Reducing the carbon footprint of cataract surgery: co-creating solutions with a departmental Delphi process

BACKGROUND

Climate change is arguably the greatest threat to global health of the 21st century. Although cataract surgery is a major contributor to global greenhouse gas emissions, recent literature review identified a paucity of evidence-based strategies for improving the environmental impact of cataract services. Our study aimed to assess the effectiveness of a departmental Delphi process for improving cataract services' environmental sustainability.

METHODS

All members of ophthalmology theatre teams in a UK teaching hospital were invited to participate in a three-stage Delphi process. Team members were surveyed for suggestions for reducing the department's environmental impact. Suggested interventions were refined during a plenary face-to-face discussion and ranked. The highest ranked interventions were combined into a mutually agreed action plan. Data on the economic and environmental cost of cataract services was collected prior to and six months after the Delphi process using the Eyefficiency mobile application.

RESULTS

Twenty-three interventions were suggested by a range of staff cadres. Interventions were ranked by 24 team members. The 2nd, 4th, 5th, 8th and 11th ranked interventions were combined into an "Eco-packs" project in collaboration with suppliers (Bausch + Lomb), saving 675 kg of waste and 350 kg of CO2 equivalent annually.

CONCLUSIONS

The Delphi process is an effective method for provoking departmental engagement with the sustainability agenda that we would encourage all ophthalmology departments to consider utilising. The baseline per case CO2 equivalent measured in our department was reproducible and could serve as a maximum benchmark to be improved upon.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of Cataract Surgery: Report 13, monitoring post-cataract surgery endophthalmitis rates-the rule of X

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.

The Royal College of Ophthalmologists' National ophthalmology database study of cataract surgery: Report 14, cohort analysis - the impact of CapsuleGuard® utilisation on cataract surgery posterior capsule rupture rates

BACKGROUND/OBJECTIVES

The aim of this study was to investigate whether the use of the silicone tipped irrigation/aspiration (I/A) handpiece CapsuleGuard® (Bausch + Lomb, Laval, Canada) reduced rates of posterior capsule rupture (PCR) during cataract surgery.

METHODS

Royal College of Ophthalmologists' National Ophthalmology Database (NOD) Cataract Audit data from 01/04/2010 and 31/03/2021 and Bausch + Lomb sales figures were combined to identify centres participating in national cataract audit who have routinely adopted the silicone tipped I/A handpiece, CapsuleGuard®. Data were included only from centres with eligible cataract operations recorded on the NOD both before and after adopting CapsuleGuard®. Review of the literature was undertaken to estimate the proportion of PCR that occurs during I/A, to evaluate the impact of adoption of CapsuleGuard® on PCR occurring in this phase of surgery.

RESULTS

Within the study period, 267 371 eligible cataract operations were performed in 14 centres with >50 eligible operations both before and after adopting CapsuleGuard®. Within centres adopting CapsuleGuard®, the rate of PCR occurrence reduction was 16.4%. Before and after the adoption of CapsuleGuard® the median change of PCR was 21.7% reduction (IQR: 4.8% to 37.7% reduction).

CONCLUSIONS

A reduction in the rate of PCR was seen after regular adoption of CapsuleGuard® during cataract operations. Review of published studies attributing PCR to various components of the cataract operation suggest around 25% of PCR may occur during I/A; adoption of CapsuleGuard may, therefore, be associated with avoidance of a substantial proportion of the PCR during that phase of surgery.

Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 11, techniques and complications of local anesthesia for cataract surgery in the United Kingdom

PURPOSE

To describe variation in local anesthesia techniques and complications over a 10-year period for cataract surgery in the United Kingdom.

SETTING

Reporting centers to the Royal College of Ophthalmologists (RCOphth) National Ophthalmology Database (NOD).

DESIGN

Retrospective cross-sectional register-based study.

METHODS

Data from the RCOphth NOD were used. Eligible for analysis were 1 195 882 cataract operations performed using local anesthesia between April 1, 2010, and March 31, 2020, in 80 centers.

