The Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: Report 7, immediate sequential bilateral cataract surgery in the UK: Current practice and patient selection

The Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: Report 17, a risk factor model for posterior capsule rupture

BACKGROUND/OBJECTIVES

To create a risk factor model for posterior capsule rupture (PCR) during cataract surgery.

SUBJECTS/METHODS

Eligible operations between 01/04/2016 and 31/03/2022 from centres supplying data to the UK national cataract audit with complete data including patients' gender and age at surgery, anterior chamber depth (ACD) measurement and preoperative visual acuity (VA) were included. A logistic regression model was fitted to identify risk factors and calculate their odds ratios (OR) and 95% confidence intervals (CI) for PCR.

RESULTS

This analysis included 961,208 cataract operations performed on 682,381 patients from 136 participating centres by 3198 surgeons. 9730 (1.01%) of surgeries were complicated by PCR. The median age was 75.7 and 76.7 years for first and second eye surgery respectively, and 5154 (53.0%) were female. The highest risk factors for PCR were less experienced trainee surgeon (OR 3.75, 95% CI 3.33-4.24, p < 0.001), pseudoexfoliation/phacodonesis (OR 3.47, 95% CI 3.05-3.94, p < 0.001), younger males (OR 3.05, 95% CI 2.23-4.16, p < 0.001) and brunescent/white/mature cataract (OR 2.41, 95% CI 2.24-2.60, p < 0.001). Other risk factors identified were glaucoma, worse preoperative VA, previous intravitreal therapy, high myopia, previous vitrectomy, systemic diabetes, diabetic retinopathy, amblyopia, older age, shallower ACD and inability to lie flat and cooperate.

CONCLUSION

Various surgical, patient and ocular factors increase the risk of PCR during cataract surgery. This risk factor model permits estimation of individualised risks for patients and allows risk-adjustment for surgeons to evaluate their PCR rates based on case complexity.

Immediate Sequential Bilateral Cataract Surgery in Patients with Bilateral Visually Significant Cataracts

Purpose

To report our experience of performing immediate sequential bilateral cataract surgery (ISBCS) in patients with visually significant cataracts and reduced preoperative corrected distance visual acuity (CDVA).

Methods

Data of patients who underwent ISBCS for visually significant cataracts and had preoperative CDVA ≤20/32 (≤0.2 logMAR) in each eye were retrospectively reviewed. Refractive and visual outcomes were evaluated for the last available postoperative visit. Intraoperative and serious postoperative adverse events occurring within the first three months of surgery were reviewed.

Results

A total of 1335 patients (2670 eyes) were included in the analysis, with a mean age of 71.9 ± 9.5 years. On the last visit, 50.2% and 89.1% of eyes achieved uncorrected distance visual acuity (UDVA) ≥20/20 (0.0 logMAR) and ≥20/32 (0.2 logMAR), respectively. Of all eyes, 83.8% were within ±0.50D, and 96.4% were within ±1.00 D of emmetropia. Ten patients had postoperative bilateral ametropia of more than 1.00D in each eye, but eight of them still achieved binocular UDVA ≥20/40. Intraoperative events occurred in 14 eyes of 13 patients (per-eye incidence: 0.524% or 1 in 191 eyes). A total of 86 postoperative adverse events occurred in 80 eyes of 53 patients (per-eye incidence 2.996% or 1 in 33 eyes), of which cystoid macular edema was the most common. Only three eyes had CDVA reduced by more than two Snellen lines compared to preoperative CDVA, two of which were not related to cataract surgery. There was no patient with bilateral CDVA loss.

Conclusion

In our cohort of patients with visually significant cataracts, ISBCS resulted in good refractive predictability and a low incidence of serious adverse events.

A quality analysis of internet patient information for immediate, sequential, bilateral cataract surgery (ISBCS)

BACKGROUND

Due to surgical capacity pressures, induced by the COVID-19 pandemic, immediate bilateral simultaneous cataract surgery (ISBCS) has been utilised increasingly throughout the U.K. This surgical method comes with both novel risks and benefits, so the consent process must be modified. Prior randomised trials have demonstrated that appropriate online information may act as an adjunct to the surgical consent process. This study aims to assess the quality of available internet information for ISBCS.

