EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78708
June 2012 surgery: Guidelines based on data nd Refractive Surgery database" Second, with regard to report- ing, it appears that data were volun- tarily entered by physicians. In describing capsular complications, the authors reported that the be- tween-country variation in capsule complications was 0.1-1.79%, with an average overall surgical complica- tion rate of 2.3%. It seems likely that the true capsular complication rate is higher than 0.1%, and in fact, the authors did concede that the num- bers should be interpreted carefully because only a few centers were rep- resented for some countries. These centers could be treating a more complex or healthier eye popula- tion, resulting in data skewed to- ward more or fewer complications, respectively. Reporting bias was also likely to be a weakness in this kind of database, as physicians may have underreported the number of com- plications that they experienced. A third weakness of this study was the definition of "long-term" visual outcomes as results occurring be- tween 7 and 60 days post-op. This is particularly problematic when con- sidering the fact that two common post-op complications, PCO and cys- toid macular edema (CME), can take more than 60 days to develop. Al- though the study reported specifi- cally on short-term PCO (less than 2 months), the variability of "long- term" follow-up as any time be- tween 7 and 60 days make the results difficult to interpret. Further- more, because there was no true long-term follow-up, the authors did not consider CME, another post-op complication that can lead to fur- ther intervention and worse long- term visual outcomes. Interestingly, countries that had records of fewer than 1,000 cases were excluded from inter-country analysis. However, the exclusion begs several questions: Did these countries really have so few cataract surgeries per year? Is it possible that economically disadvantaged coun- tries were therefore less likely to have contributed to the database? If so, does this restrict this article's ap- plication of standards of care to more advantaged healthcare and economic environments? The au- thors reported that Belgium and Germany had higher rates of good pre-op visual acuity in the operative eye, as well as higher rates of good pre-op visual acuity in the better eye. As standards of living are rela- tively high in these two countries, this type of patient selection can be expected. However, it would have been interesting to report countries with worse average pre-op visual acuities as well and to determine if the average post-op CDVA was corre- spondingly lower. It is reasonable to assume that countries with poorer access to healthcare have cases with worse average pre-op visual acuities and a higher overall rate of complex- ity. These difficult cases would be more likely to result in more surgical complications and lower post-op CDVA. However, this information was not provided in the study and may be skewing the benchmark standards introduced in this study. The authors had long-term follow- up data for only 241,136 of the 523,921 cases, and they presented it as a binary choice of vision of better or worse than 6/12. While they re- ported many interesting facts, such as approximately 40% of surgeries are for a second eye, or approxi- mately 60% are performed on women, they did not relate these data with outcomes or complica- tions. Furthermore, they did not present data about the visual out- comes in patients with complicated surgeries. It seems odd to be crafting guidelines without relating the vari- ables to outcomes. In summary, this large, multi- country, multi-year data accrual and analysis offers a compelling descrip- tion of modern standards of cataract surgical management throughout Europe. The major strength of this study is the large amount of data, which provides benchmarks for post-op visual acuity and refractive outcomes. While the results will surely be used as international guidelines for surgical standards of care, one must temper the value of the study, and validity of the bench- marks, with an understanding of the study's limitations and internal bi- ases. Standardization of data report- ing across countries as well as correlation between reported vari- ables and outcomes would strengthen the validity of similar future studies. EW Contact information Winn: bjw15@columbia.edu Leaders in Managing the Business of Ophthalmology CER TIFIED O F OP HT HAL MI C E EXECU TIV E Christ opher L. Blan INLAND ph E "A theyy consta tly h ve to r re u of that e the our adm istr skill-set ophth pr ra tice. acti ce. " The A merican Society of Oph thalmic Administrat ors— the fastest, most reliable, and accurate resourc e for ophthalmic practice staffff.. 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