RESULTS

Overall, topical anesthesia alone was used in 152 321 operations (12.7%), combined topical and intracameral in 522 849 (43.7%), sub-Tenon in 461 175 (38.6%), and peribulbar/retrobulbar in 59 537 (5.0%). In National Health Service (NHS) institutions, 48.3% of operations were topical with/without intracameral vs 88.7% in independent sector treatment centers (ISTCs). 45.9% were sub-Tenon in NHS vs 9.6% in ISTCs. 5.8% were peribulbar/retrobulbar in NHS vs 1.7% in ISTCs. Anesthetic complication rates decreased from 2.7% in the 2010 NHS year to 1.5% in the 2019 NHS year (overall, 2.1% for NHS; 0.2% for ISTCs). Overall anesthetic complication rates were 0.3%, 0.3%, 3.5%, and 3.1% for topical alone, combined topical/intracameral, sub-Tenon, and peribulbar/retrobulbar, respectively. Complication rates were higher for sharp-needle anesthesia (peribulbar/retrobulbar) in patients taking warfarin rather than direct oral anticoagulants (4.8% vs 3.1%; P = .024). Considerable variation was observed between centers on anesthetic choices and anesthetic complication rates.

CONCLUSIONS

Combined topical and intracameral is the most common choice of anesthesia for cataract surgery in the United Kingdom and is associated with lower anesthetic-related complication rates than sub-Tenon and peribulbar/retrobulbar anesthesia. Variation in the anesthetic choice exists between centers and between NHS and ISTC sectors.

The Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 16, influence of remuneration model on choice of intraocular lens in the UK

BACKGROUND/OBJECTIVES

Cataract surgery with intraocular lens (IOL) implantation is one of the most commonly performed surgeries worldwide. Within the UK, publicly funded cataract surgery is remunerated by two models: (1) "block contract" (BC), which commissions organisations to deliver whole service pathways without considering specific activity items; or (2) "payment by results" (PbR), which pays a tariff price for each procedure. This study aimed to examine the association between remuneration model and the cost and types of IOL used.

SUBJECTS/METHODS

Cataract operations recorded on the Royal College of Ophthalmologists' National Ophthalmology Database were included, with additional data collected for remuneration model from NHS England and cost of IOL from the NHS Spend Comparison Service.

RESULTS

We included 907,052 cataract operations from 87 centres. The majority of operations were performed in PbR centres (456 198, 50.3%), followed by BC centres (240 641, 26.5%) and mixed models centres (210 213, 23.2%). The mean price of hydrophobic (n = 7) and hydrophilic IOLs (n = 5) were £45.72 and £42.86, respectively. Hydrophobic IOLs were predominantly used (650 633, 71.7%) and were significantly more commonly used in centres remunerated by BC (96.5% vs. 3.5%) than those by PbR (65.7% vs. 34.3%) when compared to hydrophilic IOLs (p < 0.001).

CONCLUSIONS

This study demonstrated that the IOL choice may be perversely incentivised by the IOL cost and remuneration model. Although hydrophobic IOLs are more expensive at the point of surgery, their potential longer-term cost-effectiveness due to reduced requirement for YAG capsulotomy should be considered.

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

BACKGROUND/OBJECTIVES

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

SUBJECT/METHODS

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

RESULTS

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

CONCLUSIONS

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

The Royal College of Ophthalmologists' National Ophthalmology Database Study of Cataract Surgery: Report 12, Risk factors for suprachoroidal haemorrhage during cataract surgery

OBJECTIVE

To establish the incidence of acute intraoperative suprachoroidal haemorrhage (AISH) during cataract surgery and identify the risk factors for this complication.

METHODS

Data from the Royal College of Ophthalmologists' National Ophthalmology Database was analysed. During the 11-year study period, from 01/04/2010 to 31/03/2021, 709 083 operations performed on 498 170 patients from 65 centres were eligible for inclusion.