METHODS

Terms searched were 'bilateral cataract surgery patient information', 'double cataract surgery patient information', and 'immediate sequential bilateral cataract surgery patient information'. The Google search engine was used. The DISCERN instrument and JAMA benchmarks were used to assess healthcare information for quality. The Flesch Reading Ease Score (FRE), Flesch Kincaid Grade (FKG) Level and Gunning Fog Score (GFS) were used to assess for readability. HONcode certification was used to assess transparency and quality.

RESULTS

Forty-six websites were found. The average DISCERN score was 41.3, meaning a "fair" quality which is below what many patients would anticipate discovering when trying to find information. National Healthcare Service websites had higher DISCERN scores than private healthcare-provided websites (p < 0.01; 95% CI: 1.13-1.88.).

CONCLUSIONS

Fair patient information for ISBCS has been demonstrated. Specific internet information sources with appropriate information should be further developed, with cited sources, and patients signposted to them if felt appropriate.

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.

Time and Motion Studies to assess surgical productivity in cataract theatre lists within the National Health Service: Immediate Sequential Bilateral Cataract Surgery versus Delayed Sequential Bilateral Cataract Surgery

BACKGROUND

To compare productivity of National Health Service cataract lists performing unilateral cataract (UC) surgery vs Immediate Sequential Bilateral Cataract Surgery (ISBCS).

METHODS

Five 4-hour lists with ISBCS cases and five with UC were observed using time and motion studies (TMS). Individual tasks and timings of each staff member in theatre was recorded by two observers. All operations were performed by consultant surgeons under local anaesthesia (LA).

RESULTS

Median number of eyes operated per 4-hour list was 8 (range 6-8) in the ISBCS group and 5 (5-7) in the UC group (p = 0.028). Mean total theatre time (defined as time between the entry of the first patient and the exit of the last patient from theatre) was 177.12 (SD 73.62) minutes in the ISBCS group and 139.16 (SD 47.73) minutes in the UC group (p = 0.36). Mean time to complete two consecutive unilateral cataract surgery operations was 48.71 minutes compared to 42.23 minutes for a single ISBCS case (13.30% time saved). Based on our collected TMS data, a possible 5 consecutive ISBCS cases and 1 UC (total 11 cataract surgeries) could be performed during a four-hour theatre session, with a theatre utilisation quotient of 97.20%, contrasting to nine consecutive UC, with a theatre utilisation quotient of 90.40%.

DISCUSSION

Performing consecutive ISBCS cases under LA on routine cataract surgery lists can increase surgical efficiency. TMS are a useful way to investigate surgical productivity and test theoretical models for efficiency improvements.

Immediate sequential vs delayed sequential bilateral cataract surgery: systematic review and meta-analysis

The main aim of this systematic review and meta-analysis was to evaluate the safety and efficacy profile of immediate sequential bilateral cataract surgery (ISBCS) compared with delayed sequential bilateral cataract surgery (DSBCS). MEDLINE Ovid, EMBASE, and CENTRAL databases were searched. Outcome measures were postoperative visual acuity, postoperative spherical equivalent (refractive outcome), endophthalmitis, corneal edema, pseudophakic macular edema, and posterior capsule rupture (PCR). 13 articles met criteria for final inclusion. A total of 11 068 622 participants (18 802 043 eyes) were included. No statistically significant differences between ISBCS and DSBCS were identified in all the postoperative outcomes evaluated. However, a higher risk for PCR was identified in the ISBCS group from the pooled analysis of nonrandomized studies (risk ratio, 1.34, 95% CI, 1.08-1.67, P = .0081). In our view, the ISBCS approach has an acceptable safety-efficacy profile, comparable with DSBCS. Future investigations are warranted, with a focus on the analysis of risk factors for surgical complications, patient-reported outcome-measures, and cost effectiveness.

