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Objectives: To describe the relationships between axial length and intraoperative complications in patients undergoing cataract surgery., Design: Cohort analysis of the Royal College of Ophthalmologists' National Ophthalmology Database (RCOphth NOD)., Setting: 110 National Health Service Trusts in England, Health Boards in Wales, Independent Sector Treatment Centres and Guernsey., Participants: 820 354 patients, aged 18 years or older, undergoing cataract surgery. Eligible operations were those from centres with at least 50 operations with a recorded axial length measurement and age at surgery between 1 April 2010 and 31 August 2019., Interventions: Phacoemulsification where the primary intention was cataract surgery alone., Outcome Measures: Posterior capsule rupture (PCR) and other recorded intraoperative complications., Results: 1 211 520 eligible operations were performed by 3210 surgeons. The baseline axial length was <21 mm (short eyes) for 17 170 (1.4%) eyes, 21-28 mm (medium eyes) for 1 182 513 (97.6%) eyes and >28 mm (long eyes) for 11 837 (1.0%) eyes. The median age at surgery was younger for patients with long eyes than those with short or medium eyes. The rate of any intraoperative complication was higher for short eyes than medium or long with complication rates of 4.5%, 2.9% and 3.3%, respectively (p<0.001). PCR occurred in 1.40% surgeries overall, and in 1.53%, 1.40% and 1.61% of short, medium and long eyes, respectively (p=0.043, not significant at the 1% level)., Conclusions: Overall PCR rates for cataract surgery in RCOphth NOD contributing centres are lower than previously reported and there is little change in PCR rates by axial length. Short eyes were more likely to have an intraoperative complication than medium or long eyes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cataract extraction is the most frequently performed surgical intervention in the world and demand is rising due to an ageing demography. One option to address this challenge is to offer selected patients immediate sequential bilateral cataract surgery (ISBCS). This study aims to investigate patient and operative characteristics for ISBCS and delayed bilateral cataract surgery (DSCS) in the UK., Methods: Data were analysed from the Royal College of Ophthalmologists' National Ophthalmology Database Audit (NOD) of cataract surgery. Eligible patients were those undergoing bilateral cataract extraction from centres with a record of at least one ISBCS operation between 01/04/2010 and 31/08/2018. Variable frequency comparison was undertaken with chi-square tests., Results: During the study period, 1073 patients had ISBCS and 248,341 DSCS from 73 centres. A higher proportion of ISBCS patients were unable to lie flat (11.3% vs. 1.8%; p < 0.001), unable to cooperate (9.7% vs. 2.7%; p < 0.001); underwent general anaesthesia (58.7% vs. 6.6% (p < 0.001)); had brunescent/white/mature cataracts (odds ratio (OR) 5.118); no fundal view/vitreous opacities (OR 8.381); had worse pre-operative acuity 0.60 LogMAR ISBCS vs. 0.50 (first) and 0.40 (second eye) DSCS and were younger (mean ages, 71.5 vs. 75.6 years; p < 0.001). Posterior capsular rupture (PCR) rates adjusted for case complexity were comparable (0.98% ISBCS and 0.78% DSCS)., Conclusions: ISBCS was performed on younger patients, with difficulty cooperating and lying flat, worse pre-operative vision, higher rates of known PCR risk factors and more frequent use of general anaesthesia than DSCS in centres recorded on NOD.

Objective: To investigate the impact of EyeSi surgical simulators on posterior capsule rupture (PCR) rates of cataract surgery performed by first and second year trainee surgeons., Design: A Royal College of Ophthalmologists' National Ophthalmology Database audit study of first and second year surgeons' PCR rates over seven consecutive National Health Service (NHS) years. Participating centres were contacted to ascertain the date when their surgeons had access to an EyeSi machine and whether this was on-site or off-site. Operations were classified as before, after or no access to EyeSi., Setting: The study took place in 29 NHS Ophthalmology Units in a secondary care setting., Results: Two-hundred and sixty five first and second year trainee surgeons performed 17 831 cataract operations. 6919 (38.8%) operations were performed before access to an EyeSi, 8648 (48.5%) after access to an EyeSi and 2264 (12.7%) operations by surgeons with no access to an EyeSi. Overall, there was a 38% reduction in the first and second year surgeon's unadjusted PCR rates from 4.2% in 2009 to 2.6% in 2015 for surgeons with access to an EyeSi, and a 3% reduction from 2.9% to 2.8% for surgeons without access to an EyeSi. The overall first and second year unadjusted PCR rates for before, after and no access to EyeSi were 3.5%, 2.6% and 3.8%, respectively. The decrease in the with-access to an EyeSi group PCR rate was similar for surgeons with access to an EyeSi 'on site' or 'off site'., Conclusions: First and second year trainee surgeons' unadjusted PCR rates have decreased since 2009 which has significant benefits for patients undergoing cataract surgery. This 38% reduction in complication rates aligns with the introduction of EyeSi simulator training., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To determine whether socioeconomic status influenced the presenting visual acuity prior to first eye cataract surgery in the English National Health Service. Retrospective case series from The Royal College of Ophthalmologists' National Ophthalmology Database Audit. In total 154,223 patients undergoing first eye cataract surgery at 68 centres in England performed between 1st September 2015 and 31st August 2017., Main Outcome Measure: Social deprivation status and pre-operative visual acuity (VA) between centres for patients undergoing first eye cataract surgery in England., Results: The median social deprivation varied between centres and ranged from decile 2 (2nd most deprived decile) to decile 9 (2nd least deprived decile). The pre-operative VA was reported for 143,401 (93.0%) eyes. The median pre-operative VA was 0.50 LogMAR (6/19), and 27.7% eyes had a preoperative VA of 0.30 LogMAR units (6/12) or better. The median pre-operative VA for each centre ranged from 0.30 to 0.60 LogMAR (6/12 to 6/24). The median pre-operative VA was mostly stable across deciles of social deprivation (0.60 LogMAR for decile 1 and 0.50 LogMAR for all other deciles), and some evidence was found linking greater deprivation to worse pre-operative VA and to lower levels of access., Conclusions: We found no strong evidence of inequality for gaining access to first eye cataract surgery in this National Ophthalmology Database analysis, however there was a possible trend towards fewer people in the more deprived deciles accessing surgery, and that some of these are presenting with quite marked levels of visual impairment.

