Complications in resident-performed phacoemulsification cataract surgery at New Jersey Medical School

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Visual outcomes and postoperative complications of eyes with dropped lens fragments during cataract surgery: multicenter database study

PURPOSE

To analyze the visual outcomes and postoperative complications of phacoemulsification cataract surgery in eyes with posterior capsule rupture (PCR) and dropped lens fragments (DLFs) in comparison with a reference group with uneventful surgery.

SETTING

8 UK National Health Service departments.

DESIGN

Retrospective comparative nonrandomized study.

METHODS

Demographic, medical history, and ocular examination data were automatically extracted from the electronic records. The main outcome variables were postoperative visual acuity (VA), and the development of postoperative cystoid macular edema (CME) as well as rhegmatogenous retinal detachment (RRD) and epiretinal membrane (ERM) requiring surgery.

RESULTS

The analysis included 175 589 eyes in the reference group, 2751 eyes in the PCR group, and 519 eyes in the DLF group. During all postoperative intervals, the mean VA in the DLF and PCR groups was significantly worse than the reference group ( P < .001). On multivariate analysis, the odds of having a VA ≤0.3 logMAR at 4 to 12 weeks postoperatively among eyes with DLF and PCR were 88% and 73% lower than the reference group ( P < .001). More eyes developed CME in the DLF and PCR groups ( P < .001). The odds of requiring RRD and ERM surgery were 3.6 and 2.1 times higher in the DLF group, and 1.8 and 1.3 times higher in the PCR group, respectively, as compared with the reference group.

CONCLUSIONS

Eyes undergoing phacoemulsification complicated by PCR, and more so with DLF, have worse visual outcomes and higher chances of CME, ERM, and RRD when compared with uneventful surgery.

Intraoperative Complication Rates in Cataract Surgery After Resuming Surgery Following the COVID-19 Shutdown

Purpose

To evaluate surgeon performance and intraoperative complication rates of cataract surgery after resumption of elective surgeries following the operating room (OR) shutdown from the coronavirus disease 2019 (COVID-19) pandemic. Subjective surgical experience is also evaluated.

Methods

This is a retrospective comparative study which analyzes cataract surgeries performed at an inner city, tertiary academic center. Cataract surgeries were categorized into Pre-Shutdown (January 1-March 18, 2020), and Post-Shutdown, for all cases which occurred after surgeries resumed (May 11-July 31, 2020). No cases were performed between March 19 and May 10, 2020. Patients undergoing combined cataract and minimally invasive glaucoma surgery (MIGS) were included, but MIGS complications were not counted as cataract complications. No other combined cataract-other ophthalmic surgeries were included. A survey was used to gather subjective surgeon experience.

Results

A total of 480 cases (n=306 Pre-Shutdown and n=174 Post-Shutdown) were analyzed. Although there was a higher frequency of complex cataract surgeries performed Post-Shutdown (5.2% vs 21.3%; p<0.00001), complication rates before versus after the shutdown were not statistically significant (9.2% vs 10.3%; p=0.75). Phacoemulsification was the step of cataract surgery in which residents were most concerned about when returning to the OR.

Conclusion

After the surgical hiatus due to COVID-19, significantly more complex cataract surgeries were reported and surgeons reported higher general anxiety level when first returning to the OR. Increased anxiety did not lead to higher surgical complications. This study provides a framework to understand surgical expectations and outcomes for patients whose surgeons faced a prolonged two-month hiatus from cataract surgery.

Resident-Performed Phacoemulsification Cataract Surgery: Impact of Resident-Level Characteristics

Purpose

To evaluate the rate of complications in resident-performed phacoemulsification and influencing factors.

Methods

In this retrospective cohort study, the outcomes of cataract surgeries performed by 18 ophthalmology residents were analyzed. The outcome of first 80 phacoemulsification cataract surgeries (1440 cataract surgeries) performed by each resident were analyzed. Outcome measures included the rate of intraoperative capsular rupture requiring anterior vitrectomy, nucleus drop, and incomplete attempts at uncomplicated procedures. Changes in the rate of complications over the surgical training course were also assessed.

Results

The most common surgical complications were capsular rupture (7.5%), followed by incomplete attempt(s) (5.9%), and nucleus drop (1.1%). Comparing the first 40 and second 40 surgeries, the rate of complications decreased as a function of surgeon experience in all resident cohorts. Greater theoretical skills and younger surgeon age were associated with a lower rate of intraoperative capsular rupture (hazard ratios = 1.421 and 1.481, respectively; P = 0.047 and P = 0.041, respectively). The use of antianxiety drugs and number of surgeries in the first 6 months demonstrated no predictive value for a lower rate of intraoperative complications (hazard ratios = 0.929 and 1.002; P = 0.711 and P = 0.745, respectively).

Conclusion

The use of antianxiety medication and more surgeries in the first 6 months did not decrease the rate of intraoperative complications of phacoemulsification, while improvement of theoretical skills may have increased the safety of resident-performed cataract surgery.

To study the learning curve of capsulorhexis in manual small incision cataract surgery among postgraduate residents in central India

PURPOSE

To evaluate the learning curve of continuous curvilinear capsulorhexis (CCC) and to assess the number of surgeries required to master it among residents in a postgraduate teaching institute.

METHODS

The present prospective observational study was based on the completion time and complication rates related to CCC performed using various techniques by 10 students in the 2^nd (JR2) and 3^rd-year (JR3) of residency. CCC was performed either by a cystotome or capsulorhexis forceps or by a combined method in 253 eyes, of which 160 eyes (63.2%) were operated by JR3 and 93 (36.8%) by JR2. The complication rates were studied with respect to the number of capsular extensions, posterior capsular rent (PCR), zonular dehiscence, need for senior surgical assistance, and nucleus drop.

RESULTS

The average time required for the completion of CCC was 412 ± 90.5 s. The average number of times residents required to fill the anterior chamber with viscoelastic was 6.9 ± 1.4. The average size of CCC was 7 ± 0.66 mm. Extended CCC was the most common complication. JR2 required assistance from a senior surgeon in 47 eyes (50.5%), whereas JR3 required assistance in 39 eyes (24.4%) (P = 0.0001). The rate of PCR was not significantly different in JR2 (7.5%) and JR3 (8.8%).

CONCLUSION

CCC is a difficult step to master in the trainee. Focusing and practicing on this step will help to reduce the complications and maximize proficiency. Approximately 6-eight surgeries are required to master CCC.

Rate of Posterior Capsule Rupture in Phacoemulsification Cataract Surgery by Residents with Institution of a Wet Laboratory Course

Purpose To determine if a structured surgical wet laboratory curriculum for ophthalmology residents reduced the rate of posterior capsule rupture (PCR) in phacoemulsification cataract surgery.

Setting James A. Haley Veterans' Hospital, Tampa, FL.

Design Retrospective cohort study.

Methods The study assessed resident-performed phacoemulsification cataract cases from 2011 to 2017, after the creation of a wet laboratory course. Primary outcome measure was PCR. If present, timing of complication, dropped lens fragments, and the need for anterior vitrectomies were noted. Self-reported rates of PCR prior to institution of a wet laboratory course (2010–2011) were compared with cases done by residents who completed the course (2011–2017).

