Eyeworld

EW CATARACT 44 March 2019 surgery complexity score system for the selection of appropriate cases for trainees, using evidence based, validated risk factors for posterior capsule rupture, patient specific factors, and complexity stratifica- tion recommendations to minimize complications, optimize outcomes, and maximize patient safety. A com- plexity score of 0–1 signified low case complexity, 4–7 intermediate, 8–9 high, and ≥10 very high surgical complexity, which was seen less frequently. "We noticed that con- sultants' operating times were fairly consistent until reaching very high scores before there was an increase in operating time. Three-quarters of patients fall within the low to intermediate scoring range while a patient with pseudoexfoliation, an only eye, or white cataract would fall in the high scoring range. Most of the high complexity cases were performed by consultants. Trainee operating times, although more variable as trainees rotated year by year, also remained fairly consistent with increases in operating times seen at scores ≥8," Dr. Nderitu said. Factors associated with operating times Pupil size can slow down operat- ing times, particularly among less experienced surgeons. "We looked at large pupils compared with small pupils and noted that even in our consultant group, there was an increase in the mean operating time in small pupil cases, which was expected," Dr. Nderitu said. "For junior trainees in their first 2 years of training, we see a small decrease in operating time, probably because the consultant takes over and is able to complete it more quickly. There was a slightly higher operation time compared to consultants among the other, more experienced trainees who can do their own small pupil cases. In cases involving a pupil expanding ring, we observed about a 4-minute increase in operating time for consultants and 6 minutes for trainees. 2 We noted a bigger increase in operating time in cases using iris hooks, which have to be put in individually, adding anoth- er mean 14 minutes to surgery for consultants and about 24 minutes for trainees. Capsular tension rings can add a mean 5 minutes to the surgical time." According to his data, the main complication that affected surgical time was posterior capsule rupture. "This can double your operating time regardless of who you are. But for consultants, starting at ~17 minutes of operating time, it can increase to 30 or 40 minutes, depending on the situation. When trainees are involved or helping to manage the complication, operation times can extend beyond 1 hour, which has also been published in the literature," Dr. Nderitu said. Temporal study data reveal a small decrease in individual consultant operating times from 21 minutes to 18 minutes over 5 years (2011–2016), including lower standard deviations, revealing an increase in efficacy through more highly standardized operative pro- cedures. This fact is also reflected by the faster operating times seen among trainees, despite the fact that trainees only spend 1–2 years in this placement. "Overall, I think what's en- couraging is that even the most junior trainees take 30 minutes to complete the whole procedure. In uncomplicated cases, we should not discourage juniors from operating. The cataract complexity score sys- tem is a useful tool for the stratifica- tion of case complexity and for the appropriate case selection to match trainee experience," he said. "Cata- ract surgery is the most frequently performed elective operation in the U.K. with around 400,000 cataract procedures per year in England alone. There are limited data in the literature on the factors that influ- ence or are associated with operat- ing time in cataract surgery, which this study delineates. We need to continue to define these factors among trainees and consultants as well as the trends we see over time," Dr. Nderitu said. EW Reference 1. Nderitu P, Ursell P. Updated cataract surgery complexity stratification score for trainee ophthalmic surgeons. J Cataract Refract Surg. 2018;44:709–717. 2. Nderitu P, Ursell P. Iris hooks versus a pupil expansion ring: operating times, complications, and visual acuity outcomes in small pupil cases. J Cataract Refract Surg. 2019;45:167–173. Editors' note: Dr. Nderitu has no finan- cial interests related to his comments. Contact information Nderitu: p.nderitu@doctors.org.uk The 30-minute continued from page 43 This figure shows that the mean operating time (in uncomplicated, topical, or sub-Tenon's cases) decreased by approximately 3 minutes among consultants with similar trends in trainee groups between 2012 and 2016. The findings of decreasing operating time among consultants who would not vary year on year supports the hypothesis that phacoemulsification cataract surgery is becoming more time efficient. Source: Paul Nderitu, MD This figure shows that in cases with a topical or sub-Tenon's anesthetic and no intraoperative complication, an increase in the cataract complexity score did not result in an increase in operating time, with the exception of high complexity scores.

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