Background: Older age is commonly associated with an increased risk of surgical complications and comparatively poor outcomes., Purpose: To report cataract surgery outcomes and risk indicators for patients aged 90 years and older., Methods: Data collected as part of routine cataract care in 34 centres contributing to the United Kingdom Royal College of Ophthalmologists' National Ophthalmology Database (NOD) were analysed. Very elderly people undergoing cataract surgery were profiled in terms of demographics, pre- and postoperative best-measured visual acuity (VA), ocular co-morbidities, intraoperative posterior capsule rupture (PCR) or vitreous loss or both, and risk indicators for operative PCR and adverse VA outcome., Results: 25,856 cataract operations in 19,166 people of 90 years or older between 2000 and 2014 are reported. Preoperative VA was available for 82.4% eyes, being 0.30 LogMAR or better in 21.5%. Postoperative VA was available for 61.8% eyes, being 0.30 LogMAR or better in 74.4%. For those without ocular co-morbidity, postoperative VA was 0.30 LogMAR or better in 84.7%. Various co-morbidities were present in 49% and contributed to an adverse VA outcome. PCR data were available for all operations and occurred in 2.7%. Significant risk indicators for PCR included pseudoexfoliation/phakodonesis, mature cataract, smaller pupil and worse preoperative VA., Conclusions: Slightly poorer cataract surgery outcome results were noted in patients of 90 years or older, more so in patients with ocular co-morbidity which was highly prevalent. However, surgeons should not be deterred from offering cataract surgery to the very elderly as successful visual rehabilitation remains achievable.

Objectives: To report outcome data on the first 5000 consecutive cataract cases at a new paperless eye unit and benchmark against the Royal College of Ophthalmologists' National Ophthalmology Database (RCOphth NOD)., Methods: Using the in-built audit tool of the electronic medical records system, data from all cataract operations performed between 1 April 2014 and 13 January 2017 were compiled., Results: Five thousand and eight cases were recorded of which the overall intra-operative complication rate was 2.4%, the most common being posterior capsular rupture-1.14%. Follow-up data on post-operative complications were recorded in 98.6% of cases. Pre- and post-operative visual acuities was measured in 98.0% of cases. In all, 40.8% of eyes achieved a visual acuity of 6/6 or better and 90.7% achieved 6/12 or better., Conclusions: A data set of >5000 consecutive cataract operations was obtained in this eye department. The recording of pre- and post-operative visual acuity in 98% of cases compare very favourably to the RCOphth NOD Audit Report 2017 where pre- and post-operative visual acuities were recorded in only 57.1% of operations. Despite this difference, the outcome measures from this unit and RCOphth NOD were very similar, validating the results of the RCOphth NOD audit reports. Significantly, when applying the RCOphth NOD audit criteria for measuring post-operative visual acuity, approximately 15% of cases were excluded from the data set, reducing the completeness of the data set. Paperless ophthalmology units are feasible in today's NHS and can produce near complete cataract data sets; this can ultimately lead to more comprehensive and reliable aggregate cataract outcome data.

