The publisher's final edited version of this article is available at Curr Opin Ophthalmol See other articles in PMC that cite the published article. Abstract Purpose Over the past several decades there have been many advances in the equipment, instrumentation and techniques of performing cataract surgery.
This review will address the impact of these advances on the safety profile of cataract surgery. Recent Findings Recent studies have demonstrated a decline in the risk of serious postoperative adverse events endophthalmitis, suprachoroidal hemorrhage, retinal detachment following cataract surgery. Factors that increase the risk of serious complications from cataract surgery include patient-related factors male sex, concomitant diabetic retinopathy, same day cataract surgery combined with another intraocular surgery, tamsulosin use and surgeon-related factors low surgical volume, limited experience, operating on patients who are most prone to adverse events.
Summary Cataract surgery continues to be a very safe surgical procedure with few patients experiencing serious sight-threatening adverse events. Studies in the literature have helped surgeons identify patients who are at high risk for surgical complications and to develop strategies to limit surgical complications when operating on these patients. As multifocal intraocular lenses, femtosecond laser technology, and other surgical innovations continue to gain popularity, it will be interesting in the coming years to determine whether there will be a continued reduction in complications of cataract surgery.
Cataract surgery, adverse events, complications Introduction Surgeons continually look for techniques to improve the efficiency, safety profile, and outcomes of cataract surgery, the most common surgical procedure in the United States. This review highlights the impact of technological advances in cataract surgery on rates of serious adverse events. Recent studies identifying patient- and surgeon-related factors that affect the risk for serious intraoperative or postoperative complications are also reviewed.
In a study performed at Aravind Eye Hospital, one-year rates of serious postoperative complications were more common with ICCE surgery For example, Schein et al. Although small-incision phacoemulsification has remained the standard of care, surgeons continue to debate whether modifications in surgical technique have affected complication rates. For example, a meta-analysis of over 3 million cataract surgeries revealed higher rates of endophthalmitis in — than in s.
The higher rates in the later years were attributed to the transition from scleral tunnel to sutureless clear cornea incisions, which may serve as a conduit for microorganisms to gain entry into the eye. In the first study, Freeman et al.
Potential factors associated with the reduced rates of severe complications in more recent cohorts include innovations in phacoemulsification technology, the types of instruments available to better manage complex cases pupil stretchers, capsular tension rings, dyes to stain the capsule , increased use of topical anesthesia, improvements in intraocular lenses, changes in preoperative or postoperative medication regimens, and better strategies to deal with intraoperative complications.
Risk Factors for Adverse Postsurgical Events The next section focuses on patient- and surgeon-related variables that may affect the risk for postoperative events. Using Medicare claims data from —, West et al. In fact, the investigators noted that white men had higher rates of adverse events, compared with other groups. Sex Several studies have reported increased rates of adverse postsurgical events among men. Patients with diabetes but no retinopathy and those with nonproliferative diabetic retinopathy had no difference in the risk for complications, compared with nondiabetic patients.
Some surgeons prefer combined surgeries, rather than staging the two procedures separately, since this affords them the opportunity to address two issues at once, without necessitating an additional trip to the operating room and a second exposure to the risks of anesthesia.
Additionally, sometimes performing cataract surgery to facilitate the ability to perform the second surgery e. Furthermore, retrobulbar anesthesia use, additional manipulation of ocular tissues, and intraocular-pressure fluctuations during these combined cases may predispose patients to suprachoroidal hemorrhage.
Additional research is needed to provide surgeons with evidence-based recommendations on whether same-day combined surgery is prudent when staging the two procedures is also an option. Surgeon Factors Surgeon Volume A few studies have assessed the impact of surgeon volume on risk of complications from cataract surgery. A study assessing adverse events from — at the Sunderland Eye Infirmary also found a decrease rate of complications among surgeons with the highest surgical volume.
Surgeon Experience Multiple investigators have studied rates of intraoperative and postoperative complications among cataract surgeries performed by resident surgeons.
Retrospective chart reviews of resident cataract surgeries the majority of which were phacoemulsifications performed at 13 different residency training programs, with sample sizes ranging from to patients, reported rates of posterior capsule rupture of 1. Critics of such comparisons have noted, however, that if some surgeons are routinely caring for more complicated patients relative to others and this is contributing to higher rates of complications, it will appear as though they are worse surgeons relative to others who routinely operate on less complex patients.
