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Buchan JC, Norridge CFE, Low L, Shah V, Donachie PHJ. The Royal College of Ophthalmologists' National Ophthalmology Database Study of Cataract Surgery: Report 13, monitoring post-cataract surgery endophthalmitis rates-the rule of X. Eye (Lond) 2024; 38:1386-1389. [PMID: 38200322 PMCID: PMC11076627 DOI: 10.1038/s41433-023-02917-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 12/05/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Cataract surgical safety has improved over recent decades, with endophthalmitis rates before 2006 typically 0.13-0.15% compared with the most recent UK national estimate of 0.02%. There remains, however, substantial variation in reported rates from different centres. Due to the low event rate, this disparity may not be noticed and opportunities to improve therefore be missed. We propose a method of monitoring post-cataract endophthalmitis rates that would help centres with higher rates identify this. METHODS A statistical tool, available to download or use online, permits comparison of local endophthalmitis rate with the estimated UK rate of 0.02%. Centres are encouraged to maintain a register of endophthalmitis cases, and when the number reaches a threshold (X cases), either in a certain time period or in a fixed number of procedures, then the centre can consider itself as an outlier and trigger local investigations to improve infection control. RESULTS Example outputs are offered, such as for a unit doing 5000 cataracts annually, a value of X is suggested such that the third case of endophthalmitis (X = 3) in a 12-month period would give 85% confidence, the fourth case 90% confidence and the fifth case 95% confidence that the true endophthalmitis rate for that unit was higher than the national average. CONCLUSIONS This statistical tool provides a basis for units to set a threshold number of cases of endophthalmitis within a given period that would trigger local processes, thus helping inform local monitoring processes for this rare but potentially catastrophic complication of cataract surgery.
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Affiliation(s)
- John C Buchan
- The Royal College of Ophthalmologists' National Ophthalmology Database Audit, London, UK.
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK.
- Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Charlotte F E Norridge
- The Royal College of Ophthalmologists' National Ophthalmology Database Audit, London, UK
- Gloucestershire Hospitals NHS Foundation NHS Trust, Cheltenham, UK
| | - Liying Low
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Vishal Shah
- King's College Hospital NHS Foundation Trust, London, UK
| | - Paul H J Donachie
- The Royal College of Ophthalmologists' National Ophthalmology Database Audit, London, UK
- Gloucestershire Hospitals NHS Foundation NHS Trust, Cheltenham, UK
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Sabharwal J, Dai X, Dun C, Chen A, Ali M, Schein OD, Ramulu PY, Makary M, Johnson TV, Woreta F. Early Endophthalmitis Incidence and Risk Factors after Glaucoma Surgery in the Medicare Population from 2016 to 2019. Ophthalmology 2024; 131:179-187. [PMID: 37709170 DOI: 10.1016/j.ophtha.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023] Open
Abstract
PURPOSE To determine early endophthalmitis incidence and risk factors after glaucoma surgeries in the Medicare population. DESIGN Retrospective, longitudinal study. PARTICIPANTS Medicare Fee-for-Service (FFS) and Medicare Advantage beneficiaries in the United States aged 65 years or older undergoing glaucoma surgery. METHODS Medicare claims were used to identify all patients who underwent glaucoma, cataract, or combined cataract/glaucoma surgery from 2016 to 2019. Endophthalmitis cases within 42 days of the index surgery were identified using the diagnostic codes. Multivariable logistic regression models were used to evaluate factors associated with postoperative endophthalmitis. MAIN OUTCOME MEASURES The 42-day postoperative endophthalmitis incidence and risk factors associated with endophthalmitis after glaucoma surgery. RESULTS There were 466 928 glaucoma surgeries, of which 310 823 (66.6%) were combined with cataract surgery. Cataract surgeries alone (n = 8 460 360) served as a reference group. Microinvasive glaucoma surgeries constituted most glaucoma procedures performed (67.8%), followed by trabeculectomy (14.0%), tube shunt (10.9%), and other procedures (7.3%). There were 572 cases of endophthalmitis identified after all glaucoma surgeries. Endophthalmitis incidence after glaucoma, combined cataract/glaucoma, and cataract surgeries alone was 1.5 (95% confidence interval [CI], 1.3-1.7), 1.1 (95% CI, 1.0-1.2), and 0.8 (95% CI, 0.8-0.8) per 1000 procedures, respectively. The median day of diagnosis of endophthalmitis was later for glaucoma surgeries (16.5 days) compared with combined cataract/glaucoma or cataract surgeries alone (8 and 6 days, respectively). Compared with microinvasive glaucoma surgery (MIGS), tube shunts were the only surgery type to be a significant risk factor for endophthalmitis for both stand-alone (adjusted odds ratio [aOR], 1.8, P = 0.002) and combined surgery (aOR 1.8, P = 0.047). The other risk factor for both stand-alone (aOR 1.1, P = 0.001) and combined (aOR 1.06, P = 0.049) surgeries was the Charlson Comorbidity Index (CCI). Age (aOR 1.03, P = 0.004) and male gender (1.46, P = 0.001) were significant risk factors for combined cataract and glaucoma surgeries. CONCLUSIONS Compared with cataract surgery, early endophthalmitis incidence was higher for both glaucoma and combined cataract/glaucoma surgeries, with the highest incidence among tube shunts. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Jasdeep Sabharwal
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xi Dai
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chen Dun
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Biomedical Informatics and Data Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ariel Chen
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Muhammad Ali
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Oliver D Schein
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pradeep Y Ramulu
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martin Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Biomedical Informatics and Data Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thomas V Johnson
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fasika Woreta
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.