Purpose: To compare the clinical results of conventional phacoemulsification surgery (CPS) with femtosecond laser-assisted cataract surgery., Setting: Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom., Design: Single-center prospective randomized interventional case-controlled trial., Methods: Patients undergoing cataract surgery were randomized to receive either CPS or femtosecond laser-assisted cataract surgery. The surgery was performed with a femtosecond laser (Lensx), and all operations were performed with a gravity-fluidics torsional phacoemulsification machine (Infiniti). The visual acuity, refraction, central corneal thickness (CCT), central foveal thickness (CFT), endothelial cell loss, and rates of intraoperative and postoperative events were recorded. Quality of life outcomes were measured with the EuroQOL 5 dimensions questionnaire (EQ-5D) and patient-reported quality of vision was assessed with a cataract surgery patient-reported outcome measures questionnaire (Cat-PROM5)., Results: The study comprised 400 eyes of 400 patients who had CPS (n = 200) or femtosecond laser-assisted cataract surgery (n = 200). Seven patients (3.5%) in the femtosecond laser-assisted group were not able to complete the treatment and received CPS. The mean uncorrected distance visual acuity (logarithm of the minimum angle of resolution [logMAR]) 0.15 ± 0.21 (SD) and 0.15 ± 0.19 logMAR after CPS and femtosecond laser-assisted surgery, respectively (P = 1.0); the pinhole-corrected visual acuity was 0.04 ± 0.12 and 0.04 ± 0.12, respectively (P = 1.0); the increase in CCT was 13 ± 19 μm and 15 ± 25 μm, respectively (P = .5); and the endothelial cell loss was 9.7 ± 13.7 % and 10.2% ± 13.7, respectively (P = .76). The manifest refraction spherical equivalent error was -0.14 ± 0.60 diopters (D) after CPS and -0.12 ± 0.60 D after femtosecond laser-assisted surgery (P = .74); the mean change in CFT was 9 ± 35 μm and 6 ± 35 μm, respectively (P = .55); and the rate of posterior capsule rupture was 3% and 0%, respectively (P = .03)., Conclusions: This study confirms the nonsignificant differences between 2 treatment modalities, notwithstanding a significant reduction in posterior capsule ruptures in the femtosecond laser-assisted surgery group., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Background Cataract surgery is the most frequently undertaken NHS surgical procedure. Visual acuity (VA) provides a poor indication of visual difficulty in a complex visual world. In the absence of a suitable outcome metric, recent efforts have been directed towards the development of a cataract patient-reported outcome measure (PROM) of sufficient brevity, precision, and responsiveness to be implementable in routine high volume clinical services.Aim To compare and contrast the two most promising candidate PROMs for routine cataract surgery.Method The psychometric performance and patient acceptability of the recently UK developed five-item Cat-PROM5 questionnaire was compared with the English translation of the Swedish nine-item Catquest-9SF using Rasch-based performance metrics and qualitative semistructured interviews.Results Rasch-based performance was assessed in 822 typical NHS cataract surgery patients across four centres in England. Both questionnaires demonstrated good to excellent performance for all metrics assessed, including Person Reliability Indices of 0.90 (Cat-PROM5) and 0.88 (Catquest-9SF), responsiveness to surgery (Cohen's standardized effect size) of 1.45 SD (Cat-PROM5) and 1.47 SD (Catquest-9SF) and they were highly correlated with each other (R=0.85). Qualitative assessments confirmed that both questionnaires were acceptable to patients, including in the presence of ocular comorbidities. Preferences were expressed for the shorter Cat-PROM5, which allowed patients to map their own issues to the questions as opposed to the more restrictive specific scenarios of Catquest-9SF.Conclusion The recently UK developed Cat-PROM5 cataract surgery questionnaire is shorter, with performance and patient acceptability at least as good or better than the previous 'best of class' Catquest-9SF instrument.

PurposeTo develop a short, psychometrically robust and responsive cataract patient reported outcome measure suitable for use in high-volume surgical environments.MethodsA prospective study in which participants completed development versions of questionnaires exploring the quality of their eyesight using items harvested from two existing United Kingdom developed parent questionnaires. Participants were 822 patients awaiting cataract surgery recruited from 4 cataract surgical centres based in the UK. Exclusion criteria were other visually significant comorbidities and age <50 years. An iterative multi-stage process of evaluation using Rasch and factor analyses with sequential item reduction was undertaken.ResultsA definitive item set of just five items delivered performance in accordance with the requirements of the Rasch model: no threshold disordering, no misfitting items, Rasch-based reliability 0.90, person separation 2.98, Cronbach's α 0.89, good targeting of questions to patients with cataract with pre-operative item mean -0.41 logits and absence of significant floor or ceiling effects, minor deviations of item invariance, and confirmed unidimensionality. The test-re-test repeatability intra-class correlation coefficient was 0.89 with excellent responsiveness to surgery, Cohen's d -1.45 SD. Rasch calibration values are provided for Cat-PROM5 users.ConclusionsA psychometrically robust and highly responsive five-item cataract surgery patient reported outcome measure has been developed, which is suitable for use in high-volume cataract surgical services.