Immediate Sequential Bilateral Surgery in Refractive Lens Exchange Patients: Clinical Outcomes and Adverse Events

PURPOSE

To evaluate outcomes and the incidence of adverse events (AEs) in patients who underwent bilateral same-day refractive lens exchange (RLE).

DESIGN

Retrospective case series.

PARTICIPANTS

Patients of a private intraocular surgery provider in the United Kingdom who underwent RLE in both eyes on the same day with treatment dates between March 2018 and December 2021.

METHODS

Clinical outcomes and AEs were collected for a continuous cohort of patients undergoing bilateral same-day RLE (in the absence of visually significant cataracts) or had mild cataracts (corrected visual acuity ≥ 20/40). One-month clinical outcomes were analyzed.

MAIN OUTCOME MEASURES

Refractive outcomes and visual acuity, intraoperative and postoperative AEs, and secondary surgical interventions recorded within the first month after surgery.

RESULTS

A total of 17 330 patients (34 660 eyes) were included in the analysis. Of these, 28 827 eyes received a multifocal intraocular lens (IOL), and 5833 eyes had a monofocal IOL. The percentage of eyes within ±0.50 diopters (D) of intended refraction was 85.5% and 86.2% for monofocal and multifocal IOL eyes, respectively. There was a total of 55 intraoperative AEs recorded in 55 eyes of 54 patients (per-eye incidence: 0.159%). Posterior capsule tear was the most common intraoperative event occurring in 37 eyes (0.107%). The number of AEs recorded within the first postoperative month was 267, occurring in 263 eyes of 177 patients (per-eye incidence: 0.759%). These included cystoid macular edema (CME) (172 eyes; 0.496%), significant corneal edema (28 eyes; 0.081%), persistent inflammation (27 eyes; 0.078%), significantly raised intraocular pressure (27 eyes; 0.078%), toxic anterior segment syndrome (8 eyes; 0.023%), wound leak (3 eyes; 0.009%), retinal detachment (1 eye; 0.003%), and retinal tear (1 eye; 0.003%). There were 56 secondary surgical interventions recorded within the first month of surgery, occurring in 54 eyes of 47 patients (per-eye incidence: 0.156%). The most common secondary intervention was the rotation of a misaligned toric IOL (24 eyes; 0.069%).

CONCLUSIONS

Elective same-day bilateral RLE had a low incidence of serious AEs, and high refractive predictability.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: Report 9, Risk factors for posterior capsule opacification

BACKGROUND/OBJECTIVES

Posterior Capsule Opacification (PCO) is the most common long-term post-operative adverse occurrence after cataract surgery often requiring treatment with YAG laser posterior capsulotomy. This study aimed to identify potential risk factors, known at the time of cataract surgery, that influence the development of PCO.

SUBJECT/METHODS

A retrospective study of publicly funded cataract surgery from The Royal College of Ophthalmologists' National Ophthalmology Database. Eligible for analysis were 500,872 cataract operations performed in 41 participating centres.

RESULTS

The 500,872 operations were performed on 243,167 (48.5%) left eyes and 257,705 (51.5%) right eyes from 373,579 patients by 2196 surgeons. Post-cataract PCO was recorded for 61,778 (12.3%) eyes and the six month, one, three, five and nine year observed rates of PCO were 2.3%, 4.4%, 19.7%, 34.0% and 46.9% respectively. Different PCO profiles were observed between IOL materials and the identified risk factors that increased the risk of developing PCO included hydrophilic IOL material, axial length >26 mm, the presence of high myopia and implantation of lower IOL powers and previous vitrectomy surgery, along with younger age and female gender.

CONCLUSIONS

Many factors influence the development of PCO relating to the patient, the eye, the lens and the surgery. Some factors are modifiable such as IOL material, therefore the opportunity exists to attempt to reduce PCO rates, benefitting patients and the UK NHS.