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Chen A, Dun C, Schein OD, Srikumaran D, Zafar S, Makary M, Woreta F. Endophthalmitis rates and risk factors following intraocular surgeries in the medicare population from 2016 to 2019. Br J Ophthalmol 2024; 108:232-237. [PMID: 37734768 DOI: 10.1136/bjo-2023-323865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/02/2023] [Indexed: 09/23/2023]
Abstract
AIMS To determine endophthalmitis rates and risk factors following intraocular surgeries in the Medicare population. METHODS Retrospective, cross-sectional study from 2016 to 2019 in Medicare fee-for-service and Medicare Advantage beneficiaries. 100% Medicare claims were used to identify eyes that underwent intraocular surgery. Exclusion criteria included eyes that had intraocular surgery 42 days before or after and eyes in patients with a history of endophthalmitis within 12 months. RESULTS 9 744 400 intraocular surgeries were performed among Medicare beneficiaries from 2016 to 2019. A 42-day postoperative endophthalmitis rate was 0.09%. Endophthalmitis rate by surgery type was 0.43% for corneal transplant, 0.36% for secondary intraocular lens (IOL), 0.24% for retina, 0.16% for glaucoma, 0.11% for cataract combined with other procedures and 0.08% for cataract surgeries alone. On multivariable analysis, the risk of endophthalmitis was increased for all intraocular surgery types when compared with cataract surgeries; adjusted OR (aOR) 5.30 (p<0.01) for corneal transplant, aOR 4.50 (p<0.01) for secondary IOL, aOR 3.00 (p<0.01) for retina, aOR 1.93 (p<0.01) for glaucoma, aOR 1.45 (p<0.01) for combined cataract surgeries. Increased risk of developing endophthalmitis was associated with older age (≥85 vs 65-75 years: aOR 1.36; p<0.01), male sex (aOR 1.20; p<0.001) and greater Charlson Comorbidity Index (≥7 vs 0: aOR 1.79; p<0.01). CONCLUSIONS Postoperative endophthalmitis rate after intraocular surgeries was 0.09% between 2016 and 2019 for Medicare beneficiaries. Endophthalmitis rates were highest for corneal transplant surgeries followed by secondary IOL surgeries and lowest for cataract surgeries. Older age, male gender and higher comorbidity index were associated with risk of endophthalmitis.
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Affiliation(s)
- Ariel Chen
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Chen Dun
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Oliver D Schein
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Divya Srikumaran
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sidra Zafar
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Martin Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland, USA
| | - Fasika Woreta
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Garg P, Khor WB, Roy A, Tan DTH. A survey of Asian Eye Institutions on perioperative antibiotic prophylaxis in cataract surgery. Int Ophthalmol 2023; 43:4151-4162. [PMID: 37526782 PMCID: PMC10520096 DOI: 10.1007/s10792-023-02816-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/17/2023] [Indexed: 08/02/2023]
Abstract
PURPOSE To determine current institutional practice patterns for the use of perioperative antibiotics and other measures to prevent infection after cataract surgery in Asia. METHODS An online survey-based study of leading eye institutions in China, Hong Kong, India, Indonesia, Japan, Malaysia, Pakistan, Philippines, Singapore, South Korea, Taiwan, Thailand and Vietnam was conducted. The survey was administered to 26 representative key opinion leaders from prominent tertiary eye institutions that are also national academic teaching institutions in Asia. Survey responses were collated and anonymized during analysis. RESULTS All surveyed institutions used povidone iodine for the preoperative antiseptic preparation of the eye, with notable variations in the concentration of povidone iodine used for conjunctival sac instillation. Preoperative topical antibiotics were prescribed by 61.5% and 69.2% of institutions in low-risk and high-risk cases, respectively. Regarding the use of intra-operative antibiotics, 60.0% and 66.7% of institutions administered intracameral antibiotics in low-risk and high-risk patients, respectively. Postoperative topical antibiotics use patterns were generally very similar in low-risk and high-risk patients. Over half of the institutions (52.2% and 68.0% in low-risk and high-risk patients, respectively) also indicated prolonged postoperative use of topical antibiotics (> 2 weeks). Not all surveyed institutions had established policies/protocols for perioperative antibiotic use in cataract surgery, endophthalmitis surveillance, and/or a monitoring program for emerging antimicrobial resistance. CONCLUSION There are variations in antimicrobial prophylaxis approaches to preoperative, intra-operative and postoperative regimens in cataract surgery in Asia. More evidence-based research is needed to support the development of detailed guidelines for perioperative antibiotic prophylaxis to reduce postoperative infections.