Results A total of 3,445 cases were reviewed of which 2.44% (84 cases) noted PCR. Of these, 19% (16) had dropped lens fragments, and 60.7% (51) required anterior vitrectomy. Sixty-nine cases documented timing of PCR with the majority, 58%, occurring during phacoemulsification. When comparing rates of PCR in cases done prior to the presence of a wet laboratory course versus after, there was a significant reduction observed (5.20% before vs. 2.44% after).

Conclusion In the presence of a wet laboratory curriculum, the rate of PCR decreased dramatically. The average rate was lower than those reported at other training programs (2.6–9.9%). Most PCR occurred during phacoemulsification, suggesting need for further focused instruction in this step.

Extended measuring depth dual-wavelength Fourier domain optical coherence tomography

In this work an enhanced wide range dual band spectral domain optical coherence tomography technique (SD-OCT) is presented to increase the depth and accuracy of the measurement of optical A-scan biometry. The setup uses a Michelson interferometer with two wide-spectrum Superluminescent Diodes (SLD). The emissions of the SLDs are filtered by a long-pass filter (900 nm) in front of the reference mirror. The light is spectrally decomposed using a single reflective diffraction grating (1,800 lines/mm) and the whole spectrum captured with two CCD line sensors. The capabilities of the system have been validated using a self-made human model eye.

[Retrospective evaluation of residencies in private ophthalmology practice from 2015 to 2018 in Champagne-Ardenne]

INTRODUCTION

Between 2010 and 2018, the quota for admission to ophthalmology residencies increased by 50 % (106 in 2010 vs 150 in 2018). In order to accommodate this increasing number of residents, the University Hospital of Reims formulated an agreement with the Regional Health Agency in May 2015 enabling certain ophthalmologists in the private sector to train a resident within their private practice for a semester. We will present the results of three and one half years of this experience.

METHODS

Two retrospective questionnaires were created and completed. One was addressed to the host supervisor, the other to the resident. Their objective was to evaluate and standardize the experience from both points of view. The following aspects were explored: the extent to which the environment was welcoming, the resident's clinical ability and progress, the resident's surgical ability and progress, time-management, resident-patient relations and respective assessments. We also requested information on the number of residents hosted by each private practice as well as the positive and negative aspects of the internship for both the supervisor and the intern.

RESULTS

Between May 2015 and October 2018 (seven semesters), 12 residents from the University Hospital of Reims did an internship with one of the six proposed private sector ophthalmologists in the Champagne-Ardennes region. The residents were between their second and eighth semesters of professional training. Seven residents did their first or second semester of ophthalmology training in a private practice. The survey results led to the conclusion of a positive experience for both trainer and trainee regarding the progress made by the resident, both clinically and surgically.

CONCLUSION

Given the growing number of ophthalmology residents and the limits of the training capacity of hospital-based residencies, private sector internships with practitioners actively involved in teaching increase the training capacity for residents and complement the conventional hospital training.

Comparing Resident Outcomes in Cataract Surgery at Different Levels of Experience

Purpose

To evaluate outcomes of resident-performed cataract surgeries in different training levels in a retrospective case series.

Patients and Methods

A total of 730 surgeries performed by residents were evaluated into three groups: surgeries performed during residents’ first semester of training in phacoemulsification (Level 1 – L1), surgeries performed during the second semester (Level 2 – L2), and surgeries performed during the third semester (Level 3 – L3). The primary outcome was the incidence of intraoperative complications in each group. Secondary outcomes were the comparisons between initial and final corrected distance visual acuity (CDVA), intraocular pressure (IOP), endothelial cell density (ECD), and central corneal thickness (CCT) in each group. Descriptive statistical analyses were employed in the presentation of the results using central tendency and variance measurements.

Results

The rate of complications within six weeks of follow-up was 24 out of 102 eyes (23.53%) in the L1 group, 63 out of 301 eyes (20.93%) in the L2 group, and 37 out of 327 (11.31%) in the L3 group (p=0.001). Posterior capsule rupture (PCR) was the most frequent intercurrence observed in all three semesters: it occurred in 12.7% of the surgeries in the first semester (13/102), 16.9% of surgeries in the second semester (51/301), and 9.5% of surgeries in the third semester (31/327). There was no significant difference in CDVA (p=0.298), ECD (p=0.067), IOP (p=0.217), or CCT (p=0.807) between the groups.

Conclusion

When measured by rates of complications and by the aforementioned parameters, surgical competency was found to improve as surgical experience and frequency increased. Therefore, this study identified some patterns of skill development that can be applied to teaching strategies and better assist surgeons in training.

Operative Time and Complication Rates of Resident Phacoemulsification Surgeries in a National University Hospital: A Five-Year Review

Purpose

To determine the operative time and complication rates of resident phacoemulsification surgeries at different time points in training.

Methods

Retrospective cross-sectional study at the Department of Ophthalmology of the Philippine General Hospital. All resident-performed elective adult phacoemulsification surgeries from January 1, 2014, to December 31, 2018, were included, while operations with planned anterior or posterior procedures were excluded. Cases were arranged chronologically and divided into time points with 25 cases each. Operative time and complication rates were computed for each time point. As defined by the ICO Ophthalmology Surgical Competency Assessment Rubric (OSCAR), 30 minutes was used to gauge competency based on operative time, while complications were compared to published rates for residents. Results for the first 50 cases, the minimum number required by graduation, were also compared with succeeding cases.

Results

A total of 4635 cases were included. Residents performed an average of 115.9 ± 30.4 cases, with no significant difference among residents (F(4,35)=2.64, p=0.12). Overall complication rate was 6% (n=276), similar to those reported internationally. Both median operative time and complication rates decreased significantly for every time point in training (p<0.001). After 50 cases, only 40% (n=16) of residents reached the operative time of 30 minutes. Median operative time is significantly lower when comparing the first 50 surgeries with the succeeding cases (37 minutes vs 29 minutes, p<0.001). Likewise, complication rate is also significantly lower (9.3% vs 3.5%, Χ² (1, N=4635) = 68.481, p<0.001), with an odds ratio of 2.85 (p<0.001, 95% CI [2.2, 3.7]).

Conclusion

There are significant improvements in both operative time and complication rates as more surgeries are performed. However, the minimum required 50 cases is not enough for resident competency based on operative time and complication rates.

Surgical Curriculum for Presbyopia-Correcting Intraocular Lenses: Resident Experiences and Surgical Outcomes

Objective

To describe a stepwise surgical curriculum that was implemented to teach novice surgeons about currently available advanced technology intraocular lenses (ATIOLs) for correction of presbyopia and to report the experiences and surgical results of ATIOL surgery performed by residents who engaged in the curriculum.

Design, Setting, and Participants

Third-year ophthalmology residents participated in a curriculum incorporating didactic lectures (with objective assessment and wet-lab practice) and observation of attending-performed ATIOL surgeries prior to performing ATIOL surgery as primary surgeon under direct supervision. Post-operative outcomes studied were best corrected distance visual acuity (BCDVA) and uncorrected distance (UDVA), intermediate (UIVA) near (UNVA) visual acuity and correction of astigmatism with at least 3 months of follow-up (POM3+). Residents were also given a survey to assess experiences with the surgical curriculum, preparedness for use of ATIOLs post-residency, and ATIOL practice pattern post-residency.

