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

Assessing the surgical competency of novice surgeons by using a three-dimensional heads-up display microscope

PURPOSE

To evaluate the surgical performance of novice surgeons operating on a three-dimensional (3D) heads-up display system compared to those using a traditional microscope (TM).

METHODS

Prospective study design in a private practice setting. Twenty novice surgeons with similar experiences in cataract surgery were selected. Each surgeon performed 20 phacoemulsification cataract surgeries: 10 surgeries on the 3D heads-up display microscope, and 10 surgeries using a TM system. Data were collected from a total of 400 patients operated on by 20 surgeons. Outcome measures were recorded and graded according to the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric-Phacoemulsification system. The main outcome measure was mean surgical competency scores.

RESULTS

Overall, 400 data points were equally distributed between TM (200) and 3D (200) surgeries. The mean surgical competency scores were 60.19 (11.41) for TM surgeries and 62.99 (11.11) for 3D surgeries. 3D surgeries had significantly higher surgical competency scores than TM surgeries ( P = 0.013). The mean surgical duration for TM and 3D surgeries was 35.98 (6.02) min and 34.31 (7.12) min, respectively. 3D surgeries took significantly less time than TM surgeries ( P = 0.012). The overall mean best corrected visual acuity in the logarithm of the minimum angle of resolution units was 0.27 (0.42); in TM and 3D surgeries, it was 0.28 (0.43) units and 0.26 (0.41) units, respectively.

CONCLUSION

The 3D heads-up display system enhances stereopsis in cataract surgery, making it a valuable training tool for novice surgeons in phacoemulsification procedures.

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.

Safety of office-based lens surgery: U.S. multicenter study

PURPOSE

To evaluate the rate of adverse events after office-based lens surgery performed across multiple private practices in the United States.

SETTING

36 private practices across the U.S.

DESIGN

Retrospective multicenter study.

METHODS

This analysis included case records of all consecutive patients who underwent office-based lens surgery for visually significant cataract, refractive lens exchange, or phakic intraocular lens implantation between August 2020 and May 2022 at 36 participating sites across the U.S. The study outcome measures included the assessment of intraoperative and postoperative complications such as the incidence of unplanned vitrectomy, iritis, corneal edema, and endophthalmitis after lens surgery. The frequency of patients requiring a return to the operating room (OR) or referral to a retina surgeon and the frequency of patients requiring hospitalization or calling emergency services (911) for any reason were also evaluated.

RESULTS

The study reviewed 18 005 cases of office-based cataract or refractive lens surgery performed at 36 clinical sites. The rates of postoperative endophthalmitis, toxic anterior segment syndrome, and corneal edema were 0.028%, 0.022%, and 0.027%, respectively. Unplanned anterior vitrectomy was performed in 0.177% of patients. Although 0.067% of patients needed to return to the OR, 0.011% of patients were referred to the hospital.

CONCLUSIONS

The rate of adverse events for office-based cataract or refractive lens surgery is similar to or less than the reported adverse event rate for modern cataract surgery in the ambulatory surgery center setting.

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.

Outcomes of Trainee-performed MIGS at Parkland Memorial Hospital: A Retrospective Cohort Study

Aims and background

As the use of minimally invasive or microinvasive glaucoma surgery (MIGS) continues to expand, it is important to look at its outcomes in the hands of trainees. This study aims to examine the efficacy and safety of Kahook Dual Blade (KDB) goniotomy and endocyclophotocoagulation (ECP) with cataract extraction (CE) done by residents and fellows.

Methods

All cases of KDB or ECP performed with CE between 2012 and 2020 at Parkland were reviewed, excluding cases with multiple MIGS procedures or other procedures.

Results

A total of 153 eyes of 136 patients who underwent KDB and 125 eyes of 124 patients who underwent ECP were included. Mean intraocular pressure (IOP) decreased from 17.2 ± 5.2 at baseline to 15.4 ± 5.5 mm Hg at postoperative (post-op) month (POM) 12 in the KDB group (p = 0.02) and from 18.6 ± 6.3 at baseline to 15.1 ± 4.9 mm Hg at POM12 in the ECP group (p < 0.001), with wide variation in IOP change among subjects for both. The mean change in IOP across all time points was statistically significant for both groups. Medication counts were reduced from baseline at POMs 1, 3, and 6, but not 12, in both the KDB and ECP groups (p = 0.43 and p = 0.35, respectively). The rate of serious complications was very low; the most common complication was cystoid macular edema (CME) (six cases) and active inflammation beyond POM1 (15 cases) for KDB and ECP, respectively.

Conclusion

Combined CE/MIGS procedures performed by trainees were safe but less efficacious in lowering IOP and medications compared to literature reporting outcomes of attending surgeons, apart from ECP/MIGS with regards to IOP lowering, which was found to be similarly efficacious.