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Affiliation(s)
| | - Wei-Boon Khor
- Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Aravind Roy
- LV Prasad Eye Institute, Vijayawada, Andhra Pradesh, India
| | - Donald Tiang-Hwee Tan
- Singapore National Eye Centre, Singapore, Singapore.
- Duke-NUS Graduate Medical School, Singapore, Singapore.
- Eye and Cornea Surgeons, Eye and Retina Surgeons, Camden Medical Center, 1 Orchard Boulevard, #13-03, Singapore, 248649, Singapore.
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5
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Felfeli T, Miranda RN, Kaur J, Chan CC, Naimark DMJ. Cost-Effectiveness of Preoperative Topical Antibiotic Prophylaxis for Endophthalmitis Following Cataract Surgery. Am J Ophthalmol 2023; 247:152-160. [PMID: 36375588 DOI: 10.1016/j.ajo.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/04/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022]
Abstract
PURPOSE To determine the cost-effectiveness of preoperative topical antibiotic prophylaxis for the prevention of endophthalmitis following cataract surgery. DESIGN Cost-effectiveness analysis using a decision-analytic microsimulation model. METHODS Preoperative topical antibiotic prophylaxis vs no-prophylaxis costs and effects were projected over a life-time horizon for a simulated cohort of 500 000 adult patients (≥18 years old) requiring cataract surgery in theoretical surgical centers in the United States. Efficacy and cost (2021 US dollars) values were obtained from the literature and discounted at 3% per year. RESULTS Based on inputted parameters, the mean incidence of endophthalmitis following cataract surgery for preoperative topical antibiotic prophylaxis vs no-prophylaxis was 0.034% (95% CI 0%-0.2%) and 0.042% (95% CI 0%-0.3%), respectively-an absolute risk reduction of 0.008%. The mean life-time costs for cataract surgery with prophylaxis and no-prophylaxis were $2486.67 (95% CI $2193.61-$2802.44) and $2409.03 (95% CI $2129.94-$2706.69), respectively. The quality-adjusted life-years (QALYs) associated with prophylaxis and no-prophylaxis were 10.33495 (95% CI 7.81629-12.38158) and 10.33498 (95% CI 7.81284-12.38316), respectively. Assuming a cost-effectiveness criterion of ≤$50 000 per QALY gained, the threshold analyses indicated that prophylaxis would be cost-effective if the incidence of endophthalmitis after cataract surgery was greater than 5.5% or if the price of the preoperative topical antibiotic prophylaxis was less than $0.75. CONCLUSIONS General use of preoperative topical antibiotic prophylaxis is not cost-effective compared with no-prophylaxis for the prevention of endophthalmitis following cataract surgery. Preoperative topical antibiotic prophylaxis, however, would be cost-effective at a higher incidence of endophthalmitis and/or a substantially lower price for prophylaxis.
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Affiliation(s)
- Tina Felfeli
- From the Department of Ophthalmology and Vision Sciences, University of Toronto (T.F., C.C.C.); Institute of Health Policy, Management and Evaluation, University of Toronto (T.F., R.N.M., D.M.J.N.); Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network (T.F., R.N.M., D.M.J.N.).
| | - Rafael N Miranda
- Institute of Health Policy, Management and Evaluation, University of Toronto (T.F., R.N.M., D.M.J.N.); Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network (T.F., R.N.M., D.M.J.N.)
| | | | - Clara C Chan
- From the Department of Ophthalmology and Vision Sciences, University of Toronto (T.F., C.C.C.); Department of Ophthalmology, Toronto Western Hospital, University Health Network (C.C.C.)
