Surgical outcomes in phacoemulsification after application of a risk stratification system

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

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

Surgical Efficiency Comparison Between Two Phacoemulsification Systems

Purpose

To assess the surgical efficiency in cataract surgery comparing two phacoemulsification systems.

Methods

Prospective, consecutive-comparative study in a two-site private practice. Three hundred and one eyes undergoing standard or femtosecond laser-assisted (FLACS) cataract surgery with either the R-Evo Smart (BVI, Waltham, USA) and/or the Centurion Vision System (Alcon, Fort Worth, USA). Preoperative eye characteristics (degree of cataract using the lens opacities classification system LOCS III grading) and intraoperative outcomes (total ultrasound time and total estimated fluid aspirated/drainage bag weighting) were registered in all cases.

Results

One hundred and fifty-five eyes undergone cataract surgery with the R-Evo Smart and 146 eyes with the Centurion Vision System phacoemulsification systems. Mean cataract grade was 3.07 ± 0.78 and 2.96 ± 0.85 for the R-Evo Smart and Centurion Vision System groups, respectively (p = 0.12). Mean total ultrasound time was 18.99 ± 12.85 and 40.24 ± 21.91 seconds for the R-Evo Smart and Centurion Vision System groups, respectively (p < 0.01). Mean total estimated fluid aspirated/drainage bag weighting was 53.00 ± 14.56 g and 54.33 ± 14.88 cc for the R-Evo Smart and Centurion Vision System groups, respectively (p = 0.21). Considering non-FLACS surgery (98 eyes with the R-Evo Smart and 63 eyes with the Centurion Vision System), mean cataract grade was 2.95 ± 0.74 and 2.97 ± 0.91 for the R-Evo Smart and Centurion Vision System groups, respectively (p = 0.44). Mean total ultrasound time was 19.96 ± 11.20 and 42.84 ± 28.35 seconds for the R-Evo Smart and Centurion Vision System groups, respectively (p < 0.01). Mean total estimated fluid aspirated/drainage bag weighting was 55.95 ± 14.76 g and 55.97 ± 13.62 cc for the R-Evo Smart and Centurion Vision System groups, respectively (p = 0.49). No adverse events were found in the two groups of eyes.

Conclusion

The objective measurement of surgical efficiency through total ultrasound time during lens removal and fluid consumption during both lens removal and irrigation/aspiration proved R-Evo Smart to be an efficient phacoemulsification platform, in comparison with the current standard of care Centurion Vision System.

Comparing morphologic features and complications of main clear corneal incision between junior and senior residents observed using anterior segment optical coherence tomography

Background

Wound construction is a critical step in phacoemulsification. Using anterior segment optical coherence tomography (AS-OCT), we compared the morphological features and complications of main incisions made by junior or senior residents during phacoemulsification.

Methods

This cross-sectional comparative study included eyes with senile cataracts that underwent uneventful phacoemulsification with a clear corneal incision made by seven senior and eight junior ophthalmology residents. All eyes underwent postoperative image acquisition using AS-OCT on day one and at three months, examining for morphological features and potential complications of the main incision.

Results

We included 50 eyes of 50 patients with a male-to-female ratio of 22 (44%) to 28 (56%); 26 (52%) were operated on by junior residents and 24 (48%) by seniors. The mean geometric features of the main incisions and the frequency of early and late wound complications were comparable between the two groups (all P > 0.05). A significant correlation was found between the incision length and angle with the superior (r = + 0.80; P < 0.001 and r = - 0.63; P < 0.001, respectively) and inferior (r = + 0.84; P < 0.001 and r = - 0.68; P < 0.001, respectively) areas of the incision, as well as between the length and angle of incision (r = - 0.74; P < 0.001). The number of planes in the wound architecture was not significantly different according to senior or junior resident status (P > 0.05). Although the number of eyes with stromal hydration was significantly greater for junior residents than for seniors (P < 0.001), the corneal thickness at the entrance to the cornea or the anterior chamber, presence of endothelial wound gaping, and Descemet's membrane detachment were comparable between eyes with and without stromal hydration (all P > 0.05). At three months, 29 (58%) patients returned for examination, in whom seven (24%) had late wound complications.

Conclusions

This study found no significant differences in the performances of junior and senior residents in terms of wound construction or its associated complications. However, considering the overall rate of some observed wound-related complications, we recommended revision of the resident educational curriculum concerning the structure and complications of the main incision.

Active-fluidics versus gravity-fluidics in lens extraction: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate differences in outcomes between active-fluidics and gravity-fluidics phacoemulsification systems.

METHODS

We searched PubMed, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) published no later than December 1, 2021. The Cochrane Collaboration risk of bias tool was used for quality assessment. We presented the outcomes as standardized mean differences (SMDs) with 95% confidence intervals (CI). Sensitivity analysis was performed by removing studies that included ≥2 types of phacoemulsification tips.