Results

A total of 12 residents from four consecutive classes completed the curriculum. Residents overall had a favorable opinion of the curriculum and felt well prepared to use ATIOLs after training. Graduates who currently perform cataract surgery felt comfortable using all available ATIOLs. A total of 100 eyes from 72 patients met the inclusion criteria for analysis in the study. At the POM3+ timepoint, 88% of eyes had UDVA of 20/30 or better, 93% had UIVA of 20/30 or better, and 71.2% had UNVA of 20/30 (J2) or better. Among eyes that received an astigmatism-correcting ATIOL, 91% had <1 diopter of astigmatism after surgery.

Conclusion

Resident surgeons learned to perform ATIOL surgery (medical knowledge) and achieve strong surgical outcomes (patient care) with all currently available ATIOLs after completion of a stepwise curriculum. Educators may be encouraged to incorporate an ATIOL curriculum based on the results of this study. The curriculum presented is a prototype and may be further improved with future experiences and studies.

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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.

Assessment of Learning Curve in Phacoemulsification Surgery Among the Eastern Province Ophthalmology Program Residents

Purpose

To assess residents’ performance of phacoemulsification surgery and determine which steps of the procedure are most difficult to learn, and to measure rate of intraoperative complications.

Design

This was a prospective observational study.

Methods

Phacoemulsification surgery was divided into steps and each step was given a proficiency grade by the attending consultant. All intraoperative complications were recorded and analyzed.

Results

200 cases performed by the Eastern Province ophthalmology program residents were evaluated. The most commonly encountered difficulty factors were hard nucleus (20.7%), small pupil (12.6%), and white cataract (10.3%). Capsulorhexis, nucleus disassembly and removal, and cortex removal were the most difficult steps to learn. General complication rate was 17.5%, and posterior capsular rupture was the most common complication (40%). Proficiency more than 90% of the time in each step was noted in residents with prior experience of more than 40 cases, except for nucleus disassembly.

Conclusion

The study showed that nucleus disassembly remained the major obstacle in the residents’ exponential learning curve of phacoemulsification surgery. Majority of complications occurred at level of capsulorhexis and cortical removal steps.

Long noncoding RNA glutathione peroxidase 3-antisense inhibits lens epithelial cell apoptosis by upregulating glutathione peroxidase 3 expression in age-related cataract

PURPOSE

Age-related cataract (ARC) is the leading cause of visual impairment and blindness worldwide. The apoptosis of lens epithelial cells (LECs) induced by oxidative damage is a major contributing factor to ARC. Long noncoding RNAs (lncRNAs) play important roles in various biologic processes. We aimed to explore the role of glutathione peroxidase 3 (GPX3)-antisense (AS) in ARCs.

METHODS

We extracted total RNAs from transparent and age-matched cataractous human lenses and detected lncRNA expression profiles using high-throughput RNA sequencing. The expression of GPX3-AS and GPX3 was detected by quantitative real-time PCR (qRT-PCR). Apoptotic proteins were detected by western blot and immunofluorescence. We treated SRA01/04 cells with H₂O₂ to mimic oxidative stress and induce cell apoptosis, which was analyzed by flow cytometry and TdT-mediated dUTP Nick-End Labeling (TUNEL) assay. The cell counting kit-8 (CCK-8) assay was used to detect the viability of SRA01/04 cells. The location of GPX3-AS was determined by fluorescence in situ hybridization (FISH) and cell nuclear and cytoplasmic RNA separation.

RESULTS

The lncRNA GPX3-AS, which is located in the nuclei of LECs, was downregulated in cataractous human lenses compared with control lenses, and proapoptotic proteins were expressed at high levels in the anterior lens capsules of ARC tissues. An in vitro study suggested that GPX3-AS inhibited H₂O₂-induced SRA01/04 cell apoptosis. As GPX3-AS is transcribed from the AS strand of the GPX3 gene locus, we further revealed its regulatory role in GPX3 expression. GPX3-AS was positively correlated with GPX3 expression. In addition, GPX3-AS inhibited H₂O₂-induced SRA01/04 cell apoptosis by upregulating GPX3 expression.

CONCLUSIONS

In summary, our study revealed that GPX3-AS downregulated the apoptosis of LECs via promoting GPX3 expression, implying a novel therapeutic target for ARCs.

Association of Preoperative Disclosure of Resident Roles With Informed Consent for Cataract Surgery in a Teaching Program

IMPORTANCE

Cataract surgery is the most commonly performed intraocular surgery. Academic centers have mandates to train the next surgeon generation, but resident roles are often hidden in the consent process.

OBJECTIVE

To investigate associations of full preoperative disclosure of the resident role with patient consent rates and subjective experience of the consent process.

DESIGN, SETTING, AND PARTICIPANTS

Full scripted disclosure of residents' roles in cataract surgery was delivered by the attending surgeon. Qualitative analysis was conducted from recorded interviews of patients postoperatively regarding consent process experience and choice of whether to allow resident participation. Associations were sought regarding demographic characteristics and consent rates. Patients were recruited though a private community office. Surgery was performed at a single hospital where resident training was routinely conducted. The study included systemically well patients older than 18 years with surgical cataract. They had no previous eye surgery, English fluency, and ability to engage in informed consent decision-making and postsurgery interview. Patients were ineligible if they had monocular cataracts, required additional simultaneous procedures, had history of ocular trauma, or had cataracts that were surgically technically challenging beyond the usual resident skill level.

INTERVENTIONS

Eligible patients received an informed consent conversation by the attending physician in accordance with a script describing projected resident involvement in their cataract surgery. Postoperatively, patients were interviewed and responses were analyzed with a quantitative and thematic qualitative approach.

MAIN OUTCOMES AND MEASURES

Consent rates to resident participation and qualitative experience of full disclosure process.

RESULTS

Ninety-six patients participated. Participants were between ages 50 and 88 years, 53 were men (55.2%), and 75 were white (85.2%). A total of 54 of 96 participants (56.3%; 95% CI, 45.7%-66.4%) agreed to resident involvement. There were no associations between baseline characteristics and consent to resident involvement identified with any confidence, including race/ethnicity (60% [45 of 75] in white patients vs 30.8% [4 of 13] in nonwhite patients; difference, 29.2%; 95% CI, -0.7% to 57.3%; Fisher exact P = .07). Thematically, those who agreed to resident involvement listed trust in the attending surgeon, contributing to education, and supervision as contributing factors. Patients who declined stated fear and perceived risk as reasons.

CONCLUSIONS AND RELEVANCE

Our results suggest 45.7% to 66.4% of community private practice patients would consent to resident surgery. Consent rates were not associated with demographic factors. Because residents are less often offered the opportunity to do surgery on private practice patients vs academic center patients, this may represent a resource for resident education.

National survey and outcomes of resident-performed cataract surgery in monocular patients in the United States

PURPOSE

To identify nationwide policies surrounding cataract surgery in monocular patients and compare outcomes of those surgeries between residents and attending surgeons.

SETTING

Wilmer Eye Institute, Baltimore, Maryland, USA.

DESIGN

Retrospective case series.

METHOD

Cataract surgery educators across the United States were surveyed on their policies concerning residents performing cataract surgery on monocular patients. A second survey assessed resident opinions on performing surgery in such patients. In addition, a retrospective chart review was performed of all monocular patients (n = 72) who had resident-performed and attending-performed cataract surgery at the same academic institution.

