Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery

PurposeTo determine whether four new operating room (OR) protocols instituted because of COVID-19 reduced the cataract surgical postoperative endophthalmitis rate (POE).DesignRetrospective, sequential, clinical registry study.Methods85 552 sequential patients undergoing cataract surgery at the Aravind Eye Hospitals between 1 January 2020 and 25 March 2020 (56 551 in group 1) and 3 May 2020 and 31 August 2020 (29 011 in group 2). In group 1, patients were not gowned, surgical gloves were disinfected but not changed between cases, OR floors were not cleaned between every case, and multiple patients underwent preparation and surgery in the same OR. In group 2, each patient was gowned, surgical gloves were changed between each case, OR floors and counters were cleaned between patients, and only one patient at a time underwent preparation and surgery in the OR.ResultsGroup 1 was older, had slightly more females, and better preoperative vision. More eyes in group 2 underwent phacoemulsification (p=0.18). Three eyes (0.005%) in group 1 and 2 eyes (0.006%) in group 2 developed POE (p=0.77). Only one eye that underwent phacoemulsification developed POE; this was in group 1. There was no difference in posterior capsule rupture rate between the two groups.ConclusionsAdopting a set of four temporary OR protocols that are often mandatory in the Western world did not reduce the POE rate. Along with previously published studies, these results challenge the necessity of these common practices which may be needlessly costly and wasteful, arguing for the reevaluation of empiric and potentially unnecessary guidelines that govern ophthalmic surgeries.

Intravitreal injection is associated with increased posterior capsule rupture risk during cataract surgery: A meta-analysis

Background: Although observational studies have suggested that prior intravitreal therapy may predict posterior capsule rupture (PCR) during cataract surgery, this finding is still controversial. Objective: To summarize current evidence on the association between prior intravitreal injection (IVI) and PCR during cataract surgery. Methods: A systematic literature search was performed up to October 27th, 2021. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using random-effects models. The potential association between IVI and PCR in future cataract surgeries was assessed using the following two models: “pooling the odds ratios of PCR in eyes with and without previous IVI(s)” and “pooling the odds ratios for PCR relative to each increase in the number of prior injections.” The quality of included studies was appraised using the Newcastle-Ottawa Scale. Results: 6 cohort studies were included in this meta-analysis, with a total of 1,051,097 eyes that underwent cataract surgery. Of these, 7,034 eyes were associated with previous IVI. The pooled odds of PCR in eyes with prior IVI was 2.01 (95% CI: 1.35–3.00) times higher than that of eyes without an IVI history. An increase in the number of previous IVI conferred increased odds of PCR of 1.03 (95% CI: 1.01–1.06). After excluding studies that failed to account for confounders, the significantly increased risk was not altered, and the significant heterogeneity was minimized in both models. Conclusion: This meta-analysis provides evidence that previous IVI significantly increases the risk of PCR during future cataract surgery. The risk of PCR should be discussed preoperatively with patients. Further studies are required to validate our findings and explore the underlying mechanisms.

Pac-Man Method: A New Technique for Nuclear Management Of Posterior Polar Cataract

Purpose We introduce an innovative technique, “Pac-Man”, for the nuclear management of posterior polar cataracts and compare it with “Chop in situ” and “Fishbowl” techniques. Method A total of 60 eyes from 60 patients were randomly assigned to groups A, B, and C, with 20 eyes in each group. Pac-Man, Chop in situ, and Fishbowl techniques were used for groups A, B, and C. In the Pac-Man method, adequate single trench sculpts, and a right-sided lateral sculpt were performed and cracked. The triangular piece was emulsified, after which the rest of the nucleus looked like a “Pac-Man” cartoon. Techniques were compared by age, visual outcome, Posterior Capsule Rupture (PCR), Cumulative Dissipated Energy (CDE), and time of surgery. Result Postoperative BCVA was significantly improved after surgery ( P = 0.0001, paired t-test). Time taken for surgeries were 25 ± 2.57, 30 ± 3.78, 40 ± 3.25 min, the CDE were 10 ± 0.95, 20 ± 1.2, 15 ± 0.48, and the PCR were 0%, 5%, and 10% for group A,B,C respectively. The total number of PCR was 3 out of 60 patients, and the percentage was 5.00%. Conclusion The “Pac-Man” method is a recommended technique due to its visual outcome, reduced surgical time, less CDE, and less chance of PCR.

