REDUCING POSTERIOR CAPSULE RUPTURE RATES

Matching cataract patients to appropriately experienced surgeons based on risk factors reduced posterior capsule rupture rates by about one-third, Lampros Lamprogiannis MD, of Aristotle University of Thessaloniki, Greece, told the XXIX Congress of the ESCRS.

“Our study focused on how application of the risk factor method can reduce the main intra-operative complication, which is posterior capsule rupture,†Dr Lamprogiannis said.

His clinic (Department of Anterior Segment, 2nd Ophthalmology Clinic, Aristotle University of Thessaloniki, Head: as. professor I.Tsinopoulos) adopted a risk-scoring method based on previous research (Muhtaseb M et al Br J Ophthalmol, 2004 Oct;88(10): 1242-6) that assigns patients points for specific preoperative clinical findings. These include advanced age, pseudoexfoliation syndrome, glaucoma, anticoagulant use, axial length, shallow anterior chamber, hard cataract, phacodonesis and diabetic retinopathy. Cataract surgeons also were divided into three groups – highly experienced, experienced and trainees.

Patients with risk scores of four or more were assigned to highly experienced surgeons only, those scoring one to three to experienced surgeons, and those with zero risk factors to trainees. For example, an 83-year-old patient with glaucoma, possible floppy iris, long axial length, a grade four cataract and only one eye scored six on the risk scale.

“He is obviously a patient who should be operated on by a skilled, experienced surgeon,†Dr Lamprogiannis said.

In a study of 388 consecutive patients operated after adopting risk-scoring, the total capsule rupture rate was 3.61 per cent. That compared with 5.53 per cent observed for 1,735 eyes operated previously, when patients were assigned to surgeons more or less randomly or based on a rough estimate of risk. The reduction was statistically significant at p<0.05.

“Our study shows graphically how complications can be reduced and outcomes can be significantly improved,†Dr Lamprogiannis said.

Improved training

Trainee surgeons made the biggest improvement, reducing rupture rates to 4.13 per cent from 7.2 per cent, a drop of about 43 per cent.

“This plays an important role not only in the training but also in the psychology of the training,†Dr Lamprogiannis said.

Grouping six or seven low-risk patients on the surgical schedule for a designated training session helps young surgeons build skill and confidence quicker than pulling trainees into the OR randomly for one case at a time, Paul Ursell MBBS, MD, FRCOphth, of the Epsom and St Helier University Hospital Trust, UK, told EuroTimes. “Repetition is the key. We know our skills fluctuate. After a long break you are not as attuned as if you are doing 10 or 15 cases every day for several weeks.â€

While some worry that limiting trainees to uncomplicated cases leaves them unprepared for real-world practice, Dr Ursell believes bringing surgeons along with cases that do not exceed their skill level enables them to focus on the newest challenge as their training progresses. He even extends the concept to parts of the procedure. He starts trainees with the easier tasks of evacuating viscoelastic and inserting the lens on several consecutive cases before moving on to the more challenging phaco and capsulorhexis steps. Having mastered the easier steps, they are better able to focus on the more difficult ones.

Dr Ursell likens the approach to erecting a building inside a supporting scaffold, which is progressively removed as the structure strengthens. Risk-scoring is an important element. His clinic adopted a method based on risk factors identified by a UK National Health Service study of 55,000 cataract cases (Sparrow JM et al. Eye (Lond). 2011 Aug;25(8):1010-5).

Surgeons tick off risk factors such as small pupils and dense nuclei on a form during examinations. For their first 50 cases, surgeons are limited to scores of zero to one, then for the next 50 from two to four, and are generally considered highly experienced after about 400 cases. It is only after the surgeon has performed over 100 cases that they are allowed to do more complex cases.

“Surgeons don’t do procedures beyond their competence. It has reduced complications in our department and increased the confidence of our trainees. It is also safer for our patients.â€

Comprehensive quality report

In a separate presentation, Jörg Förster, CEO of Eye Hospital Bellevue, Kiel, Germany, reported significantly improved patient satisfaction, post-surgery clinical findings and visual outcomes over three years after implementing a structured quality report for cataract surgeons.

Dr Förster partnered with 44 eye professionals in 2007 to create a quality network. “Our thesis is that increasing quality means learning from the past and from each other. To learn means to analyse data.â€

The network created a structured quality report that collects data in three categories: nine subjective findings such as clarity of cornea, five objective measures such as best corrected visual acuity, and five patient satisfaction measures such as satisfaction with nursing care. Data are collected at three follow-up visits. The database now includes nearly 41,000 cases with 114,595 follow-up visits and 1.8 million discrete data items.

For each item, findings are translated into a school note according to the German school note system in which 1 = best and 6 = worst. For example, for cornea quality, no abnormal finding = 1, oedema = 3 and Descemet’s folds = 4. For 13,828 cases, the average quality score for cornea is 1.762 +/- 1.225. For six surgeons, the scores varied from 1.622 +/-1.136 to 2.314 +/-1.376. Results for each category can be summed, as can a total quality score.

Surgeons use the reports to analyse their performance and discuss techniques for improvement. Every month a team of senior surgeons selects a topic for discussion. Topics have included reducing phaco energy, cleaning the chamber angle, post-op medications and behaviour toward patients.

From 2007 through 2010, overall patient satisfaction scores improved 18 per cent, quality in post-surgery findings by 13.3 per cent, and quality of measured findings, including post-op visual acuity, spherical equivalent and IOP, by 6.5 per cent, Dr Förster reported. Total quality improved 10.2 per cent, ranging by surgeon from 5.8 per cent to 31 per cent.

Standard deviation is also useful, Dr Förster said.

“You see one surgeon has some months with very good notes. We have to find out the difference between the months with very good notes and the ones not as good.

This surgeon has the highest potential to improve.â€