RESULTS

Forty-seven residency programs responded to the survey. Although the majority of cataract surgery educators from these programs thought it was ethical for residents to perform cataract surgery on monocular patients, only 18 programs (38.3%) had implemented specific policies. The resident survey response rate was 39.1%. Residents were more anxious and did more preparation for monocular cases than for routine cataract surgery cases. Analysis of the comparative case series found intraoperative complications (9.7% versus 5.6%; P = .37) and postoperative visual outcomes were comparable between resident and attending surgeon monocular cases. The resident status of the surgeon was not predictive of an increased risk for complications (odds ratio, 0.98; 95% confidence interval, 0.13-7.55; P = .99).

CONCLUSIONS

Although most educators and resident trainees deemed resident-performed cataract surgery on monocular patients to be acceptable, the majority of residency programs did not have specific guidelines for residents performing surgery on such patients. Outcomes of resident-performed cataract surgeries on monocular patients at the same institution were comparable to surgeries performed by attending surgeons.

Outcomes of resident-performed small incision cataract surgery in a university-based practice in the USA

Purpose

To assess outcomes of resident-performed small incision cataract surgery (SICS) at a single academic institute and to determine the availability of SICS-oriented educational resources in residency programs across the USA.

Patients and methods

A retrospective chart review was conducted on all patients who underwent SICS performed by postgraduate year 4 residents between January 2014 and January 2018 at the Wilmer Eye Institute, Baltimore, MD, USA. Postoperative visual acuity, intraoperative complications, and postoperative complications were the main outcomes measured. In addition, a survey was administered to all ophthalmology residency program directors in the USA to assess the presence of SICS-related content in their surgical training curriculum.

Results

Twenty-two eyes of 17 patients underwent planned resident-performed SICS, mainly for white cataracts. Intraoperative complications occurred in two (9.1%) eyes. The most common postoperative complication was transient increased intraocular pressure (two eyes, 9.1%). Mean preoperative best-corrected visual acuity (BCVA) was approximately 20/4,000. The large majority (95.2%) of eyes experienced improved BCVA following SICS, with a mean postoperative BCVA of 20/138 over an average follow-up of 4.2 months. Forty-seven programs responded to the survey (40.1% response rate). Residents were trained in SICS in 66.7% of these programs. However, more than half of all the programs did not have SICS-oriented educational resources available for residents.

Conclusion

Resident-performed SICS was found to be a safe and effective technique for cataract management. Considering the limited surgical volume for SICS in the USA, training programs might instead consider implementing SICS-oriented content in their surgical curriculum, including wet labs.

A Comprehensive Surgical Curriculum Reduced Intra-operative Complication Rates of Resident-performed Cataract Surgeries

OBJECTIVES

To evaluate the impact of a comprehensive cataract surgery curriculum on the incidence of intraoperative complications.

DESIGN

We retrospectively compared the total number of cataract surgeries that the residents performed in all of the teaching sites, and the incidences of intraoperative complications (anterior capsule tear, posterior capsule rent, vitreous loss, anterior vitrectomy, zonular dialysis, iris trauma, hemorrhage, dropped lens fragment, corneal wound burn, incorrect intraocular lens) for the surgeries performed at Massachusetts Eye & Ear by residents in the pre-intervention group (residents graduating in 2004 and 2005), before the implementation of a surgical curriculum, and the residents in the post-intervention group (residents graduating in 2014 and 2015).

SETTING

Ophthalmology residency program at a major academic institution.

PARTICIPANTS

Residents graduating in 2004, 2005, 2014, and 2015.

RESULTS

We reviewed 4373 charts. 2086 of those surgeries were performed at Massachusetts Eye & Ear. The incidence of posterior capsule rent/vitreous loss/anterior vitrectomy was lower in the post-intervention group (1.4% versus 7.7%, p < 0.0001). Other complications were also lower in the post-intervention group.

CONCLUSIONS

Implementation of a comprehensive cataract surgery curriculum focusing on pre-operative, intra-operative and post-operative interventions, with an emphasis on patient outcomes resulted in a decrease in the rate of intraoperative complications.

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.

Outcomes of complex Descemet Stripping Endothelial Keratoplasty performed by cornea fellows

BACKGROUND

A major obstacle that academic institutions face is the steep learning curve for cornea fellows initially learning to perform Descemet Stripping Endothelial Keratoplasty (DSEK). The purpose of this study is to evaluate the outcomes of complex DSEK performed by cornea fellow supervised by an attending surgeon at an academic institution.

METHODS

Patients who underwent a complex DSEK procedure performed by a cornea fellow during the years 2009-2013 were included. All the surgeries were supervised by the same cornea attending. All patients had a minimum follow-up of 6 months. Charts were reviewed for demographic data, intraoperative and postoperative complications and clinical outcomes. Corneal graft survival was calculated using the Kaplan-Meier analysis.

RESULTS

Fifty-seven eyes of 55 patients (mean age 77.5 ± 8.5 years) were included in the study with a mean follow-up time of 16.4 ± 15.6 months. Previous graft failure, presence of a tube and history of trabeculectomy were the leading diagnoses to define the surgery as complex. No intraoperative complications occurred. In 21.1% of cases a corneal graft detachment was documented in the first postoperative day. Mean visual acuity improved from 1.06 LogMAR (20/230) preoperatively to 0.39 LogMAR (20/50, p < 0.001) by the sixth postoperative month and to 0.52 LogMAR (20/65, p < 0.001) at the last follow-up visit. Graft failure rate was 29.8%. Kaplan-Meier analysis found a 67.2% graft survival rate at 20 months.

CONCLUSIONS

Complex DSEK can be performed successfully with an acceptable postoperative complication rate by cornea fellows during their training period when supervised by an experienced attending.

Surgical Simulation Training Reduces Intraoperative Cataract Surgery Complications Among Residents

INTRODUCTION

This retrospective consecutive case series examined whether training on a surgical simulator reduces intraoperative complication rates among novice ophthalmology residents learning cataract surgery.

METHODS

Beginning July 2014, training on the Eyesi simulator became mandatory for novice postgraduate year 3 ophthalmology residents before live cataract surgery at our institution. Complication rates of the 11 simulator-trained residents (study group) were compared with their immediate 11 simulator-naive predecessors (comparison group). Only straightforward cataract cases (according to standardized preoperative criteria) where postgraduate year 3 residents served as the primary surgeon were included. Complication data were obtained from Morbidity and Mortality records and compared using Fisher exact test. A survey was administered to the residents to gauge the perceived utility of simulation training.

RESULTS

The simulator-trained group (n = 501 cataract cases) and the simulator-naive comparison group (n = 454 cases) were analyzed. The complication rate in the simulator group was 2.4% compared with 5.1% in the comparison group (P = 0.037, Fisher exact test). Both the mean posterior capsule tear rate and vitreous prolapse rate in the simulator group were 2.2% compared with 4.8% in the comparison group (P = 0.032, Fisher exact test). The survey had a response rate of 100% (11/11), and 91% (10/11) of respondents felt that the training was "extremely worthwhile" and should be mandatory.

CONCLUSIONS

The addition of surgical simulation training was associated with a significantly reduced rate of complications, including posterior capsule tears and vitreous prolapse, among novice postgraduate year 3 residents. There is a perceived utility among residents to incorporate virtual simulation into surgical training.