Clinical significance

Cataract extraction (CE) combined with KDB or ECP in the hands of trainees decreased mean IOP from baseline and was safe. IOP and medication reduction of MIGS/CE in the hands of trainees were overall lesser than reported values by attending surgeons.

How to cite this article

Da J, Gillings M, Kamat S, et al. Outcomes of Trainee-performed MIGS at Parkland Memorial Hospital: A Retrospective Cohort Study. J Curr Glaucoma Pract 2023;17(3):134-140.

Outcomes of "Complex" Cataract Surgeries Performed by Long-Term Glaucoma Fellows in a Tertiary Eye Centre from Eastern India

Purpose

To evaluate the outcomes of operating on "complex cataracts" by the glaucoma fellows.

Patients and Methods

This was a retrospective study done at a tertiary referral eye care centre in eastern India. After obtaining IRB approval, a retrospective chart review of all patients who underwent "complex" cataract surgery by one of four long-term (2 years) glaucoma fellows between January 2016 and November 2020 was conducted. 'Complex' was defined as cataracts complicated with pseudoexfoliation syndrome, phacodonesis with or without blunt ocular trauma, posterior polar cataract, small pupil, co-existent corneal opacity or uveal coloboma, post-glaucoma filtering surgery, post-vitreoretinal surgery, co-existent glaucoma or post-laser iridotomy and monocular patients.

Results

Out of a total of 677 eyes done by the glaucoma fellows during the study period, 83 eyes had complex cataract surgery and completed the six-week post-operative follow-up. Intraoperative surgical complications like posterior capsular rent or vitreous loss were noted in 36 of the cases. Thirty of the eyes were left aphakic. Despite a high rate of complications, the LogMAR best-corrected visual acuity (mean ± standard deviation) improved from the preoperative level of 1.7 (±0.5) to 1.0 (± 0.8) at post-operative six weeks, significant at p < 0.001. As far as the surgeon's experience was concerned-less than or more than a year since joining the fellowship-there was statistically no difference in the final visual acuity. The group with greater experience had shorter surgical time and lesser complications though this difference was not statistically significant.

Conclusion

This is the first study in the literature reporting the outcomes of "complex" cataract surgery performed by glaucoma fellows. Though high rates of postoperative complications were noted in this study, the mean best-corrected visual acuity improved significantly in all eyes after the surgery.

Comparison of Trabeculectomy Outcomes Performed by Residents in Training and Ophthalmologists

PRCIS

Resident-performed trabeculectomies present higher intraocular pressure and lower complete success rate at 1 year.

PURPOSE

To compare the 1-year outcomes of ab externo trabeculectomy between residents in training and staff ophthalmologists.

PATIENTS AND METHODS

This retrospective study included all consecutive eyes submitted to ab externo trabeculectomy between January 2015 to June 2020. A 1-year complete success rate was considered using all the following criteria: intraocular pressure (IOP)≤21 mm Hg and ≥6mm Hg without ocular hypotensive medications; IOP reduction≥30%; without loss of light perception, phthisis bulbi, and further glaucoma surgery (excluding suture lysis and bleb needling).

RESULTS

One hundred and ten eyes from 99 patients were included. Thirty percent (n=33) of the trabeculectomies were performed by residents. There were no significant preoperative differences between groups, apart from age at surgery, which was higher in the residents' group (72.39±6.83 vs. 62.00±15.07 years, P<0.001), and visual field index (Humphrey Field Analyzer), which was lower in the ophthalmologists' group (51.81±34.74% vs. 32.04±33.83%, P=0.013). IOP at 1-, 3-, 6 months, and 1 year after surgery was significantly higher in the resident's group (P<0.05). Resident-performed trabeculectomies achieved a significantly lower complete success rate when compared with the ophthalmologists' group (39.39% vs. 64.94%, P=0.013). The overall rate of the postoperative complications and reintervention did not differ between groups, but the occurrence of a shallow anterior chamber was more frequent in the residents' group (15.15% vs. 4.05%, P=0.037).

CONCLUSIONS

Resident-performed trabeculectomies present significantly higher postoperative IOP levels and a lower complete success rate when compared with staff ophthalmologists. It is, therefore, fundamental to adopt strategies to change this gap, improve patient safety, and strengthen resident confidence.

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.

Predictors of visual acuity improvement after phacoemulsification cataract surgery

Purpose

This study aimed to assess preoperative predictors of visual outcome after phacoemulsification cataract surgery in Jordan, a Middle Eastern country.

Methods

This was a retrospective longitudinal study of adult patients who underwent phacoemulsification cataract surgery from January 2019 to July 2021. For each patient, we included only the first operated eye. We obtained pre-operative ocular history, cataract surgery complication risk based on a predesigned score, visual acuity, best correction, and best corrected visual acuity. We recorded intraoperative complications. We also obtained postoperative best corrected visual acuity and refractive error for correction after 1–3 months.