RESULTS

AISH occurred in 0.03% (204/709 083, approximately 1 in 3 500) of eligible cataract operations performed during the study period. Posterior capsule rupture was the risk factor most strongly associated with AISH (OR: 17.6, 95% CI: 12.4-24.9, p < 0.001). Other ocular risk factors identified were raised intraocular pressure (IOP) preoperatively (OR: 3.7, 95% CI: 2.5-5.5, p < 0.001), glaucoma (OR: 1.7, 95% CI: 1.2-2.4, p = 0.004). Risk increased with age and patients aged over 90 years were at greatest risk (OR: 6.7, 95% CI: 3.5-12.8, p < 0.001). The addition of intracameral anaesthetic when performing surgery under topical anaesthetic appears to be protective (OR: 0.5, 95% CI: 0.3-0.8, p = 0.003), compared to topical anaesthetic alone. There was a 16-fold increase in the incidence of vision loss when AISH occurred.

CONCLUSIONS

The risk of AISH during modern cataract surgery is approximately 1 in 3 500 and is associated with a significant increase in the risk of vision loss should it occur. Posterior capsule rupture is the risk factor most strongly associated with AISH. Preoperative IOP control is a modifiable risk factor. The use of intracameral anaesthesia may reduce the risk of AISH.

Determinants of late presentation of glaucoma in Hong Kong

BACKGROUND

Glaucoma is the commonest cause of irreversible blindness worldwide. As it is typically asymptomatic until advanced, the risk of blindness from late presentation is higher than other eye diseases. This study aims to investigate the risk factors for late presentation of primary glaucoma patients.

METHODS

We undertook a hospital-based case-control study of a random sample of glaucoma patients from a hospital in Hong Kong. Structured questionnaires and existing information from the electronic patient record were used, and the odds of presenting late were analysed by logistic regression.

RESULTS

Of 210 recruited participants, 83 (39.5%) presented with advanced glaucoma unilaterally or bilaterally. The mean age of participants was 61.1 ± 11.9 years, with 110 males (52.4%). Univariate analysis revealed that male sex and primary angle-closure glaucoma (PACG) have 3.06 (CI95:1.71-5.48; P < 0.001) and 2.47 (CI95:1.11-5.49; P = 0.03) times higher odds of late presentation, respectively. Multivariate analysis revealed late presenters were 3.54 (CI95:1.35-9.35; P = 0.01) times more likely to have PACG than primary open-angle glaucoma (POAG). Patients with elevated baseline intraocular pressure (IOP) also had 1.06 times higher odds of presenting with advanced glaucoma (CI95:1.02-1.11; P = 0.002). Linear regression revealed that PACG patients present with 7.12 mmHg higher IOP than POAG patients (CI95:4.23-10.0; P < 0.001).

CONCLUSION

In conclusion, a high proportion of glaucoma patients present late in Hong Kong, with gender and type of glaucoma being significant determinants. Our study shows that PACG presents with higher IOP and, along with male gender, are more likely to have advanced disease than POAG.

Cataract services for all: Strategies for equitable access from a global modified Delphi process

Vision loss from cataract is unequally distributed, and there is very little evidence on how to overcome this inequity. This project aimed to engage multiple stakeholder groups to identify and prioritise (1) delivery strategies that improve access to cataract services for under-served groups and (2) population groups to target with these strategies across world regions. We recruited panellists knowledgeable about cataract services from eight world regions to complete a two-round online modified Delphi process. In Round 1, panellists answered open-ended questions about strategies to improve access to screening and surgery for cataract, and which population groups to target with these strategies. In Round 2, panellists ranked the strategies and groups to arrive at the final lists regionally and globally. 183 people completed both rounds (46% women). In total, 22 distinct population groups were identified. At the global level the priority groups for improving access to cataract services were people in rural/remote areas, with low socioeconomic status and low social support. South Asia and Sub-Saharan Africa were the only regions in which panellists ranked women in the top 5 priority groups. Panellists identified 16 and 19 discreet strategies to improve access to screening and surgical services, respectively. These mostly addressed health system/supply side factors, including policy, human resources, financing and service delivery. We believe these results can serve eye health decision-makers, researchers and funders as a starting point for coordinated action to improve access to cataract services, particularly among population groups who have historically been left behind.

