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Purpose: To analyze risk factors for refractive error after cataract surgery and provide a benchmark for refractive outcomes after standard cataract surgery., Setting: One hundred cataract surgery clinics from 12 European countries., Design: Multicenter database study., Methods: Data on consecutive cataract extractions reported to the European Registry of Quality Outcomes for Cataract and Refractive Surgery between January 1, 2014 and December 31, 2015 were analyzed in terms of demographics, preoperative corrected distance visual acuity (CDVA), target refraction, coexisting eye diseases, surgical difficulties including previous ophthalmic interventions, type of surgery, intraocular lens (IOL), and surgical complications. For clinics committed to reporting follow-up data within 7 to 60 days after surgery, postoperative CDVA and refraction were analyzed., Results: Of the 548 392 cases analyzed, follow-up data were available for 282 811 cases. The absolute mean biometry prediction error in spherical equivalent was 0.42 diopters (D). A biometry prediction error within ±0.50 D was achieved for 205 675 eyes (72.7%). A biometry prediction error within ±1.0 D was achieved for 263 015 eyes (93.0%). Poor preoperative CDVA, target refraction, coexisting eye diseases, surgical difficulties including previous ophthalmic interventions, and surgical complications were in varying degrees related to a postoperative refractive error., Conclusions: Several risk factors (poor preoperative CDVA, ocular comorbidity, and previous eye surgery) were related to poor refractive outcomes after cataract extraction. When these risk factors are present, care should be taken with the preoperative examination and choice of IOL to avoid a refractive surprise. The average outcomes can be used as a refractive outcome benchmark., (Copyright © 2018 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze visual outcomes after cataract surgery in patients with previous corneal refractive surgery., Setting: Cataract surgery clinics in 18 European countries and Australia., Design: Database study., Methods: Cases of cataract extraction with corneal refractive surgery eyes (corneal refractive cases) were identified from all cataract extractions reported to the European Registry of Quality Outcomes for Cataract and Refractive Surgery database over a 5-year period. Preoperative and postoperative measurements and trends over time were analyzed., Results: Of 807,220 cataract extractions, 1229 (0.15%) were corneal refractive cases. There was a significant increase, over time, in the number of corneal refractive cases (P < .001). Corneal refractive patients were younger than patients without corneal refractive surgery (nonrefractive patients) (62.9 years versus 74.0 years; P < .001) but had similar mean preoperative and postoperative corrected-distance visual acuity (CDVA) (preoperative logMAR 0.44[6/16] for both [P = .286]; postoperative logMAR 0.06[6/7] for both [P = .245]). Postoperative CDVA was worse than preoperative CDVA in 35 (4%) corneal refractive and 8,999 (1.5%) nonrefractive patients (P < .001). In all, 74 (8.5%) of 873 corneal refractive versus 16,566 (2.8%) /584,496 nonrefractive patients, having cataract surgery, had preoperative CDVA of logMAR 0.0[6/6] or better (P < .001). Nineteen (54.3%) of 35 corneal refractive case patients who had worse postoperative CDVA had preoperative CDVA of logMAR 0.0(6/6) or better., Conclusion: Cataract surgery has been reported with increasing frequency in corneal refractive surgery patients, since 2008. These patients had preoperative CDVA similar to those of patients without previous corneal refractive surgery but were younger and were at higher risk of worse postoperative CDVA, especially if they had preoperative CDVA of logMAR 0.0(6/6) or better., Financial Disclosure: No author has any financial or proprietary interest in any material, or method, mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: A project aimed at creating a multi-national database for cataract and refractive surgery was initiated in 2008. The database was intended for learning and clinical improvement, not supervision. The project was co-funded by the European Union, under the Executive Agency for Health and Consumers and the European Society of Cataract and Refractive Surgeons (ESCRS) and supported by 11 national societies for cataract and refractive surgery. The purpose of this article is to describe the setup of the database and the ensuing achievements within cataract surgery after four years., Design/methodology/approach: A web-based system was created for input and output of data, with a software interface to two databases, one for cataract surgery and one for refractive surgery. Data can be put in either manually through web forms or by transfer of data from existing national registries or large electronic medical record systems. Output of reports from the system or export of one's own data is available on the web. The data are anonymous to all users, with the sole exception that reporting surgeons and clinics have access to their own data. The system does not include any patient identification., Findings: After four years, data from 16 countries have been entered into the system, including reports of more than 900,000 cataract extractions. The database has been used by individual clinics for benchmarking and clinical improvement work, and has also served as the basis for new clinical guidelines for cataract surgery. The ESCRS has guaranteed the sustainability of the database after the project period., Originality/value: A European quality registry with data input from surgeons and clinics in 16 European countries has been established. Close to one million surgeries have been entered into the system during the first four years. Evidence-based guidelines have been published based on data in the registry. The system is used for benchmarking by both experienced surgeons and trainees.