Cataracts

94 million people are blind or visually impaired globally, and cataract is the most common cause of blindness worldwide. However, most cases of blindness are avoidable. Cataract is associated with decreased quality of life and reduced life expectancy. Most cases of cataract occur after birth and share ageing and oxidative stress as primary causes, although several non-modifiable and modifiable risk factors can accelerate cataract formation. In most patients, phacoemulsification with intraocular lens implantation is the preferred treatment and is highly cost-effective. There has been an increase in the use of comprehensive cataract surgical services, including diagnoses, treatment referrals, and rehabilitation. However, global inequity in surgical service quality is still a limitation. Implementation of preoperative risk assessment, risk reduction strategies, and new surgical technologies have made cataract surgery possible at an earlier stage of cataract severity with the expectation of good refractive outcomes. The main challenge is making the service that is currently available to some patients accessible to all by use of universal health coverage.

Outcome of Cataract Surgery in Patients With Retinitis Pigmentosa

PURPOSE

To assess the visual outcome of cataract surgery in patients with retinitis pigmentosa (RP).

DESIGN

Retrospective, noncomparative clinical study.

METHODS

Preoperative, intraoperative, and postoperative data of patients with RP who were undergoing cataract surgery were collected from several expertise centers across Europe.

RESULTS

In total, 295 eyes of 226 patients were included in the study. The mean age at surgery of the first eye was 56.1 ± 17.9 years. Following surgery, best-corrected visual acuity (BCVA) improved significantly from 1.03 to 0.81 logMAR (ie, 20/214 to 20/129 Snellen) in the first treated eye (-0.22 logMAR; 95% CI = -0.31 to -0.13; P < .001) and from 0.80 to 0.56 logMAR (ie, 20/126 to 20/73 Snellen) in the second treated eye (-0.24 logMAR; 95% CI = -0.32 to -0.15; P < .001). Marked BCVA improvements (postoperative change in BCVA of ≥0.3 logMAR) were observed in 87 of 226 patients (39%). Greater odds for marked visual improvements were observed in patients with moderate visual impairment or worse. The most common complications were zonular dialysis (n = 15; 5%) and (exacerbation of) cystoid macular edema (n = 14; 5%), respectively. Postoperative posterior capsular opacifications were present in 111 of 295 eyes (38%).

CONCLUSION

Significant improvements in BCVA are observed in most patients with RP following cataract surgery. Baseline BCVA is a predictor of visual outcome. Preoperative evaluation should include the assessment of potential zonular insufficiency and the presence of CME, as they are relatively common and may increase the risk of complications.

Developing refractive management recommendations for patients undergoing cataract surgery: A Delphi study

PURPOSE

Currently, there are no UK optometric guidelines regarding the pre and postoperative refractive management of patients undergoing cataract surgery. This study used a Delphi method to gain consensus on best practice.

METHODS

Eighteen recommendations targeted areas of concern/variability in advice that were highlighted in an earlier focus group study of refractive management for patients who had received cataract surgery. These covered three topics: preoperative target refraction discussions, postoperative refractive management and driving advice postoperatively. The recommendations were then developed using evidence from optometry and ophthalmology clinical expertise and the research literature. Eighteen recommendations underwent a process of agreement and modification using a Delphi study consisting of a panel of 22 highly experienced optometrists (N = 11, 25 years mean clinical experience) and ophthalmologists (N = 11, 17 years mean clinical experience) who rated and commented upon the importance and feasibility of each recommendation. The responses were considered by the research team and the recommendations modified and/or removed prior to a second Delphi round of responses to a modified series of recommendations. Consensus of opinion was defined as greater than 80% of panellists 'agreed' or 'strongly agreed' on the recommendation for both importance and feasibility.

RESULTS

Fourteen of the 18 recommendations reached consensus in the first round. A second round of the Delphi method saw 17 modified recommendations scored and commented upon by 20 clinicians. Fifteen recommendations reached consensus after two rounds of the Delphi method.