| | - David M J Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto (T.F., R.N.M., D.M.J.N.); Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network (T.F., R.N.M., D.M.J.N.); and Department of Medicine, Sunnybrook Health Sciences Centre (D.M.J.N.), Ontario, Canada
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6
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Joshi S, Vibhute G, Ayachit A, Ayachit G. Commentary: Dexamethasone and dilemma. Indian J Ophthalmol 2022; 70:2842-2843. [PMID: 35918925 PMCID: PMC9672734 DOI: 10.4103/ijo.ijo_3213_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Shrinivas Joshi
- Department of Vitreoretina, M. M. Joshi Eye Institute, Hubli, Karnataka, India
| | - Giriraj Vibhute
- Department of Vitreoretina, M. M. Joshi Eye Institute, Hubli, Karnataka, India
| | - Apoorva Ayachit
- Department of Vitreoretina, M. M. Joshi Eye Institute, Hubli, Karnataka, India
| | - Guruprasad Ayachit
- Department of Vitreoretina, M. M. Joshi Eye Institute, Hubli, Karnataka, India
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Fuller SD, Hu J, Liu JC, Gibson E, Gregory M, Kuo J, Rajagopal R. Five-Year Cost-Effectiveness Modeling of Primary Care-Based, Nonmydriatic Automated Retinal Image Analysis Screening Among Low-Income Patients With Diabetes. J Diabetes Sci Technol 2022; 16:415-427. [PMID: 33124449 PMCID: PMC8861785 DOI: 10.1177/1932296820967011] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Artificial intelligence-based technology systems offer an alternative solution for diabetic retinopathy (DR) screening compared with standard, in-office dilated eye examinations. We performed a cost-effectiveness analysis of Automated Retinal Image Analysis System (ARIAS)-based DR screening in a primary care medicine clinic that serves a low-income patient population. METHODS A model-based, cost-effectiveness analysis of two DR screening systems was created utilizing data from a recent study comparing adherence rates to follow-up eye care among adults ages 18 or older with a clinical diagnosis of diabetes. In the study, the patients were prescreened with an ARIAS-based, nonmydriatic (undilated), point-of-care tool in the primary care setting and were compared with patients with diabetes who were referred for dilated retinal screening without prescreening, as is the current standard of care. Using a Markov model with microsimulation resulting in a total of 600 000 simulated patient experiences, we calculated the incremental cost-utility ratio (ICUR) of the two screening approaches, with regard to five-year cost-effectiveness of DR screening and treatment of vision-threatening DR. RESULTS At five years, ARIAS-based screening showed similar utility as the standard of care screening systems. However, ARIAS reduced costs by 23.3%, with an ICUR of $258 721.81 comparing the current practice to ARIAS. CONCLUSIONS Primary care-based ARIAS DR screening is cost-effective when compared with standard of care screening methods.
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Affiliation(s)
- Spencer D. Fuller
- John F. Hardesty Department of
Ophthalmology and Visual Sciences, Washington University School of Medicine, Saint
Louis, MO, USA
- Spencer D. Fuller, MD, MPH, John F. Hardesty
Department of Ophthalmology and Visual Sciences, Washington University School of
Medicine, 660 South Euclid Avenue, Campus Box 8096, Saint Louis, MO 63110, USA.
| | - Jenny Hu
- Shiley Eye Institute, University of
California San Diego School of Medicine, La Jolla, CA, USA
| | - James C. Liu
- John F. Hardesty Department of
Ophthalmology and Visual Sciences, Washington University School of Medicine, Saint
Louis, MO, USA
| | - Ella Gibson
- John F. Hardesty Department of
Ophthalmology and Visual Sciences, Washington University School of Medicine, Saint
Louis, MO, USA
| | - Martin Gregory
- John T. Milliken Department of Medicine,
Division of Gastroenterology, Washington University School of Medicine, St. Louis,
MO, USA
| | - Jessica Kuo
- John F. Hardesty Department of
Ophthalmology and Visual Sciences, Washington University School of Medicine, Saint
Louis, MO, USA
| | - Rithwick Rajagopal
- John F. Hardesty Department of
Ophthalmology and Visual Sciences, Washington University School of Medicine, Saint
Louis, MO, USA
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Machiele RD, Guduru A, Herndon LW. Hydrogel Sealant for Closure of Clear Corneal Incisions in Combined Glaucoma Procedures. Clin Ophthalmol 2022; 16:861-865. [PMID: 35340668 PMCID: PMC8942120 DOI: 10.2147/opth.s354531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/10/2022] [Indexed: 11/28/2022] Open
Abstract
Purpose The purpose of this study is to determine whether ReSure hydrogel sealant is superior to standard suture for closure of clear corneal incisions in the setting of combined glaucoma procedures. Setting Glaucoma Department, Duke University Eye Center. Design This is a retrospective case series. Subjects studied were patients in a 6-year period undergoing combined phacoemulsification and glaucoma surgery. All cases were performed by the same surgeon. Wound closure methods correlated with discrete timeframes, as ReSure replaced suture midway through the study period, thereby establishing sutured closure as an analogous control group. Methods All cases included a phacoemulsification procedure requiring a 2.4 mm clear corneal incision. Upon completion of the phacoemulsification portion of the case, the wound was closed with either ReSure hydrogel or standard 10–0 suture closure. The researchers assessed the rate of Seidel-positive corneal wound leak on postoperative day one. Results In all cases employing ReSure, no wound leak was observed at postoperative day one. Within the suture group, 3 cases showed Seidel positivity of the corneal incision. This equates to a statistically significant difference in wound leak frequency of 2.04% (P = 0.012); confidence interval, 0.21 to 5.82. Conclusion ReSure was able to maintain closure 100% of the time over hundreds of combined cases. Suture, though the standard of practice, did not perform to this level, presenting with 3 cases of spontaneous wound leak. We conclude that ReSure is highly effective and superior to suture in closure of clear corneal incisions in combined glaucoma procedures.