Purpose: To investigate time to pseudophakic retinal detachment (RD) after cataract surgery with posterior capsule rupture (PCR) to provide an evidence-based guide for postoperative management., Design: Retrospective case series., Participants: A total of 61 907 eyes of 46 824 patients undergoing cataract surgery., Methods: Subanalysis of the United Kingdom Royal College of Ophthalmologists' National Ophthalmology Database from 13 sites where data on both cataract and vitreoretinal surgery were recorded on the same electronic medical records system. Overall, 61 907 cataract operations were performed between October 2006 and August 2010. Analyses were restricted to cases with at least 3 months of potential postoperative follow-up., Results: Pseudophakic RD surgery was performed on 131 eyes of 129 patients (0.21%; 95% confidence interval [CI], 0.18%-0.25%). Of these, 36 were in eyes that had PCR during cataract surgery (3.27%; 95% CI, 2.37%-4.50%) and 95 were in eyes that did not have PCR (0.16%; 95% CI, 0.13%-0.19%). For eyes that progressed to RD surgery, the median time to pseudophakic RD surgery was 44 days for eyes with PCR, and 6.3 months for eyes without PCR. For all eyes (both with and without PCR), pseudophakic RD occurred earlier in cases performed by a trainee cataract surgeon., Conclusions: Pseudophakic RD occurs earlier after cataract surgery complicated by PCR. Surgeon grade is a risk factor for pseudophakic RD. Posterior vitreous detachment and RD symptoms should be discussed with patients who undergo cataract surgery and have PCR to facilitate early attendance, and careful dilated postoperative examination for retinal tears is recommended in the first 2 months after surgery., (Copyright © 2016 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: 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., Methods: 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)., Results: 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)., Conclusion: Rates of ocular comorbidities vary by axial length. PCR rates in eyes with very short or long axial lengths were lower than expected.

Importance: Aligning outcome measures for cataract surgery, one of the most frequently performed procedures globally, may facilitate international comparisons that can drive improvements in the outcomes most meaningful to patients., Objective: To propose a minimum standard set of outcome measures for cataract surgery that enables global comparisons., Design, Setting, and Participants: A working group of international experts in cataract outcomes and registries was convened, along with a patient advocate, to agree on a consensus of outcome measures for cataract surgery. In a modified Delphi process, the group met regularly between November 10, 2012, and November 21, 2013, to discuss which outcomes to include in a standard set. Included factors were based on extant literature, existing registries, and the experience of group members. Similarly, a series of consensus discussions were held to determine a set of risk factors to be gathered for each patient. The final shortlist was compiled into a standard set. Analysis was performed from November 22, 2013, to April 5, 2014., Main Outcomes and Measures: Development of a recommended standard set encompassing preoperative metrics including patient risk factors, intraoperative factors including surgical complications, and postoperative cataract surgery outcomes., Results: The recommended standard set encompasses all patients treated for cataracts by 1 of 4 surgical approaches (phacoemulsification, sutured manual extracapsular cataract extraction, sutureless manual extracapsular cataract extraction, or intracapsular cataract extraction). The recommended metrics to be recorded preoperatively include demographics, ocular history and comorbidities, preoperative visual acuity, and patient-reported visual function. The recommended outcomes were split into intraoperative and postoperative metrics. Intraoperative outcomes include capsule-related problems, dislocation of lens nucleus fragments into the vitreous, and other complications. Postoperative outcomes include visual acuity, refractive error, patient-reported visual function, and early and late complications of surgery. The suggested follow-up for collection of postoperative outcomes is up to 3 months., Conclusions and Relevance: A minimum standard set of outcome measures for cataract surgery is important for meaningful comparison across contexts. The proposed data set is a compromise between all useful data and the practicalities of data collection.

Aims: To describe the outcomes of cataract surgery in the United Kingdom., Methods: 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. Outcome measures included intraoperative and postoperative complication rates, and preoperative and postoperative visual acuities., Results: Median 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., Conclusion: These 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.

Aim: To report the vitreoretinal (VR) surgical case mix in the United Kingdom, the intraoperative complication rate of pars plana vitrectomy (PPV), and the incidence of post-vitrectomy cataract extraction., Methods: Participating hospitals prospectively collected ophthalmic data using a single electronic medical record system, with automatic extraction of anonymised data to a national database. This study included the subset of 11618 VR operations undertaken on 9619 eyes, of 8741 patients, over 8 years, from 27 sites. Surgical data included the indication for surgery, all procedure elements, and whether or not an intraoperative complication occurred. Post-vitrectomy cataract data were also analysed. The main outcome measures were a description of the indications for surgery, intraoperative PPV complication rate, and percentage of eyes undergoing post-vitrectomy cataract surgery (PVCS)., Results: The most common indications for VR intervention were retinal breaks and rhegmatogenous retinal detachment (48.5%), macular hole (9.8%), epiretinal membrane (9.6%), and diabetic eye disease (7.3%). Overall, 7.8% of PPVs had at least one intraoperative complication-the most common were iatrogenic retinal breaks (3.2%), and lens touch (1.2-1.6% of phakic eyes). PVCS occurred in 50.2, 68.7, and 74.0% of eyes at 1, 2, and 3 years, respectively., Conclusion: VR surgery is undertaken for a wide range of conditions, but a small number of diagnoses encompass the majority of cases. Intraoperative PPV complications are not uncommon, and post-vitrectomy cataract is to be expected in most phakic eyes.