CONCLUSIONS

Recommendations to guide the pre and postoperative refractive management of patients undergoing cataract surgery were agreed between highly experienced optometrists and ophthalmologists using a 2-round Delphi method. Patients would benefit from consistent target refraction discussions, postoperative refractive management and driving advice, and recommendations were of particular benefit to less experienced optometrists.

Immediate sequential bilateral cataract surgery: patient perceptions and preferences

BACKGROUND

Recent national data suggests that less than 0.5% of NHS cataract patients undergo immediate sequential bilateral cataract surgery (ISBCS). Since ISBCS improves service efficiency, increasing its practice may help tackle the ever-growing burden of cataract in the UK, and reduce the COVID-19 cataract backlog. Surgeon attitudes are known to be a significant barrier to increasing the practice of ISBCS. However, little is known about patient perceptions of ISBCS.

METHODS

Patients at cataract clinics across three NHS hospital sites were recruited to complete an investigator-led structured questionnaire. Open-ended and closed-ended questions were used to assess awareness of ISBCS, willingness to undergo ISBCS and attitudes towards ISBCS.

RESULTS

Questionnaires were completed by 183 patients. Mean participant age was 70.5 (9.9) years and 58% were female. Forty-three percent were aware of ISBCS, chiefly via clinic staff. Just over a third would choose ISBCS if given the choice, and participants that perceived they were recommended ISBCS were more likely to opt for it. The most common motivator and barrier to uptake of ISBCS was convenience and the perceived risk of complications in both eyes respectively. Concerns related to the recovery period were common, including misunderstandings, such as the need to wear eye patches that obscure both eyes.

CONCLUSIONS

Our study indicates that significantly more NHS patients would be willing to undergo ISBCS if given the choice. The reluctance of surgeons to recommend ISBCS and patient misunderstandings regarding the recovery period may be limiting its uptake.

Predictive accuracy of an intraoperative aberrometry device for a new monofocal intraocular lens

PURPOSE

To evaluate refractive outcomes for the Clareon monofocal intraocular lens (IOL) in terms of achieved target refraction for the ORA (ALCON) intraoperative wavefront aberrometry device and preoperative noncontact biometry.

SETTING

University Eye Clinic Maastricht, Maastricht University Medical Center+, the Netherlands.

DESIGN

Prospective observational clinical trial.

METHODS

Patients with bilateral age-related cataracts undergoing phacoemulsification, either by delayed sequential surgery or on the same day, were included in the study. Exclusion criteria were an increased risk for refractive surprise or complicated surgery. Implanted IOL power was based on noncontact optical biometry data using the Barrett Universal II (BU-II) formula, optimized for the Clareon IOL. Postoperative subjective refraction was measured 4 to 6 weeks after surgery. Catquest-9SF questionnaires were completed preoperatively and 3 months after surgery.

RESULTS

100 eyes (51 patients) were included. The percentages of eyes within 1.0 diopters (D), 0.75 D, 0.50 D, and 0.25 D of target for ORA vs BU-II were 84% (84 eyes), 72% (72 eyes), 57% (57 eyes), and 21% (21 eyes) vs 97% (97 eyes), 88% (88 eyes), 77% (77 eyes), and 53% (53 eyes), respectively. Mean absolute prediction error was significantly higher for ORA vs preoperative biometry (P < .001). After global optimization, the prediction accuracy of ORA improved significantly (P < .001). Catquest-9SF questionnaires showed improved levels of ability at 3 months after surgery (P < .001).

CONCLUSIONS

This study showed lower percentages of eyes within target refraction for ORA (prior to lens constant optimization) compared with the BU-II formula when implanting the Clareon IOL. However, prediction accuracy of ORA improved significantly after global optimization. Therefore, further intraoperative measurements, postoperative measurements, and optimization are needed to improve the ORA prediction for this IOL.