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Affiliation(s)
- Ryan D Machiele
- Department of Ophthalmology, University of North Carolina, Chapel Hill, NC, USA
| | - Abhilash Guduru
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA
| | - Leon W Herndon
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA
- Correspondence: Leon W Herndon, Department of Ophthalmology, Duke University Medical Center, 2351 Erwin Road, Durham, NC, 27705, USA, Tel +1 919 681 3937, Fax +1 919 684 0547, Email
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Lacy M, Kung TPH, Owen JP, Yanagihara RT, Blazes M, Pershing S, Hyman LG, Van Gelder RN, Lee AY, Lee CS. Endophthalmitis Rate in Immediately Sequential versus Delayed Sequential Bilateral Cataract Surgery within the Intelligent Research in Sight (IRIS®) Registry Data. Ophthalmology 2022; 129:129-138. [PMID: 34265315 PMCID: PMC8755857 DOI: 10.1016/j.ophtha.2021.07.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 06/11/2021] [Accepted: 07/06/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To compare the rate of postoperative endophthalmitis after immediately sequential bilateral cataract surgery (ISBCS) versus delayed sequential bilateral cataract surgery (DSBCS) using the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry database. DESIGN Retrospective cohort study. PARTICIPANTS Patients in the IRIS Registry who underwent cataract surgery from 2013 through 2018. METHODS Patients who underwent cataract surgery were divided into 2 groups: (1) ISBCS and (2) DSBCS (second-eye surgery ≥1 day after the first-eye surgery) or unilateral surgery. Postoperative endophthalmitis was defined as endophthalmitis occurring within 4 weeks of surgery by International Classification of Diseases (ICD) code and ICD code with additional clinical criteria. MAIN OUTCOME MEASURES Rate of postoperative endophthalmitis. RESULTS Of 5 573 639 IRIS Registry patients who underwent cataract extraction, 165 609 underwent ISBCS, and 5 408 030 underwent DSBCS or unilateral surgery (3 695 440 DSBCS, 1 712 590 unilateral surgery only). A total of 3102 participants (0.056%) met study criteria of postoperative endophthalmitis with supporting clinical findings. The rates of endophthalmitis in either surgery eye between the 2 surgery groups were similar (0.059% in the ISBCS group vs. 0.056% in the DSBCS or unilateral group; P = 0.53). Although the incidence of endophthalmitis was slightly higher in the ISBCS group compared with the DSBCS or unilateral group, the odds ratio did not reach statistical significance (1.08; 95% confidence interval, 0.87-1.31; P = 0.47) after adjusting for age, sex, race, insurance status, and comorbid eye disease. Seven cases of bilateral endophthalmitis with supporting clinical data in the DSBCS group and no cases in the ISBCS group were identified. CONCLUSIONS Risk of postoperative endophthalmitis was not statistically significantly different between patients who underwent ISBCS and DSBCS or unilateral cataract surgery.
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Affiliation(s)
- Megan Lacy
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Timothy-Paul H. Kung
- Department of Ophthalmology, University of Washington, Seattle, Washington.,Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York
| | - Julia P. Owen
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Ryan T. Yanagihara
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Marian Blazes
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Suzann Pershing
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, California.,Veterans Affairs Palo Alto Health California System, Palo Alto, California
| | - Leslie G. Hyman
- The Vision Research Center, Wills Eye Hospital, Philadelphia, Pennsylvania
| | - Russell N. Van Gelder
- Department of Ophthalmology, University of Washington, Seattle, Washington.,Roger and Angie Karalis Johnson Retina Center, Seattle, Washington
| | - Aaron Y. Lee
- Department of Ophthalmology, University of Washington, Seattle, Washington.,Roger and Angie Karalis Johnson Retina Center, Seattle, Washington
| | - Cecilia S. Lee
- Department of Ophthalmology, University of Washington, Seattle, Washington.,Roger and Angie Karalis Johnson Retina Center, Seattle, Washington
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Tabl A, Masoud M, Abdelhalim G, Tabl M. Outcomes of early vitrectomy for endophthalmitis after cataract surgery in delta population, Egypt, 2015–2020. JOURNAL OF THE EGYPTIAN OPHTHALMOLOGICAL SOCIETY 2022. [DOI: 10.4103/ejos.ejos_14_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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Nguyen AM, Roberts TL, Ryu WY, Lambert SR. Endophthalmitis after pediatric cataract surgery in the United States: report using an insurance claims database. J Cataract Refract Surg 2021; 47:1161-1166. [PMID: 34468453 PMCID: PMC8411018 DOI: 10.1097/j.jcrs.0000000000000602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 01/21/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe the characteristics and incidence of children developing endophthalmitis within the first 90 days following pediatric cataract surgery. SETTING Deidentified commercial and Medicare Advantage health claims across the United States. DESIGN Population-based retrospective cohort study. METHODS In a retrospective review of approximately 58 million charts in Optum's deidentified Clinformatics Data Mart Database, patients aged <13 years who underwent cataract surgery in one or both eyes with or without primary intraocular lens (IOL) implantation between 2003 and 2017 were identified. Excluded were patients with traumatic cataract, <90 days of continuous insurance coverage, a prior diagnosis of endophthalmitis, and a diagnosis of endophthalmitis occurring after 90 days of cataract surgery. The main outcome measure was the incidence of endophthalmitis occurring within the first 90 days of cataract surgery and the odds ratio for developing endophthalmitis according to demographic and intraoperative factors. RESULTS Cataract surgery was performed on 789 eyes (52.6% male), with a median age of 4 (interquartile range 1-8) years. The rate of IOL implantation at the time of cataract surgery was 66.8%. Endophthalmitis was diagnosed in 4 of 789 eyes (0.51%). The median time to diagnosis of endophthalmitis was 6.5 days (range: 5-44 days). There was no significant association between endophthalmitis and age, sex, or primary IOL implantation. CONCLUSIONS In this large insurance claims database, the incidence of endophthalmitis following pediatric cataract surgery reported was more than the rate previously reported by any study with patients of a similar age.