Aims: To report risk factors for visual acuity (VA) improvement and harm following cataract surgery using electronically collected multi-centre data conforming to the Cataract National Dataset (CND)., Methods: Routinely collected anonymised data were remotely extracted from the electronic patient record systems of 12 participating NHS Trusts undertaking cataract surgery. Following data checks and cleaning, analyses were performed to identify risk indicators for: (1) a good acuity outcome (VA 6/12 or better), (2) the pre- to postoperative change in VA, and (3) VA loss (doubling or worse of the visual angle)., Results: In all, 406 surgeons from 12 NHS Trusts submitted data on 55,567 cataract operations. Preoperative VA was known for 55,528 (99.9%) and postoperative VA outcome for 40,758 (73.3%) operations. Important adverse preoperative risk indicators found in at least 2 of the 3 analyses included older age (3), short axial length (3), any ocular comorbidity (3), age-related macular degeneration (2), diabetic retinopathy (3), amblyopia (2), corneal pathology (2), previous vitrectomy (2), and posterior capsule rupture (PCR) during surgery (3). PCR was the only potentially modifiable adverse risk indicator and was powerfully associated with VA loss (OR=5.74)., Conclusion: Routinely collected electronic data conforming to the CND provide sufficient detail for identification and quantification of preoperative risk indicators for VA outcomes of cataract surgery. The majority of risk indicators are intrinsic to the patient or their eye, with a notable exception being PCR during surgery.

Aims: To develop a methodology for case-mix adjustment of surgical outcomes for individual cataract surgeons using electronically collected multi-centre data conforming to the cataract national data set (CND)., Methods: Routinely collected anonymised data were remotely extracted from electronic patient record (EPR) systems in 12 participating NHS Trusts undertaking cataract surgery. Following data checks and cleaning, analyses were carried out to risk adjust outcomes for posterior capsule rupture rates for individual surgeons, with stratification by surgical grade., Results: A total of 406 surgeons from 12 NHS Trusts submitted data on 55,567 cataract operations between November 2001 and July 2006 (86% from January 2004). In all, 283 surgeons contributed data on >25 cases, providing 54,319 operations suitable for detailed analysis. Case-mix adjusted results of individual surgeons are presented as funnel plots for all surgeons together, and separately for three different grades of surgeon. Plots include 95 and 99.8% confidence limits around the case-mix adjusted outcomes for detection of surgical outliers., Conclusions: Routinely collected electronic data conforming to the CND provides sufficient detail for case-mix adjustment of cataract surgical outcomes. The validation of these risk indicators should be carried out using fresh data to confirm the validity of the risk model. Once validated this model should provide an equitable approach for peer-to-peer comparisons in the context of revalidation.

Aims: To demonstrate variations in posterior capsule rupture (PCR) rate between surgeons of the same and different grades as a by-product of routine clinical care., Method: NHS departments using electronic medical record (EMR) systems to collect the Cataract National Dataset (CND) were invited to submit data. Data were remotely extracted, anonymised, assessed for conformity and completeness, and analysed for rates of PCR for individual surgeons within each of the three grades., Results: Data were extracted on 55,567 cataract operations performed at 12 NHS trusts by 406 surgeons between November 2001 and July 2006. Data on the grade of 404 of the 406 surgeons who contributed to the study were available for 55,515 cases (99.9%) and were used for this analysis. Variation in PCR rate between surgeons was highest for the most junior grade of surgeon and between those surgeons contributing relatively few cases to the data set. Variation in PCR was lowest among experienced surgeons contributing large numbers of cases to the data set., Conclusions: Considerable variation in PCR rate exists both between and within surgical grades. Routine electronic collection of the CND allows detailed analysis of variations in PCR rates between individual surgeons. To define acceptable limits for this benchmark complication of cataract surgery, further work is needed to adjust surgeons' outcomes for the case mix complexity.

Purpose: Calculation of intraocular lens (IOL) power for implantation during cataract surgery depends on ocular biometric measurements. The aim of this study was to characterise the normal range of intra- and interindividual variation in axial length (AL) and corneal power (K) when IOLMaster measurements were possible and to derive recommendations as to which outlying measurements merit verification before acceptance., Methods: The Medisoft electronic patient database contains prospectively collected data conforming to the United Kingdom (UK) Cataract National Dataset on 55,567 cataract operations. From this AL and K information on the 32,556 eyes (14,016 paired) of patients older than 25 years, without corneal pathology, history of intraocular surgery and who had all biometric measurements taken with the Zeiss IOLMaster (Carl Zeiss Meditec) were extracted. R 2.8.1 (R Foundation for Statistical Computing) was used for statistical analysis., Results: Mean age was 76.4 years and 62.0% were female. Mean (95% confidence interval) values for AL, mean K and corneal astigmatism were 23.40 (21.27-26.59) mm, 43.90 (40.94-47.01) D and 1.04 (<2.50) D. Nearly all astigmatism was either with or against the rule. Differences between paired eyes were not statistically significant. 95% individuals had asymmetry of AL and mean K<0.70 mm and 0.92 D, respectively., Conclusions: On the basis of approximation of the 95% CI above, it is suggested that AL, mean K and keratometric astigmatism measurements outside the ranges 21.30-26.60 mm, 41.00-47.00 D and >2.50 D, respectively, and intraindividual asymmetry of AL >0.70 mm or mean K>0.90 D should be verified before acceptance.