RESULTS

We analyzed six RCTs that totally enrolled 884 patients. Patients undergoing lens extraction with active-fluidics systems exhibited lower cumulative dissipated energy (CDE), total aspiration time (TAT), and estimated fluid usage (EFU) compared with patients who did not (SMD [95% CI]: CDE, - 0.818 [ - 1.054 to - 0.582]; TAT, - 0.664 [ - 0.850 to - 0.479]; EFU, - 0.655 [ - 0.932 to - 0.378]). A sensitivity analysis revealed similar results for CDE, TAT, and EFU. For endothelial cell density (ECD) 1 week after surgery, ECD 1 month after surgery, and central corneal thickness (CCT) 1 week after surgery, outcomes of both systems were comparable (ECD at 1 week, 0.074 [ - 0.177 to 0.325]; ECD at 1 month, 0.069 [ - 0.167 to 0.305]; CCT 1 week after surgery, 0.077 [ - 0.173 to 0.328]). No severe adverse events in patients treated with either system were reported in the studies.

CONCLUSION

Active-fluidics systems are superior to gravity-fluidics systems with respect to CDE, TAT, and EFU; no differences in postoperative ECD and CCT were observed. Future studies are required to determine the reasons for heterogeneity and to detect rare adverse events.

Efficacy of Preoperative Risk Stratification on Resident Phacoemulsification Surgeries

Purpose

To evaluate efficacy of a novel risk stratification system in minimizing resident surgical complications and to evaluate whether the system could be used to safely introduce cataract surgery to earlier levels of training.

Materials and Methods

This is a retrospective cross-sectional study on 530 non-consecutive cataract cases performed by residents at Columbia University. Risk scores, preoperative best corrected visual acuity (BCVA), intraoperative complications, postoperative day 1 (POD1), and month 1 (POM1) exam findings were tabulated. The relationship between risk scores and POD1 and POM1 BCVA was modeled using linear regression. The relationship between risk scores and complication rates was modeled using logistic regression. Logistic regression was used to model the rates of complications across different levels of training. Rates of complications were compared between diabetic versus non-diabetic patients using t-tests.

Results

Risk scores did not have significant association with intraoperative complications. Risk scores were predictive of corneal edema (OR = 1.36, p = 0.0032) and having any POM1 complication (OR = 1.20, p = 0.034). Risk scores were predictive of POD1 (β = 0.13, p < 0.0001) and POM1 (β = 0.057, p = 0.00048) visual acuity. There was no significant association between level of training and rates of intraoperative (p = 0.9) or postoperative complications (p = 0.06). Rates of intraoperative complication trended higher among diabetic patients but was not statistically significant (p = 0.2).

Conclusion

Higher risk scores were predictive of prolonged corneal edema but not risk of intraoperative complications. Our risk stratification system allowed us to safely introduce earlier phacoemulsification surgery.

Cataract surgery risk stratification in phacoemulsification and manual small incision cataract surgery in a teaching hospital

PURPOSE

To evaluate a system that objectively assesses the risk of cataract surgery complications performed with phacoemulsification and manual small incision cataract surgery (MSICS) techniques.

METHODS

The study was a retrospective comparative interventional case series. Electronic medical records of consecutive eyes that underwent cataract surgery from January 2019 to December 2019 were evaluated. Patient's demographic data and preoperative risk factors were identified, and cataract was categorized as per Lens Opacities Classification System (III). Cataract eyes were grouped into normal cataract cases (G1) and complex cataract cases (G2 and G3), based on the risk factors. The rate of complications in each group and the rate of each complication were calculated and compared.

RESULTS

The overall rate of anyone complication was 2.2% with 2.3% in G1, 1.0% in G2 and 3.9% in G3 (p < 0.001). MSICS technique, mostly used for complex cases (54.2%), reported a higher complication rate than the phacoemulsification technique (2.9% vs 1.4%, p < 0.001). However, the complication rates among the normal and complex cases were similar (2.3% vs 2.2%, p = 0.376). The total posterior capsular tear rate was 1.1% with no vitreous loss in nearly 1 in eight eyes.

CONCLUSION

A preoperative risk stratification system is crucial for obtaining informed consent and better allocation of cases to surgeons based on their expertise to minimize intraoperative complications.

Development of a reliable preoperative risk stratification system for phacoemulsification

PURPOSE

To present a statistically validated risk classification system for intraoperative complications in cataract surgery.

SETTING

2nd Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece.

DESIGN

Prospective observational study.

METHODS

All patients underwent phacoemulsification surgery by experienced, high-volume surgeons for cases with intraoperative complications. The presence of several risk factors was statistically assessed with the help of multiple correspondence analysis to determine the more reliable rank categorization for severity and to calculate a total risk score.

RESULTS

This study included 1572 consecutive patients. The proposed system had 3 risk groups and a no-risk group and had high statistical reliability. A comparison of this system against a previously asserted empirical system showed higher internal reliability.

CONCLUSIONS

Previous efforts to construct a risk classification system for intraoperative complications in cataract surgery have been empirically defined and tested against practice-as-usual. The system in this study quantified risk more accurately and provided an experienced clinician with a reliable means of assessing the preoperational likelihood of intraoperative complications.