Effect of wet-laboratory training on resident performed manual small-incision cataract surgery

Purpose:

The aim of this study was to study the effect of wet-laboratory training on the surgical outcome of resident performed manual small-incision cataract surgery (MSICS).

Methods:

We conducted a retrospective, comparative observational study on resident performed MSICS in our institute. We collected data of 464 patients of which Group A had 232 cases performed by residents without prior wet-laboratory training and Group B had 232 resident performed cases after adequate skill training in the wet laboratory. The demographics, type of cataract, intraoperative, postoperative complications, and immediate visual outcome were compared between the two groups.

Results:

The age, sex, and type of cataract were similar in both groups of residents. The frequency of intraoperative complications was higher in Group A (23.7%) than in Group B (15.08%) (P = 0.019). The occurrence of posterior capsule (PC) rupture and vitreous loss showed a statistically significant difference, with Group A showing a high rate of 14.3% PC rent and vitreous loss while only 6.9% (P = 0.01) had this complication in Group B. The postoperative visual outcome also was better in Group B than in Group A, with 62.06% of patients in Group B, having a postoperative day 1 vision of better than 6/18 as compared to only 38.36% in Group A.

Conclusion:

The wet-laboratory training is an effective method of improving the skills of the ophthalmology residents in MSICS. The reduction of complications will improve the quality of surgery and improve the postoperative visual outcome.

Residents' Learning Curve for Manual Small-Incision Cataract Surgery at Aravind Eye Hospital, India

PURPOSE

The goal of this study was to document the resident learning curve for manual small-incision cataract surgery (MSICS) and to identify implications for the design of ophthalmology residency programs aimed to train surgeons for developing countries.

DESIGN

Hospital-based retrospective cohort study.

PARTICIPANTS

All 38 residents entering 2 postgraduate residency programs at Aravind Eye Hospital, Madurai, in 2012 and 2013.

METHODS

Surgical complications and reoperations for all MSICSs performed by residents during the residency training period were evaluated using a computerized patient database. Multivariate logistic regression models were used to estimate the effect of the cumulative number of surgeries performed on incidence of intraoperative complications, postoperative complications, and reoperations, controlling for covariates.

MAIN OUTCOME MEASURES

Incidence of intraoperative and first-day postoperative complications of Oxford Cataract Treatment and Evaluation Team (OCTET) grades II and III and the incidence of reoperations. Analyses controlled for patient-, resident-, and residency program-level covariates.

RESULTS

The study evaluated 13 159 surgeries performed by the 38 residents between October 15, 2012, and August 24, 2016. The mean number of surgeries performed by a resident was 346.3 (standard deviation, 269.4). Three hundred forty-two eyes (2.60%) with at least 1 intraoperative complication, 234 eyes (1.78%) with at least 1 first-day postoperative complication, and 154 reoperations (1.17%) were observed. After controlling for baseline covariates, increasing surgical experience was associated with reduced risk of intraoperative and postoperative complications, as well as reoperations. The odds decreased by 17% (intraoperative complications), 12% (postoperative complications measured 1 day after surgery), and 7% (reoperations) per 100 additional surgeries performed. Patient-level factors such as older age, left eye surgery, and lower preoperative uncorrected visual acuity were found to be associated with higher risk of intraoperative complications (P < 0.01 for all).

CONCLUSIONS

The risk of surgical complications and reoperations in MSICS decreased steadily with surgical experience gained by resident surgeons. We recommend that ophthalmology residency programs in developing nations teaching MSICS provide opportunities to perform 300 surgeries or more by residents so as to achieve rates of intraoperative and postoperative complications of less than 2%.

Resident surgeon efficiency in femtosecond laser-assisted cataract surgery

Purpose

Comparison of resident surgeon performance efficiencies in femtosecond laser-assisted cataract surgery (FLACS) versus conventional phacoemulsification.

Patients and methods

A retrospective cohort study was conducted on consecutive patients undergoing phacoemulsification cataract surgery performed by senior ophthalmology residents under the supervision of 1 attending physician during a 9-month period in a large Veterans Affairs medical center. Medical records were reviewed for demographic information, preoperative nucleus grade, femtosecond laser pretreatment, operative procedure times, total operating room times, and surgical complications. Review of digital video records provided quantitative interval measurements of core steps of the procedures, including completion of incisions, anterior capsulotomy, nucleus removal, cortical removal, and intraocular lens implantation.

Results

Total room time, operation time, and corneal incision completion time were found to be significantly longer in the femtosecond laser group versus the traditional phacoemulsification group (each P<0.05). Mean duration for manual completion of anterior capsulotomy was shorter in the laser group (P<0.001). There were no statistically significant differences in the individual steps of nucleus removal, cortical removal, or intraocular lens placement. Surgical complication rates were not significantly different between the groups.

Conclusion

In early cases, resident completion of femtosecond cataract surgery is generally less efficient when trainees have more experience with traditional phacoemulsification. FLACS was found to have a significant advantage in completion of capsulotomy, but subsequent surgical steps were not shorter or longer. Resident learning curve for the FLACS technology may partially explain the disparities of performance. Educators should be cognizant of a potential for lower procedural efficiency when introducing FLACS into resident training.

Goat's eye integrated with a human cataractous lens: A training model for phacoemulsification

A relatively simple and inexpensive technique to train surgeons in phacoemulsification using a goat's eye integrated with a human cataractous nucleus is described. The goat's eye is placed on a bed of cotton within the lumen of a cylindrical container. This is then mounted on a rectangular thermocol so that the limbus is presented at the surgical field. After making a clear corneal entry with a keratome, the trainer makes a 5–5.5 mm continuous curvilinear capsulorhexis in the anterior lens capsule, creates a crater of adequate depth in the cortex and inserts the human nucleus within this crater in the goat's capsular bag. The surgical wound is sutured, and the goat's eye is ready for training. Creating the capsulorhexis with precision and making the crater of adequate depth to snugly accommodate the human nucleus are the most important steps to prevent excessive wobbling of the nucleus while training.

Update and clinical utility of the LenSx femtosecond laser in cataract surgery

The introduction of femtosecond lasers to cataract surgery has been the major disruptive technology introduced into ophthalmic surgery in the last decade. Femtosecond laser cataract surgery (FLACS) integrates high-resolution anterior segment imaging with a femtosecond laser allowing key steps of cataract surgery to be performed with computer-guided laser accuracy, precision, and reproducibility. Since the introduction of FLACS, there have been significant advances in laser software and hardware as well as surgeon experience, with over 250 articles published in the peer-reviewed literature. This review examines the published evidence relating to the LenSx platform and discusses surgical techniques, indications, safety, and clinical results.

Risk Factors for Return to the Operating Room after Resident-Performed Cataract Surgery

OBJECTIVE

Investigate risk factors for unplanned return to the operating room after resident-performed cataract surgery.

DESIGN

Retrospective case-control study.

SETTING

Institutional.

METHODS

Study population: All patients with reoperation within 90 days of resident-performed phacoemulsification were matched to four control eyes which had surgery within 30 days of the reoperation at the same institution.

OBSERVATION PROCEDURE

Billing codes were used to identify all patients who underwent resident-performed intended phacoemulsification with intraocular lens placement from January 2005 to December 2010.

