Pre-Operative Stratification Of Surgical Difficulty For Teaching Cataract Surgery

To report on the results of systematic surgical risk stratification prior to cataract surgery according to surgeon experience and its impact on surgical teaching and complication rates between residents, general attendings and attendings specializing in cataract surgery.

Single center academic university hospital.

Single-center retrospective chart review. All cases submitted to cataract surgery were preoperatively classified in three levels of surgical difficulty (1/2/3, with 3 being the hardest difficulty) considering casemix factors that included patient cooperation for topical anesthesia, lens density, pupillary dilation, likelihood of IFIS, pseudoexfolliation, zonulopathy, eye status (single functioning eye or not). The experience of the surgeon performing the surgery was also recorded in 3 categories (resident, attending, attending specialized in cataract surgery). Visual outcomes, including patient satisfaction using CATQUEST9SF and incidence of early and late post-operative complications were collected.

We included 6667 surgeries. Surgeries were performed by residents in 20% of cases, attendings in 42% and attendings specializing in cataract surgery in 38% of cases.  Unadjusted proportion of cases with postoperative CDVA equal or greater to 20/40 and 20/20 was 91%/72%, 90%/65% and 86%/56% in these three groups respectively and CATQUEST9SF scores in the preop/postop were -0.51/-1.57 log, -0.38/-1.63 log and +0.36/-2.11 log. Intra-operative surgical complications were observed in 0.25%, 0.16% and 0.62% of surgeries in these three groups respectively.  After adjustment for casemix variables, visual acuity, patient reported outcomes and complications are similar regardless of surgeon experience.

Our method of pre-operative stratification of surgical risk and difficulty lead to similar visual outcomes and complication rates between residents and attendings not specialized in cataract surgery, supporting the hypothesis that with adequate risk assement and supervision, surgery performed by residents does not lead to worse patient outcoms. Actually, worse results were observed in attendings specialized in cataract surgery, which was attributable to indication bias (surgical difficulty and visual comorbidities).