Immediate sequential bilateral surgery versus delayed sequential bilateral surgery for cataracts

BACKGROUND

Age-related cataract affects both eyes in most cases. Most people undergo cataract surgery in both eyes on separate days, referred to as delayed sequential bilateral cataract surgery (DSBCS). An alternative procedure involves operating on both eyes on the same day, but as two separate procedures, known as immediate sequential bilateral cataract surgery (ISBCS). Potential advantages of ISBCS include fewer hospital visits for the patient, faster visual recovery, and lower healthcare costs. Nevertheless, concerns exist about possible bilateral, postoperative, sight-threatening adverse effects with ISBCS. Therefore, there is a clear need for evaluating evidence regarding the safety, effectiveness, and cost-effectiveness of ISBCS versus DSBCS.

OBJECTIVES

To assess the safety of ISBCS compared to DSBCS in people with bilateral age-related cataracts and to summarise current evidence for the incremental resource use, utilities, costs, and cost-effectiveness associated with the use of ISBCS compared to DSBCS in people with bilateral age-related cataracts (primary objectives). The secondary objective was to assess visual and patient-reported outcomes of ISBCS compared to DSBCS in people with bilateral age-related cataracts.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 5); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov; the WHO ICTRP; and DARE and NHS EED on the CRD Database on 11 May 2021. There were no language restrictions. We limited the searches to a date range of 2007 onwards.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) to assess complications, refractive outcomes, best-corrected distance visual acuity (BCDVA) and patient-reported outcome measures (PROMs) with ISBCS compared to DSBCS. We included non-randomised (NRSs), prospective, and retrospective cohort studies comparing ISBCS and DSBCS for safety assessment, because of the rare incidence of important adverse events. To assess cost-effectiveness of ISBCS compared to DSBCS, we included both full and partial economic evaluations, and both trial-based and model-based economic evaluations.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures and assessed risk of bias for NRSs using the ROBINS-I tool. For cost-evaluations, we used the CHEC-list, the CHEERS-checklist, and the NICE-checklist to investigate risk of bias. We assessed the certainty of evidence with the GRADE tool. We reported results for economic evaluations narratively.

MAIN RESULTS

We included 14 studies in the review; two RCTs, seven NRSs, and six economic evaluations (one study was both an NRS and economic evaluation). The studies reported on 276,260 participants (7384 for ISBCS and 268,876 for DSBCS) and were conducted in Canada, the Czech Republic, Finland, Iran, (South) Korea, Spain (Canary Islands), Sweden, the UK, and the USA. Overall, we considered the included RCTs to be at 'high to some concerns' risk of bias for complications, 'some concerns' risk of bias for refractive outcomes and visual acuity, and 'high' risk of bias for PROMs. The overall risk of bias for NRSs was graded 'serious' regarding complications and 'serious to critical' regarding refractive outcomes.  With regard to endophthalmitis, we found that relative effects were estimated imprecisely and with low certainty, so that relative estimates were not reliable. Nonetheless, we found a very low risk of endophthalmitis in both ISBCS (1/14,076 participants) and DSBCS (55/556,246 participants) groups. Based on descriptive evidence and partially weak statistical evidence we found no evidence of an increased risk of endophthalmitis with ISBCS. Regarding refractive outcomes, we found moderate-certainty (RCTs) and low-certainty (NRSs) evidence there was no difference in the percentage of eyes that did not achieve refraction within 1.0 dioptre of target one to three months after surgery (RCTs: risk ratio (RR) 0.84, 95% confidence interval (CI) 0.57 to 1.26; NRSs: RR 1.02, 95% CI 0.60 to 1.75). Similarly, postoperative complications did not differ between groups (RCTs: RR 1.33, 95% CI 0.52 to 3.40; NRSs: 1.04, 95% CI 0.47 to 2.29), although the certainty of this evidence was very low for both RCTs and NRSs. Furthermore, we found low-certainty (RCTs) to very low-certainty (NRSs) evidence that total costs per participant were lower for ISBCS compared to DSBCS, although results of individual studies could not be pooled. Only one study reported on cost-effectiveness. This study found that ISBCS is cost-effective compared to DSBCS, but did not measure quality-adjusted life years using preferred methods and calculated costs erroneously. Finally, regarding secondary outcomes, we found limited evidence on BCDVA (data of two RCTs could not be pooled, although both studies individually found no difference between groups (very low-certainty evidence)). Regarding PROMs, we found moderate-certainty evidence (RCTs only) that there was no difference between groups one to three months after surgery (standardised mean difference -0.08, 95% CI -0.19 to 0.03).