Cataracts

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

Addressing the environmental sustainability of eye health-care delivery: a scoping review

The demand for eye care-the most common medical speciality in some countries-is increasing globally due to both demographic change and the development of eye health-care services in low-income and middle-income countries. This expansion of service provision needs to be environmentally sustainable. We conducted a scoping review to establish the nature and extent of the literature describing the environmental costs of delivering eye-care services, identify interventions to diminish the environmental impact of eye care, and identify key sustainability themes that are not yet being addressed. We identified 16 peer-reviewed articles for analysis, all published since 2009. Despite a paucity of research evidence, there is a need for the measurement of environmental impacts associated with eye care to be standardised along with the methodological tools to assess these impacts. The vastly different environmental costs of delivering clinical services with similar clinical outcomes in different regulatory settings is striking; in one example, a phacoemulsification cataract extraction in a UK hospital produced more than 20 times the greenhouse gas emission of the same procedure in an Indian hospital. The environmental costs must be systematically included when evaluating the risks and benefits of new interventions or policies aimed at promoting safety in high-income countries.

Visual outcome following posterior capsule rupture during manual small incision cataract surgery

Background

The quality of cataract surgery can be measured by visual outcome, which is sometimes limited by intraoperative complications, most commonly posterior capsular rupture.

Aims

The aim of the study was to assess visual outcome at the last visit (≥8 weeks) following posterior capsule rupture (PCR) in patients who had manual small incision cataract surgery (MSICS) managed without access to an automated vitrector.

Methods

A review of medical records of all manual small incision cataract surgeries performed between January 2013 and December 2016 at the National Eye Centre, Kaduna, Nigeria was conducted. Descriptive statistics and logistic regression analysis were performed using STATA 14.0 to examine risk factors for the development of a poor visual outcome and to assess the impact of PCR on development of poor visual outcome.

Results

In total, 405 patients were operated on with MSICS (50.6% males). Mean age was 62.4 (SD 12.6) years. PCR was the most common complication (n = 19 (4.7%)). The proportion of good outcomes (≥6/18) rose from 12.4% non-PCR and 0.0% for those with PCR at day 1 postoperative review, to 71.5 and 26.3%, respectively, by final follow up (P = 0.001). Patients with PCR were 7.0 (P = 0.0001) times more likely to have borderline/poor visual outcome (<6/18) compared to those without PCR. Age >60 years increased the odds of borderline/poor by 1.4 times (P = 0.002).

Conclusion

PCR significantly affects the visual outcome of cataract patients in settings with no facilities for automated vitrectomy. Minimizing complications will improve visual outcome of cataract patients and increase uptake of cataract surgical services.

What Glaucoma Surgical Rate could Serve as a Target for West Africa? A Systematic Review

Aim and objective

This study aimed to use the available evidence to model a glaucoma surgical rate (GSR), which could serve as a target for West Africa.

Materials and methods

A comprehensive literature search was performed in Medline, Embase, Global Health, and CINAHL, and studies published between January 1, 2000, and June 19, 2020, were retrieved. Study selection, quality appraisal, and data extraction were performed and the results of individual studies aggregated and presented using a narrative synthesis. Using these data, we aimed to construct a target GSR per million population per year that is sufficient to offer trabeculectomy to most patients with glaucoma who are diagnosed, and for whom other treatment options are either ineffective or inappropriate. The findings were then used to develop a trabeculectomy target for West Africa.

Results

Initial searches returned 633 references, of which 33 unique studies were eligible for inclusion. The glaucoma prevalence population-based surveys identified, reported a wide range of prevalence of primary open-angle glaucoma (POAG) ranging from 1.0 to 8.4%. The studies on glaucoma medications reported intraocular pressure (IOP)-lowering effects ranging from 12.8% (beta-blockers) to 63.7% (Timolol–Latanoprost combinations). The adherence rate to antiglaucoma medications spanned from 10.3 to 82.3%. Regarding selective laser trabeculoplasty (SLT), only two studies were found. All the studies on trabeculectomy showed a significant reduction in IOPs at different follow-up periods with many reporting the absence of vision-threatening complications. From these available data, a GSR of 50 trabeculectomies was suggested for countries in West Africa.

Conclusion

This trabeculectomy target metric is expected to minimize POAG blindness in the West African subregion.