The impact of COVID-19 lockdown on cataract surgery: a surgeons' perspective

CLINICAL RELEVANCE

In the last months, the whole world is dealing with an unprecedented public health crisis due to COVID-19 outbreak. Consequently, many governments have implemented lockdowns on a national level, affecting, among others, ophthalmic surgical practice in a globe scale.

BACKGROUND

The aim of this study is to evaluate the impact of surgical theatre lockdown due to COVID-19 pandemic on the surgical performance of cataract surgeons.

METHODS

Intraoperative complications and surgical time of the first 160 cataract surgeries performed by eight consultants (20 cases each) after a two-month lockdown were recorded and analysed in a cross-sectional study. The results were plotted against the last 30 cases of each surgeon before the implementation of the lockdown (240 cases). Cataract surgeons were asked to rate their subjective perspective and difficulties faced after re-opening through a questionnaire.

RESULTS

The average duration of all surgeries after the lockdown was 19.1 ± 6.2 minutes showing a 14% increase compared to the one before the lockdown (16.8 ± 5.1 minutes, p = 0.0001). The complications rate was 2.09% (5/240 cases) before the abstention and 3.12% (5/160 cases) after the abstention not yielding any statistically significant difference (p = 0.74). When complicated surgeries were excluded from the analysis, surgical time was still higher after the lockdown (18.9 ± 5.9 minutes) than before (16.6 ± 5.0 minutes, p < 0.0001). 37.5% of consultants (3/8) stated that the two-month abstention from cataract surgeries has affected their surgical skills somewhat or a lot, while 62.5% (5/8) reported being more careful in their first cases after the lockdown. Most complications occurred in the hands of one surgeon who stated to be very anxious upon restart.

CONCLUSION

The operating theatres' lockdown due to COVID-19 pandemic did not seem to affect the intraoperative complications rate in cataract surgery. A slight increase of surgical duration was noted, while most surgeons reported being more careful upon restart.

Reoperations After Cataract Surgery: Is the Incidence Predictable Through a Risk Factor Stratification System?

Introduction

The objective of the study was to quantify the number of procedures needed to achieve the best possible surgical outcome, depending on the number and type of risk factors identified.

Methods

Two independent observers reviewed the medical records of 1,502 patients who underwent phacoemulsification surgery, during a two-year period (January 1, 2014 to December 31, 2015). Preoperative risk factors were documented according to the stratification system used. Based on the total risk score, each case was allocated to one of four risk groups with 0, 1-2, 3-5, and >6 total risk factors, respectively. All qualitative and quantitative characteristics were gathered and included in a multivariate analysis.

Results

A total of 1,792 eyes were included. Αge over 88 years, low cooperation ability with the patient, and surgeries performed by residents tended to have more often complications, while white/intumescent cataract, iridodonesis/phacodonesis, α1 blockers intake, and male gender are risk factors positively associated with more than one surgery.

Conclusions

Risk factors tend to be prognostic for possible intraoperative complications. The number of procedures needed for the best possible surgical outcome seems to depend on these preoperative risk factors. A stratification method increases the level of awareness of the surgeon, and therefore may decrease the number of complications and even procedures while enhancing the "safe" practice and skills of residents.

Can Applying a Risk Stratification System, Preoperatively, Reduce Intraoperative Complications during Phacoemulsification?

SIGNIFICANCE

Adopting a risk stratification system and appropriate listing of cases reduces the rates of intraoperative complications during phacoemulsification. Such listing would allow both safe surgery and enhance training, by ensuring an appropriately experienced surgeon is available to operate on a case or supervise and teach a junior surgeon.

PURPOSE

To assess if the application of a simple, robust, validated preoperative scoring system can reduce the rates of intraoperative complications if patients are assigned to the appropriately experienced surgeon's list and surgical time is modified accordingly.

METHODS

Prospective data collection. One thousand one hundred and thirty five (1135) consecutive patients undergoing phakoemulsification cataract surgery were assessed preoperatively according to weighted criteria. According to the points of risk they accumulated using this system, the patients were preoperatively allocated to one of the four risk groups. The total rate of intraoperative complications for each risk group as well as the rate of each reported complication for each risk group was calculated.

RESULTS

The rate of intraoperative complications through the risk groups was 1 = 0.62%, 2 = 0.44%, 3 = 0.18%, and 4 = 0% (P = .005). Thirty-seven per cent 37% (n = 420) of all operations were performed on eyes of patients carrying at least one risk factor for intraoperative complications. The overall rate of any intraoperative complication was 1.2% (n = 14). There was a 0.4% (n = 5) rate of a posterior capsule tear with 2 of these cases with vitreous loss.

CONCLUSIONS

Risk stratification, allowing adequate theatre time and appropriate surgical experience, can reduce the rates of intraoperative complications. The risk stratification system allows for better planning of surgical lists and could be used as a transition for those trainees deemed to have sufficient experience for the more 'challenging' cases under adequate supervision.

A Comparative Assessment of Intraoperative Complication Rates in Resident-Performed Phacoemulsification Surgeries According to Najjar-Awwad Preoperative Risk Stratification

Introduction

Phacoemulsification cataract surgery presents a challenge to resident surgeons with lower experience, which confronts with patient safety. In this study, we compared major intraoperative surgical complications of resident-performed phacoemulsification surgeries between cases with low intraoperative risk and random cases with unknown intraoperative risk.