AUTHORS' CONCLUSIONS

Current evidence supports there are probably no clinically important differences in outcomes between ISBCS and DSBCS, but with lower costs for ISBCS. However, the amount of evidence is limited, and the certainty of the evidence was graded moderate to very low. In addition, there is a need for well-designed cost-effectiveness studies.

Immediately sequential bilateral cataract surgery: an academic teaching center's experience

PURPOSE

To evaluate the safety and outcomes of immediately sequential bilateral cataract surgery (ISBCS) at a Canadian academic teaching center.

SETTING

Tertiary university teaching hospital of Laval University, Quebec City, Canada.

DESIGN

Retrospective cohort study.

METHODS

2003 consecutive patients (4006 eyes) who underwent ISBCS under topical anesthesia from January 2019 to December 2019 were included. All charts were retrospectively reviewed. Outcome measures included intraoperative and postoperative complications, postoperative uncorrected distance (UCVA) and pinhole (PHVA) visual acuities, and autorefraction measurements.

RESULTS

4006 eyes from 1218 (60.8%) female and 785 (39.2%) male patients with a mean age of 74 ± 8 years had a mean preoperative visual acuity of 0.503 logMAR (Snellen 20/63). The mean axial length was 23.53 ± 1.37 mm. Most eyes had monofocal intraocular lenses (IOLs) implanted (n = 3738, 93.3%) followed by toric (n = 226, 5.6%), multifocal (n = 25, 0.6%), and multifocal toric (n = 17, 0.4%) IOLs. Intraoperative complications included 14 (0.3%) posterior capsule ruptures with 5 (0.1%) requiring sulcus IOL placement, and 7 (0.2%) partial zonulysis, with 3 requiring capsular tension rings (0.07%). There were no cases of endophthalmitis or toxic anterior segment syndrome. Mean 5-week postoperative UCVA was 0.223 (Snellen 20/33), PHVA was 0.153 (Snellen 20/28) with a mean spherical equivalent of -0.21 diopters.

CONCLUSIONS

ISBCS performed following International Society of Bilateral Cataract Surgeons recommended guidelines is a safe procedure. This cohort of 4006 eyes had very few complications, with none attributable to the surgery being done bilaterally. The UCVA, PHVA, and refractive outcomes were good.

The effect of surgical abstinence on the risk of posterior capsule rupture during cataract surgery

PURPOSE

To evaluate the impact of surgery restrictions on cataract surgery performance.

SETTING

Moorfields Eye Hospital, NHS Foundation Trust, London, UK.

DESIGN

Retrospective, observational cross-sectional study.

METHODS

Single-centre, retrospective review of all patients that underwent phacoemulsification surgery at Moorfields Eye Hospital, between September 2019 and January 2021. Our main outcome measure was Posterior Capsule Rupture (PCR) rate before and after COVID-19 imposed restrictions to elective cataract surgery.

RESULTS

We identified a total of 15689 surgeries in the period of the study performed by 256 different surgeons. In the pre-surgery restriction period (September 2019 to March 2020), the PCR rate was 0.99% while on surgery restarting after 19 weeks, the PCR rate spiked to 1.62% (Odds Ratio 1.65; p=0.001; CI 1.24-2.20; Relative Risk: 1.64).

CONCLUSIONS

COVID-19 pandemic provided a unique opportunity to assess a large group of surgeons' performances after prolonged surgical abstinence. A 19-weeks period of restrictions in surgical activity showed an increased incidence of PCR complications. This is relevant as it can concern any surgeon on extended time off work such as sickness, sabbatical, research and parental leave. Supporting strategies should be implemented by associated regulators to minimize this negative impact.

