Posterior Capsule Rupture Rates Research Articles

Intraoperative complication rates in cataract surgery performed by ophthalmology resident trainees compared to staff surgeons in a Canadian academic center

To compare the intraoperative complication rates in cataract surgery performed by resident trainees and staff ophthalmologists. Kensington Eye Institute, University of Toronto, Toronto, Canada. Prospective case series. This study included 8738 consecutive cases of primary phacoemulsification cataract surgery performed by staff surgeons and resident trainees from January to December 2016. There were no exclusion criteria. Data collected included the level of resident training, case complexity, degree of resident involvement, and intraoperative complications. Primary outcome measures included intraoperative complication rates and level of complexity of cataract surgeries performed by resident trainees and staff surgeons. Resident trainees were involved in 44% of surgeries. Of those, 82% were completed in their entirety by a resident and 18% were performed by both the staff surgeon and resident. Staff surgeons performed 56% of all surgeries without resident involvement. Sixty-seven percent of surgeries were simple and 33% were complex, with small pupil or intraoperative floppy-iris syndrome being the most common reason for complex cases. For simple cases, there was no difference in the overall complication rates (1.7% and 2.0%; P=.52), posterior capsule rupture rates (0.9% and 0.8%; P=.76), or vitreous loss rates (0.4% and 0.2%; P=.08) between staff and residents, respectively. There were no differences in complication rates between the two groups.

INTRAOPERATIVE AND POSTOPERATIVE COMPLICATIONS IN PHACOVITRECTOMY FOR EPIRETINAL MEMBRANE AND MACULAR HOLE: A Clinical Audit of 1,000 Consecutive Eyes.

The aim of this study was to report the intraoperative and postoperative complications of phacovitrectomy for epiretinal membrane (ERM) and macular hole (MH). This was a retrospective audit of 1,052 phacovitrectomy operations (410 for ERM and 642 for MH) by the same surgical team between 1998 and 2017. Outcome measures included rates of intraoperative anterior segment and posterior segment complications such as posterior capsule rupture and retinal breaks. A subgroup analysis of 189 procedures in which postoperative complications were rigorously recorded was also undertaken. The rate of posterior capsule rupture was 2.2%, with no difference between ERM and MH (1.7 vs. 2.5%; P = 0.40). Iatrogenic retinal tears were more common in MH than in ERM surgery (15.6 vs. 6.8%; P < 0.001). The chance of one or more anterior segment or posterior segment intraoperative complications occurring (excluding iatrogenic retinal breaks) was not associated with: indication for surgery, grade of surgeon, gauge of surgery, surgical machine, diabetic status, patient sex, or patient age. Subgroup analysis showed postoperative events as follows: posterior capsular opacification 10.6% (20/189), posterior synechiae 4.2% (8/189), uveitis 2.1% (4/189), angle closure glaucoma 1.6% (3/189), and rhegmatogenous retinal detachment 1.1% (2/189). Phacovitrectomy seems to be safe in phakic patients with ERM or MH, performed either by fellows or consultants. It avoids the requirement for repeat surgery and is more cost and resource efficient.

Reduced posterior capsular rupture rate observed among trainee surgeons utilizing a disposable silicone-tipped irrigation and aspiration handpiece for soft lens removal

ABSTRACTBackground: To determine if there is an association between lower posterior capsule rupture (PCR) rates among trainees using silicone-tipped handpieces compared with trainees using conventional instrumentation.Methods: In a retrospective audit, anonymized data was extracted for two groups of supervised deanery trainees. Group one operated with conventional IA handpieces. Group two utilized silicone-tipped IA handpieces. Risk factors found to increase the likelihood for intraoperative PCR were included in the analysis. Statistical significance was tested using a parametric test of two proportions.Results: Group one performed 782 surgeries and had a PCR rate of 3.6% vs 1.6% from 933 surgeries in group two. Following adjustment for risk factors, the p-value was 0.057. Group two had no IA-related PCR complications vs 12% in group one. Both groups demonstrated highest rates of PCR during phacoemulsification, 48% and 57%, respectively.Conclusion: Group two had lower than expected complication rates compared to the published literature. Trainees utilizing a 45-degree silicone-tipped IA handpiece had a lower rate of PCR and vitreous loss compared to group one and experienced no complications during IA. This suggests silicone-tipped IA handpieces may be safer for soft lens extraction compared to conventional instrumentation.