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Affiliation(s)
- Angeline M. Nguyen
- The Vision Center at Children’s Hospital Los Angeles, Los Angeles, California, U.S.A
- USC Roski Eye Institute, Keck School of Medicine of the University of Southern California, Los Angeles, California, U.S.A
| | - Tawna L. Roberts
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Won Yeol Ryu
- Department of Ophthalmology, Dong-A University College of Medicine, Busan, Republic of Korea
| | - Scott R. Lambert
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California, U.S.A
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Sun J, Guo Z, Li H, Yang B, Wu X. Acute Infectious Endophthalmitis After Cataract Surgery: Epidemiological Characteristics, Risk Factors and Incidence Trends, 2008-2019. Infect Drug Resist 2021; 14:1231-1238. [PMID: 33790593 PMCID: PMC8007477 DOI: 10.2147/idr.s304675] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/05/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Intended to investigate the epidemiological characteristics, risk factors and incidence trend of endophthalmitis after cataract surgery in recent 12 years. Methods A retrospective study was conducted on the patients who underwent cataract surgery in Qingdao Eye Hospital from January 1, 2008, to December 31, 2019, including age, sex, history of diabetes, intraoperative operation and complications. In addition, the related risk factors and incidence trend of acute infective endophthalmitis were analyzed. The incidence of endophthalmitis and its related factors were analyzed by univariate and multivariate logistic regression analysis. Results A total of 55,612 cases of cataract surgery were performed in our hospital in 12 years, and 42 cases of acute infective endophthalmitis occurred (the incidence rate was 0.076%). The average occurrence time was 10.57 days ± 11.17, with eye pain as the main complaint and anterior chamber fibrin exudation as the main clinical manifestation. In addition, there were eight cases of anterior chamber hypopyon and 18 cases of vitreous reaction, the results of anterior aqueous humor or vitreous fluid culture in 10 patients were positive. Univariate analysis showed that intraoperative rupture of posterior capsule, non-use of antibiotics and non-use of behind-the-lens washout were the risk factors of infectious endophthalmitis after cataract surgery (P=0.032, P=0.000, P=0.000). Besides, multivariate logistic regression analysis showed that intraoperative rupture of posterior capsule was the main risk factor. Conclusion The occurrence of endophthalmitis after cataract surgery is mainly related to intraoperative rupture of posterior capsule, absence of antibiotics and behind-the-lens washout. In addition, the incidence of endophthalmitis after cataract surgery decreased during the past 12 years.
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Affiliation(s)
- Jiajun Sun
- Qingdao Eye Hospital of Shandong First Medical University, Qingdao, 266071, People's Republic of China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Qingdao, 266071, People's Republic of China
| | - Zhen Guo
- Qingdao Eye Hospital of Shandong First Medical University, Qingdao, 266071, People's Republic of China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Qingdao, 266071, People's Republic of China
| | - Honglei Li
- Qingdao Eye Hospital of Shandong First Medical University, Qingdao, 266071, People's Republic of China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Qingdao, 266071, People's Republic of China
| | - Baoxia Yang
- Qingdao Eye Hospital of Shandong First Medical University, Qingdao, 266071, People's Republic of China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Qingdao, 266071, People's Republic of China
| | - Xiaoming Wu
- Qingdao Eye Hospital of Shandong First Medical University, Qingdao, 266071, People's Republic of China.,State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Qingdao, 266071, People's Republic of China
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Moussa G, Bhatt H, Reekie I, Butt G, Ng A, Blanch R, Rauz S. Using the West Midlands CONCERT to characterise regional incidence of acute-onset post cataract surgery endophthalmitis. Eye (Lond) 2020; 35:1730-1740. [PMID: 32873947 PMCID: PMC8169918 DOI: 10.1038/s41433-020-01158-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/27/2020] [Accepted: 08/19/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Whilst research and innovation is embedded within the UK's National Health Service (NHS) constitution, Doctors-in-training have little opportunity to contribute to designing, leading and recruiting into clinical trials or cohort studies. We formed the West Midlands Collaborative