MAIN OUTCOME MEASURES

Investigated risk factors for reoperation included cataract characteristics and preexisting ocular co-morbidities, including diabetic retinopathy, retinal detachment history, glaucoma, corneal pathology, and uveitis. Additional preoperative risk factors studied included resident training year, history of tamsulosin use, phacodonesis, pupillary dilation, presence of pseudoexfoliation, myopia, history of trauma, visual acuity, and monocular status. Intraoperative variables were the use of iris expansion devices, use of capsular stain, attending type, incision type, use of sutures, vitreous loss, anesthesia type, and phacoemulsification technique.

RESULTS

There were 67 returns to the operating room (i.e., cases) over five years that were assigned to 268 control eyes. In preoperative multivariate analysis, phacoemulsification done by a first- or second-year resident (OR 3.2, 95% CI: 1.7-6.0, p < 0.001) was associated with an increased risk of reoperation. In postoperative multivariate analysis, only the use of the divide-and-conquer technique (OR 4.0, 95% CI:1.7-9.2, p = 0.001) was associated with an increased risk of reoperation.

CONCLUSIONS

Phacoemulsification done by a junior resident or using the divide-and-conquer technique had the highest risk of reoperation.

Intraoperative Complications of Cataract Surgery in Tehran Province, Iran

PURPOSE

To determine the prevalence and types of intraoperative complications of cataract surgery and examine potential risk factors.

METHODS

Data were obtained from the 2011 Iranian Cataract Surgery Survey in which information about cataract surgeries throughout the nation was collected. In the Province of Tehran, 55 centers and 1 week per season per center were randomly selected for sampling. In each center, the charts of all patients who underwent cataract surgery during the selected weeks (total of 20 weeks per center) were reviewed for data extraction. The prevalence of different types of intraoperative cataract surgery complications were determined, and their relationships with age, sex, surgical method, surgeon, and hospitalization time were examined.

RESULTS

The prevalence of intraoperative complications of cataract surgery was 4.15% (95% confidence interval, 0.94 to 7.36). The prevalence of posterior capsular rupture with vitreous loss, posterior capsular rupture without vitreous loss, retrobulbar hemorrhage, suprachoroidal effusion/hemorrhage, intraocular lens drop, and nucleus drop was 2.86, 0.69, 0.06, 0.39, 0.03, and 0.11%, respectively. The prevalence of cataract surgery complications decreased from 6.95% in 2006 to 3.07% in 2010. The results of multiple logistic regression showed that surgery by residents, nonphacoemulsification methods of surgery, and patient age less than 10 years and more than 70 years were the risk factors for complications.

CONCLUSIONS

This study evaluated the prevalence of intraoperative complications of cataract surgery for the first time in Tehran Province. The prevalence of complications was high in this study. To achieve the goals of the Vision 2020 Initiative and improve surgical quality, it is necessary to minimize complication rates. Factors to note for decreasing complication rates include type of surgery, surgeon experience, and patient age.

Comparison of Different Types of Complications in the Phacoemulsification Surgery Learning Curve According to Number of Operations Performed

Objectives:

To compare the differences in intraoperative complications rates by the number of resident-performed sequential phacoemulsification surgeries.

Materials and Methods:

Preoperative and postoperative ophthalmological examination records and intraoperative data of 180 eyes of 140 patients who underwent cataract surgery by two residents between November 2009 and February 2012 were analyzed retrospectively. The data of 180 eyes were separated into 3 groups based on the number of operations performed: Group A (first 1-60 eyes), group B (61-120 eyes) and group C (last 121-180 eyes). The number of direct supervisor interventions and the rates of different types of complications were compared between the three groups.

Results:

The number of direct supervisor interventions was 45, 35 and 19 in group A, B and C, respectively. The number of complications anterior to the iris plane was 3, 4 and 12 in group A, B and C, respectively. The difference in the rate of complications between group B and C was statistically significant (p=0.029). The number of complications posterior to the iris plane was 6, 14 and 3 in group A, B and C, respectively. The difference in the rate of complications between the groups was statistically significant (p=0.042, p=0.004).

Conclusion:

This study provides insight into which types of complications might arise during the phacoemulsification training period. The trends in the rates of different complication types in clinics may be analyzed, and this analysis may be used to improve and modify phacoemulsification training programmes according to the needs of residents.

Risk factors for intra-operative complications during phacoemulsification performed by residents

The purpose of this study was to determine the risk factors for occurrence of intra-operative complications during phacoemulsification performed by residents. One hundred fifty patients with cataract who underwent phacoemulsification by residents, with an experience of five or more phacoemulsification surgery, at a tertiary care centre were included in this study. The pre-operative data of these patients were collected from the hospital records. Surgeons were interviewed immediately after the surgery regarding the surgeon experience, phacoemulsification technique, machine factors, and intra-operative complications. Statistical analysis was done to determine pre-operative and intra-operative risk factors. The overall surgical complication rate in resident-performed phacoemulsification was 37 % of which major and minor complications were 21 and 16 %, respectively. Success in terms of placement of intraocular lens in capsular bag was 84 %. The most common major and minor complications found were posterior capsular tear and irregular capsulorhexis, respectively. Systemic and ocular features of patients as well as type of machine (longitudinal versus torsional longitudinal) had no significant association in terms of complication rate. Increase in success rate was seen with increase in semester and number of surgeries performed. Patient factors including general physical condition, systemic diseases, and anatomical factors do not influence success in resident-performed phacoemulsification. With increase in semester of residents, there is a significant decrease in intra-operative complications. Minor complications in the beginning of case lead to increase in major complications later on during the case and decrease in success rate by junior-semester residents.

Comparing resident cataract surgery outcomes under novice versus experienced attending supervision

PURPOSE

To determine whether supervision by an attending who is new to surgical teaching, or an experienced attending measurably influences intraoperative complications rates or outcomes in phacoemulsification performed by ophthalmology residents.

SETTING

Single tertiary hospital.

DESIGN

Retrospective cohort study.

METHODS

Resident-performed phacoemulsification cases supervised by one novice attending (N=189) and experienced attending (N=172) over 1 year were included. Data included: resident year, patient age, sex, preoperative risk factors (4+ on the four point scale for dense/white/brunescent cataracts, Flomax, zonular dialysis, pseudoexfoliation, glaucoma risk, post-vitrectomy), intraoperative risk factors (Trypan blue, iris hooks), and intraoperative complications (capsule tears, vitreous loss, zonular dialysis, zonular dehiscence, burns, nuclear fragment loss, Descemet's tear). Experienced attending data were compared against those of the novice attending.

RESULTS

Regarding preoperative risks, experienced attending cases more likely involved 4+ cataract (P=0.005), Flomax (P<0.001), or glaucoma risk (P=0.001). For intraoperative risks, novice attending cases more likely involved Trypan blue (P<0.001). Regarding complications, novice attending cases were associated with vitreous loss (P=0.002) and anterior capsule tears (P<0.001). When comparing total complications, the novice attending was more likely to have both increased number of cases with complications and total complications than the experienced attending. The novice attending's overall complication rate trended downward (rate from 28% in first 25 cases to 6.67% in last 15).

CONCLUSION

Early cases for the novice attending were accompanied by greater complications (vitreous loss and anterior capsule tear), likely due to a learning curve. Surgical judgment in the operating room likely develops with experience. Training programs may focus on these specific areas to aid new instructors.