Specific Complications Endophthalmitis Endophthalmitis is a serious complication resulting from microorganisms gaining entry into the eye. Numerous studies have sought to identify the frequency of acute postoperative endophthalmitis, whether there has been an increase or decline in frequency with changes in surgical techniques, and risk factors that predispose patients to this complication. Estimates of postoperative endophthalmitis from eight large studies range from 0.
Collectively, among the 3,, patients undergoing cataract surgery, the endophthalmitis rate was 0. However, they noted a spike in endophthalmitis rates, up to 0. In multiple studies, rupture of the posterior capsule or need for anterior vitrectomy increases the risk of endophthalmitis considerably. Suprachoroidal Hemorrhage Suprachoroidal hemorrhage is a rare sight-threatening complication associated with incisional intraocular surgery. In the few studies that have quantified the incidence of suprachoroidal hemorrhage during or after cataract surgery, the rates have ranged from 0.
Two recent large-scale studies have quantified the proportion of patients experiencing posterior capsule rupture during cataract surgery.
Reviewing data on 55, cataract surgeries during — in the United Kingdom, Narendran et al. As technological advances, such as microincision cataract surgery, femtosecond laser assisted cataract surgery, and the use of multifocal intraocular lenses, continue to gain popularity, we will learn whether surgeons can achieve further reductions in the already low rates of adverse events associated with this procedure.
The Madurai Intraocular Lens Study. National outcomes of cataract extraction: Risk of endophthalmitis after cataract extraction: Variation in cataract surgery practice and clinical outcomes. Significant nonsurgical risk factors for endophthalmitis after cataract surgery: Invest Ophthalmol Vis Sci. Clinical outcomes and costs of cataract surgery performed by planned ECCE and phacoemulsification. Acute endophthalmitis following cataract surgery: Rate of endophthalmitis after cataract surgery in Quebec, Canada, — Severe adverse events after cataract surgery among medicare beneficiaries.
The analysis looked at temporal trends in rates of severe adverse events among the cohorts and identified risk factors associated with adverse events. Prevalence and predictors of ocular complications associated with cataract surgery in United States veterans. This study assessed predictors of adverse events among 45, individuals who underwent cataract surgery at Veteran Affairs Medical Centers throughout the United States from — Cataract surgery complications in nonagenarians.
The incidence of endophthalmitis after cataract surgery among the U. Medicare population increased between and The Cataract National Dataset electronic multicentre audit of 55, operations: Risk factors for retinal detachment after cataract surgery: Risk of retinal detachment after cataract extraction, — Retinal detachment after phacoemulsification cataract extraction. J Cataract Refract Surg. Relationship between retinal detachment and biometry in cataractous eyes.
Late increased risk of retinal detachment after cataract extraction. Upper lid skin bacterial count of surgical eye patients in Ibadan, Nigeria.
Afr J Med Med Sci. Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery. Prevalence of diabetes and impaired fasting glucose in adults in the U. National Health and Nutrition Examination Survey — Surgeon volumes and selected patient outcomes in cataract surgery: Association of hospital and surgeon operation volume with the incidence of postoperative endophthalmitis: Eye Lond Aug;20 8: The relation of volume with outcome in phacoemulsification surgery.
The Cataract National Dataset electronic multi-centre audit of 55, operations: Eye Lond May;24 5: Surgical outcomes of cataract extractions performed by residents using phacoemulsification. Visual outcomes and incidence of vitreous loss for residents performing phacoemulsification without prior planned extracapsular cataract extraction experience.
The resident surgeon phacoemulsification learning curve. Complications in resident-performed phacoemulsification cataract surgery at New Jersey Medical School. Outcomes of cataract surgery by residents at a public county hospital. Cataract surgery complications in 1 year at an academic institution.
Rowden A, Krishna R. Resident cataract surgical training in United States residency programs. Visual results and complications of phacoemulsification with intraocular lens implantation performed by ophthalmology residents.
Complications and results of phacoemulsification performed by residents. Phacoemulsification with topical anesthesia: Incidence of vitreous loss among third-year residents performing phacoemulsification. Outcomes of extracapsular cataract extraction and phacoemulsification performed in a university training program. Influence of surgery simulator training on ophthalmology resident phacoemulsification performance. The role of case mix in the relation of volume and outcome in phacoemulsification.
The Swedish National Cataract Register: Risk factors for acute endophthalmitis after cataract surgery: Risk factors of acute endophthalmitis after cataract extraction: National cataract surgery survey —8: Suprachoroidal haemorrhage complicating cataract surgery in the UK: Risk of acute suprachoroidal hemorrhage with phacoemulsification.
Obuchowska I, Mariak Z.