Methods

This prospective randomized controlled study was done on patients who underwent phacoemulsification surgery by third- and fourth-year residents in Khatam-al-Anbia eye hospital, Mashhad, Iran. Preoperative risk was calculated using Najjar-Awwad risk score after slit lamp examination and the patients with scores 7 or higher were considered high-risk. Patients were randomly assigned into a study group, in which only low-risk cases were operated by third-year residents, or control group, in which third-year residents were able to operate any patient regardless of the risk score. In both groups, the remaining patients were operated by fourth-year residents. All intraoperative complications were recorded. Data were analyzed using SPSS, considering P<0.05 significant.

Results

Overall, 475 patients with cataract in the study (N=232) and control (N=243) groups were operated. Mean overall Najjar-Awwad risk scores did not differ significantly between the groups, but pseudoexfoliation and poor pupil dilatation occurred significantly more frequently in the control group (P=0.010 and P=0.014, respectively). Overall, 36 surgeries in the study group (15.5%) and 47 surgeries in the control group (19.3%) were complicated (P=0.273). There was a significant difference between the third- and fourth-year residents regarding the inability to complete continuous curvilinear capsulorhexis (P=0.033). The risk of overall and major complications in high-risk cases was significantly higher among those operated by 3rd-year residents compared with those operated by 4th-year residents (OR=3.45, 95% CI=1.2–9.9, P=0.016 and OR=6.37, 95% CI=1.99–20.34, P=0.001, respectively).

Conclusion

Although supervised resident-performed phacoemulsification has a relatively safe learning curve in our residency program, it is best to stratify preoperative risk and assign high-risk cases to senior residents with higher experience.

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

PURPOSE

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

SETTING

Centro Hospitalar São João, Oporto, Portugal.

DESIGN

Retrospective study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Safety of air tamponade versus corneal hydration for sealing clear corneal incisions in cataract surgery

PURPOSE

To compare safety of wound hydration to anterior chamber air tamponade for securing watertight closure of clear corneal incisions, during uneventful cataract surgery.

METHODS

Prospective, comparative case-control series. Patients undergoing phacoemulsification were assigned to receive either anterior chamber air bubble (Group A) or intrastromal wound hydration with balanced salt solution (Group B) at the end of the procedure. Two high-volume surgeons operated equal number of cases in each group employing identical surgical technique, except for corneal side incision management. Patients were assessed pre- and postoperatively at day 1, day 4, day 9, and day 30 after surgery.

RESULTS

One hundred eyes of 100 patients were enrolled, of which 2 were lost to follow-up. The two groups were comparable in terms of preoperative risk factor assessment, baseline central corneal thickness (CCT), preoperative endothelial cell density, as well as cumulative dissipated energy and duration of phacoemulsification (p > 0.05). Mean CCT and best-corrected visual acuity were better in Group B on the first postoperative day, but did not differ between the two groups at all other timepoints. Surgically induced astigmatism was comparable in the two groups (p > 0.05). Endothelial cell density loss at 1 month postoperatively was greater in Group A (34.06%) compared to Group B (16.45%).

CONCLUSIONS

Wound sealing with intrastromal hydration proved to be safer than air tamponade in terms of preserving endothelial cell density and function.

Auckland Cataract Study IV: Practical application of NZCRS cataract risk stratification to reduce phacoemulsification complications

IMPORTANCE

Reduction of intraoperative complications in phacoemulsification cataract surgery.

BACKGROUND

To assess practicability of a risk stratification system, the New Zealand Cataract Risk Stratification (NZCRS) system, in a major teaching hospital service, without investigator oversight, to ascertain whether benefits identified in research studies are maintained in busy clinical practice.

DESIGN

Prospective cohort study in a major public teaching hospital.

PARTICIPANTS

Five hundred cases of phacoemulsification cataract surgery.

METHODS

NZCRS system inserted into 621 consecutive preoperative cataract patient files. Recommendation to allocate higher-risk cases to experienced surgeons.

MAIN OUTCOME MEASURES

NZCRS system uptake and adherence, appropriate identification of high risk cases and intraoperative complication rates.

RESULTS

NZCRS scores calculated in 500 of 621 (80.5%) cases and 98 (19.6%) scored as "high risk." Cataract surgery (N = 500) performed by: 12 Registrars (20%), 4 Fellows (7.2%), 26 Consultants (72.8%). Risk scores adhered to in 99%. Overall intraoperative complications (3.0%) included iris prolapse 1.6% and posterior capsule tear 0.8%. No statistical difference in complication rates identified between surgeon grades. Mean best-corrected visual acuity was 6/10 (20/32). Postoperatively, cystoid macular oedema occurred in 3.2%. Rescoring by an experienced investigator noted a greater number of "high risk scores" (31.6% vs 19.6%) related to differences in subjective scoring of anterior chamber depth and cataract density.