Update on simulation-based surgical training and assessment in ophthalmology: a systematic review

TOPIC

This study reviews the evidence behind simulation-based surgical training of ophthalmologists to determine (1) the validity of the reported models and (2) the ability to transfer skills to the operating room.

CLINICAL RELEVANCE

Simulation-based training is established widely within ophthalmology, although it often lacks a scientific basis for implementation.

METHODS

We conducted a systematic review of trials involving simulation-based training or assessment of ophthalmic surgical skills among health professionals. The search included 5 databases (PubMed, EMBASE, PsycINFO, Cochrane Library, and Web of Science) and was completed on March 1, 2014. Overall, the included trials were divided into animal, cadaver, inanimate, and virtual-reality models. Risk of bias was assessed using the Cochrane Collaboration's tool. Validity evidence was evaluated using a modern validity framework (Messick's).

RESULTS

We screened 1368 reports for eligibility and included 118 trials. The most common surgery simulated was cataract surgery. Most validity trials investigated only 1 or 2 of 5 sources of validity (87%). Only 2 trials (48 participants) investigated transfer of skills to the operating room; 4 trials (65 participants) evaluated the effect of simulation-based training on patient-related outcomes. Because of heterogeneity of the studies, it was not possible to conduct a quantitative analysis.

CONCLUSIONS

The methodologic rigor of trials investigating simulation-based surgical training in ophthalmology is inadequate. To ensure effective implementation of training models, evidence-based knowledge of validity and efficacy is needed. We provide a useful tool for implementation and evaluation of research in simulation-based training.

Long-term trends and outcomes of anterior vitrectomy in Western Australia

PURPOSE

To describe trends, risk factors and outcomes of anterior vitrectomy during cataract and intraocular lens (IOL) surgery.

METHODS

All patients 16 years and older undergoing cataract and IOL surgery in Western Australia (WA) from January 1980 to December 2001 (n = 115 815) were included. Hospital administrative data were used to identify all cataract and IOL procedures and subsequent admissions for retinal detachment, IOL dislocation, endophthalmitis and pseudophakic corneal oedema. Data were validated with chart review and analysed to identify trends and risk factors for anterior vitrectomy and the risk of subsequent complications.

RESULTS

In total, 1390 (1.2%) anterior vitrectomies were performed. The rate increased with change in surgical technique. Significant risk factors for anterior vitrectomy were age <50 years (OR 1.31), male sex (OR 1.23), IOL procedure (OR 11.45) and operations in public hospitals (OR 1.99) or rural/remote (OR 1.40) areas. Anterior vitrectomy was strongly associated with increased risk of retinal detachment (RD) (RR 18.5), endophthalmitis (RR 3.6), IOL dislocation (RR 21.1) and pseudophakic corneal oedema (RR 17.3). Retinal detachments and IOL dislocations occur earlier after anterior vitrectomy.

CONCLUSION

Anterior vitrectomy rates have remained stable since the introduction of phacoemulsification. Anterior vitrectomy is a major risk factor for serious complications compared with uncomplicated surgery, particularly RD and IOL dislocation. We identified an increasing trend in anterior vitrectomy being performed during extracapsular and IOL surgery.

Factors affecting cataract surgery complications and their effect on the postoperative outcome

OBJECTIVE

To identify factors associated with the development of complications during or after cataract surgery and to determine the effect of complications on improvements in visual acuity and visual function.

DESIGN

Longitudinal study.

PARTICIPANTS

A total of 4335 patients at 17 hospitals in the Spanish National Health Service undergoing cataract removal by phacoemulsification.

METHODS

Clinical data were collected before the intervention and 6 weeks postoperatively. All patients were mailed the Visual Function Index (VF-14) and additional questions concerning their ocular disease, preoperatively and 3 months after surgery. Logistic regression models were used to identify factors associated with the presence of complications, and general linear models to study the effect of complications on changes in visual acuity and VF-14 scores.

RESULTS

Some type of perioperative complication was found in 10.35% of patients and postoperative complications in 26.63%. Age, visual acuity greater than 0.3, moderate or high technical complexity, and the presence of perioperative complications, such as posterior capsular rupture or vitreous hemorrhage, were most strongly associated with the development of postoperative complications. Patients who had either perioperative or postoperative complications had lower levels of preoperative and postoperative visual acuity levels and visual function, and less improvement was seen for these parameters.

CONCLUSIONS

We identified factors associated with the development of surgery-related complications and showed that the presence of complications is associated with poorer postoperative visual acuity and function. These findings are useful for health care management, clinical decision making, and providing patients and clinicians with realistic expectations.

Evaluation of complications of extracapsular cataract extraction performed by trainees

Background:

Cataract extraction is the most common intraocular surgery taught to residents.

Aim:

This study aims to review the complications of trainee-performed extracapsular cataract extraction (ECCE) so as to identify the steps in which the trainee can benefit from closer supervision and practice.

Subjects and Methods:

This was a descriptive retrospective study of complications in the initial 150 ECCE with intraocular lens implant performed by two Ophthalmologists, from the University of Nigeria Teaching Hospital, Enugu, who visited a high volume training center. Both the intraoperative and early post-operative complications were studied. Data entry and analysis were performed descriptively using the Statiscal Package for the Social Sciences, SPSS version 15.0 (Chicago, IL, USA).

Results:

The age range of the patients was 40-95 years. The intraoperative complications included capsular flaps 12/161 (7.5%), posterior capsule rent, 10/161 (6.2%) and vitreous loss, 8/161 (5.0%). Corneal complications (striate keratopathy, superior corneal edema, generalized corneal edema and corneal folds) ranked highest in post-operative complications accounting for 34% (56/164).

Conclusions:

Performance of adequate and proper anterior capsulotomy, minimal handling of the cornea and avoidance of posterior capsular rent are some of the challenges of the trainee in mastering ECCE. Stepwise supervised training can help a trainee master these steps while keeping the complications at acceptably low levels.

2013 update on the management of posterior capsular rupture during cataract surgery

PURPOSE OF REVIEW

Posterior capsular rupture (PCR) is an infrequent complication of cataract surgery that can lead to significant ocular morbidity and permanent vision loss. In the setting of PCR, the primary objective is the safe and thorough evacuation of vitreous and lens fragments from the anterior segment. The secondary objective is the stable placement of an intraocular lens (IOL) selected for best refractive outcomes. Expedited referral to vitreoretinal specialists is recommended for management of posteriorly dislocated lens material and surveillance for retinal injury. It is the intention of this review to present current guidelines for the management of PCR.

RECENT FINDINGS

There are new techniques available to anterior and posterior segment surgeons in the setting of PCR. Endoillumination may facilitate visualization during anterior vitrectomy and the IOL may be used as a pupillary barrier to prevent loss of lens fragments. When secondary procedures are needed, early return to the operating room and small-gauge pars plana techniques may reduce patient morbidity.

SUMMARY

When approached carefully and systematically, patients may have good outcomes in the setting of PCR. Recent advancements in instrumentation and technique encourage further study and may lead to new standards of care.

Serious adverse events after cataract surgery

PURPOSE OF REVIEW

Over the past several decades, there have been many advances in the equipment, instrumentation and techniques of performing cataract surgery. This review will address the impact of these advances on the safety profile of cataract surgery.