Ophthalmology Network for Clinical Effectiveness & Research by Trainees (The West Midlands CONCERT) and undertook a characterisation of post cataract surgery endophthalmitis as a proof-of-concept study to test the feasibility of the CONCERT model. METHODS Doctors-in-training formed a collaborative working group to test the concept of delivering a pan-regional clinical effectiveness study across multiple hospital sites by performing retrospective analyses of post cataract endophthalmitis over a 6-year period. RESULTS Overall, 157,653 cataract surgeries were performed by participating centres accredited to deliver the Royal College of Ophthalmologists training curriculum. Thirty-eight cases of post cataract endophthalmitis were identified, giving an incidence of 2.41 per 10,000 cases (0.0241%). A further 15 endophthalmitis cases presented who had surgery in non-training centres, giving a total of 53 cases. The most common organisms were S. epidermidis (14 (51.9%)) and P. aeruginosa (5 (18.5%)). Anterior-chamber and vitreous sampling yielded positive culture in 33.3% (6/18) and 50.9% (27/53), respectively. At 6 months follow-up, 19 (51.4%) patients achieved visual acuities of ≤0.5 LogMAR. Repeat intravitreal injections (11 (20.8%)) and vitrectomy (n = 22 (41.5%)) were not associated with better outcomes. CONCLUSIONS Using post cataract endophthalmitis as a pilot cohort, this study highlights the feasibility of using the CONCERT model for studies across multiple sites. A UK-CONCERT could provide a powerful infrastructure enabling characterisation of patient cohorts and a platform for high-quality interventional studies, improving patient care.
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Affiliation(s)
| | - Hetvi Bhatt
- Birmingham and Midland Eye Centre, Birmingham, UK
| | - Ian Reekie
- University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Gibran Butt
- Birmingham and Midland Eye Centre, Birmingham, UK.,Academic Unit of Ophthalmology, University of Birmingham, Birmingham, UK
| | - Aaron Ng
- Birmingham and Midland Eye Centre, Birmingham, UK
| | - Richard Blanch
- Academic Unit of Ophthalmology, University of Birmingham, Birmingham, UK.,Academic Unit of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.,University Hospitals Birmingham, Birmingham, UK
| | | | - Saaeha Rauz
- Birmingham and Midland Eye Centre, Birmingham, UK. .,Academic Unit of Ophthalmology, University of Birmingham, Birmingham, UK.
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14
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Conrady CD, Feist RM, Vitale AT, Shakoor A. Long-term visual outcomes of endophthalmitis and the role of systemic steroids in addition to intravitreal dexamethasone. BMC Ophthalmol 2020; 20:181. [PMID: 32375683 PMCID: PMC7201644 DOI: 10.1186/s12886-020-01449-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 04/23/2020] [Indexed: 11/18/2022] Open
Abstract
Background The purpose of this study was to evaluate the role of systemic steroids in post-procedural endophthalmitis as the role of intravitreal steroids in treatment algorithms of endophthalmitis remain controversial. Methods This is a retrospective analysis from a single tertiary referral center of all patients older than 18 years old that developed presumed post-procedure endophthalmitis and were treated at our center from 2009 to 2018. Results Eighty-three patients were followed after being treated for post-procedural endophthalmitis that either received systemic steroids or did not around the time of diagnosis. Almost 30 % of all patients regained a final visual acuity of 20/40 or better, while 31.2% had poor visual outcomes of count fingers or worse. Non-clearing debris was the most significant long-term complication. Visual improvement plateaued in 67.7% by 1 month after diagnosis and initial treatment in both groups. There was no difference in visual outcomes when comparing the sixteen patients that received systemic steroids and the sixty-seven that did not; however, no enucleation or evisceration was required in patients receiving systemic steroids. Five patients that did not receive systemic steroids required an enucleation or evisceration due to a blind, painful eye. Conclusions The use of systemic steroids does not seem to worsen long-term outcomes of endophthalmitis compared to those patients that did not receive them and they may prove beneficial in the most severe cases by reducing the risk of losing the globe altogether.
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Affiliation(s)
- Christopher D Conrady
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA. .,Department of Ophthalmology and Visual Sciences, University of Michigan, 1000 Wall St, Ann Arbor, MI, 48103, USA.