Purpose: To assess and analyze refractive outcome after cataract surgery in Sweden from 2008 through 2010., Setting: Swedish cataract surgery units participating in outcome registration of National Cataract Register., Design: Cohort study., Methods: Planned and actual postoperative refractions were analyzed for cataract procedures and preoperative and postoperative corneal astigmatism for procedures performed in 2008 though 2010. Induced astigmatism was calculated with Naeser and Behrens polar coordinates., Results: Postoperative refraction was analyzed for 17,056 procedures and corneal astigmatism for 7448 procedures. Emmetropia was targeted in 78.1% of eyes and achieved in 52.7%; 43.0% had less than 1.00 diopter (D) of astigmatism. "Reading myopia" of -3.5 to -1.6 D was targeted in 7.0% of eyes and achieved in 7.8%. Planned hyperopia greater than 1.0 D or myopia greater than -3.5 D was rare. The mean absolute biometry prediction error was 0.402 D ± 0.338 (SD) in all eyes; however, astigmatic eyes and eyes planned for myopia or hyperopia had higher biometry prediction errors. Younger patients were more often astigmatic and planned for a more myopic outcome. Preoperatively, one third of eyes had more than 1.0 D of corneal astigmatism; postoperatively this figure was largely unaltered. The mean induced astigmatism was 0.525 ± 0.804 D in all eyes., Conclusions: Emmetropia (spherical equivalent -0.5 to +0.5 D and <1.0 D astigmatism) is the goal in most cataract cases but was reached in only 55% of eyes planned for emmetropia. Factors precluding emmetropia included remaining corneal astigmatism and biometry prediction errors in astigmatic and ametropic eyes., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

In March 2008, the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) commenced. This 3-year project was cofunded by the European Union (EU) and the European Society of Cataract & Refractive Surgeons (ESCRS). The ESCRS became the lead partner in the project with 11 national societies as associated partners. The aims of the project were to improve treatment and standards of care for cataract and refractive surgery and to develop evidence-based guidelines for cataract and refractive surgery across Europe. Surgeons from all participating societies contributed to the database, which contained data on 820,000 cataract surgeries in November 2011. The present guidelines are based on data entered from January 1, 2009, to August 28, 2011 (523,921 cataract extractions). The guidelines include only those steps in the cataract surgery process that can be analyzed by the database., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To define the incidence of capsule complication and its risk factors in Sweden over an 8-year period., Setting: Fifty-two ophthalmic surgery units in Sweden., Design: Database study., Methods: Data were collected prospectively in the Swedish National Cataract Register (NCR) from 2002 through 2009. The NCR contains 97.3% of the total number of cataract extractions in Sweden over the 8-year study period. One mandatory variable in the register is capsule complications during surgery. As a means to validate the accuracy of register data on capsule complications, a randomly selected sample of 2400 registrations was compared with corresponding medical records., Results: The analyses were based on 602,553 cataract extractions reported to the NCR. A capsule complication was reported in 12,574 cataract extractions, corresponding to a frequency of 2.09%. The incidence of this complication consistently decreased each year from 2002 to 2006, after which it stabilized. Poor corrected distance visual acuity in the surgical eye (≤ 0.1), the occurrence of glaucoma, diabetic retinopathy, and age were among the parameters significantly related to a capsule complication. Some of these parameters also decreased over time. However, even after adjusting for this, there was an obvious decrease in capsule complications over time. The validity test showed a certain underreporting of capsule complications to the registry, but it was not significant and did not change over time., Conclusion: The incidence of capsule complications decreased over time. This may be partly the result of fewer risk factors and of better surgical quality., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

This review summarizes data collected by the Swedish National Cataract Register, which now contains data pertaining to more than a million cataract surgery procedures, representing 95.6% of the surgeries performed in Sweden during 1992-2009. During this period, the rate of cataract surgery rose from 4.47 to 9.00 per 1000 inhabitants. The mean patient age increased until 1999 but has slowly decreased since then. Preoperative visual acuity has risen steadily. The distribution between the sexes was stable until 2000, after which the proportion of women slowly decreased. Registration of subjective benefit has brought new knowledge regarding indications and expectations. An improved questionnaire, Catquest-9SF has been used since 2008. The outcome register generally shows good results from the surgery. Endophthalmitis has decreased from 0.10% to below 0.040%., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To study the incidence of aphakia after cataract extraction and evaluate the relative risk for this outcome in subgroups of patients based on preoperative conditions., Setting: Sixty-two community-run or private clinics participating in the Swedish National Cataract Register., Methods: Data on cataract extractions were collected prospectively from 1997 through 2001. The set of data also covered type of surgery and type of intraocular lens (IOL), including a "no lens implanted" option. All data were stored in a database. Database calculations were made of frequencies and risk ratios of postoperative aphakia in the subgroups of patients based on preoperative conditions., Results: For the entire study period, postoperative aphakia was reported in 1410 of 287,951 surgeries for which complete IOL data were available, corresponding to an overall frequency of 0.49%. The occurrence of ocular comorbidity and poor preoperative visual acuity (< or = 0.1) in the eye to be operated on was significantly related to postoperative aphakia for each year of the study (P<.001). Glaucoma and poor visual acuity (< or =0.1) in the surgical eye meant a 12.8 higher risk for aphakia after surgery than a better visual acuity (>0.1) and no ocular comorbidity., Conclusions: This national 5-year survey showed that in routine cataract surgery performed during the study, 1 of every 200 operations ended in postoperative aphakia. Poor visual acuity (< or =0.1) in the eye to be operated on combined with ocular comorbidity was the highest risk factor for postoperative aphakia.