Clinical significance

The proposed GSR will enable eye care workers involved in glaucoma care in West Africa to assess their efforts compared with the proposed target. The gap will signal the potential for improvement.

How to cite this article

Eni EN, Nolan W, Eval B, et al. What Glaucoma Surgical Rate could Serve as a Target for West Africa? A Systematic Review. J Curr Glaucoma Pract 2021;15(1):19–27.

Intense Simulation-Based Surgical Education for Manual Small-Incision Cataract Surgery: The Ophthalmic Learning and Improvement Initiative in Cataract Surgery Randomized Clinical Trial in Kenya, Tanzania, Uganda, and Zimbabwe

Importance

Cataracts account for 40% of cases of blindness globally, with surgery the only treatment.

Objective

To determine whether adding simulation-based cataract surgical training to conventional training results in improved acquisition of surgical skills among trainees.

Design, Setting, and Participants

A multicenter, investigator-masked, parallel-group, randomized clinical educational-intervention trial was conducted at 5 university hospital training institutions in Kenya, Tanzania, Uganda, and Zimbabwe from October 1, 2017, to September 30, 2019, with a follow-up of 15 months. Fifty-two trainee ophthalmologists were assessed for eligibility (required no prior cataract surgery as primary surgeon); 50 were recruited and randomized. Those assessing outcomes of surgical competency were masked to group assignment. Analysis was performed on an intention-to-treat basis.

Interventions

The intervention group received a 5-day simulation-based cataract surgical training course, in addition to standard surgical training. The control group received standard training only, without a placebo intervention; however, those in the control group received the intervention training after the initial 12-month follow-up period.

Main Outcomes and Measures

The primary outcome measure was overall surgical competency at 3 months, which was assessed with a validated competency assessment rubric. Secondary outcomes included surgical competence at 1 year and quantity and outcomes (including visual acuity and posterior capsule rupture) of cataract surgical procedures performed during a 1-year period.

Results

Among the 50 participants (26 women [52.0%]; mean [SD] age, 32.3 [4.6] years), 25 were randomized to the intervention group, and 25 were randomized to the control group, with 1 dropout. Forty-nine participants were included in the final intention-to-treat analysis. Baseline characteristics were balanced. The participants in the intervention group had higher scores at 3 months compared with the participants in the control group, after adjusting for baseline assessment rubric score. The participants in the intervention group were estimated to have scores 16.6 points (out of 40) higher (95% CI, 14.4-18.7; P < .001) at 3 months than the participants in the control group. The participants in the intervention group performed a mean of 21.5 cataract surgical procedures in the year after the training, while the participants in the control group performed a mean of 8.5 cataract surgical procedures (mean difference, 13.0; 95% CI, 3.9-22.2; P < .001). Posterior capsule rupture rates (an important complication) were 7.8% (42 of 537) for the intervention group and 26.6% (54 of 203) for the control group (difference, 18.8%; 95% CI, 12.3%-25.3%; P < .001).

Conclusions and Relevance

This randomized clinical trial provides evidence that intense simulation-based cataract surgical education facilitates the rapid acquisition of surgical competence and maximizes patient safety.

Trial Registration

Pan-African Clinical Trial Registry, number PACTR201803002159198.

Ophthalmic Simulated Surgical Competency Assessment Rubric for manual small-incision cataract surgery

Purpose

To develop and test the validity of a surgical competency assessment tool for simulated small-incision cataract surgery (SICS).

Setting

Participating ophthalmologists contributed from 8 countries.

Design

Qualitative and quantitative development and evaluation of face and content validity of an assessment rubric, and evaluation of construct validity and reliability.

Methods

The SICS Ophthalmic Simulated Surgical Competency Assessment Rubric (Sim-OSSCAR) was developed and assessed for face and content validity by an international group of experienced ophthalmologists. Groups of novice and competent surgeons from 4 countries were recorded performing surgery, and masked assessments were performed by 4 expert surgeons, to determine construct validity and reliability.