Aims: To compare the quality of referrals and listing rates of direct optometric referrals vs traditional GP referrals for cataract surgery., Methods: A retrospective cohort of 124 patients referred for cataract surgery was identified (62 via optometric pathway and 62 via GP pathway). The quality of the referral was assessed by establishing if it contained adequate information relating to the College of Optometrists' referral framework document. Age, sex, drug history, listing rate, operative rate, and visual acuity (best corrected) at referral and at the postoperative visit were recorded and compared between the two referral pathways using the Fisher's exact test., Results: Optometric referrals, relative to GP referrals, were more likely to include information relating to objective visual loss (100 vs 87%, P=0.0061) and to counsel the patient (97 vs 18%, P=0.0001). GP referrals, relative to optometric referrals, were more likely to comment on personal circumstances (32 vs 3%, P=0.0001), past medical history (95 vs 68%, P=0.0001), and drug history (94 vs 69%, P=0.0009). Operative rates were higher for the optometric direct referrals relative to GP referrals (87 vs 69%, P=0.0284). There was no difference in the visual acuity before or after surgery between the pathways., Conclusions: Optometric direct cataract referrals provide better information on objectively measured vision and better delivery of preoperative counselling. Traditional GP referrals contain better medical history, drug information, and details of personal circumstances. Rates of surgery were slightly higher with optometric referrals.

Aims: To pilot the use of the Cataract National Dataset (CND) using multi-centre data from Electronic Patient Record (EPR) systems and to demonstrate the ability of the CND to deliver certain of its intended benefits, including detailed preoperative profiling of cataract surgery patients and updating of benchmark standards of care in the NHS and beyond., Methods: NHS departments using EPR systems to collect a minimum preoperative, anaesthetic, operative and postoperative data set, the CND, were invited to submit data, which were remotely extracted, anonymised, assessed for conformity and completeness, and analysed., Results: Four-hundred and six surgeons from 12 NHS Trusts submitted data on 55,567 cataract operations between November 2001 and July 2006 (86% from January 2004). Mean age (SD) was 75.4 (10.4) years, 62.0% female. Surgery was for first eyes in 58.5%, under local anaesthesia in 95.5% and by phacoemulsification in 99.7%. Trainees performed 33.9% of operations. Preoperative visual acuity (VA) was 6/12 or better in 42.9% eyes overall, in 35.3% first eyes and in 55.3% second eyes. Complication rates included the following: posterior capsule rupture and/or vitreous loss of 1.92%, simple zonule dialysis of 0.46% and retained lens fragments of 0.18%. Postoperative VA of 6/12 or better (and 6/6 or better) was achieved for 91.0% (45.9%) of all eyes, 94.7% (51.0%) of eyes with no co-pathologies and 79.9% (30.2%) of eyes with one or more co-pathologies respectively., Conclusions: The CND is fit for purpose, is able to deliver useful benefits and can be collected as part of routine clinical care via EPR systems. This survey confirms shifts in practice since the 1997-1998 UK National Survey with full conversion to phacoemulsification, better preoperative acuity, a halving of the surgical 'index' benchmark complication of posterior capsule rupture and/or vitreous loss, and improved VA outcomes.

Aims: This study aims to establish the prevalence of aspirin, dipyridamole, clopidogrel, and warfarin use in patients undergoing cataract surgery, and to compare local anaesthetic and intraoperative complication rates between users and non-users., Methods: The Cataract National Dataset was remotely extracted and anonymised on 55,567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006., Results: This report analyses 48,862 of the 55,567 operations from the eight centres, which routinely recorded a drug history. In all, 28.1% of the 48,862 patients were taking aspirin, 5.1% warfarin, 1.9% clopidogrel, and 1.0% dipyridamole. The recording of any complication of a sharp needle or subtenon's cannula local anaesthetic block was increased in patients taking clopidogrel, 8.0% (P<0.0001) or warfarin, 6.2% (P=0.0026) vs non-users, 4.3%, but no increase in potentially sight-threatening complications was identified. The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel, 4.4% (P<0.0001) or warfarin, 3.7% (P<0.0001) vs non-users, 1.7%. The recording of any operative complication was increased in those taking clopidogrel, 7.3% (P=0.0002) vs non-users, 4.4%, but the haemorrhagic operative complications of choroidal/suprachoroidal haemorrhage and hyphaema were not significantly increased. The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel, 3.23% (P=0.0057) vs non-users, 1.77%., Conclusions: Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenon's cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications.

Aims: To identify and quantify risk factors for posterior capsule rupture or vitreous loss or both (PCR or VL or both) during cataract surgery and provide a method of composite risk assessment for individual operations., Methods: The Cataract National Dataset was extracted on 55,567 operations from 12 National Health Service (NHS) Trusts using an electronic patient record (EPR) system between November 2001 and July 2006. Risk indicators for variations in the rate of 'PCR or VL or both' were identified by univariate and multivariate analyses. Adjusted odds ratios (ORs) were used to formulate a composite 'bespoke' risk for individual cases., Results: Overall 'PCR or VL or both' rate was 1.92% (95% CI=1.81-2.04%). Risk indicators for this complication were increasing age, male gender, presence of glaucoma, diabetic retinopathy, brunescent/white cataract, no fundal view/vitreous opacities, pseudo-exfoliation/phacodonesis, reducing pupil size, axial length > or = 26.0 mm, the use of the alpha-blocker doxazosin, inability to lie flat and trainee surgeons performing operations. Adjusted ORs for these variables are used to estimate overall composite risk across multiple risk indicators in the form of a predicted probability of PCR or VL or both. Predicted probability for this complication ranged from less than 0.75% to more than 75%, depending on risk profile of individual operations., Conclusions: Higher-risk cases can be predicted, thus better informing the consent process and allowing surgeons to take appropriate precautions. Case-mix is a major determinant of the probability of an intraoperative complication. A simple composite risk estimation system has been developed.