A Database Study of Visual Outcomes and Intraoperative Complications of Postvitrectomy Cataract Surgery

To analyze the visual outcomes and rate of intraoperative complications of phacoemulsification surgery after prior pars plana vitrectomy (PPV). Retrospective, multicenter database study. Eyes that underwent phacoemulsification between June 2005 and March 2015 at 8 sites in the United Kingdom. Study eyes were classified as vitrectomized (prior PPV group) or nonvitrectomized (reference group) depending on the vitreous state at the time of cataract surgery. Eyes with multiple intraocular surgeries or history of ocular diseases known to cause cataract progression or increased risk of intraoperative complications during phacoemulsification were excluded. Logarithm of the minimum angle of resolution (logMAR) visual acuity (VA), rate of intraoperative complications, and time interval to cataract surgery. Eyes in the prior PPV group (n= 2221) had worse preoperative logMAR VA (0.96±0.60 vs. 0.62±0.52, P < 0.0001), were from younger patients, and had longer axial lengths than the nonvitrectomized group (n= 136 533). At all postoperative time points measured up to 24 weeks, mean vision was poorer in the prior PPV group (0.41±0.47 vs. 0.17±0.29 at 4-12 weeks, P < 0.0001) and a smaller proportion of eyes achieved postoperative VA ≤0.30 logMAR (Snellen, ≥20/40) (60.8% vs. 86.5% at 4-12 weeks, P < 0.0001). The rate of posterior capsular rupture was not different between the prior PPV (1.5%) and the nonvitrectomized (1.7%) groups, but the incidences of zonular dialysis (1.3% vs. 0.6%) and dropped nuclear fragments (0.6% vs. 0.2%) were higher in the prior PPV group (P < 0.0001). The mean time interval between PPV and cataract surgery was 399 days. We found a significant improvement in VA with postvitrectomy cataract surgery. However, compared with eyes without prior PPV, there was a worse mean postoperative vision of 0.2 logMAR units, a higher rate of zonular dialysis and dropped nuclear fragments, and a similar rate of posterior capsule rupture.

Analysis of competency in phacoemulsification trainees using the cumulative sum analysis

To determine the number of cases required to achieve competency in phacoemulsification in terms of the posterior capsule rupture rate. Singapore National Eye Centre, Singapore. Retrospective cohort study. The posterior capsule rupture rate of the first 300 phacoemulsification cases performed by each trainee in the Singapore National Eye Centre (2004 to 2012) was charted using cumulative sum graphs. Competency was primarily defined as a posterior capsule rupture rate of 2% or lower and secondarily as 5% or lower. Twenty trainees fulfilled the inclusion criteria. Four trainees (20%) and 19 trainees (95%) achieved a posterior capsule rupture rate of 2% and 5%, respectively. At least 41 cases were required to achieve a 5% posterior capsule rupture rate (mean 106, median 83). There was considerable variation in the trainees' abilities. Only 20% of the trainees achieved a posterior capsule rupture rate of 2% or lower and required at least 212cases.

Managing the posterior polar cataract: An update.

Posterior polar cataracts (PPC) have always been a challenge for cataract surgeons due to their inherently higher propensity for posterior capsule rupture. Over the years, several technical modifications have been suggested to enhance safety and reduce posterior capsule rupture rates in these polar cataracts. This review article tries to present the various techniques and strategies to published in literature to manage PPCs. It also discusses pearls for making surgery more reproducible and consistent, as well as the role of newer diagnostic and surgical technology based on the published literature on the subject.