To develop a method to estimate the cost per quality-adjusted life year (QALY) gained with cataract surgery using large patient registries.Four centers in Sweden. Five hundred patients scheduled for cataract extraction in 1 eye at 1 of 4 centers in Sweden during March 1999 were asked to complete the EQ-5D, a preference-based quality-of-life instrument, and the Catquest, a disease-specific disability measure, before surgery. Multiple regression analysis was used to study the correlation between utility and visual acuity and/or disability and utility and QALY gain through the intervention estimated. Visual acuity and Catquest scores were available for 484 patients. The mean age was 76.1 years; the mean logMAR visual acuity was 0.59 in the surgical eye and 0.26 in the other eye. The mean Catquest disability score was 13.79 and the mean utility, 0.74. Utilities correlated significantly with visual acuity and disability scores, and the correlations remained significant when both were included in a regression model, indicating that the 2 measure different concepts. The hypothetical cost per QALY gained (discounted at 3%) was estimated at 45000 SKr (4500 US dollars) using the Swedish Cataract Registry. The results indicate that visual acuity and visual disability significantly affect utilities controlled for age and ophthalmic comorbidity. It is thus possible to use data on visual acuity and disability in large registries to estimate the cost-effectiveness of cataract surgery and to compare the cost per QALY gained with other health care interventions.

The Swedish National Cataract Register (NCR) has been collecting data on cataract extractions in Sweden since 1992. This unique national database now contains data pertaining to more than 400 000 operations, representing 93.4% of all operations performed nationwide during 1992-2000. Clinic participation in the NCR is voluntary. Tests have shown NCR data to be extremely reliable, while the participation of nearly all providers of cataract surgery in Sweden makes the data highly representative of cataract surgery throughout the country. The NCR collects pre- and per-operative data for every cataract extraction performed at participating clinics. Surgical outcome data and data about patients' self-assessed visual function is collected in approximately 10% of cases. Since 1998, all cases of suspected postoperative endophthalmitis have also been reported to the NCR. The rate of surgery has increased from 4.47 to 7.26 per 1000 inhabitants during the period. Female subjects have constituted about 66% of all operated subjects each year and the mean age of patients has slowly increased from 75.2 to 76.1 years. Average pre-operative visual acuity has improved each year. Second eye surgery has increased from 28.5% to 36.8% of all surgeries. Phacoemulsification has reached 98% as type of surgery (in 2000) and 92.7% of all intraocular lenses are foldable. Surgical outcome has improved by achieving a final refraction closer to the target refraction and less surgically induced astigmatism. The positive impact of cataract surgery in very elderly people has been demonstrated, as has the positive effect of second eye surgery, especially in young subjects. The NCR has served to enhance knowledge about trends and results of cataract surgery in Sweden. This review article describes some of the activities carried out and their results.

Purpose: To study the benefits of surgery and satisfaction with vision after first- and second-eye cataract surgery in comparable groups of patients., Setting: Clinics participating in the Swedish National Cataract Outcome Study from 1995 to 1999., Methods: A prospective observational study evaluated patients' self-assessed visual function and satisfaction with vision before and 6 months after cataract extraction. Patients who had another cataract surgery in the fellow eye during the 6-month study were excluded. Data of 8595 patients having cataract extraction at participating clinics during the month of March for 1995 to 1999 were collected. Preoperative and intraoperative data were reported at the time of surgery. Final postoperative visual acuity was recorded. The Catquest questionnaire was completed before surgery and 6 months after surgery., Results: First-eye surgery was performed in 5570 patients and second-eye surgery, in 3025. Patient-assessed benefits of surgery and satisfaction with vision as defined by the Catquest was higher after second-eye surgery (P <.001). The outcomes were studied in detail in patients with equal visual acuity in the fellow eye before and after surgery and without ocular comorbidity. The better outcome after second-eye surgery was most pronounced in patients with good or intermediate visual acuity in the fellow eye., Conclusion: The self-assessed visual outcomes and satisfaction with vision were better after second-eye surgery than after first-eye surgery in comparable groups of patients.