Results

A total of 1,370 patients were included in this study, with a mean age of 66.39 (± 9.48). 48.4% of patients achieved visual acuity ≥ 0.8, and 72.7% achieved visual acuity ≥ 0.5. The mean visual acuity improvement after phacoemulsification cataract surgery was 0.33 (95% CI 0.31–0.35). In the regression model, significant predictors that affected visual acuity improvement included the presence of diabetic retinopathy, glaucoma, and complication risk factors (i.e., high-risk surgery).

Conclusion

Predictors of visual acuity improvement vary between studies. This study was conducted in a developing country; we defined predictors of visual acuity improvement. We also provided a new preoperative phacoemulsification cataract surgery complication risk score.

Surgical Results of Phacoemulsification Performed by Residents: A Time-Trend Analysis in a Teaching Hospital from 2005 to 2021

Purpose

To report a long-term trend of surgical results of phacoemulsification performed by residents in a teaching hospital.

Methods

This study analyzed 1,409 consecutive cases of phacoemulsification performed by residents under a single supervisor from July 2005 to March 2021. The 15.75-year period was divided into seven equal intervals for time-trend analysis. Main Outcome Measures. Rates of completion and complications were collected to assess the surgical results.

Results

The overall completion rate was 60.5% (852/1409), and the intraoperative complication rate was 14.5% (204/1409). The completion rates from the first to the seventh interval were 44.7%, 54.2%, 60.6%, 50.6%, 65.1%, 72.5%, and 81.8%, respectively. The completion rate improved significantly with time, mainly in the steps of anterior capsulorhexis and nucleus emulsification. The intraoperative complication rates from the first to the seventh interval were 27.4%, 20.4%, 14.0%, 11.8%, 8.2%, 9.6%, and 7.3%, respectively. The complication rate also decreased significantly with time, mainly in the steps of anterior capsulorhexis, nucleus emulsification, and cortex removal. The major complications included anterior capsulorhexis tear (n = 95), vitreous loss (n = 40), iris damage or prolapse (n = 36), and posterior capsule tear without vitreous loss (n = 29). There was a significant improvement of surgical results with the level of residency in the completion rate but not in the complication rate.

Conclusions

With a long-term evolution in the surgical training curriculum, it is possible to reach a goal of both higher completion and lower complication rates of resident-performed phacoemulsification.

Outcomes of Resident Performed Hydrus, iStent, and Kahook Glaucoma Procedures in a Predominantly African American Population

PRCIS

This retrospective study characterized the efficacy and safety of 3 different microinvasive glaucoma surgery (MIGS) procedures in a predominantly African American population at the Philadelphia Veterans Affairs Hospital (Hydrus, Kahook, iStent), demonstrating no significant difference in intraocular pressure (IOP) and medication reduction between the 3 at long-term follow-up.

PURPOSE

To compare the efficacy and safety of 3 different MIGS procedures in a predominantly African American population.

METHODS

Retrospective cohort study of patients undergoing cataract extraction combined with 1 of 3 MIGS procedures (Hydrus, iStent, Kahook) at the Philadelphia Veterans Affairs Medical Center between January 1, 2015 and November 1, 2020. Analysis of variance and regression models were used to compare reduction in IOP and medication use among 3 MIGS types.

RESULTS

A total of 123 eyes of 112 patients were included, including 56 (45.5%) eyes for Hydrus, 40 (32.5%) eyes for iStent, and 27 (22.0%) eyes for Kahook. Adjusted mean IOP reduction was greater for Hydrus at postoperative day 1 (-4.49 vs. -1.76 for iStent and -1.69 for Kahook, P=0.05 and greater for Kahook at postoperative week 1 (-2.53 vs. +0.70 for iStent vs. -1.41 for Hydrus, P=0.02), but did not differ significantly between MIGS types at subsequent postoperative visits (all P>0.05). In multivariable analysis, MIGS type was not significantly associated with reduction in IOP or medication use at 9 to 12 months postoperatively. There were no significant differences in complication rates across MIGS types.

CONCLUSION

In this study, the difference in IOP lowering and medication reduction postoperatively between the Hydrus, iStent, and Kahook was not statistically significant after postoperative day 1. More studies are needed to evaluate outcomes of MIGS surgeries in glaucoma populations of different disease severity.

Evidence-based cataract surgery teaching milestones - a guide to evaluate resident achievement

PURPOSE

Develop evidence-based milestones for cataract surgery teaching and identify performance indicators.

SETTING

Edmonton, Alberta, Canada.

DESIGN

Retrospective cohort study.