Eleven year review of risk factors and visual outcomes of patients with posterior capsule rupture (PCR) as a complication of cataract surgery at a district general hospital

PurposeTo report risk factors and visual outcomes of cataract surgery complicated by posterior capsule rupture (PCR) at Portsmouth Hospital over an 11 year period (2004–2015)MethodsA search of all cataract surgery complicated by PCR was performed on our Electronic Patient Record (EPR). Clinical data was extracted from the EPR, patient case notes and clinical letters. Only patients with a minimum of 3 months VA recorded were included.ResultsIn total 366 patients were identified. The mean number of cataract operations performed per year was 3,832 giving an overall PCR rate of 0.98%. Of the cases affected the average age was 74 years and 56% were female. The most common risk factors were dense cataract (15%), high myopia (8%) and previous vitrectomy (6%). Thirty five percent of PCR cases occurred during a trainee surgical list. Initial mean best corrected VA in all patients was 0.68, 0.62 at 3 months and 0.46 at 1 year. The mean length of follow up was 35 months and the mean VA was 0.36 at the final visit.ConclusionsPCR rate at Portsmouth is almost half the national rate. We found in our cohort of patients, previous vitrectomy was a common risk factor which was not reflected in the Royal College of Ophthalmologists’ National Database. Over a third of PCR occurred during trainee lists, emphasising the need for risk stratification preoperatively to identify difficult cases.

Effect of cataract surgery training on operating room productivity: How long trainees take

To determine the effect of specialty training on cataract operation times and operating room efficiency. Manchester Royal Eye Hospital, Manchester, United Kingdom. Retrospective consecutive case series. Specialty training and consultant case times with preparation times were recorded betweenAugust 2014 and May 2015. Cases with posterior capsule rupture requiring anterior vitrectomyor iris hook insertion were analyzed. The study reviewed 1904 cases (906 consultant cases, 797 specialty training cases). Trainees' case time was significantly longer than consultants' (mean 24.25minutes±12.36 [SD] versus 19.59±10.05minutes) (P<.0001). The difference between the 1- to 3-year trainees' mean surgical time and 4- to 7-year trainees' mean surgical time was statistically significant (P<.0001). Mean case time decreased from 27.63±12.57 minutes (1- to 3-year trainees) to 22.55±11.90 minutes (4- to 7-year trainees). The mean posterior capsule rupture rate was 2.76% for trainees and 1.77% for consultants. When posterior capsule rupture occurred, the mean surgical time increased to 49.81±18.69minutes for the consultant group and 67.00±26.26minutes for the trainee group (P=.024). When iris hooks were required, the mean case time was 26.41±11.28minutes and 34.11±15.06minutes, respectively (P=.026). Specialty training cases had a longer duration than consultant cases, although the mean surgical time decreased with increased trainee experience. After 3years of training, trainees did not have a significant effect on operating room efficiency. None of the authors has a financial or proprietary interest in any material ormethod mentioned.

Confidence of ophthalmology specialist trainees in the management of posterior capsule rupture and vitreous loss

PurposeTo ascertain ophthalmology trainee confidence in managing posterior capsule rupture (PCR) and vitreous loss.MethodsAn electronic survey was distributed to ophthalmology trainees in a single UK postgraduate training Deanery. Data collected included the stage of training, number of completed cataract operations, cumulative PCR rate, number of PCRs personally managed by the trainee, previous vitrectomy experience during vitreoretinal rotations, and attendance at advanced phacoemulsification courses. Trainees self-evaluated their confidence in managing PCR with vitreous loss, including the management of specific aspects of the procedure.ResultsAcross training grades, only 9.1% (2/22) felt confident managing PCR without senior support. Respondents were most confident with fluidic parameters and IOL considerations, but 77.3% (17/22) lacked confidence in avoiding a dropped nucleus. Eleven respondents had completed >350 cases (mean 576; range 383-1087). In this subgroup, mean cumulative PCR rate was 2.1% (range 0.9-4.9%), and trainees personally managed a mean 3.5 cases of PCR (range 1-7). Only 18.2% felt they could manage PCR and vitreous loss without senior support, and 45.5% stated they were not confident in avoiding a dropped nucleus. The most experienced trainee (1087 cases) had personally managed PCR just six times, and three trainees with >350 cases had only managed PCR once each.ConclusionsThe Royal College of Ophthalmologists' requirement of 350 completed cases appears insufficient for independent cataract surgery, as opportunities to manage complications as a trainee are scarce. A competency-based assessment framework may be preferable, with a more targeted approach to training incorporating surgical simulation within the formal curriculum.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of cataract surgery: report 2, relationships of axial length with ocular copathology, preoperative visual acuity, and posterior capsule rupture.

