone or combined with cataract surgery were included using the French National Healthcare system database. For surgery performed by ophthalmologists carrying out ≥50 procedures during the year, the incidence per 100 000 of population ≥ 20 years of age, the number and mean age of surgeons and the number of surgeons aged >55 years were calculated.

RESULTS

Overall, 57 947 posterior segment surgical procedures were included, 40% in the public sector and 49% in the private sector for private surgeons and/or public centres performing ≥50 procedures/year. The remaining 11% of procedures were from private surgeons and/or public centres performing <50 procedures/year. The analysis included 356 surgeons with a mean age of 41 ± 10 years (39% female) in the public sector and 47 ± 10 years (14% female) in the private sector. The majority of urgent surgery was for retinal detachment (n = 30 290 [52% of total surgical procedures]). Scheduled surgery involved surgery for macular holes and epiretinal membranes (n = 16 454 [28% of total surgical procedures]). Combined vitrectomy-phacoemulsification surgery (n = 10 120) represented 17% of all vitreoretinal surgery. University regions with the fewest surgeons and regions with surgeons >55 years of age were identified, to anticipate the training need for new surgeons.

CONCLUSION

This study demonstrated disparities in the geographic distribution of vitreoretinal surgery in France and identified regions that need increased training capacities to ensure a sufficient number of surgeons.

Risk factors for predicted refractive error after cataract surgery in clinical practice. Retrospective observational study

OBJECTIVES

To describe the preoperative characteristics of patients undergoing cataract surgery in our hospital, to determine the final visual and refractive results and to determine the preoperative characteristics that conditioned the presence of a residual refractive error (RRE) greater than one diopter.

METHODS

Retrospective analysis of cataract surgeries performed at Araba University Hospital between February 2017 and December 2019. Sociodemographic, eye comorbidity, biometric, surgical and post-surgical characteristics were collected.

RESULTS

A total of 1419 patients and 1578 surgeries were included for analysis. Of these, 9.07% had preoperative legal blindness, 31.69% eye comorbidity and 4.18% had previous surgery. Overall, 95.82% of patients achieved a corrected final visual acuity (VA) ≥ 0.5 Snellen decimal and 63.12% ≥ 1, and 96.70% of patients improved VA after surgery. RRE was between ±0.5 diopters in 77.82% of patients and between ±1 diopter in 94.74%. The most prominent risk factors that conditioned the presence of RRE greater than 1 diopter were the use of ultrasonic contact biometer, a history of glaucoma surgery, the presence of white or hard cataract, and prior legal blindness.

CONCLUSIONS

The visual results of cataract surgery were excellent, with 63.12% of patients obtaining corrected VA ≥ 1 and an RRE of ±1 diopter in 94.74%. Different risk factors influenced the achievement of poor refractive outcomes: preoperative conditions (previous surgeries, white/hard cataract, previous VA) and biometrics.

Strabismus outcomes after surgery: the nationwide SOS France study

PURPOSE

To describe the types of strabismus operated on, the surgical procedures performed, and the 2-year reoperation rate in France.

METHODS

Entire population 5-year cross-sectional analysis of a national medico-administrative database in France between January 2013 and December 2017 included all patients who underwent a first strabismus surgery, with a 2-year follow-up. Patient identification was based on the diagnostic codes of the 10th International Classification of Diseases and surgical procedures on the codes of the Common Classification of Medical Acts. A subgroup analysis comparing non-paralytic and paralytic strabismus was performed.

RESULTS

Among the 56,654 patients included (women: 50.8%), 26,892 (47.5%) patients were under 10 years old. Overall, 52,711 (93%) were diagnosed with non-paralytic strabismus and 3,943 (7%) with paralytic strabismus. Among the non-paralytics, the most frequent diagnosis was esotropia (21,282, 37.6%), followed by exotropia (14,392, 25.4%) and vertical strabismus (2,017, 3.6%). Among the paralytics, fourth cranial nerve palsy (1,499, 2.6%) was more frequent than sixth cranial nerve palsy (691, 1.2%) and third cranial nerve palsy (431, 0.8%). The 2-year reoperation rate was 7.7% (4,362 patients), the lowest for non-paralytic (7.4%) and the highest for paralytic (11.4%).

CONCLUSION

This first French population-based study about strabismus will contribute to the evaluation of practices at a national level and permit comparisons between countries. Although the 2-year reoperation rate was found to be 1 out of 13 patients, it should be interpreted with caution. Long-term follow-up is still warranted due to considerable variability of the type and severity of strabismus as well as surgical practices.

Risk factors for posterior capsule rupture in cataract surgery as reflected in the European Registry of Quality Outcomes for Cataract and Refractive Surgery

PURPOSE

To analyze the incidence and risk factors for posterior capsule rupture (PCR) in cataract surgery.

SETTING

European clinics affiliated with the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO).

DESIGN

Retrospective cross-sectional register-based study.