Purpose: The primary aim of this study was to detail anaesthetic techniques and complications for cataract surgery in the UK., Methods: The Cataract National Dataset was extracted from 12 National Health Service Trusts that used the same electronic patient record system between November 2001 and July 2006 on a total of 55,567 cataract operations., Results: Anaesthesia was administered by an ophthalmologist in 56.7% of the cases, a career anaesthetist in 42.1% of the cases, a clinical assistant anaesthetist in 0.3% of the cases, and staff were not recorded in 0.9% of the cases. Local anaesthesia (LA) was used in 95.5%, with topical anaesthesia alone in 22.3% (range by site, 0-99.8%), topical and intracameral in 4.7% (range, 0-24.1%), subtenons in 46.9% (range, 0-81.8%), peribulbar in 19.5% (range, 0-63.4%), and retrobulbar in 0.5% (range, 0-5.3%). One or more minor complications occurred in 4.3% of 38,058 local blocks administered by either sharp needle or subtenons (blunt) cannula. Minor complications were 2.3 times more common with subtenons blocks (P<0.001). Serious complications, defined as sight or life threatening occurred in 25 eyes, 0.066%, undergoing sharp needle or subtenons cannula blocks. Sharp needle techniques had a 2.5-fold increased risk of serious complications compared with subtenons cannula techniques (P=0.026)., Conclusion: Subtenons anaesthesia was the most widely used anaesthetic technique for cataract surgery but wide variation existed by site. There was a low rate of reported LA complications. There was a statistically significant increased risk of serious complications with sharp needle anaesthesia compared with subtenons technique.

Background: Endophthalmitis remains a serious and potentially blinding complication of cataract surgery with an overall incidence of approximately 0.14% or one in 700 operations. Despite this knowledge of overall frequency, healthcare providers find themselves confronted with clusters of cases where the appropriate level of response to the cluster is uncertain., Aim: To illustrate, by means of Monte-Carlo simulation models, the likelihood of random clustering of cases arising in units within a healthcare setting resembling the NHS and separately within the practices of individual surgeons., Method: Simulation models were constructed within a programming language in which individual cataract operations were simulated with a one in 700 likelihood of each operation resulting in a 'case of endophthalmitis'. Random clustering of 'cases of endophthalmitis' was observed in the models and 'outbreaks' were noted and tracked for various outbreak definitions., Results: The model outputs are presented graphically as the proportion of 'simulated units' affected by an 'outbreak' in a year and separately as the proportion of surgeons affected for a range of 'outbreak definitions'., Conclusion: These data presentations are easy to use and should facilitate a better understanding of shifts from endemic to epidemic rates of endophthalmitis with appropriate investigation of situations where a remediable common cause may exist.

Aim: The primary aim of this large pilot survey was to demonstrate the use and benefits of electronic data collection with respect to rapidly monitoring the access, delivery, and outcome of cataract surgery in the NHS and to update benchmark standards for these parameters of care., Method: Eight NHS departments that currently use specialty-specific electronic clinical systems or Electronic Patient Records (EPR) to collect a minimum preoperative, operative, and anaesthetic data set for cataract surgery agreed to pool their data., Results: A total of 162 surgeons from 50 consultant teams and eight NHS Trusts agreed to submit their data on a total of 16,541 operations for age-related cataract. This report describes the age, sex, and ethnic profiles of the patients, waiting time for surgery, ocular copathology causing a reason for a guarded visual prognosis, visual impairment on admission, visual acuity in the operated eye, and the characteristics of the anaesthetic and surgical procedures., Conclusions: This survey has raised the benchmark standards established by the last National Survey in 1997. There has been a near universal switch to day case, phacosurgery under local anaesthesia (all used in > or =99.1% of cases compared with 70, 77, and 86%, respectively in 1997). The visual impairment in the operated eye is lower with 45% having 6 / 12 or better compared with 27% in 1997. Waiting times and visual impairment in the fellow eye have probably improved although data collection for these variables was incomplete. All departments require specialty-specific clinical systems to efficiently collect and analyse these data and this survey proves their potential to form the basis for national electronic surveys in the future.