To describe the relationships of axial length with ocular copathology, preoperative visual acuity, and posterior capsule rupture rates in patients undergoing cataract surgery.DesignThe Royal College of Ophthalmologists' National Ophthalmology Database (NOD) study. Anonymised data on 180 114 eyes from 127 685 patients undergoing cataract surgery between August 2006 and November 2010 were collected prospectively from 28 sites. Data parameters included: demographics, biometry, ocular copathology, visual acuity measurements, and surgical complications including posterior capsule rupture, or vitreous loss or both (PCR). Consultant surgeons performed a higher proportion of operations on eyes whose axial length were at the extremes. Glaucoma and age related macular degeneration were more common in eyes with shorter axial lengths, whilst previous vitrectomy was associated with longer axial lengths. Eyes with brunescent or white cataracts or amblyopia were more common at both axial length extremes. Preoperative visual acuities were similar for eyes with axial length measurements up to approximately 28 mm and worse for eyes with longer axial length measurements. PCR rates showed little change with axial length (overall mean 1.95%, 95% CI: 1.89 to 2.01%), except for a borderline increase in eyes with axial length <20.0 mm where rates were 3.6% (95% CI: 2.0 to 6.3%). The likelihood of PCR in eyes with axial length <20.0 mm was 1.88 times higher than those of ≥20.0 mm (P=0.0373). Rates of ocular comorbidities vary by axial length. PCR rates in eyes with very short or long axial lengths were lower than expected.

Femtodelineation to enhance safety in posterior polar cataracts

We describe the technique of femtodelineation for posterior polar cataracts. In this technique, the femtosecond laser is used with a cylindrical pattern of lens division to create multiple cylinders within the lens, which results in sharply demarcated layers. The number, size, and depth of the cylinders can be controlled by the surgeon using the live anterior segment optical coherence tomography view. The multiple layers act as mechanical cushions that protect each layer as it is removed. Because of its sharp demarcation, the last epinuclear layer can be easily stripped using a combination of the phaco probe and bimanual irrigation/aspiration. This approach eliminates the need for any type of hydro procedure in posterior polar cataracts. It reduces posterior capsule rupture rates and enhances safety in posterior polar cataract emulsification. Dr. A.R. Vasavada receives research support from Alcon Laboratories, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

The Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: report 1, visual outcomes and complications.

AimsTo describe the outcomes of cataract surgery in the United Kingdom.MethodsAnonymised data on 180 114 eyes from 127 685 patients undergoing cataract surgery between August 2006 and November 2010 were collected prospectively from 28 sites. Outcome measures included intraoperative and postoperative complication rates, and preoperative and postoperative visual acuities.ResultsMedian age at first eye surgery was 77.1 years, 36.9% cases had ocular co-pathology and 41.0% patients underwent cataract surgery on both eyes. Preoperative visual acuity was 0.30 logMAR or better in 32.0% first eyes and 47.7% second eyes. Postoperative best-measured visual acuity was 0.00 and 0.30 logMAR or better in 50.8 and 94.6% eyes without ocular co-pathology, and 32.5 and 79.9% in eyes with co-pathology. For eyes without co-pathology, postoperative uncorrected distance visual acuity was 0.00 and 0.30 logMAR or better in 27.3 and 80.9% eyes. Posterior capsule rupture or vitreous loss or both occurred in 1.95% cases, and was associated with a 42 times higher risk of retinal detachment surgery within 3 months and an eight times higher risk of endophthalmitis.ConclusionThese results provide updated data for the benchmarking of cataract surgery. Visual outcomes, and the rate of posterior capsule rupture or vitreous loss or both appear stable over the past decade.

