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Reducing cataract complications: the role of risk stratification scoring systems

Poster Details

First Author: H.Hurairah UK

Co Author(s):    W. Muen              

Abstract Details



Purpose:

1) To determine the rate of operative complications of cataract surgery particularly posterior capsular rupture rate with or without vitreous loss (PCR +/- VL) in our department and compare this against the current UK national standards 2) To identify any modifiable risk factors to further reduce our PCR +/- rate 3) To design a standardized preoperative PCR +/- VL risk stratification system for use in our cataract pre-assessment pathway 4) To improve the quality of surgical residents' training by ensuring appropriate phacoemulsification cases are assigned to the correct surgeon grade

Setting:

Royal Eye Unit, Kingston Hospital NHS Trust

Methods:

This prospective clinical study looked at all the intra- and postoperative cataract complications in our department between October 2012 and October 2013. A total of 32 cases were identified in this period through surgical logbooks and our medical coding department. The data collected included: age, gender, first or second operated eye, pre- and postoperative visual acuity, surgical complication type, suggested surgeon (determined at pre-assessment clinic), actual operating surgeon grade and pre-operative risk factors. These risk factors included patient age, gender, glaucoma, diabetic retinopathy, brunescent/white cataract, no fundal view/vitreous opacities, pseudoexfoliation/phacodonesis, pupil size, axial length, -1 adrenergic blocker use, patient' ability to lie flat and operating surgeon grade. Based on data from the UK's Cataract National Dataset electronic multicentre audit (55,567 analysed cataract operations between November 2001 and July 2006), we were able to design a PCR +/- VL risk calculator on Microsoft Excel. This was used to calculate a retrospective PCR risk on our cataract complications to determine whether the correct surgeon grade had operated on appropriate cataract cases by comparing the actual operating surgeon's risk with a consultant's operating risk. Additionally, higher risk cases were examined to ascertain whether the correct surgeon grade had operated i.e. appropriate case allocation.

Results:

1685 phacoemulsification cases were performed in the 12-month period. 30 out of the 32 identified complications were evaluated. Male to female ratio was 1:1 with an average age of 72.8 years. 56.7% of the cases were first eyes. 23.3% of the complications were performed under subtenons anaesthesia. Preoperatively, 19 out of 30 patients had a best-corrected visual acuity (BCVA) of 6/9 or better but were significantly symptomatic. The remaining 11 patients had BCVA of 6/12 or worse. 2 patients had worse vision postoperatively; one developed chronic cystoid macular oedema and one is awaiting a secondary lens implant. Overall complication rate was 1.90% (32/1685) The PCR +/- VL rate was 1.19% (20/1685), better than the current UK national standards of 1.92%. Consultant surgeons carried out 11 (36.7%) cases and 19 (63.3%) were performed by other surgeon grades. Using the risk stratification system, a PCR +/- VL risk of more than 1% was classified as a‘senior surgeon only' case. 12 out of the 20 identified complications were calculated to have a risk of more than 1% and half of these cases had been allocated preoperatively to ‘any surgeon'. Almost half of the 12 ‘senior only' cases were operated on by non-consultant surgeons.

Conclusions:

Our PCR +/- VL risk is 1.19%, above the UK national standards of 1.92%. According to our results, more than half of the ‘senior only' cases were allocated to non-specific surgeon grades which contributed to the incidence of complications. The introduction of an adjuvant preoperative PCR +/- VL risk stratification system offers an objective means for the assessing clinician to determine appropriate surgeon allocation and reduce intra- and postoperative complications rate. The decision to proceed with cataract surgery is one in which careful examination by the assessing clinician plays a significant role in the efficiency of the surgical procedure. Poor patient selection, the failure to identify pre-operative risk factors and incorrect surgeon allocation leads to wasted theatre time, unnecessary cancellations and patient disappointment. Other factors issues should be considered when listing patients for surgery such as poor positioning, deep-set eyes, patient anxiety and perceived postoperative medication compliance. A detailed discussion regarding desired visual outcome and informed patient consent is crucial. We advocate the use of an adjunct objective risk stratification system during pre-operative assessment clinics with the intention to assist with decision-making. In all cases, the visual benefits of the surgery should outweigh the risks of the procedure to ensure maximal patient satisfaction. FINANCIAL INTEREST: NONE

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