Cataract surgery audit at an Australian urban teaching hospital

Cataract surgery in Australia: a review of the regional literature and outcomes from 5018 cases at a tertiary teaching hospital

OBJECTIVES

To report visual and surgical outcomes of phacoemulsification cataract surgery from 5018 consecutive cases from Sydney, Australia. A review of the Australian and New Zealand literature was undertaken to provide a benchmark of outcomes from the region.

METHODS

The electronic medical record system was used to review three time-points for all phacoemulsification cataract surgeries at a tertiary-referral centre between May 2017 and August 2020: preoperative, intraoperative and one month postoperatively. Variables collected included uncorrected distance visual acuity (UDVA) and pinhole visual acuity, surgeon seniority and ocular pathology.

RESULTS

Of the 5018 eyes, 37.3% were operated on by consultants, 47.1% by trainees and 15.6% by fellows. Ocular pathology was seen in 48.9% of eyes (n=1709). The mean preoperative and one month postoperative UDVA was 6/48 and 6/12, respectively. There was an intraoperative complication in 7.6% of eyes (n=379) and posterior capsular rupture (PCR) occurred in 2.7% (n=136). PCR rates between consultants (3.1%, n=56), trainees (2.6%, n=61) and fellows (2.1%, n=16) showed no statistically significant difference (p≥0.355). The key risk factors for PCR were advanced cataract, alpha-antagonist use, small pupil size and the presence of glaucoma.

CONCLUSION

We present visual and surgical outcomes from the largest study on phacoemulsification cataract surgery in Australia and New Zealand, acknowledging the study's retrospective nature preventing inter-eye correlations, subdivision of cataract subspecialist versus not and trainee rank, and the minority of missing data. Our findings were comparable to regional and international benchmarks despite a high rate of ocular pathology and trainee case load. The lack of a regional cataract surgery registry represents a critical need in assessing and claiming key performance indicators, capturing emerging trends and identifying region-specific risk factors to deliver the best patient outcomes.

Association Between Intraoperative Cataract Surgical Complications and Mortality

PURPOSE

To evaluate the association between intraoperative complications of cataract surgery and postoperative mortality.

METHODS

A retrospective review of patients who underwent cataract surgery at our institution from 2014 to 2020 was conducted. Intraoperative complications included choroidal hemorrhage, posterior capsule rupture, vitreous loss, retained lens, and/or severe zonular dialysis in either eye. All-cause mortality statistics were obtained through a collaborative agreement with the Colorado Department of Public Health and Environment. Hazard ratios (HRs) from Cox proportional hazard models were used to estimate survival following cataract surgery.

RESULTS

Among 8,054 patients, the mean follow-up time was 4.4 (SD = 2.3) years and the mortality rate was 15% (n = 1,175). The overall complication rate was 2.2% (n = 181), and the rate of retained lens was 0.7% (n = 58). In univariate analysis, retained lens (HR: 1.86, 95% CI: 1.08-3.21, p = 0.026), severe zonular dialysis (HR: 2.00, 95% CI: 1.29-3.12, p = 0.002), and any intraoperative complication (HR: 1.51, 95% CI: 1.09-2.11, p = 0.015) were associated with higher hazard of mortality. When adjusted for demographic factors, comorbid medical conditions, and pre-operative visual acuity, intraoperative complications were not associated with mortality.

CONCLUSION

Intraoperative cataract surgery complications were associated with mortality in univariate analysis. However, this association was not significant in the multivariable analysis as it is confounded by other factors such as pre-operative visual acuity.

Twenty-Year Follow-Up of Cataract Surgery in Car-Drivers: Associations Between Subjective Visual Difficulties and Objective Visual Function

Background/Aims

Driving especially at night is a visually demanding task. Long-time outcome of cataract surgery in drivers is important to study, as many patients live for decades after surgery. The purpose of this study is to longitudinally investigate visual function in active car drivers, 20 years after cataract surgery.

Methods

From a population-based, prospective, cohort of cataract surgery patients, initiated in 1997-98, 114 of the 133 surviving patients were included. Preoperatively, postoperatively 5, 10, 15 and 20 years after surgery, the patients answered a visual function questionnaire including driving status and difficulty. Habitual visual acuity, best corrected visual acuity (BCVA), and low contrast acuity (LCVA) 10% and 2.5% were measured.

Results

The driving difficulties in daylight were almost absent after surgery and did not change over 20 years. Nighttime driving was more difficult and declined longitudinally after surgery, p=0.013, but were at 20 years still less than before cataract surgery. Patients with better BCVA experienced less difficulties driving in darkness, p=0.005. Self-reported problems with glare were significantly associated with BCVA of the better-seeing eye, LCVA 10% and LCVA 2.5% (p=0.046, p=0.033, and 0.024 respectively). Self-reported difficulties with seeing in low-contrast conditions were also significantly associated with BCVA, p=0.004.

Conclusion

Twenty years after cataract surgery, most active drivers have no or minor visual functional problems during driving in daytime. Difficulties in nighttime driving are more common and increase significantly over time. Twenty years after surgery, all current drivers had still better subjective ability to drive, compared with before surgery.

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.

Cataract surgery: factors influencing decision to treat and implications for training (south-east Scotland 2008-2014)

PURPOSE

To describe the population referred for cataract surgery, identify factors that influenced decision to treat, and patients suitable for ophthalmic training.

PATIENTS AND METHODS

A total of 2,693 consecutive referrals over 6 years were interrogated using Business Objects software on cataract electronic patient records.

RESULTS

A total of 2,693 patients were referred for cataract surgery (group A). Of these patients 2,132 (79%) had surgery (group B) and 561 (21%) did not (group C). Age for group B vs group C: 672 (32%) vs 115 (20%) ≤69 years, P<0.001; 803 (38%) vs 225 (40%) 70-79 years, P=0.48; 586 (27%) vs 203 (36%) 80-89 years, P<0.05; 71 (3%) vs 18 (3%) ≥90 years, P=1.0. Visual acuity, group B vs group C: 556 (26%) vs 664 (59%) 6/12 or better; 1,275 (60%) vs 367 (33%) 6/18-6/60; 266 (12%) vs 64 (6%) counting fingers or worse, P<0.05. Medical history for group B vs C: cognitive impairment: 55 (2.6%) vs 29 (5.2%), P<0.05; cardiovascular accident: 158 (7.4%) vs 60 (10.7%), P<0.05; diabetes: 372 (17.4%) vs 96 (17.1%), P=0.87; COPD/asthma: 382 (17.9%) vs 93 (16.6%), P=0.53; heart disease: 535 (25.1%) vs 155 (27.6%), P=0.35; hypertension: 971 (45.5%) vs 263 (46.9%), P=0.73. Ocular history for group B vs C was significant (P<0.05) for age-related macular degeneration 255 (12.0%) vs 93 (16.6%), other macular pathology 38 (1.8%) vs 25 (4.5%), corneal pathology 92 (4.3%) vs 36 (6.4%), amblyopia 37 (1.7%) vs 22 (3.9%). Detailed data on presenting complaint, ophthalmic history, and social status is discussed.

CONCLUSION

We observed that surgery at a younger age with good levels of visual acuity was a factor in deferring cataract surgery. Cognitive impairment, cardiovascular accident, amblyopia, corneal and macular pathology significantly affected decision not to operate. We estimate that 80% of patients would be suitable for ophthalmic training.