| | - Richard M Feist
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Albert T Vitale
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Akbar Shakoor
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
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Pershing S, Lum F, Hsu S, Kelly S, Chiang MF, Rich WL, Parke DW. Endophthalmitis after Cataract Surgery in the United States. Ophthalmology 2020; 127:151-158. [DOI: 10.1016/j.ophtha.2019.08.026] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 08/13/2019] [Accepted: 08/20/2019] [Indexed: 11/25/2022] Open
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16
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Nowak MS, Grzybowski A, Michalska-Małecka K, Szaflik JP, Kozioł M, Niemczyk W, Grabska-Liberek I. Incidence and Characteristics of Endophthalmitis after Cataract Surgery in Poland, during 2010-2015. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16122188. [PMID: 31226859 PMCID: PMC6617312 DOI: 10.3390/ijerph16122188] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 06/11/2019] [Accepted: 06/17/2019] [Indexed: 11/18/2022]
Abstract
Background: The assessment of the incidence and characteristic of acute and chronic postoperative endophthalmitis (POE) after cataract surgery in Poland during 2010–2015. Patients and methods: All hospitalizations of patients, in the National Database of Hospitalizations, who underwent cataract surgery alone or in combined procedures in Poland between January 2010 and December 2015, with a billing code of endophthalmitis, were selected. Acute endophthalmitis was identified if symptoms occurred within 1–42 days from the cataract surgery and chronic endophthalmitis if symptoms occurred ≥43 days after cataract surgery, respectively. Results: In total, 1331 cases of POE after 1,218,777 cataract extractions were identified. The overall incidence of POE decreased from 0.125% in 2010 to 0.066% in 2015. In multiple logistic regression analyses, increasing age was significantly associated with acute POE, while type II diabetes mellitus, extracapsular cataract extraction, and one-day surgery were significantly associated with chronic POE. The combined cataract surgery and male sex were significant risk factors for both acute and chronic POE. A total of 62.51% of all eyes affected by POE received antibiotic treatment and 37.49% had vitrectomy treatment. Conclusions: During the study period, the total incidence of postoperative endophthalmitis after cataract surgery decreased significantly.
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Affiliation(s)
- Michał S Nowak
- Provisus Eye Clinic, 42-209 Czestochowa, Poland.
- Saint Family Hospital Medical Center, 90-302 Lodz, Poland.
| | - Andrzej Grzybowski
- Department of Ophthalmology, University of Warmia and Mazury, 10-082 Olsztyn, Poland.
- Institute for Research in Ophthalmology, Foundation for Ophthalmology Development, 60-554 Poznan, Poland.
| | - Katarzyna Michalska-Małecka
- Department of Ophthalmology, School of Medicine in Katowice, Medical University of Silesia, 40-952 Katowice, Poland.
| | - Jacek P Szaflik
- Department of Ophthalmology, SPKSO (Samodzielny Publiczny Kliniczny Szpital Okulistyczny) Ophthalmic Hospital, Medical University of Warsaw, 03-709 Warsaw, Poland.
| | - Milena Kozioł
- Department of Analyses and Strategies, Polish Ministry of Health, 00-952 Warsaw, Poland.
| | - Wojciech Niemczyk
- Department of Analyses and Strategies, Polish Ministry of Health, 00-952 Warsaw, Poland.
| | - Iwona Grabska-Liberek
- Department of Ophthalmology, Centre of Postgraduate Medical Education, 231 Czerniakowska str., 01-416 Warsaw, Poland.
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Jamison A, Benjamin L, Lockington D. Quantifying the real-world cost saving from using surgical adjuncts to prevent complications during cataract surgery. Eye (Lond) 2018; 32:1530-1536. [PMID: 29875386 DOI: 10.1038/s41433-018-0133-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 04/28/2018] [Accepted: 05/16/2018] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Surgical adjuncts in cataract surgery are often perceived as sometimes necessary, always expensive, particularly in the "lean" cost-saving era. However, prevention of a surgical complication, rather than subsequent management, should always be the preferred strategy. We wished to model real-world costs associated with surgical adjuncts use and test the maxim for cataract surgery-"if you think of it, use it". METHODS We compared UK list prices for equipment and related costs of preventing vitreous loss (VL) via use of surgical adjuncts vs its subsequent management in a hypothetical cataract surgery scenario of a white swollen cataract with a moderately dilated pupil. RESULTS The original surgery costs for the "cautious with adjuncts, no complications" approach was £943.54, including adjuncts costing £137.47. In the "minimalist, no adjunct" scenario, management of VL using the Anterior Vitrectomy Kit cost £142.45, and additional management and follow-up costs resulted in total cost of £1178.20 (£234.66 (25%) more expensive). If left aphakic, an additional operation for secondary iris clip IOL insertion and further follow-up to address the impact of the complication ultimately cost £2124.67 overall. An additional initial spend on surgical adjuncts of £137.47 could potentially prevent £1293.60 (9× increase) in direct costs in this scenario. CONCLUSIONS Through simple scenario modelling, we have demonstrated the cost benefits provided by the use of precautionary surgical adjuncts during cataract surgery. VL costs significantly more in terms of complication management and follow-up. This supports the cataract surgeon's maxim-"if you think of it, use it".
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Affiliation(s)
- Aaron Jamison
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, UK
| | - Larry Benjamin
- Department of Ophthalmology, Stoke Mandeville Hospital, Aylesbury, HP21 8AL, UK
| | - David Lockington
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, UK.
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Current Strategies for Prevention and Treatment of Postoperative Endophthalmitis. CURRENT OPHTHALMOLOGY REPORTS 2018. [DOI: 10.1007/s40135-018-0171-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Reply. Retina 2017; 37:e107-e108. [DOI: 10.1097/iae.0000000000001808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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