CONCLUSIONS AND RELEVANCE

Practical uptake of cataract risk stratification was promising in this study with NZCRS calculated in 80.5% with 99% adherence to scoring recommendations. Compared to baseline studies, in the day-to-day clinical setting, a continued, decreasing trend in frequency and severity of intraoperative complications was noted. Subjective variability of risk scoring may be further improved by better, objective, standardization.

Preoperative Vision and Surgeon Volume as Predictors of Visual Outcomes after Cataract Surgery

PURPOSE

To evaluate the relationship between preoperative vision and surgeon volume with visual outcomes after cataract surgery.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients aged ≥18 years old enrolled in the Kaiser Permanente Southern California Health Plan who underwent cataract surgery by nontrainee surgeons.

METHODS

Patients who underwent cataract surgery between January 1, 2013 and December 31, 2015, were included. A multivariate analysis using Generalized Additive Mixed Models was performed to determine the relationship between surgeon volume and postoperative visual acuity after controlling for patient age, preoperative visual acuity, history of diabetes, and history of diabetic retinopathy. Modeling was done for the relationship between preoperative vision and visual outcomes while controlling for surgeon volume, patient age, history of diabetes, and history of diabetic retinopathy.

MAIN OUTCOME MEASURE

Absolute letter change and percentage of patients to achieve ≥5 Early Treatment Diabetic Retinopathy Study (ETDRS) letter gain postoperatively.

RESULTS

There were 103 920 cataract surgeries performed by 136 surgeons included in this analysis. Patients whose surgeons performed <91.0 surgeries/year (95% confidence interval [CI], 61.1-139; P < 0.05) gained fewer letters postoperatively than the overall average, whereas those whose surgeons performed >91 but <227 surgeries/year (95% CI, 169-∞; P < 0.05) gained more letters than average. Although statistically significant, the difference between the lowest and highest performing surgeons was approximately 1.25 letters. Surgeons who performed <110 surgeries/year (95% CI, 81.7-149; P < 0.05) had fewer patients who gained ≥5 letters. Surgeons who performed >110 but <293 surgeries/year (95% CI, 232-∞; P < 0.05) were approximately 15% more likely to have patients who gained ≥5 letters. Patients with preoperative vision <74.7 letters (95% CI, 74.7-74.8; P < 0.05) and <75.8 letters (95% CI, 75.8-75.9; P < 0.05) gained more letters and were more likely to gain ≥5 letters postoperatively, respectively.

CONCLUSIONS

Patients whose vision is approximately 20/32 or worse are more likely to have significant visual gains after cataract surgery. Although statistically significant differences exist in postoperative vision based on surgeon volume, these do not appear to be clinically meaningful. Overall, visual outcomes are functionally comparable across a wide range of surgeon volumes.

Eleven Years of Cataract Surgery in Veterans Without Pre-existing Ocular Comorbidities

Introduction

In 2017, over 75,000 cataract surgeries were performed within the Veterans Health Administration System (VHA). Previous reports of outcomes of cataract surgery in veterans include patients with pre-existing ocular disease, which can affect vision. To exclude the confounding factor of pre-existing ocular comorbidities, we investigated the long-term visual outcomes and complications associated with small incision cataract surgery performed on veterans without any pre-existing eye disease.

Materials and Methods

Institutional Review Board approved cohort study with detailed retrospective chart review of all phacoemulsification (small incision) cataract surgeries performed at the Veterans Affairs Medical Center in Washington D.C. over 11 years, including all pre-and postoperative visits until postoperative month 12.

Results

A total of 1,513 consecutive surgical cases without any pre-existing ocular disease except the cataract were included. Vision improved significantly after cataract surgery compared to the preoperative best-corrected visual acuity (BCVA) (p = 0.0001) and remained stable over the first intra- and postoperative year. All eyes without complicated surgery and 99.1% of eyes with complications achieved 20/40 or better final vision postoperatively. The most common intra-and postoperative complications were vitreous loss (3.1%) and cystoid macular edema (CME; 1.4%). Patients with complications achieved final mean BCVA of 0.04 (20/22, vitreous loss) and 0.06 (20/23, CME) mean logMAR (Snellen).

Conclusion

Analysis of 11 years of small incision cataract surgery in eyes without pre-existing ocular disease within the VHA showed significant improvement in vision and stability 12 months after uncomplicated and complicated surgery in veterans.

Auckland Cataract Study III: Refining Preoperative Assessment With Cataract Risk Stratification to Reduce Intraoperative Complications

PURPOSE

To assess intraoperative complications of phacoemulsification surgery in public teaching hospital settings using modified preoperative risk stratification systems.

DESIGN

Prospective cohort study.

METHODS

Preoperative risk stratification of 500 consecutive cataract cases using the New Zealand Cataract Risk Stratification (NZCRS) scoring system. Recommended allocation of higher-risk phacoemulsification procedures to experienced surgeons in public teaching hospital setting.

MAIN OUTCOME MEASURE

Intraoperative complications relative to adherence to stratification recommendations.