Introduction: The aim of this study was to assess the vision-related quality of life (VR-QOL) in patients with good distance Snellen visual acuity (VA) who are listed for cataract surgery., Methods: An observational cross-sectional prospective study of patients listed for cataract surgery. VA and VR-QOL data using the VCMI questionnaire were collected on patients attending preoperative assessment during June 2002., Results: A total of 397 cataract patients were listed during this month. Following exclusions there were 378 eligible individuals, 210 (56%) of whom had a VA of 6/12 or better in the eye scheduled for surgery. Of these, 40% patients had only mild VR-QOL impairment. More than half of the patients with good VA (6/12 or better) in the surgery eye and mild VR-QOL impairment described their vision as poor in this eye. However, most of these patients were not dissatisfied with their overall level of vision., Conclusion: A significant number of patients listed for cataract surgery with VA of 6/12 or better had only mild VR-QOL impairment and were not dissatisfied with their overall level of vision. The decision to list a patient for surgery may have been based on the patient's perception of monocular vision rather than their quality of life.

Aim: To investigate the examination of lens opacities in routine ophthalmic clinical practice., Method: A questionnaire survey was mailed to 703 consultant ophthalmologists in the UK. The surgeons were asked which lens feature(s) they assessed in their clinics when deciding whether to offer cataract surgery., Results: 489 replies were received. A broad range of lens opacities was assessed, with differences between surgeons for some opacities with high prevalences in the population, particularly cortical opacities. Many (74% of 467) surgeons assessed one or more lens opacities (anterior subcapsular cataract, vacuoles, water clefts, coronary flakes, focal dots, retrodots, fibre folds) which may be visually important but which have received relatively little attention by researchers., Conclusions: Some classes of lens opacity which are traditionally measured by researchers may be ignored in clinical practice and opacities which are traditionally ignored by some researchers are regarded as clinically important by a substantial number of surgeons.

Aim: To provide information on the use of vision tests in clinical decision making about cataract surgery in the UK., Method: A questionnaire survey was mailed to 703 consultant ophthalmologists., Results: A response rate of 70% was obtained. Monocular distance visual acuity was the only visual function that was tested routinely by all surgeons. Supplementary use of contrast sensitivity and glare testing was low. Many surgeons (35%) were willing to consider surgery at acuity levels better than 6/9 and a small but substantial number (12%) indicated that they did not use an acuity criterion. Being prepared to consider surgery at relatively good levels of acuity was not associated with more common use of other tests of vision., Conclusion: Many UK surgeons are prepared to consider cataract extraction at relatively good levels of visual acuity and use other vision tests infrequently.

Background: The effectiveness of cataract surgery on one eye is well established, but concerns over health-care expenditure have called into question the value of cataract surgery on the second eye. We examined the effects of second eye surgery in terms of patient perceptions as well as through visual acuity, contrast sensitivity, and stereoacuity tests., Methods: 208 otherwise healthy patients awaiting second eye cataract surgery were recruited into our randomised trial. At randomisation participants were allocated expedited surgery (planned to take place within 6 weeks) or routine surgery (routine waiting time, 7-12 months). Assessments were made at randomisation and again at review after about 6 months. Eight primary trial outcomes consisted of four questionnaire items and four visual function tests, done with both eyes open., Findings: Traditional clinical tests of success in cataract surgery (visual acuity and contrast sensitivity) showed only slight differences in binocular vision in favour of the expedited-surgery group. There were major benefits for the expedited-surgery group in terms of reported visual symptoms and effects on quality of life. At review, differences in self-reported vision related difficulties between the two groups ranged from 11% (95% CI 4.4-17%, activities) to 30% (19-41%, reading). Stereoacuity was better in the expedited surgery group, the difference between the groups for the proportions with stereoacuity of 3000 s of arc or worse was 58% (47-69%)., Interpretation: This trial has shown that there is a clear benefit from second eye cataract surgery.

Forty-six cases of vitreous loss during planned extracapsular cataract extraction salvaged by anterior vitrectomy and primary anterior chamber lens implantation were compared in a retrospective cohort study with 92 individually matched controls. The postoperative visual outcome for cases with vitreous loss was significantly poorer than that for controls even after adjustment for confounding variables. Part of this visual morbidity was explained by cystoid macular oedema and retinal detachment, but even after adjusting for these two complications visual outcome remained worse among cases than controls. There was a significantly higher incidence of clinically apparent cystoid macular oedema amongst cases compared with controls (20% versus 1%). Two retinal detachments occurred among the cases but this difference in incidence was not statistically significant.

A study is reported on cataract surgery, with intraocular lens implant, with measurement of the preoperative astigmatism and of the postoperative astigmatism over 28 weeks. Nine interrupted 10/0 nylon sutures are used to close a limbal section. Preoperative astigmatism is compensated for in the method of suturing by the placement of additional sutures. Postoperatively sutures are cut in line with the plus cylinder axis in eyes showing excessive astigmatism with the rule. Final postoperative astigmatism is controlled within 2.25 D cyl. 68% of cases lie within 1.0 D cyl with the rule to 1.0 D cyl against the rule. The average case in which sutures are not cut is one having 1.51 D cyl with the rule at one week postoperatively, declining to zero at approximately 12 weeks, and having a final value of 0.17 D cyl against the rule. No significant change in cylinder is seen after 10 weeks. The final postoperative astigmatism is only weakly correlated with the preoperative astigmatism, showing that the surgical method is effective. The spherical equivalent error is shown to shift in the direction of myopia in the postoperative period.