Posterior Capsular Rupture In Cataract Surgery At Moorfields Eye Hospital: A 10-Year Audit Of Trends And Multivariate Analysis Of Risk Factors.

A Learning Health System, as postulated by Hardie, describes a cycle of data to knowledge, knowledge to practice and practice to data. We sought to understand rates of posterior capsular rupture (PCR) complications and associated risk factors at Moorfields Eye Hospital (MEH). We used autocorrelation to ascertain whether there was any statistically significant monthly seasonality to PCR rates, especially for August and February (months in which registrar and fellow surgeons rotate between and within hospitals). Finally, we explored whether there was any difference in PCR risk following Sub-Tenon versus topical anaesthetic. These insights may help MEH tailor its service to best serve the local population.

Posterior capsular rupture (PCR) is the most significant complication associated with cataract surgery. Whilst previous studies have sought to understand risk factors for cataract surgery, little is known about local contemporaneous risk factors at MEH, or whether registrar and fellow surgeons’ training rotation patterns affect local PCR rates. Additionally, there is limited evidence on best practices for local anaesthesia techniques to minimise PCR rates.

Using Structured Query Language (SQL), we extracted data on 172,803 cataract operations performed between 2012 and 2022 from Electronic Health Records at MEH. Time Series Analysis, autocorrelation by month and multivariate Ordinary Least Squares Regression were used to identify long-term trends and PCR risk factors. For multivariate analysis, data was collected on patient age, ethnicity, anaesthetic type (general, local and/or sedation), local anaesthetic delivery (topical, Sub-Tenon, subconjunctival, retrobulbar, peribulbar), surgeon grade and whether PCR occurred.

Average PCR rates were stable (0.75-1.75%) over 10 years, without monthly seasonality, apart from an early 2020 spike to 4%. Multivariate regression revealed higher PCR rates with Asian (adjusted odds ratio (AOR) 1.003, 95% confidence interval (CI) 1.001-1.005), Black (AOR 1.006, 95% CI 1.004-1.008) and Other ethnicities (AOR 1.003, 95% CI 1.001-1.005). Higher rates were also associated with subconjunctival anaesthesia (AOR 1.012, 95% CI 1.003-1.033), registrar (AOR 1.011, 95% CI 1.006-1.017) and fellow surgeon grades (AOR 1.005, 95% CI 1.000-1.009). Lower rates were associated with both Sub-Tenon (AOR 0.993, 95% CI 0.987-0.999) and topical anaesthetic (AOR 0.992, 95% CI 0.985-0.998); no significant difference between the two was noted.

PCR rates remained similar to national standards from the National Ophthalmology Database Cataract Audit over the 10-year period. A temporary rise in early 2020 was thought to be due to low volume prioritisation of complex cases during the Covid-19 pandemic. Sub-Tenon and topical anaesthesia are both associated with similarly low rates of PCR. PCR rates appear to be uncorrelated to any particular month, including those during which registrar and fellow surgeons rotate between and within hospitals.

Further research into causes of observed ethnic variations in PCR rates is warranted to define targeted approaches for cataract surgery safety in these groups. This will help tailor our practice and optimise surgical outcomes.