RESULTS

NZCRS classified 192 cases (38%) as high-risk, recommended for fellows or consultants (attendings). Primary surgeons were residents (n = 142, 28%), fellows (n = 88, 18%), and consultants (n = 270, 54%). Overall rate (N = 500) of any intraoperative complication was 5.0%. Where NZCRS scoring recommendations were observed (n = 448) the intraoperative complication rate was 4.5% but in "nonadherence" cases (n = 52 residents operating on higher-risk cases) this nearly doubled (9.6%). Postoperative complications occurred in 5.2%, primarily cystoid macular edema (3.7%). Postoperatively, mean unaided visual acuity was 6/12 (20/40) and best-corrected visual acuity improved from 6/20 (20/63) preoperatively to 6/10 (20/32) postoperatively (P < .05).

CONCLUSIONS

The NZCRS system aids identification of higher-risk cataract cases and appropriate case-to-surgeon allocation and may increase surgeon awareness of risk factors. Compared to 2 previous studies under similar conditions in the same institution, the NZCRS system was associated with a 40% reduction in intraoperative complications (8.4% to 5%). The rate of posterior capsular tear was 0.6% (P = .035) compared to 2.6% in baseline phase and 1.4% in a prior risk stratification phase. Risk stratification seems to reduce intraoperative phacoemulsification complications in public teaching hospital settings.

Outcomes in resident-performed cataract surgeries with iris challenges: Results from the Perioperative Care for Intraocular Lens study

PURPOSE

To assess the outcomes of resident-performed cataract surgeries with iris challenges and to compare these outcomes with similar surgeries performed by attending surgeons.

SETTING

Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.

DESIGN

Retrospective chart review.

METHODS

All cases of cataract extraction by phacoemulsification with intraocular lens implantation, performed by comprehensive ophthalmologists between January 1 and December 31, 2014, were reviewed. Cases with preoperative or intraoperative miosis, iris prolapse, and intraoperative floppy iris syndrome, were included for analysis. Visual outcomes and the rate of perioperative adverse events were compared between resident and attending surgeon cases. Factors predicting adverse events were also assessed.

RESULTS

In total, 1931 eye cases of 1434 patients were reviewed, and 65 resident cases and 168 attending surgeon cases were included. The mean logarithm of the minimum angle of resolution corrected distance visual acuity was better in the resident group 1 month after surgery (0.051 ± 0.10 [SD] versus 0.132 ± 0.30, P = .03); however, the difference was eliminated when controlling for macular disease. The mean operative time was 43.8 ± 26.5 minutes and 30.9 ± 12.6 minutes for cases performed by resident surgeons and attending surgeons, respectively (P  .0001). Residents utilized supplemental pharmacologic dilation or retraction more frequently than attending surgeons (98% versus 87% of cases, P = .008). The overall rate of adverse events was no different between residents and attending surgeons (P = 0.16). Dense nuclear sclerosis predicted adverse events in cataract cases with iris challenges (adjusted odds ratio, 1.86; 95% confidence interval, 1.17-2.94; P = .001).

CONCLUSION

Although requiring longer operative times and more surgical manipulation, residents who performed cataract surgeries with iris challenges achieved outcomes comparable to those performed by attending surgeons, and residents should be given the opportunity to operate on these eyes.

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

PURPOSE

To determine the effect of the early introduction of cataract surgery training on the complication rates of resident-performed cataract surgery.

SETTING

University of California San Diego, San Diego, California, USA.

DESIGN

Retrospective case series.

METHODS

Two classes of ophthalmology residents were examined, one class with a late introduction of cataract surgery and one with an early introduction of cataract surgery. All cataract cases in which residents acted as primary surgeon were included. Patient charts were reviewed to collect data on patient characteristics, surgical details, and intraoperative and postoperative complications.

RESULTS

The late-introduction cohort comprised 3 residents who performed 540 cataract cases, all during their final year of residency. The early-introduction cohort comprised 4 residents who performed 780 cataract cases beginning in the first year of residency. The late-introduction cohort had higher rates of major intraoperative complications than the early-introduction cohort (8.5% versus 3.1%) and of anterior vitrectomy (7.6% versus 2.1%) (both P < .001). Examination of the anterior vitrectomy rate as a function of experience showed the early-introduction cohort had a stable anterior vitrectomy rate of 1% to 2% throughout training, while the late-introduction cohort had a peak anterior vitrectomy rate of 12% at approximately case 20. Multivariable regression analysis showed the early-introduction cohort was independently associated with a lower rate of anterior vitrectomy (hazard ratio, 0.49; 95% confidence interval, 0.36-0.66) after adjusting for differences in patient characteristics and surgical complexity.

CONCLUSIONS

Early introduction of cataract surgery training significantly decreased the rate of major intraoperative complications, specifically anterior vitrectomy, in resident-performed cataract surgeries.

The Auckland Cataract Study II: Reducing Complications by Preoperative Risk Stratification and Case Allocation in a Teaching Hospital

PURPOSE

To assess the effect of preoperative risk stratification for phacoemulsification surgery on intraoperative complications in a teaching hospital.

DESIGN

Prospective cohort study.