The Learning Curve of the Deliberate Practice of Phacoemulsification in the Ophthalmic Training System

Objective: To determine the number of surgeries needed for trainees to achieve competence in performing phacoemulsification with deliberate practice (DP). Materials and Methods: The present study was a prospective observational study, the residents were observed as they progressed through their third year of residency. Resident and patient demographic data were recorded. Complexities of the cases and surgical steps and rate of surgical complications were recorded. Self and staff assessments as to the DP learning zone attained by the trainees were collected. Risk adjusted-cumulative summation (RA-CUSUM) was used to evaluate the competency of the trainees to achieve the acceptable posterior capsule rupture (PCR) rate of 5%. Kaplan-Meier analysis was used to determine the median number of surgeries required to attain competency. Results: Eight of the 10 trainees achieved competence in performing phacoemulsification. A median of 28 cases and 278 days was required before competence was attained. There were no statistically significant associations between the achievement of competence and the gender of the trainees, perceived complexity of the cases, or the grade-point average of the residents during their tenure in medical school. A median of four cases were required for a shift in the trainees’ DP confidence levels from “panic” to “learning” from self-assessment, while the median of ten case were required from staff assessment. The PCR was 8.53% and dropped to 6% at two years after the trainees finished residency training. Conclusion: Trainees require at least 28 cases of non-complicated phacoemulsification surgery to achieve a minimum level of competency. The perceived skill in performing phacoemulsification differs between novice and experienced surgeons. Phacoemulsification skills can be further developed after graduating from the training program. Assisting staff should be attentive when trainees perform lens nucleus division and lens nucleus removal to avoid complications. Keywords: Residency training; Phacoemulsification; CUSUM; Deliberate practice; Cataract

Establishing the influence of case complexity on the order of cataract lists: a cross-sectional survey

ObjectiveOrder of the theatre list and complexity of the cases are important considerations which are known to influence surgical outcomes. This survey aimed to establish their influence on cataract surgery.Methods and AnalysisCataract surgeons ordered five cataract cases according to their surgical preference, first using case notes and second using composite ORs (CORs) for posterior capsule rupture. Descriptive and non-parametric statistics were used to analyse the data.ResultsBetween 11 June and 14 July 2020, 192 cataract surgeons from 14 countries completed the online survey. Majority of the surgeons (142 vs 50) preferred to choose the order of their list (p<0.01) and to review the case notes prior to the day of surgery (89 vs 53; p=0.04). 39.86% preferred to start with the less risky case and 32.43% reserved the last position on the list for the riskiest case. There was a significant trend to order the list in an ascending level of risk, independent of whether case notes or CORs were used. Additionally, 44.79% of the respondents indicated they would be happy to have their list order planned by an automated program based on their preferred risk score.ConclusionThis survey demonstrates that cataract surgeons prefer to choose the order of their theatre list and that the order is dependent on the complexity of cases. There is support among surgeons for automated list ordering based on an objective score for risk stratification, such as a COR.

Managing intraocular lens dislocation with one-port pars plana vitrectomy under direct vision with microscope illumination

AIM: To describe a technique of managing intraocular lens (IOL) with deep dislocation in the vitreous cavity by performing pars plana vitrectomy (PPV) with only one pars plana incision under the direct illumination of the surgical microscope. METHODS: Patients who had in-the-bag or out-of-the-bag (spontaneous) IOL dislocation after uneventful phacoemulsification cataract extractions, with the dislocated IOL or IOL-capsular bag complex dropping completely into the vitreous since 2013 were included in our studies. The postoperative patients were followed up for 6mo. Detailed description of technique and retrospective description of eight typical cases were demonstrated in this study. RESULTS: A total of 40 surgeries were conducted using this technique. The main possible predisposing conditions included: post-vitrectomy, posterior capsule rupture or broken zonules, a history of ocular trauma, long axial length, secondary IOL implantation, chronic uveitis, retinitis pigmentosa and post-glaucoma surgery. In all eyes, the IOLs were successfully removed. No intraoperative or postoperative complications related to the procedures occurred. The preoperative corrected distance visual acuity (CDVA) ranged from 20/133 to 20/25, and at 6mo postoperatively, the CDVA was similar or the same. The intraocular pressure was all within the normal range. CONCLUSION: One-port PPV under direct vision with microscope illumination is a simple and safe surgical technique to managing IOL dislocation, which shortens the surgical time, and largely avoids surgical complications.