METHODS

Data were obtained from the EUREQUO. The database contains data on demographics, comorbidities, and intraoperative complications, including PCR for the study period from January 1, 2008, to December 31, 2018. Univariate and multivariate logistic regression analyses were performed to estimate the (adjusted) odds ratio (OR) and 95% confidence intervals (CIs).

RESULTS

We analyzed EUREQUO registry data of 2,853,376 patients, and 31,749 (1.1%) cataract surgeries were complicated by a PCR. Data were available of 2 853 376 patients, and 31 749 (1.1%) cataract surgeries were complicated by a PCR. The PCR rate ranged from 0.60% to 1.65% throughout the years, with a decreasing trend (P < .001). The mean age of the PCR cohort was 74.8 ± 10.5 years, and 17 29 (55.5%) patients were female. Risk factors most significantly associated with PCR were corneal opacities (OR 3.21, 95% CI, 3.02-3.41, P < .001), diabetic retinopathy (OR 2.74, 95% CI, 2.59-2.90, P < .001), poor preoperative visual acuity (OR 1.98, 95% CI, 1.88-2.07, P < .001), and white cataract (OR 1.87, 95% CI, 1.72-2.03, P < .001).

CONCLUSIONS

Risk factors for PCR were identified based on the EUREQUO, and the incidence of this complication is decreasing over time.

Changing practice patterns in European cataract surgery as reflected in the European Registry of Quality Outcomes for Cataract and Refractive Surgery 2008 to 2017

PURPOSE

To study practice patterns in European cataract surgery over a 10-year period.

SETTING

European clinics affiliated to the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO).

DESIGN

Registry cohort study.

METHODS

The EUREQUO contains preoperative, intraoperative, and postoperative parameters reported by surgeons in many European clinics. All data reported to the registry are anonymized. Preoperative parameters included age, sex, visual acuity, target refraction, ocular comorbidity, and surgical difficulties. Surgical data included anesthesia, surgical technique, intraocular lens optic biomaterial, and complications. Postoperative parameters included visual acuity, refraction, and short-term complications.

RESULTS

During the study period (January 1, 2008, to December 31, 2017), a total of 2 714 108 cataract extractions were reported to the EUREQUO. Preoperative data changed over time, with decreases in mean age (74.5-73.0 years), proportion of women from 60.6% (100 373/165 628) to 57.2% (174 908/305 845), and proportion of coexisting eye diseases from 30.0% (49 638/165 650) to 27.0% (82 704/305 846) and with improvements in preoperative visual acuity (mean logarithm of minimum angle of resolution [logMAR] 0.46 to 0.37). The use of topical anesthesia increased over time from 28.1% (26 238/93 320) to 71.7% (130 525/182 083). Surgical complications showed a significant decrease from 2.5% (4107/165 650) to 1.2% (3573/305 846). The visual outcome improved over time (mean logMAR 0.08 to 0.05), as did the absolute median prediction error (0.38 diopter [D] to 0.28 D).

CONCLUSIONS

Trends in European cataract surgery practice patterns from 2008 to 2017 have moved toward younger patients with better preoperative visual acuity, fewer surgical complications, and better predicted refractions and visual outcomes.

Postoperative Endophthalmitis in Immediate Sequential Bilateral Cataract Surgery: A Nationwide Registry Study

PURPOSE

To report the incidence of postoperative endophthalmitis (PE) after immediate sequential bilateral cataract surgery (ISBCS) in Sweden.

DESIGN

Retrospective cohort registry study.

PARTICIPANTS

Patient data from 1 457 172 cataract extractions, including 1 364 934 unilateral surgeries and 92 238 ISBCSs.

METHODS

Endophthalmitis cases reported to the Swedish National Cataract Register (NCR) during a 16-year period (2002-2017) were analyzed in comparison to all control cases with regard to patient characteristics, surgical technique, and capsule complication.

MAIN OUTCOME MEASURE

Incidence and determinants for PE in ISBCS compared with unilateral surgeries.

RESULTS

A total of 422 cases of PE were identified in 1 457 172 cataract extractions, yielding an overall incidence of 0.029% (95% confidence interval [CI], 0.0262-0.0317). For unilateral procedures, the rate was 0.0299% (95% CI, 0.0270-0.0328) or 408 cases in 1 364 934 operations, whereas that for ISBCS was 0.0152% (95% CI, 0.0072-0.0231) or 14 incidents in 92 238 operations (P = 0.01). In a logistic regression model including all cataract procedures, nonuse of intracameral (IC) antibiotics (ABs), capsule complication, age 85 years or more, male gender, and ocular comorbidity were found to be independent risk factors for PE. All these parameters were less frequent in ISBCS. Notwithstanding, in the same multivariate analysis, ISBCS in itself was associated with a significantly lower risk for PE. At follow-up, 5 of the 14 PE cases in the ISBCS cohort had a visual acuity (VA) of 20/200 or worse. Of these, one 93-year-old ISBCS patient developed bilateral infection.

