SURGERY INDICATIONS

 A review of the Swedish National Cataract Register shows about four per cent of patients in 2012 and 5.5 per cent in 2013 received 2nd-eye cataract surgery without a discernible clinical indication.

Mats Lundström MD, PhD, Karlskrona, Sweden, told the 2014 AAO annual meeting in Chicago (held in conjunction with SOE 2014) that of these, 19 per cent perceived greater visual disability after surgery than before. In addition, 10 per cent reported no improvement and nine per cent ended up with worse visual acuity.

A sharp rise in cataract volume prompted Dr Lundström to initiate the study. In 2013 nearly 120,000 cataract procedures were performed for a rate exceeding 11,000 per million inhabitants, up from about 8,600 in 2004.

Outcomes

The database study examined prospectively collected data on 7,303 consecutive cataract cases during March 2012 and March 2013. March was selected because it is the month the register collects patient-reported outcomes in addition to other cataract data, Dr Lundström said.

Data collected before surgery included best corrected distance visual acuity, the surgeon’s opinion about indications for surgery, and completed Catquest-9SF, a Rasch-analysed patient questionnaire that asks about activities of daily life.

Surgical data, postoperative visual acuity refraction and a second Catquest-9SF taken three months after surgery were also examined.

Altogether 4,325 first-eye and 2,974 second-eye procedures performed at 46 surgical units were examined for a total of 7,303. A stepwise process was used to exclude patients who the researchers thought had reasonable indications for surgery, Dr Lundström said.

Poor vision, defined as best corrected 20/40 or worse, was the first criteria. Nearly 80 per cent of first-eye surgeries, or 3,388, and 60 per cent of second-eye surgeries, or 1,772, met this test, leaving 2,139 eyes.

Next, Dr Lundström looked at the Catquest-9SF results. Patient dissatisfaction with vision, defined as rather or very dissatisfied plus some functional disability, eliminated 683 first-eye and 646 second-eye surgeries, leaving 810 eyes. Patients satisfied with vision but who perceived vision-related difficulty performing daily life activities eliminated another 595, leaving 215 eyes.

ELIMINATED

Finally, the surgeon’s opinion of a reasonable indication such as anisometropia or high intraocular pressure (IOP) eliminated another 26 eyes.

That left 47, or 1.1 per cent, of first-eye surgeries and 142, or 4.8 per cent, of second-eye surgeries without what reviewers considered an adequate clinical indication, Dr Lundström said.

Projecting the numbers on to an entire year, this means about 900 first-eye surgeries and 2,500 second-eye surgeries were done in Sweden in 2013 with a 29 per cent risk of not perceiving better visual function and a nine per cent risk of worse visual outcome after surgery, Dr Lundström said.

UNACCEPTABLE

“If we go outside health care and talk about these risk numbers for delivering a service or product, they are definitely definitely definitely unacceptable,” he said.

A possible weakness of the study is the fact that the decision to operate could be based on not reported circumstances.

Prof Lundström intends to follow the trend in the future. He will also start a discussion within the ophthalmic community about indications for cataract surgery. “We want to do that before the payers, which they have done in some European countries.”

Mats Lundstrom:
mats.lundstrom@
karlskrona.mail.telia.com