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A new cataract surgery complexity score for trainee ophthalmic surgeons: stratification of intraoperative and postoperative complications with case complexity

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Session Details

Session Title: Cataract Surgery Special Cases

Session Date/Time: Monday 09/10/2017 | 14:30-16:00

Paper Time: 14:30

Venue: Meeting Center Room I

First Author: : P.Nderitu UK

Co Author(s): :    P. Ursell                    

Abstract Details


We have devised a new comprehensive cataract surgery complexity score for use in the selection of appropriate cases for ophthalmology trainees. This evidence-based complexity score utilises validated risk factors for posterior capsular rupture (PCR), patient-specific factors and complexity stratification recommendations that correlate with trainee experience. It aims to minimise intraoperative complications and optimise postoperative outcomes. We present data to validate its use in protecting patients, maximizing safety and improving training.


All patients who underwent primary phacoemulsification cataract surgery from 1st Jan 2011 until 31st Dec 2016 at Epsom and St Helier University NHS Trust were included with exclusion of combined corneal, glaucoma or posterior segment procedures.


All cataract procedures have been preoperatively scored since December 2009. Anonymised data on demographics, pupil size, pupil expander use, intra/postoperative complications and postoperative best-corrected distance visual acuity (BCDVA) were extracted from our electronic medical records. Patients were stratified by complexity score (groups 1 to 5 corresponding to scores 0-1, 2-3, 4-7, 8-9 and 10+ respectively) and surgeon grade (consultant, junior, intermediate, senior trainee and fellows). Logistic regression analyses, with 95% confidence intervals (CI), were used to assess the association between complexity group, intraoperative and postoperative complications. Linear regression was used to assess the association between complexity group and postoperative BCDVA.


From 11,468 included cases, 8,200 (71.5%) had a completed preoperative complexity score. Small pupil, pupil expander use (odds ratio (OR): 6.72 (95%CI: 4.67-9.67)), iris damage, zonular dialysis, postoperative raised intraocular pressure and corneal oedema (OR: 3.17 (95%CI: 2.05-4.92)) were significantly associated with increasing complexity score, particularly amongst trainees. The complexity score was not associated with PCR but rates were low amongst all surgeons (consultant 1.2%, junior 2.7%, intermediate 2.3%, senior trainee 2.1% and fellows 2.9%). The mean BCDVA decreased with increasing complexity group (p<0.001) being lower amongst senior trainees at higher scores although this was not statistically significant (p=0.786).


The new cataract complexity score is a useful comprehensive tool for the stratification of case complexity and guides appropriate case selection to match trainee experience. Higher complexity scores are associated with greater intraoperative and postoperative complications and lower postoperative BCDVA; hence patients with higher scores should be made aware of the more guarded prognosis when obtaining consent.

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