Application of anterior segment optical coherence tomography to identify eyes with posterior polar cataract at high risk for posterior capsule rupture

To use anterior segment optical coherence tomography (AS-OCT) to identify eyes with posterior polar cataract at high risk for posterior capsule rupture (PCR) during cataract extraction. Hong Kong Eye Hospital, Hong Kong, China. Retrospective case series. Eyes with clinically diagnosed posterior polar cataract that had AS-OCT imaging and phacoemulsification were included. Each eye was graded according to the features of the posterior lens opacity and the underlying capsule. Eyes were categorized as having grade 1 or grade 2 cataract depending on the amount of clearance between the posterior opacity and the capsule (≥ 50% clearance and <50% clearance, respectively). Grade 3 represented the absence of an intact posterior capsule. The incidence of intraoperative PCR was compared with the AS-OCT grading to identify eyes at high risk for PCR. The study assessed 37 eyes, 19 with grade 1 cataract, 13 with grade 2, and 5 with grade 3. Posterior capsule rupture occurred in 8 eyes (21.6%), 1 (5.3%) with grade 1 cataract, 4 (30.8%) with grade 2, and 3 (60.0%) with grade 3. The PCR rate was statistically significantly different between the groups (P = .018). When grade 2 cases and grade 3 cases were combined, AS-OCT had a sensitivity of 87.5% and specificity of 62.1%. Anterior segment OCT can be used to grade posterior polar cataracts and identify eyes at high risk for PCR, allowing better surgical planning and preoperative counseling.

Complication rate of posterior capsule rupture with vitreous loss during phacoemulsification at a Hawaiian cataract surgical center: a clinical audit

PurposeTo compare the complication rate of posterior capsule rupture (PCR) with vitreous loss during phacoemulsification at an ambulatory surgical center with published results as a clinical audit for quality control.MethodsA retrospective chart review of 3,339 consecutive patients who underwent routine phacoemulsification by four experienced private practice surgeons from January 1, 2011 to June 30, 2012 at The Surgical Suites, Honolulu, HI, USA. All cases with PCR and vitreous loss were identified and selected for the study. Risk factors of this complication were further examined. Data were sent to John H Stroger Jr Hospital of Cook County, Division of Ophthalmology, for literature review, analysis, and write-up.ResultsTwenty-three of the 3,339 cases incurred PCR and vitreous loss during phacoemulsification, for an incidence rate of 0.68%. Miosis, shallow chamber, restlessness, pseudoexfoliation syndrome, floppy iris syndrome, and zonulopathy were the main causes. In addition, surgeon volume (number of cases) was inversely correlated with PCR.ConclusionThe rate of PCR with vitreous loss during phacoemulsification in this study may be lower than other published results done at academic centers. However, there was no compatible study available for comparison, as existing studies performed at academic centers included resident cases. This study identified risk factors for PCR/vitreous loss both preoperatively and postoperatively that may assist in application of preventive measures to decrease rates of PCR/vitreous loss.

A 5-Year Audit of Cataract Surgery Outcomes After Posterior Capsule Rupture and Risk Factors Affecting Visual Acuity

To describe the posterior capsule rupture rates and visual outcomes after phacoemulsification, analyze risk factors for poor vision, and compare results of faculty (F) and residents (R). Retrospective audit study. Visual success of all capsule ruptures (2006-2010) was analyzed and compared to uneventful cases. Rupture rates of faculty and residents were compared (χ², P < .05). Success was defined as % best-corrected visual acuity (BCVA) ≥20/40 at 3 months (excluding poor-prognosis eyes) and studied in relation to age, sex, surgeon type, stage of surgery, vitreous loss, dropped nucleus, and other complications (eg, retinal detachment, corneal decompensation, dislocated intraocular lens [IOL]). Final risk factors were identified using multivariate logistic regression analysis. From 2006 to 2010, there were 887 capsule ruptures in 48 377 phacoemulsification cases (rate 1.8%). Uneventful cases had significantly better visual outcomes than capsule ruptures (98.5% vs 93.9%; P < .01). Faculty rupture rates were lower (F = 1.4%) than residents' (R = 3.4%; P < .01), but visual outcomes were similar (F = 93.8%, R = 93.7%; P > .05). Ruptures most frequently occurred during phacoemulsification (59.6%) and irrigation and aspiration (24.8%) stages. Risk factors for poor outcomes included age >65 years, dropped nuclei, and other complications. The overall capsule rupture rate was 1.8%. Although residents had higher rates, visual success matched faculty's, possibly attributable to case mix and close supervision. Associated risk factors for poor vision included age >65 years, dropped nuclei, and postoperative retinal, corneal, and IOL complications.

