EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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58 EW RESIDENTS June 2012 EyeWorld journal club Review of "Evidence-based guidelines for cataract in the European Registry of Quality Outcomes for Cataract an by Elizabeth Dale, M.D., Lora Dagi Glass, M.D., Mary Whitman, M.D., Royce WS Chen, M.D., and Bryan J. Winn, M.D. Bryan J. Winn, M.D., associate residency program director for ophthalmology Columbia University, New York This month, I asked the Columbia residents to analyze the conclusions from this study of the EUREQUO database for cataract surgery. David F. Chang, M.D., chief medical editor I n an effort to create evidence- based guidelines for cataract surgery and ultimately improve the quality of cataract and re- fractive surgery, the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EU- REQUO) was created. This 3-year project (January 2009-August 2011) involved the creation of a database for documentation of information pertaining to cataract surgeries per- formed throughout Europe, includ- ing the European Society of Cataract and Refractive Surgeons and 11 other national societies. In total, the database included 523,921 reported surgeries. In their recent article, "Ev- idence-based guidelines for cataract surgery: Guidelines based on data in the European Registry of Quality Outcomes for Cataract and Refrac- tive Surgery database," Lundström et al. provide both a summary of this The Columbia University ophthalmology residents Source: Department of Ophthalmology, Columbia University surgical data and evidence-based recommendations for surgical stan- dards in cataract surgery. The follow- ing data were collected for the EUREQUO: first- versus second-eye surgery, outpatient versus inpatient surgery, demographic data, pre-op corrected distance visual acuity (CDVA) and refraction, ocular co- morbidity, level of complexity, type of anesthesia, surgical technique, IOL type, surgical complications, visual outcome, refractive outcome, and post-op complications. Analysis of the acquired data was used to de- velop evidence-based guidelines for Evidence-based guidelines for cataract surgery: Guidelines based on data in the European Registry of Quality Outcomes for Cataract and Refractive Surgery database Mats Lundström, M.D., Ph.D., Peter Barry, F.R.C.S., Ype Henry, M.D., Paul Rosen, F.R.C.S., F.R.C.Ophth., Ulf Stenevi, M.D., Ph.D. J Cataract Refract Surg. (June) 2012; 38:1092-1099. I n March 2008, the European Registry of Quality Outcomes for Cataract and Refractive Surgery commenced. This 3-year project was cofunded by the European Union and the European Society of Cataract and Re- fractive Surgeons (ESCRS). ESCRS became the lead partner in the project with 11 national societies as associated partners. The aims of the project were to improve treatment and standards of care for cataract and refrac- tive surgery and to develop evidence-based guidelines for cataract and re- fractive surgery across Europe. Surgeons from all participating societies contributed to the database, which contained data on 820,000 cataract surgeries in November 2011. The present guidelines are based on data entered from January 1, 2009, to August 28, 2011 (523,921 cataract extractions). The guidelines include only those steps in the cataract surgery process that can be analyzed by the database. Financial disclosure: No author has a financial or proprietary interest in any material or method mentioned. cataract surgery that can be summa- rized as follows: All patients with vi- sual disability from cataract should be treated regardless of age, gener- ally in an outpatient setting. No spe- cific CDVA limit can be given for patient selection. Ocular comorbidi- ties are not a contraindication to cataract surgery, but the likelihood of worse visual outcomes must be discussed with the patient. Local anesthesia is generally sufficient, and phacoemulsification should be considered the standard technique. Hydrophobic acrylic lenses are the most commonly used lenses, al- though all lenses have strengths and weaknesses. Capsular complications, while unavoidable, should be rare, and a rate under 2% should be possi- ble to achieve. 97% of eyes with no comorbidity should have a final CDVA outcome of 6/12 or better, and the final refractive outcome should fall within 0.6 diopters of the target. Post-op complications, which may be related to factors such as surgeon experience and pre-existing ocular comorbidities, should be min- imized. Limiting complications such as a capsule rupture, introducing prophylactic intracameral antibi- otics, and creating watertight inci- sions are key steps to preventing post-op endophthalmitis, which should occur no more often than 1 in 2,000 surgeries. The goal of creating evidence- based guidelines for cataract surgery is a worthy one, and the number of cases in this database is impressive. The data provided in this prospec- tive study are further strengthened by the diversity of countries repre- sented. In an effort to ensure fair comparison of surgical standards be- tween countries, only those with greater than 1,000 surgeries in the database were included when inter- country comparisons were made. Despite this feat of data collection and analysis, we find that the rec- ommendations for standards of care may be limited by multiple factors ranging from data entry to data analysis and subsequent applicabil- ity in different economic environ- ments and health systems. First, while the different coun- tries contributed the same types of data to the EUREQUO database, there was no clear standardization for reporting among the countries. Therefore, the data may be inconsis- tent across the different studied out- comes. For example, for post-op endophthalmitis, data from the U.K. were not included because the au- thors stated that the variable was missing from the electronic medical records system. The complication of posterior capsular opacity (PCO) af- fecting vision was not reported by Holland and Sweden, two of the largest contributors to the overall data set. These two countries also did not report the complication of uveitis requiring medication. For both of these complication cate- gories, the number of eligible cases therefore dropped from 241,136 to 35,553.