RECENT FINDINGS

Recent studies have demonstrated a decline in the risk of serious postoperative adverse events (endophthalmitis, suprachoroidal hemorrhage, retinal detachment) following cataract surgery. Factors that increase the risk of serious complications from cataract surgery include patient-related factors (male sex, concomitant diabetic retinopathy, same day cataract surgery combined with another intraocular surgery, tamsulosin use) and surgeon-related factors (low surgical volume, limited experience, operating on patients who are most prone to adverse events).

SUMMARY

Cataract surgery continues to be a very well tolerated surgical procedure with few patients experiencing serious sight-threatening adverse events. Studies in the literature have helped surgeons identify patients who are at high risk for surgical complications and develop strategies to limit surgical complications when operating on these patients. As multifocal intraocular lenses, femtosecond laser technology, and other surgical innovations continue to gain popularity, it will be interesting in the coming years to determine whether there will be a continued reduction in complications of cataract surgery.

Analysis of resident-performed manual small incision cataract surgery (MSICS): an efficacious approach to mature cataracts

To examine and improve outcomes of resident-performed manual small incision cataract surgery (MSICS) cases via analysis of visual recovery, intraoperative adverse events, and early postoperative course. Particular focus was directed toward mature cataracts extracted by MSICS. A retrospective review was performed to identify MSICS cases performed by resident surgeons unfamiliar with the technique (initial ten cases) in an academic setting. Preoperative history, intraoperative adverse events, and postoperative course were reviewed. Of 30 cases identified, mean preoperative acuity was 1.8 ± 0.9 logMAR units (Snellen equivalent = 20/1262) improving to 0.20 ± 0.35 logMAR units (20/31) at final follow-up (p < 0.0001). Mean follow-up was 22.1 ± 19.0 days. The most frequent intraoperative adverse events were wound leak requiring intraoperative suturing (33 %), vitreous loss (6.7 %), and capsulorhexis radialization (6.7 %). Transient cornea edema was the most frequent (56.7 %) early postoperative minor complication. Two major complications occurred that required wound revision in one eye and iridoplasty in one eye. Of the 30 eyes undergoing surgery, 19 were noted to have mature cataracts. In this subset, mean acuity was 2.25 ± 0.64 logMAR units (20/3557) improving to 0.28 ± 0.42 logMAR (20/38) at final follow-up (p < 0.0001). Complications were similar in nature and frequency to the entire population in this subgroup. Supervised resident MSICS cataract surgery can result in excellent anatomic and visual outcomes. Appropriate wound construction is a frequently encountered difficulty, so particular attention should be directed to this step by both trainers and trainees.

Complication rate and risk factors for intraoperative complications in resident-performed phacoemulsification surgery

BACKGROUND/AIM

To determine the complication rate and risk factors for intraoperative complications in resident-performed phacoemulsification surgery at a tertiary care center during the first 100 surgeries.

METHODS

Retrospective chart review of the first 100 performed phacoemulsification cases of six consecutive residents. Posterior capsule tear, vitreous loss, and dislocation of lenticular fragments into the vitreous were defined as intraoperative complications. Patient characteristics considered risk factors for surgery were identified and correlated with the occurrence of intraoperative complications.

RESULTS

Complications occurred in 23 of 600 operations (3.8 %). Surgery was complicated by posterior capsular tear in 23 eyes (3.8 %) with vitreous loss in 17 eyes (2.8 %) and loss of lenticular fragments into the vitreous in seven eyes (1.2 %). Eyes with dense nuclear sclerosis (p = 0.002) and white cataracts (p = 0.019) were associated with a statistically significantly greater incidence of posterior capsular tears and vitreous loss (p = 0.007 and p = 0.027 respectively). An intraocular lens was implanted in 591 eyes as intended.

CONCLUSIONS

Residents achieve an acceptable complication rate during their initial 100 phacoemulsification cases.

Long-term outcomes of phacoemulsification cataract surgery performed by trainees and consultants in an Australian cohort

BACKGROUND

  It is unclear whether differences exist in surgical complication rates and long-term visual acuity outcomes between patients whose phacoemulsification cataract surgery was performed by ophthalmological trainees and those performed by consultants.

DESIGN

  Prospective clinical cohort study.

PARTICIPANTS

  1851 participants of the Cataract Surgery and Age-related Macular Degeneration study, aged ≥64 years, had cataract surgery performed at Westmead Hospital, Sydney.

METHODS

  Surgical complication rates and visual acuity at 24-month postoperative visits were compared between patients who were operated on by trainees and those operated on by consultants.

MAIN OUTCOME MEASURES

  Surgical outcomes included operative complications recorded in surgical audit forms and 24-month postoperative visual acuity.

RESULTS

  Of 1851 patients, 1274 (68.8%) were reviewed 24 months after surgery. Of these, 976 had data on the type of surgeon who performed the operation. After excluding 152 challenging cases and three cases operated on by first-year trainees at the beginning of their training, 821 patients were included in this study, of those, 498 were operated on by trainees and 323 by consultants. Habitual visual acuity ≥6/12 was achieved in 77.3% (n = 385/498) and 74.3% (n = 240/323), respectively, of the two groups of patients 24 months postoperatively. Of 514 patients who had surgical audit data, the major complication rate was numerically greater, but not significantly different for the 330 trainee-operated (6.1%) patients, compared with the 184 consultant-operated patients (2.7%, P = 0.091).

CONCLUSIONS

  We found relatively comparable complication rates and visual outcomes after 2 years between patients operated on by ophthalmological trainees and those by consultants, in a cataract surgical cohort at Westmead Hospital.

Comparative outcomes of manual small incision cataract surgery and phacoemulsification performed by ophthalmology trainees in a tertiary eye care hospital in India: a retrospective cohort design

OBJECTIVE

To compare the outcomes of manual small incision cataract surgery (MSICS) and phacoemulsification performed by ophthalmology trainees.

DESIGN

Retrospective cohort design.

SETTING

Tertiary eye care centre.

PARTICIPANTS

A total of 1029 subjects underwent cataract surgeries with MSICS technique or phacoemulsification by trainees during one quarter (July-September 2007). Only 484 (47%) subjects were males. Surgeries which were primarily large incision extracapsular or intracapsular cataract extraction and performed on patients less than 20 years of age were excluded.

OUTCOME MEASURES

The postoperative best corrected visual acuity (BCVA) along with the rates and types of complications were compared between both the groups.

RESULTS

A total of 1029 surgeries were performed by 22 resident surgeons. In all, 522 (50.7%) were done using MSICS technique and 507 (49.2%) were done by phacoemulsification. Those in the MSICS group were significantly older (age >70 years; 5.7% vs 3.4%; p<0.001) and had worse preoperative visual acuity (visual acuity <6/60; 69.3% vs 40.4%; p<0.001). Postoperatively, the number of patients having BCVA≥6/12 was similar in both the groups (84.3% vs 88%; p=0.09). The complication rates were higher in MSICS group (15.1% vs 7.1%, p<0.001). Most common risk factor for poor outcome (postoperative BCVA<6/60) in both the groups was presence of associated ocular pathologies (OR 7.4 95% CI 3.4 to 16.4) and having a complications (OR 5.7 95% CI 3.0 to 10.8).

CONCLUSIONS

Although the complication rate was higher in the MSICS group, there was no difference in BCVA in both the groups.