Management of Cataract in Patients with Age-Related Macular Degeneration

Cataract and age-related macular degeneration (AMD) are two of the most common eye diseases of aging. This review addresses the pre-operative, intra-operative, and post-operative considerations in managing cataract in patients with age-related macular degeneration. Surgery for visually significant cataracts in patients with AMD can substantially improve the quality of life and reduce the risk of falls. Pre-operative optical coherence tomography is now recommended where possible to identify pre-existing macula disease. Careful counselling of patients is required before cataract surgery, especially with respect to the expected visual outcome, intraocular lens choice and potential risks of surgery. Real-world data has suggested 6 months of intravitreal anti-VEGF therapy for neovascular AMD before cataract surgery is compatible with optimum long-term visual outcomes. Patients receiving intravitreal therapy for neovascular AMD should be advised of the slightly higher risk of intraoperative complications and the surgeon should be prepared to manage these during the operation. During cataract surgery, unnecessary light exposure should be avoided to reduce phototoxicity. Careful planning of intravitreal therapy for neovascular AMD just before cataract surgery allows the eye greater recovery time in the post-operative period before further planned intravitreal therapy.

A stakeholder meeting exploring the ethical perspectives of immediately sequential bilateral cataract surgery

PURPOSE

The purported benefits and risks of immediately sequential bilateral cataract surgery (ISBCS) have been well described, yet the procedure remains controversial among UK ophthalmologists. As many of the controversies of ISBCS are underpinned by ethical dilemmas, the aim of this work was to explore the ethical perspectives of ISBCS from a variety of stakeholder viewpoints.

METHOD

A semi-structured independent stakeholder meeting was convened at the Royal College of Ophthalmologists London headquarters in June 2018. In total, 29 stakeholders attended the meeting. The professional characteristics of stakeholders included but were not limited to: ophthalmologists (9), patients (5), religious leaders (4), ethicists (2), lawyers (2) and commissioners (1). Thematic qualitative analysis using methodology proposed by Braun and Clarke was conducted on the resultant transcript of the discussion.

RESULTS

Themes identified include: (1) beneficence and non-maleficence (patient benefits, patient risks, the uncertainties of risk, patient interpretation of the risk-benefit analysis); (2) autonomy (informed consent, the barriers to communication); (3) distributive justice (the allocation of resources: the individual vs the collective).

CONCLUSION

This analysis provides a reference point for the ethical factors surrounding ISBCS. The stakeholders concluded that this approach was an ethical undertaking provided patient autonomy was appropriately attained. This requires a patient's interpretation of the risk-benefit balance, which must include an understanding of the low but unquantifiable risk of severe complications. A surgeon must aim to minimise risks through the adaption of accepted surgical protocols and by performing appropriate patient selection. Currently, cost savings to healthcare that may occur following the implementation of ISBCS should be considered a secondary benefit of the protocol.

Cataract service redesign in the post-COVID-19 era

COVID-19 pandemic of 2020 has impacted all aspects of clinical practice in the UK. Cataract services suffered severe disruption due to necessary measures taken to reduce elective surgery in order to release capacity to support intensive care requirements. Faced with a potential 50% increase in cataract surgery workload per week in the post-COVID-19 world, eye units should use this event to innovate, not just survive but to also evolve for a sustainable future. In this article, we discuss the inadequacies of existing service rationing options to tackle the COVID-19 cataract backlog. This includes limiting rationing based on visual acuity, limiting surgery to first or only seeing eyes, and postponing clinic and surgical dates according to referral dates. We propose units use the lockdown time to reset and develop a comprehensive patient-centred care pathway using principles of value-based healthcare: the cataract integrated practice units. Developing an agile surgical database that incorporates all aspects of patient need from education to follow-up in their individual cataract journey will allow units to react and plan quickly in the early phase of recovery and beyond. We also discuss the considerations units should bear in mind on telemedicine, modifications for face-to-face clinics, theatre organisation and options of expanding cataract throughput capacity. The pause in elective surgery due to the pandemic may have provided cataract services a rare opportunity to reset and transform cataract service pathways for the digital era.