Manual small incision cataract surgery (MSICS) with posterior chamber intraocular lens versus phacoemulsification with posterior chamber intraocular lens for age-related cataract

Age-related cataract is a major cause of blindness and visual morbidity worldwide. It is therefore important to establish the optimal technique of lens removal in cataract surgery. To compare manual small incision cataract surgery (MSICS) and phacoemulsification techniques. We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 6), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2013), EMBASE (January 1980 to July 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to July 2013), Web of Science Conference Proceedings Citation Index - Science (CPCI-S) (January 1970 to July 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 23 July 2013. We included randomised controlled trials (RCTs) for age-related cataract that compared MSICS and phacoemulsification. Two authors independently assessed all studies. We defined two primary outcomes: 'good functional vision' (presenting visual acuity of 6/12 or better) and 'poor visual outcome' (best corrected visual acuity of less than 6/60). We collected data on these outcomes at three and 12 months after surgery. Complications such as posterior capsule rupture rates and other intra- and postoperative complications were also assessed. In addition, we examined cost effectiveness of the two techniques. Where appropriate, we pooled data using a random-effects model. We included eight trials in this review with a total of 1708 participants. Trials were conducted in India, Nepal and South Africa. Follow-up ranged from one day to six months, but most trials reported at six to eight weeks after surgery. Overall the trials were judged to be at risk of bias due to unclear reporting of masking and follow-up. No studies reported presenting visual acuity so data were collected on both best-corrected (BCVA) and uncorrected (UCVA) visual acuity. Most studies reported visual acuity of 6/18 or better (rather than 6/12 or better) so this was used as an indicator of good functional vision. Seven studies (1223 participants) reported BCVA of 6/18 or better at six to eight weeks (pooled risk ratio (RR) 0.99 95% confidence interval (CI) 0.98 to 1.01) indicating no difference between the MSICS and phacoemulsification groups. Three studies (767 participants) reported UCVA of 6/18 or better at six to eight weeks, with a pooled RR indicating a more favourable outcome with phacoemulsification (0.90, 95% CI 0.84 to 0.96). One trial (96 participants) reported UCVA at six months with a RR of 1.07 (95% CI 0.91 to 1.26).Regarding BCVA of less than 6/60: there were only 11/1223 events reported. The pooled Peto odds ratio was 2.48 indicating a more favourable outcome using phacoemulsification but with wide confidence intervals (0.74 to 8.28) which means that we are uncertain as to the true effect.The number of complications reported were also low for both techniques. Again this means the review is underpowered to detect a difference between the two techniques with respect to these complications. One study reported on cost which was more than four times higher using phacoemulsification than MSICS. On the basis of this review, removing cataract by phacoemulsification may result in better UCVA in the short term (up to three months after surgery) compared to MSICS, but similar BCVA. There is a lack of data on long-term visual outcome. The review is currently underpowered to detect differences for rarer outcomes, including poor visual outcome. In view of the lower cost of MSICS, this may be a favourable technique in the patient populations examined in these studies, where high volume surgery is a priority. Further studies are required with longer-term follow-up to better assess visual outcomes and complications which may develop over time such as posterior capsule opacification.

Incidence of and risk factors for vitreous loss in resident-performed phacoemulsification surgery

To determine the incidence of and risk factors for posterior capsule rupture and vitreous loss during phacoemulsification performed by ophthalmology residents. Academic ophthalmology resident training center, Tehran, Iran. Cross-sectional study. This study included patients who had phacoemulsification by ophthalmology residents from August 2010 to August 2011. The complications occurring during surgery and the rate of vitreous loss and posterior capsule rupture were studied. Five hundred eyes of 500 patients, including 255 (51%) men and 245 (49%) women with a mean age of 67 years ± 10 (SD) (range 27 to 105 years), were studied. Fifty-one eyes (10.2%) developed vitreous loss, and 48 eyes (9.6%) developed posterior capsule rupture and vitreous loss. On univariate analysis, significant risk factors for vitreous loss included diabetes mellitus (P=.001), shallow anterior chamber (P=.01), absence of supervision by a faculty member (P=.007), larger capsulorhexis (P=.02), anterior capsule tear (P=.001), and longer effective phacoemulsification time (EPT) (P=.003). Multivariate data analysis using stepwise logistic regression analysis showed anterior capsule tear (odds ratio [OR], 2.63; 95% confidence interval [CI], 1.09-6.29), longer EPT (OR, 1.01; 95% CI, 1.003-1.02), and lack of supervision by attending physicians (OR, 4.28; 95% CI, 1.44-12.67) to be significant independent risk factors associated with vitreous loss. Direct attending supervision and careful case selection for the level of cataract surgery residency are of utmost importance in avoiding sight-threatening complications.