Purpose: A Swedish National Cataract Register was instituted in 1992, monitoring nearly all cataract operations in Sweden, and since its inception comprising about 95% of all operations. Data from a total of approximately 290 000 operations have been collected during 1992-1998. Data quality is an important factor, and we have therefore assessed the various types and frequencies of data entry errors in the material., Methods: The medical records for all operations in five selected participating clinics were retrieved for a set month. Each data transfer step from the record to the final data base was monitored for a total of 574 operations. A total of 10 variables were recorded for each operation., Results: Significant sources of error were absent in most variables. However, possibly important errors appeared in three: "date entering waiting list", "preoperative best corrected visual acuity in the operated eye", or "visual acuity in the fellow eye". There were also noteworthy variations between the five clinics, different for different parameters. Errors were predominantly prone to appear at the very first step of registration. In most cases this was due to deviations from the data collection instructions., Conclusions: The reliability is good for most values entered into the register, but it is important to ensure that data definitions are exact and adhered to. Repeated information to the involved persons on how to fill in the forms appears to be a requisite for maintaining good input quality.

Purpose: To study the utilisation and increase of first eye cataract surgery in one-year age groups between 60 and 90 years of age during 1992-1999., Methods: Data was extracted from the National Swedish Cataract Register (NCR) that covers about 93.2% of all cataract extractions performed in Sweden during 1992-1999. The total number of living persons in each one-year age group was collected from the Year Book of Statistics in Sweden (1993-2000)., Results: The number of cataract extractions in Sweden increased by 54.8% from 1992 to 1999. The rates of first eye cataract surgery in one-year age groups between 60 and 90 years of age were different for females and males and this difference did not change during a 37% increase of the surgery volume from 1992 to 1999. The rate of first eye cataract surgery increased significantly both for females (+29.4%) and males (+27.2%) during 1992 to 1999 in Sweden., Conclusion: The rate of first eye cataract surgery increased significantly from 1992 to 1999 but the gender difference in age-related utilisation of surgery remained unchanged. The increase in rate was about the same in all age groups.

Purpose: To study the gender difference in total utilisation of cataract surgery in Sweden during the years 1992-1997., Methods: The study is based on data from the National Swedish Cataract Register which covers about 95% of all cataract operations performed in Sweden during the study period., Results: Utilisation of cataract surgery in Sweden was significantly higher in females than in males for all age groups between 50 and 89 years of age during the period 1992-1997. This gender difference was more pronounced for second eye surgery than first eye surgery in most age groups. The gender difference varied also depending on the pre-operative visual acuity., Conclusion: The cataract surgery rate was significantly higher for females compared to males during the study period. Three hypotheses to explain the gender difference are discussed.

Purpose: To test the viability of performing a national cataract outcome study with a national cataract register as a reference base., Methods: Seven Swedish eye clinics participated. All patients operated during the month of January 1994 were included. The total number of patients was 605., Results: This outcome study is based on few, but well defined parameters. On the basis of these measurements quality indicators are suggested that makes comparison between surgeons/clinics possible., Conclusion: Outcome studies are different from controlled clinical trials. They are less time consuming and designed to describe the outcome of surgery in daily practise. An outcome study of cataract surgery does not replace the careful monitoring of each patient at the clinical level, which is necessary for the development of new surgical technics and medical treatments. However, an outcome study can provide an overall quality description of cataract surgery in the daily practise of any given surgical unit.

To increase access to care for cataract patients in Sweden, it was decided, starting in 1992, that all cataract patients listed for surgery and with priority should have their cataract extraction performed within three months. To evaluate the effect of this waiting time guarantee, a National Cataract Register (NCR) was initiated in late 1991. In 1992, 81% of all cataract extractions performed in Sweden were reported to the NCR; in 1993 this figure was 92%. Reasons for this high participation ratio are discussed. In 1993, 74.4% (range between different clinics, 40-99%) of the patients with priority had their operation performed within three months. Great variation in visual acuity and age was found in patients with priority among the different surgical units.

In 1992 a Swedish National Cataract Register was instituted. More than 90% of all cataract surgeries are performed at community run eye clinics. All community run eye clinics in the country participated and 89% of all cataracts performed are included in this register. In total 31,679 eyes were entered. All the pertinent preoperative information on these patients can be found in the register. As indicated in other studies two-thirds of the surgeries were performed on women and one-third of the surgeries was performed on second eyes. The number of surgeries equals 4.5 per 1000 inhabitants and this figure has steadily increased since 1980.