CONCLUSIONS

After ISBCS in Sweden, PE occurred once in 6600 surgeries. The risk of sustaining a final VA of 20/200 or less was 1 incident in 18 000 operated eyes. When counseling potential ISBCS patients about the risk of PE, it seems reasonable to state that the reported risk in the literature is lower than that with unilateral surgery but not negligible. Precautions remain necessary.

Surgical Outcomes among Focused versus Diversified Cataract Surgeons

PURPOSE

Narrowly focused surgical practice has become increasingly common in ophthalmology and may have an effect on surgical outcomes. Previous research evaluating the influence of surgical focus on cataract surgical outcomes has been lacking. This study aimed to evaluate whether surgeons' exclusive surgical focus on cataract surgery influences the risk of cataract surgical adverse events.

DESIGN

Population-based cohort study.

PARTICIPANTS

All patients 66 years of age or older undergoing cataract surgery in Ontario, Canada, between January 1, 2002, and December 31, 2013.

METHODS

Outcomes of isolated cataract surgery performed by exclusive cataract surgeons (no other types of surgery performed), moderately diversified cataract surgeons (1%-50% noncataract procedures), and highly diversified cataract surgeons (>50% noncataract procedures) were evaluated using linked healthcare databases and controlling for patient-, surgeon-, and institution-level covariates. Surgeon-level covariates included both surgeon experience and surgical volume.

MAIN OUTCOME MEASURES

Composite outcome incorporating 4 adverse events: posterior capsule rupture, dropped lens fragments, retinal detachment, and suspected endophthalmitis.

RESULTS

The study included 1 101 864 cataract operations. Patients had a median age of 76 years, and 60.2% were female. Patients treated by the 3 groups of surgeons were similar at baseline. Adverse events occurred in 0.73%, 0.78%, and 2.31% of cases performed by exclusive cataract surgeons, moderately diversified surgeons, and highly diversified surgeons, respectively. The risk of cataract surgical adverse events for patients operated on by moderately diversified surgeons was not different than for patients operated on by exclusive cataract surgeons (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.00-1.18). Patients operated on by highly diversified surgeons had a higher risk of adverse events than patients operated on by exclusive cataract surgeons (OR, 1.52; 95% CI, 1.09-2.14). This resulted in an absolute risk difference of 0.016 (95% CI, 0.012-0.020) and a number needed to harm of 64 (95% CI, 50-87).

CONCLUSIONS

Exclusive surgical focus did not affect the safety of cataract surgery when compared with moderate levels of surgical diversification. The risk of cataract surgical adverse events was higher among surgeons whose practice was dedicated mainly to noncataract surgery.

A Composite Risk Score for Capsule Complications Based on Data from the Swedish National Cataract Register: Relation to Surgery Volumes

PURPOSE

To investigate case mix in relation to capsule complication, possible associations between case mix and operation volume, and change in case mix over time.

DESIGN

Register-based study.

PARTICIPANTS

Swedish patients who underwent cataract surgery between 2007 and 2016.

METHODS

Demographics and data on ocular comorbidity, intraoperative difficulties, and capsule complications were registered from 2007 to 2016 and analyzed retrospectively in relation to coded data on individual surgeons' operation volume. Single factor analysis and logistic regression were performed, and a composite risk score was created.

MAIN OUTCOME MEASURES

Risk of capsule complication, given as adjusted and composite odds ratio in relation to cataract surgery volume.

RESULTS

Preoperative and intraoperative variables significantly associated with capsule complications were best-corrected visual acuity (BCVA) ≤0.1 (decimal, adjusted odds ratio [aOR], 1.82; P < 0.001); pseudoexfoliation (PEX) (aOR, 1.53; P < 0.001); sight-threatening ocular comorbidity other than age-related macular degeneration (AMD), diabetic retinopathy, glaucoma, or cornea guttata (aOR, 1.35; P = 0.006); use of Trypan blue (aOR, 1.76; P < 0.001); mechanical pupil dilation (aOR, 1.36; P = 0.024); and iris hooks at the rhexis margin (aOR, 6.99; P < 0.001). The composite risk score was 3.09 ± 6.40 (mean ± standard deviation) for patients with capsule complication and 1.28 ± 1.66 for uncomplicated procedures (P < 0.001). High-volume cataract surgeons (≥500 procedures yearly) had a significantly lower composite risk score (mean risk score ≤1.28; range, 1.01-2.02) compared with low- and medium-volume cataract surgeons (1.34 ± 0.56; range, 1.00-4.55 and 1.49 ± 0.58; range, 1.01-5.19), respectively. During the period 2007-2016, the proportion of patients aged >88 years, patients with BCVA ≤0.1, and patients with intraoperative difficulties decreased.

CONCLUSIONS

Case mix, as calculated from a composite risk score based on preoperative and intraoperative parameters registered in the National Cataract Register (NCR), may contribute to the decrease in capsule complications from 2007 to 2016 and the lower complication rate observed in cases managed by high-volume cataract surgeons.