METHODS

Prospective assessment of consecutive phacoemulsification cases (N = 500) enabled calculation of a risk score (M-score of 0-8) using a risk stratification system. M-scores of >3 were allocated to senior surgeons. All surgeries were performed in a public teaching hospital setting, Auckland, New Zealand, in early 2016. Postoperatively, data were reviewed for complications and corrected distance visual acuity (CDVA). Results were compared to a prospective study (N = 500, phase 1) performed prior to formal introduction of risk stratification.

RESULTS

Intraoperative complications increased with increasing M-scores (P = .044). Median M-score for complicated cases was higher (P = .022). Odds ratio (OR) for a complication increased 1.269 per unit increase in M-score (95% confidence interval [CI] 1.007-1.599, P = .043). Overall rate of any intraoperative complication was 5.0%. Intraoperative complication rates decreased from 8.4% to 5.0% (OR = 0.576, P = .043) comparing phase 1 and phase 2 (formal introduction of risk stratification). The severity of complications also reduced. A significant decrease in complications for M = 0 (ie, minimal risk cases) was also identified comparing the current study (3.1%) to phase 1 (7.2%), P = .034. There was no change in postoperative complication risks (OR 0.812, P = .434) or in mean postoperative CDVA (20/30, P = .484) comparing current with phase 1 outcomes.

CONCLUSION

A simple preoperative risk stratification system, based on standard patient information gathered at preoperative consultation, appears to reduce intraoperative complications and support safer surgical training by appropriate allocation of higher-risk cases.

The Auckland Cataract Study: Assessing Preoperative Risk Stratification Systems for Phacoemulsification Surgery in a Teaching Hospital

PURPOSE

To evaluate 2 preoperative risk stratification systems for assessing the risk of complications in phacoemulsification cataract surgery, performed by residents, fellows, and attending physicians in a public teaching hospital.

DESIGN

Cohort study.

METHODS

One observer assessed the clinical data of 500 consecutive cases, prior to phacoemulsification cataract surgery performed between April and June 2015 at Greenlane Clinical Centre, Auckland, New Zealand. Preoperatively 2 risk scores were calculated for each case using the Muhtaseb and Buckinghamshire risk stratification systems. Complications, intraoperative and postoperative, and visual outcomes were analyzed in relation to these risk scores.

RESULTS

Intraoperative complication rates increased with higher risk scores using the Muhtaseb or Buckinghamshire stratification system (P = .001 and P = .003, respectively, n = 500). The odds ratios for residents and fellows were not significantly different from attending physicians after case-mix adjustment according to risk scores (P > .05). Postoperative complication rates increased with higher Buckinghamshire risk scores but not with Muhtaseb scores (P = .014 and P = .094, respectively, n = 476). Postoperative corrected-distance visual acuity was poorer with higher risk scores (P < .001 for both, n = 476).

CONCLUSION

This study confirms that the risk of intraoperative complications increases with higher preoperative risk scores. Furthermore, higher risk scores correlate with poorer postoperative visual acuity and the Buckinghamshire risk score also correlates with postoperative complications. Therefore, preoperative assessment using such risk stratification systems could assist individual informed consent, preoperative surgical planning, safe allocation of cases to trainees, and more meaningful analyses of outcomes for individual surgeons and institutions.

Laboratory assessment of thermal characteristics of three phacoemulsification tip designs operated using torsional ultrasound

Purpose

Ultrasound activation of phacoemulsification (phaco) tips can create considerable thermal energy that may increase the risk of tissue damage during cataract surgery. The purpose of this study was to define the thermal profiles of three phaco tip designs in simulated surgical conditions.

Methods

In this laboratory investigation, sleeved phaco tips (mini-flared Kelman^® tip with aspiration bypass port and Intrepid^® Balanced Tip with aspiration bypass port, and MST A1 bent-mini phaco tip (without aspiration bypass) were tested using an ultrasonic phaco device operated in torsional mode at power levels of 50%, 75%, and 100% amplitude. An automated fixture applied a 30 g load to simulate compression against the incision site, leading to friction between the silicone sleeve and the titanium tip. Temperature was recorded by high rate infrared imaging under conditions of free flow and occlusion, which was simulated by clamping the aspiration line. Data were summarized using descriptive statistics.

Results

Baseline temperatures of ~26°C were observed for all tips. During ultrasonic operation at 50%, 75%, and 100% amplitude, temperatures were lower for the mini-flared and balanced tips versus the bent-mini tip, both when load was applied and during occlusion. The bent-mini tip reached temperatures as high as 70°C during occlusion with load when operated at 100% amplitude, whereas the mini-flared tip remained <50°C, and the balanced tip remained <36°C in all test conditions. For the mini-flared and balanced tips, temperature increases during operation were not markedly different from free flow and no-load conditions when occlusion or frictional events were simulated.

Conclusion

In all experiments for each tip design, increasing ultrasound power was associated with greater increases in tip temperature. Tip temperatures increased with applied load, but marked temperature increases during occlusion were observed only with the bent-mini tip. The balanced tip produced minimal thermal peaks in all tests.

One-Year Progress in Ophthalmic Education: Annual Review

PURPOSE

The aim of this study was to update the practicing ophthalmologist on the English language literature about medical education from the prior year.

DESIGN

A search of English language literature was performed on PubMed from January 1, 2014, to December 31, 2014.