Results

The Sim-OSSCAR for SICS was assessed by a panel of 12 international experts from 8 countries. In response to the question, “Do you think the OSSCAR represents the surgical techniques and skills upon which trainees should be assessed?,” all respondents either agreed or strongly agreed. Face validity was rated as 4.60 (out of 5.0). The content was iteratively agreed to by the panel of experts; final content validity was rated as 4.5. Interobserver reliability was assessed, and 17 of 20 items in the assessment matrix had a Krippendorff α correlation of more than 0.6. A Wilcoxon rank-sum test showed that competent surgeons perform better than novices (P = .02).

Conclusions

This newly developed and validated assessment tool for simulation SICS, based on the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric, has good face and content validity. It can play a role in ophthalmic surgical education.

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

BACKGROUND

Cataract extraction is the most frequently performed surgical intervention in the world and demand is rising due to an ageing demography. One option to address this challenge is to offer selected patients immediate sequential bilateral cataract surgery (ISBCS). This study aims to investigate patient and operative characteristics for ISBCS and delayed bilateral cataract surgery (DSCS) in the UK.

METHODS

Data were analysed from the Royal College of Ophthalmologists' National Ophthalmology Database Audit (NOD) of cataract surgery. Eligible patients were those undergoing bilateral cataract extraction from centres with a record of at least one ISBCS operation between 01/04/2010 and 31/08/2018. Variable frequency comparison was undertaken with chi-square tests.

RESULTS

During the study period, 1073 patients had ISBCS and 248,341 DSCS from 73 centres. A higher proportion of ISBCS patients were unable to lie flat (11.3% vs. 1.8%; p < 0.001), unable to cooperate (9.7% vs. 2.7%; p < 0.001); underwent general anaesthesia (58.7% vs. 6.6% (p < 0.001)); had brunescent/white/mature cataracts (odds ratio (OR) 5.118); no fundal view/vitreous opacities (OR 8.381); had worse pre-operative acuity 0.60 LogMAR ISBCS vs. 0.50 (first) and 0.40 (second eye) DSCS and were younger (mean ages, 71.5 vs. 75.6 years; p < 0.001). Posterior capsular rupture (PCR) rates adjusted for case complexity were comparable (0.98% ISBCS and 0.78% DSCS).

CONCLUSIONS

ISBCS was performed on younger patients, with difficulty cooperating and lying flat, worse pre-operative vision, higher rates of known PCR risk factors and more frequent use of general anaesthesia than DSCS in centres recorded on NOD.

Systematic bias in real-world tonometry readings based on laterality?

AIMS

In research settings, the first eye examined tends to have a higher intraocular pressure (IOP) than the second. We sought to verify whether clinicians in Yorkshire, UK, measure IOP in right eyes before left and whether such behavioural factors affect IOP readings at the population level.

METHODS

We observed 128 IOP measurements taken by 28 ophthalmologists using Goldmann applanation tonometry (GAT) over a 4-month period in 2018, recording which eye was examined first. All IOP measurements on electronic patient records for Leeds Teaching Hospitals NHS Trust, UK, between January 2002 and June 2017 were extracted, yielding IOP readings for 562,360 eyes, analysed for evidence of systematic bias in IOP measurement.

RESULTS

Right eye IOP was measured before left in 112/128 observations (87.5% (95% CI: 75.2%-94.2%)). For IOP measured by GAT, there was no statistically significant difference (p = 0.121) between right and left eye IOP (mean IOP 16.95 and 16.96 mmHg, respectively). Even values of IOP were reported more frequently than odd values (136,503/214,628 (63.6%) were even). Identical IOP readings for both eyes were recorded in 124,392/254,380 patients (48.9%) who had both eyes measured.

CONCLUSIONS

Our study found no IOP difference based on laterality, but strong evidence of certain trends associated with IOP measurement by GAT, such as a preference for even values and the same IOP being recorded for both left and right eyes. Such effects may be explained by behavioural aspects of GAT and suggest that there are substantial opportunities for improvement in the way GAT is utilised in real world settings.