Intensive cataract training: a novel approach

To evaluate the safety of an intensive cataract surgery training programme. An intensive cataract surgery training programme was implemented in August 2010 for year 3 ophthalmology trainees in the East Midlands Deanery North Rotation (United Kingdom). Trainees participated in extra-ocular surgery and 50 h of virtual reality cataract surgery simulator training over a 2-year period. Their third year comprised 6 months of intensive phacoemulsification training in a tertiary centre followed by a 6-month period of consolidation in a district general hospital. The complication rates and case numbers were evaluated after the first 2 years of implementation. At 2 years, three trainees had completed a full year of intensive training. In the first 6 months of training, Trainee 1 completed 156 cases, Trainee 2 completed 194 cases, and Trainee 3 completed 151 full cases as primary surgeons with an average rate of posterior capsule rupture (PCR) of 1%. At 12 months, Trainee 1 completed 291, Trainee 2 completed 318, and Trainee 3 completed 294 cases, with an average PCR rate of 0.66%. The trainees required 84 lists on average to complete 150 full cataract procedures. The combination of simulation and the new intensive training programme is safer than the traditional programme for cataract surgery training.

Cataract skills: how do we judge competency?

The approach suggested by Ho and Claoue1 of using the rate of posterior capsule rupture (PCR) during cataract surgery as a surrogate marker for competency in cataract surgery for surgeons who are not in training programmes is a reasonable one. The occurrence of PCR considerably increases the likelihood of further complications and a poorer than expected visual outcome. A model has also been proposed for the adjustment of PCR rates to take account of known preoperative risk factors, which can increase the risk of PCT by a factor of 50 or more.2 However, considerable caution is required when interpreting the rate of an adverse event when the number of operations performed is small. A second occurrence of PCR in a sample of 50 cataract operations doubles the rate from 2% to 4%, for example. It is therefore important to consider not just the rate of PCR but the clinical course following each occurrence of PCR. If the complication is not recognized or not managed adequately during the procedure, the risk of further complications (e.g. macular oedema, retinal detachment) and a poor visual outcome increases greatly.

COMPARISON OF INTRAOPERATIVE COMPLICATIONS OF PHACOEMULSIFICATION BETWEEN SEQUENTIAL AND COMBINED PROCEDURES OF PARS PLANA VITRECTOMY AND CATARACT SURGERY

To compare intraoperative complications during phacoemulsification between sequential and combined procedures of vitrectomy and cataract surgery. We retrospectively reviewed the medical records of 54 patients who underwent cataract surgery in a previously vitrectomized eye (sequential group) and 311 patients who underwent combined vitrectomy and cataract surgery (combined group). Primary outcome measures were intraoperative complications during phacoemulsification. Secondary measures were preoperative and intraoperative cataract gradings. The most common complication during phacoemulsification was posterior capsule rupture. The rate of posterior capsule rupture was higher in the sequential group (6 eyes, 11.4%) than in the combined group (14 eyes 4.5%, P = 0.049). Preoperative lens density (nuclear color and posterior subcapsular scores) was higher in the sequential group (P < 0.001). Intraoperative nuclear grading was higher compared with the preoperative one in the sequential group, but the two gradings did not differ in the combined group. Phacoemulsification in a vitrectomized eye is associated with a higher rate of posterior capsule rupture than the one in combined vitrectomy. These results may have been caused by hard nucleus cataract in a vitrectomized eye.