METHODS

Because the search using the main topic of the review "medical education" came up with 7394 citations, authors finally decided to narrow the search to 3 topics of their interest:1. Current state of competency-based education and teaching methods of competencies. This section included ophthalmic/ophthalmology education, core competencies, competency-based education, teaching strategies, tools and methods in medical education.2. E-learning. This section included e-learning, online learning, online teaching, Web-based teaching, Web-based learning, and flipped classroom.3.

ASSESSMENTS

This section included assessment of medical students, residents, fellows, faculty, attending physicians, and medical teachers, assessment of medical student ophthalmology programs, ophthalmology residency programs, residency programs, and fellowship programs.

RESULTS

The authors reviewed and summarized articles published in 2014 examining or describing the 3 main areas of the review described previously.

CONCLUSIONS

This review updates the comprehensive ophthalmologist on advances in ophthalmic medical education. Ophthalmic educators could apply the ideas presented in this review according to their possibilities in their own settings and programs.

Sub-Tenon's anaesthesia versus topical anaesthesia for cataract surgery

BACKGROUND

Local anaesthesia for cataract surgery can be provided by sub-Tenon's or topical anaesthesia. Both techniques offer possible advantages. This review, which originally was published in 2007 and was updated in 2014, was undertaken to compare these two anaesthetic techniques.

OBJECTIVES

Our objectives were to compare the effectiveness of topical anaesthesia (with or without intracameral local anaesthetic) versus sub-Tenon's anaesthesia in providing pain relief during cataract surgery. We reviewed pain during administration of anaesthesia, postoperative pain, surgical satisfaction with operating conditions and patient satisfaction with pain relief provided, and we looked at associated complications.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE (last search in November 2014) and the reference lists of published articles. We looked for conferences abstracts and trials in progress and placed no constraints on language or publication status.

SELECTION CRITERIA

We included all randomized studies that compared sub-Tenon's anaesthesia versus topical anaesthesia for cataract surgery.

DATA COLLECTION AND ANALYSIS

We assessed trial quality and extracted data in the format allowing maximal data inclusion.

MAIN RESULTS

We included eight studies in this updated review but could retain in the analysis only seven studies on 742 operated eyes of 617 participants. Two cross-over trials included 125 participants, and five parallel trials included 492 participants. These studies were published between 1997 and 2005. The mean age of participants varied from 71.5 years to 83.5 years. The female proportion of participants varied from 54% to 76%. Compared with sub-Tenon's anaesthesia, topical anaesthesia (with or without intracameral injection) for cataract surgery increases intraoperative pain but decreases postoperative pain at 24 hours. The amplitude of the effect (equivalent to 1.1 on a score from 0 to 10 for intraoperative pain, and to 0.2 on the same scale for postoperative pain at 24 hours), although statistically significant, was probably too small to be of clinical relevance. The quality of the evidence was rated as high for intraoperative pain and moderate for pain at 24 hours. We did find differences in pain during administration of local anaesthetic (low level of evidence), and indications that surgeon satisfaction (low level of evidence) and participant satisfaction (moderate level of evidence) were less with topical anaesthesia. There was not enough evidence to say that one technique would result in a higher or lower incidence of intraoperative complications compared with the other.

AUTHORS' CONCLUSIONS

Both topical anaesthesia and sub-Tenon's anaesthesia are accepted and safe methods of providing anaesthesia for cataract surgery. An acceptable degree of intraoperative discomfort has to be expected with either of these techniques. Randomized controlled trials on the effects of various strategies to prevent intraoperative pain during cataract surgery could prove useful.

Comparison of occlusion break responses and vacuum rise times of phacoemulsification systems

Background

Occlusion break surge during phacoemulsification cataract surgery can lead to potential surgical complications. The purpose of this study was to quantify occlusion break surge and vacuum rise time of current phacoemulsification systems used in cataract surgery.

Methods

Occlusion break surge at vacuum pressures between 200 and 600 mmHg was assessed with the Infiniti® Vision System, the WhiteStar Signature® Phacoemulsification System, and the Centurion® Vision System using gravity-fed fluidics. Centurion Active Fluidics^TM were also tested at multiple intraoperative pressure target settings. Vacuum rise time was evaluated for Infiniti, WhiteStar Signature, Centurion, and Stellaris® Vision Enhancement systems. Rise time to vacuum limits of 400 and 600 mmHg was assessed at flow rates of 30 and 60 cc/minute. Occlusion break surge was analyzed by 2-way analysis of variance.

Results

The Centurion system exhibited substantially less occlusion break surge than the other systems tested. Surge area with Centurion Active Fluidics was similar to gravity fluidics at an equivalent bottle height. At all Centurion Active Fluidics intraoperative pressure target settings tested, surge was smaller than with Infiniti and WhiteStar Signature. Infiniti had the fastest vacuum rise time and Stellaris had the slowest. No system tested reached the 600-mmHg vacuum limit.

Conclusions

In this laboratory study, Centurion had the least occlusion break surge and similar vacuum rise times compared with the other systems tested. Reducing occlusion break surge may increase safety of phacoemulsification cataract surgery.