Post-cataract eye drops can be avoided by depot steroid injections

There are over 400 000 cataract operations now being performed annually in the UK. With the majority of those patients being older people, comorbidities such as dementia or arthritis can prevent patients putting in their own post-operative eye drops. Where there is a lack of family or other support, district nursing services are often called upon to administer these eye drops, which are typically prescribed four times a day for 4 weeks, thus potentially totalling 112 visits for drop instillation per patient. To reduce the burden of these post-operative eye drops on district nursing services, administration of an intra-operative sub-Tenon's depot steroid injection is possible for cataract patients who then do not require any post-operative drop instillation. As a trial of this practice, 16 such patients were injected in one year, thus providing a reduction of 1792 in the number of visits requested. Taking an estimated cost of each district nurse visit of £38, this shift in practice potentially saved more than £68 000; the additional cost of the injection over the cost of eye drops was just £8.80 for the year. This practice presents an opportunity to protect valuable community nursing resources, but advocacy for change in practice would be needed with secondary care, or via commissioners.

What are the priorities for improving cataract surgical outcomes in Africa? Results of a Delphi exercise

PURPOSE

The quality of cataract surgery delivered in sub-Saharan Africa (SSA) is a significant constraint to achieving the elimination of avoidable blindness. No published reports from routine SSA cataract services attain the WHO benchmarks for visual outcomes; poor outcomes (<6/60) often comprise 20% in published case series. This Delphi exercise aimed to identify and prioritise potential interventions for improving the quality of cataract surgery in SSA to guide research and eye health programme development.

METHODS

An initial email open-question survey created a ranked list of priorities for improving quality of surgical services. A second-round face-to-face discussion facilitated at a Vision 2020 Research Mentorship Workshop in Tanzania created a refined list for repeated ranking.

RESULTS

Seventeen factors were agreed that might form target interventions to promote quality of cataract services. Improved training of surgeons was the top-ranked item, followed by utilisation of biometry, surgical equipment availability, effective monitoring of outcomes of cataract surgery by the surgeon, and well-trained support staff for the cataract pathway (including nurses seeing post-operative cases).

CONCLUSION

Improving the quality of cataract surgery in SSA is a clinical, programmatic and public health priority. In the absence of other evidence, the collective expert opinion of those involved in ophthalmic services regarding the ranking of factors to promote quality improvement, refined through this Delphi exercise, provides us with candidate intervention areas to be evaluated.

Are we monitoring the quality of cataract surgery services? A qualitative situation analysis of attitudes and practices in a large city in South Africa

PURPOSE

To evaluate the current quality "assurance" and "improvement" mechanisms, the knowledge, attitudes and practices of cataract surgeons in a large South African city.

METHODOLOGY

A total of 17 in-depth semi-structured interviews were conducted with ophthalmologists in June 2012 at 2 tertiary institutions in the Republic of South Africa. Recruitment of the purposive sample was supplemented by snowball sampling. The study participants were 5 general ophthalmologists and 2 pediatric ophthalmologists; 4 senior and 4 junior registrars and a medical officer. Participants were interviewed by a trained qualitative interviewer. The interview lasted between 20 and 60 min. The interviews were recorded, transcribed verbatim and analyzed for thematic content.

RESULTS

Mechanisms for quality assurance were trainee logbooks and subjective senior staff observation. Clinicians were encouraged, but not obliged to self-audit. Quality improvement is incentivized by personal integrity and ambition. Poorly performing departments are inconspicuous, especially nationally, and ophthalmologists rely on the impression to gauge the quality of service provided by colleagues. Currently, word of mouth is the method for determining the better cataract surgical centers.

CONCLUSION

The quality assurance mechanisms were dependent on insight and integrity of the individual surgeons. No structures were described that would ensure the detection of surgeons with higher than expected complication rates. Currently, audits are not enforced, and surgical outcomes are not well monitored due to concerns that this may lead to lack of openness among ophthalmologists.

