Elsevier

Ophthalmology

Volume 126, Issue 3, March 2019, Pages 355-361
Ophthalmology

Original article
Preoperative Vision and Surgeon Volume as Predictors of Visual Outcomes after Cataract Surgery

Presented at: the 2016 American Academy of Ophthalmology Annual Meeting, October 15–18, 2016, Chicago, Illinois.
https://doi.org/10.1016/j.ophtha.2018.10.030Get rights and content

Purpose

To evaluate the relationship between preoperative vision and surgeon volume with visual outcomes after cataract surgery.

Participants

Patients aged ≥18 years old enrolled in the Kaiser Permanente Southern California Health Plan who underwent cataract surgery by nontrainee surgeons.

Methods

Patients who underwent cataract surgery between January 1, 2013 and December 31, 2015, were included. A multivariate analysis using Generalized Additive Mixed Models was performed to determine the relationship between surgeon volume and postoperative visual acuity after controlling for patient age, preoperative visual acuity, history of diabetes, and history of diabetic retinopathy. Modeling was done for the relationship between preoperative vision and visual outcomes while controlling for surgeon volume, patient age, history of diabetes, and history of diabetic retinopathy.

Main Outcome Measure

Absolute letter change and percentage of patients to achieve ≥5 Early Treatment Diabetic Retinopathy Study (ETDRS) letter gain postoperatively.

Results

There were 103 920 cataract surgeries performed by 136 surgeons included in this analysis. Patients whose surgeons performed <91.0 surgeries/year (95% confidence interval [CI], 61.1–139; P < 0.05) gained fewer letters postoperatively than the overall average, whereas those whose surgeons performed >91 but <227 surgeries/year (95% CI, 169–∞; P < 0.05) gained more letters than average. Although statistically significant, the difference between the lowest and highest performing surgeons was approximately 1.25 letters. Surgeons who performed <110 surgeries/year (95% CI, 81.7–149; P < 0.05) had fewer patients who gained ≥5 letters. Surgeons who performed >110 but <293 surgeries/year (95% CI, 232–∞; P < 0.05) were approximately 15% more likely to have patients who gained ≥5 letters. Patients with preoperative vision <74.7 letters (95% CI, 74.7–74.8; P < 0.05) and <75.8 letters (95% CI, 75.8–75.9; P < 0.05) gained more letters and were more likely to gain ≥5 letters postoperatively, respectively.

Conclusions

Patients whose vision is approximately 20/32 or worse are more likely to have significant visual gains after cataract surgery. Although statistically significant differences exist in postoperative vision based on surgeon volume, these do not appear to be clinically meaningful. Overall, visual outcomes are functionally comparable across a wide range of surgeon volumes.

Section snippets

Methods

A retrospective cohort study was performed on patients enrolled in the Kaiser Permanente Southern California Health Plan who underwent cataract surgery between January 1, 2013 and December 31, 2015. The Kaiser Permanente Southern California Institutional Review Board approval was attained, and the tenets of the Declaration of Helsinki were followed. Patients were excluded from this study if they had any of the following criteria:

  • 1.

    Less than 18 years old at the time of surgery.

  • 2.

    Surgeries were

Results

A total of 136 surgeons performed 106 962 surgeries, of which 103 920 (97.3%) met inclusion criteria. Mean patient age at the time of surgery was 72 years (18–105 years). The majority (57.7%) of the patients were female, and 11.4% had a prior diagnosis of diabetic retinopathy. Table 1 provides a summary of baseline characteristics.

The distribution of preoperative vision was similar between surgeon volume categories: ≤149 surgeries, 150–249 surgeries, 250–349 surgeries, 350–449 surgeries, and

Discussion

Good postoperative vision was the norm after cataract surgery in this large and diverse cohort, with most patients achieving 20/25 or better vision. A total of 28% of all patients had better than 20/25 preoperative vision, which demonstrates that most surgeons were willing to perform surgery even in those with good preoperative vision. It may seem intuitive that higher-volume surgeons achieve such surgical numbers by having a lower visual threshold to perform surgery; however, the distribution

References (14)

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Cited by (4)

Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

D.F.S.: Grant funding outside this study – Allergan, ThromboGenics, Regeneron, Nightstar.

Funding provided by the Kaiser Permanente Center for Effectiveness & Safety Research.

HUMAN SUBJECTS: Human subjects were included in this study. The Kaiser Permanente Southern California Institutional Review Board approved the study and waived the need for patient consent for this retrospective study. All research adhered to the tenets of the Declaration of Helsinki.

No animal subjects were used in this study.

Author Contributions:

Conception and design: Modjtahedi, Hull, Adams, Munz, Luong, Fong

Analysis and interpretation: Modjtahedi, Hull, Adams, Munz, Luong, Fong

Data collection: Modjtahedi, Hull, Adams, Munz, Luong, Fong

Obtained funding: Funding provided by the Kaiser Permanente Center for Effectiveness & Safety Research.

Overall responsibility: Modjtahedi, Hull, Adams, Munz, Luong, Fong

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