METHODS

Operative records from a single surgeon were reviewed for resident participation when learning cataract surgery over a 14-year time period. Time to complete a resident's first complete case was the primary outcome. Secondary outcomes included mean time to perform each categorical step of the procedure, number of cases participated in, rate of participation, complex case involvement and complications. Strong resident performance was defined as time to first complete case one standard deviation quicker than mean performance; weak performance was the opposite.

RESULTS

Residents performed beginner steps for 3.1 ± 3.2 months, intermediate steps until month 4.3 ± 3.3, and by month 5.1 ± 3.4 residents were able to do complete cases. Time to perform a complete case increases with lower case participation (p=0.02); mean proportion of complex cases that a resident participated in was 7.9% (n=17.6 ± 10.0).; Less than 1% of resident cases resulted in posterior capsular rupture (n=1.4 ± 1.3 cases). Based on this data, weaker achievement is defined as failure to achieve beginner-step competency by month 6.3, intermediate step competency by month 7.6, or inability to perform a complete case by month 8.5. In this dataset, 23.1% of residents met this definition (n=3).

CONCLUSIONS

Residents who train with multiple teachers during a focused cataract surgery rotation can perform complete cases after a mean of 5.1 ± 3.4 months with a low PCR rate.

Phacoemulsification: Proposals for Improvement in Its Application

A cataract is defined as opacity of the crystalline lens. It is currently one of the most prevalent ocular pathologies and is generally associated with aging. The most common treatment for cataracts is surgery. Cataract surgery is a quick and painless process, is very effective, and has few risks. The operation consists of removing the opacified lens and replacing it with an intraocular lens. The most common intraocular lens removal procedure that is currently used is phacoemulsification. The energy applied in this process is generated by ultrasonic waves, which are mechanical waves with a frequency higher than 20 kHz. A great deal of research on the different ways to perform the stages of this surgical procedure and the analysis of the possible side effects of the operation has been published, but there is little information on the technical characteristics, the intensities applied, and the use of ultrasound-emitting (U/S) equipment for cataract removal. More studies on the method and depth of absorption of ultrasonic waves in our visual system when performing the phacoemulsification procedure are needed. It would be advisable for health authorities and medical professionals to develop guidelines for the handling and use of ultrasonic wave-emitting equipment, such as those that exist for ultrasound and physiotherapy. This could help us to reduce undesirable effects after the operation.

Classification Tree to Analyze Factors Connected with Post Operative Complications of Cataract Surgery in a Teaching Hospital

Background: Artificial intelligence (AI) is becoming ever more frequently applied in medicine and, consequently, also in ophthalmology to improve both the quality of work for physicians and the quality of care for patients. The aim of this study is to use AI, in particular classification tree, for the evaluation of both ocular and systemic features involved in the onset of complications due to cataract surgery in a teaching hospital. Methods: The charts of 1392 eyes of 1392 patients, with a mean age of 71.3 ± 8.2 years old, were reviewed to collect the ocular and systemic data before, during and after cataract surgery, including post-operative complications. All these data were processed by a classification tree algorithm, producing more than 260 million simulations, aiming to develop a predictive model. Results: Postoperative complications were observed in 168 patients. According to the AI analysis, the pre-operative characteristics involved in the insurgence of complications were: ocular comorbidities, lower visual acuity, higher astigmatism and intra-operative complications. Conclusions: Artificial intelligence application may be an interesting tool in the physician’s hands to develop customized algorithms that can, in advance, define the post-operative complication risk. This may help in improving both the quality and the outcomes of the surgery as well as in preventing patient dissatisfaction.

Classification Tree to Analyze Factors Connected with Post Operative Complications of Cataract Surgery in a Teaching Hospital

BACKGROUND

Artificial intelligence (AI) is becoming ever more frequently applied in medicine and, consequently, also in ophthalmology to improve both the quality of work for physicians and the quality of care for patients. The aim of this study is to use AI, in particular classification tree, for the evaluation of both ocular and systemic features involved in the onset of complications due to cataract surgery in a teaching hospital.

METHODS

The charts of 1392 eyes of 1392 patients, with a mean age of 71.3 ± 8.2 years old, were reviewed to collect the ocular and systemic data before, during and after cataract surgery, including post-operative complications. All these data were processed by a classification tree algorithm, producing more than 260 million simulations, aiming to develop a predictive model.

RESULTS

Postoperative complications were observed in 168 patients. According to the AI analysis, the pre-operative characteristics involved in the insurgence of complications were: ocular comorbidities, lower visual acuity, higher astigmatism and intra-operative complications.

CONCLUSIONS

Artificial intelligence application may be an interesting tool in the physician's hands to develop customized algorithms that can, in advance, define the post-operative complication risk. This may help in improving both the quality and the outcomes of the surgery as well as in preventing patient dissatisfaction.