Quality assurance in trichiasis surgery: a methodology

BACKGROUND

Trachoma remains a significant cause of blindness in many parts of the world. The major route to blindness involves upper lid entropion leading to trachomatous trichiasis (TT), which promotes progressive corneal opacification. The provision of surgery to correct TT in the populations most severely affected is a major challenge for the global effort to eliminate trachoma blindness by the year 2020. Most attention has focused on increasing the quantity of TT surgery performed, and large numbers of non-doctor operators have been trained to this end. Surgical audit by those performing TT surgery is not a routine part of any national trachoma control programme, and no effective mechanism exists for identifying surgeons experiencing poor outcomes. The authors propose a methodology for surgical audit at the level of the individual surgeon based on Lot Quality Assurance.

METHODS

A set number of patients operated on previously for upper eyelid TT are examined to detect the recurrence of TT. The number of recurrent cases found will lead to categorisation of the TT surgeon to either 'high recurrence' or 'low recurrence' with reasonable confidence. The threshold of unacceptability can be set by individual programmes according to previous local studies of recurrence rates or those from similar settings.

CONCLUSIONS

Identification of surgeons delivering unacceptably high levels of recurrent TT will guide managers on the need for remedial intervention such as retraining.

Accuracy of referencing in the ophthalmic literature

PURPOSE

To investigate the frequency of citation and quotation errors in the ophthalmic literature.

DESIGN

Analysis of 200 references from 100 papers published in 10 ophthalmic journals.

METHODS

A sample of 20 references was randomly selected from each of the 10 journals and each reference was checked for accuracy. Quotations were categorized as totally, partially, or not accurate.

RESULTS

There were 35 citation errors in 32 references, only four of which were errors in PubMed. Thirty quotations of references were not accurate; 20 were partially accurate.

CONCLUSIONS

Citation and quotation errors are relatively common within the ophthalmic literature. This may be improved through technical editing.

Participatory evaluations of trachoma control programmes in eight countries

OBJECTIVES

Trachoma is a major cause of blindness. The objective of this initiative was to conduct participatory process evaluations of the trachoma control programmes receiving support from the International Trachoma Initiative in eight countries.

METHODS

During each 2- to 4-week evaluation we analysed information collected at the central, district and community level through interviews, focus groups, questionnaires, direct observation of trachoma control activities, and existing data.

RESULTS

Mapping and assessment of disease prevalence had been completed in four of eight countries. Integration of trachoma control activities into national planning and district-level service provision varied. Intersectoral partnerships to implement the SAFE strategy (i.e. surgery, antibiotics, facial cleanliness and environmental change) were well established in a few countries. In all eight countries, the number of surgeries performed annually was insufficient; and quality of surgery was rarely monitored. Mass distribution of antibiotics was carried out well in extremely resource-poor settings and good coverage was achieved, although the strategy for antibiotic distribution varied. Inadequate water and sanitation remained a major problem in all programme areas. Monitoring of programme activities was generally inadequate. The Morocco programme is an example from which lessons and processes can be learnt and adapted to other programme countries.

CONCLUSIONS

Significant achievements have been made in implementing the SAFE strategy. Scaling up of activities to true national coverage should be planned and implemented provided the resources can be made available. Further standardization of how to assess, implement and monitor trachoma control activities will facilitate expansion of the programme.

Nurse triage, diagnosis and treatment of eye casualty patients: a study of quality and utility

INTRODUCTION

Patients presenting to the Accident and Emergency department of a district general hospital with an eye problem are referred directly to a dedicated eye casualty service. They are then triaged by a staff nurse from the eye department. This eye casualty sees around 8000 patients per annum. This study assesses whether the nurse triage of eye casualty patients forms an effective filter of problems which do not require the attention of the doctor on duty. The incidence of cases of misdiagnosis and inappropriate discharge of patients resulting in a delay in diagnosis and treatment was also assessed.

METHODS

All patients presenting in a 3-month period managed solely by the triage nurse, were identified from the casualty register, and the hospital records retrieved and examined.

RESULTS

Four hundred and forty of a total 1976 patients (22%) were seen exclusively by triage nurses; eight (2.5%) of these 440 patients returned unplanned to the eye department. In all cases it was considered that the return of the patient would not have been preventable by initial attention of the ophthalmologist on duty.

DISCUSSION

With appropriate threshold for referral, nurses trained in slit lamp examination can offer a successful service to safely diagnose and treat common eye casualty presentations.