Eyeworld

EW RESIDENTS 56 July 2018 posterior capsular rupture or zonular rupture (PCR/ZR) and vitreous loss (VL) with increasing complexity score. Junior trainees had statistical- ly higher rates of PCR/ZR and VL in the study when compared to con- sultants, but not when compared to senior trainees. According to the authors' risk stratification, patients with the highest complexity carried a 4-fold increase of intraoperative iris-phaco damage. Higher complexity scores resulted in worse postoperative best distance visual acuity overall, but the highly complex patients had a greater mean improvement in post- operative vision when compared to less complex patients. Lastly, control patients without a complexity score were found to have higher intra- operative complications, thereby supporting the authors' assertion that a scoring system is needed to better match these patients with an appropriately trained surgeon. The authors present a unique evidence-based cataract complexity score that incorporates several es- tablished risk factors for PCR. Using logistic regression analysis they were able to show a correlation between the complexity score and intra- and postoperative complications. Uti- lizing a score like this in a training setting has the potential to signifi- cantly simplify and standardize the cataract surgery learning process. Stratifying surgeries by complexity level not only allows more effective tailoring to surgeon experience, but also optimizes the chance of achiev- ing favorable outcomes for patients. Additionally, the complexity score can be a tool for counseling pa- tients on surgical and postoperative expectations. Explaining their risk stratification process, the surgeons could minimize patient preoperative concerns with reassurance that a complex patient would not be in- appropriately matched to a surgeon with less experience. The study benefits from a large sample size obtained from an extensive and reliable database. The electronic medical record (EMR) at the study site's clinic, which utiliz- es forced data entry, ensures that a complete preoperative profile is created for all patients. The au- thors collected data over 6 years of surgeries with inclusion of nearly 50 surgeons, which allows for a more uniform spread of surgical abili- ty. However, the large majority of surgeries were not performed by the trainees for whom the complexity score is designed, which is a factor that will likely need to be addressed in future validations of this model. In regard to the complexity score, the authors make the ap- propriate choice to incorporate evidence-based risk factors for PCR, which avoids the question of relevancy of these factors. They take their model a step further by considering other patient factors such as preoperative corneal edema or monocular status, which may not necessarily be predictive of PCR but are significant considerations when contemplating intraoperative risks. Unfortunately, as the authors point out, these risk factors were consid- ered in aggregate when calculating the complexity score, therefore making it difficult to determine the contribution of each particular risk factor from this data alone. Addi- tionally, the complexity score does not take into account several other risk factors, such as grading bru- nescent/density of cataract, history of prior surgery, history of trauma (though it does consider phaco- donesis), or anatomical variations like large brows or deep sulci. These factors, while they may not neces- sarily predict PCR, do contribute to the difficulty of the surgery and are oftentimes a large component of de- termining the appropriate surgeon training level for the case. At the same time, it is also vital to recog- nize the importance of having a simple model that can be calculated and applied quickly. A complicated complexity score incorporating too many variables can become cumbersome and inefficient. Thus, an effective model must strike a balance between simplicity and comprehensiveness. The current study may also be affected by reporting bias, as all intraoperative and postopera- tive events may not necessarily be recorded in the EMR, thus a prospec- tive study could reduce the presence of such bias. It is also crucial to consider evaluating the complexity score on populations outside the study site in order to demonstrate broader applicability of the model. In summary, the authors pres- ent a new model for standardizing cataract evaluation and assignment of cases to trainees. Through several thousand cases they show that their complexity score does indeed cor- relate with intra- and postoperative complications. While this model would benefit from a prospective validation on a different population with more trainees, it does show promise for improving the cataract surgery learning process. EW References 1. National Institute for Health and Care Excellence. Cataracts in adults: management. October 2017. www.nice.org.uk/guidance/ ng77. Accessed June 11, 2018. 2. Najjar DM, Awwad ST. Cataract surgery risk score for residents and beginning surgeons. J Cataract Refract Surg. 2003;29:2036–7. 3. Muhtaseb M, et al. A system for preop- erative stratification of cataract patients according to risk of intraoperative complica- tions: a prospective analysis of 1441 cases. Br J Ophthalmol. 2004;88:1242–6. 4. Habib MS, et al. The role of case mix in the relation of volume and outcome in phacoemulsification. Br J Ophthalmol. 2005;89:1143–6. 5. Gupta A, et al. Cataract classification sys- tem for risk stratification in surgery. J Cataract Refract Surg. 2011;37:1363–4. 6. Narendran N, et al. The Cataract National Dataset electronic multicentre audit of 55,567 operations: risk stratification for posterior capsule rupture and vitreous loss. Eye (Lond). 2009;23:31–7. Contact information Weikert: mweikert@bcm.edu Review continued from page 54 An updated cataract surgery complexity stratification score for trainee ophthalmic surgeons Paul Nderitu, MBChB, Paul Ursell, MD J Cataract Refract Surg. 2018;44(6). Article in press. Purpose: We devised a comprehensive cataract surgery complexity score for the selection of appropriate cases for trainees and consultants. This evidence-based complexity score utilizes validated risk factors of posterior capsular rupture (PCR), patient-specific factors and complexity stratification recommendations according to surgeon competence. It aims to minimize complications, optimize outcomes, and maximize patient safety. Setting: Patients undergoing primary phacoemulsification cataract surgery from 1 Jan 2011 until 31 Dec 2016 at Epsom and St Helier University NHS Trust, UK were included; combined corneal, glaucoma or posterior segment procedures were excluded. Design: Retrospective cohort study Methods: Anonymized data on demographics, pupil size, pupil expander use, intra/postoperative complications and postoperative best distance visual acuity (BDVA) were extracted. Patients were stratified by complexity score and surgeon grade (consultant, junior, intermediate, senior trainee and fellow). Results: From 11,468 included cases, 8,200 (71.5%) had a complexity score. Small pupil, pupil expander use, iris-phaco damage, zonular dialysis, postoperative raised intraocular pressure and corneal edema (OR: 3.17 [95% CI: 2.05–4.92]) were significantly associated with increasing complexity score. Use of appropriate complexity grade allocation per surgeon grade resulted in no association between PCR and complexity group. Increasing complexity score was associated with lower postoperative BDVA. Conclusions: The updated, evidence-based comprehensive cataract complexity score is a useful tool for the stratification of case complexity and guides appropriate case selection to match trainee experience. Higher complexity scores are associated with greater intraoperative and postoperative complications and lower postoperative BDVA. Patients with higher scores should be made aware of the guarded prognosis when obtaining consent.

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