To the Editor:
Qadir et al. raise a very important point in modern medical practice [1]. They argue that the outcome of cataract surgery is worse when performed by trainees on the basis of posterior capsule rupture (PCR) “complication” as a surrogate for an adverse outcome and this should be discussed during the consent process. Although Narendran et al. [2] found a higher rate of PCR amongst trainees in the Cataract National Dataset, a subsequent analysis looking specifically at visual outcomes did not confirm poor results from trainees [3] nor did a study from a District General Hospital with a commitment to cataract surgery training [4]. 85% of patients who suffer PCR have improved or satisfactory vision following the procedure [4, 5], which is the intended outcome on the consent form for most cataract operations. Conversely poor outcomes occur in the absence of PCR or other reported adverse events. On the basis of published data, trainee surgeons are not a ‘material risk’.
It is vital that the terminology used is properly defined and understood in the same way by medical practitioners, patients and their legal representatives. A surgical complication is an adverse event resulting in an undesirable outcome [6]. Under this definition, PCR is an adverse event and not a complication if well managed with good vitreous clearance and a properly positioned IOL giving good visual acuity as is usually the case.
Visual loss data is available for a limited number of surgeons (https://www.nodaudit.org.uk/public) but accurate outcome data for many trainees is unavailable at present because of the number of complete reports required. There may be bias in self reported outcome data particularly if this will be made public. Surgeons are keen to reduce the incidence of adverse events and complications and should be encouraged to compare their figures. The patient is primarily interested in the outcome although prolonged surgery, delay in visual rehabilitation and more follow up visits in managing adverse events are undesirable. Patients should be counselled on the basis of information that is relevant to them and not surgeons’ benchmarks and this needs to be considered when such data is made public.
Compliance with ethical standards
Conflict of interest
The author is an NHS consultant who performs cataract surgery.
Footnotes
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Qadir MO, Abdullah Y, Mulholland H, Masood I, Vernon SA, Madge SN. Montgomery in, Bolam out: are trainee surgeons ‘material risks’ when taking consent for cataract surgery? Eye. 2020;34:1334–40. doi: 10.1038/s41433-020-0785-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Narendran N, Jaycock P, Johnston R, Taylor H, Adams M, Tole DM, et al. The Cataract National Dataset electronic multicentre audit of 55567 operations: risk stratification for posterior capsule rupture and vitreous loss. Eye. 2009;23:31–37. doi: 10.1038/sj.eye.6703049. [DOI] [PubMed] [Google Scholar]
- 3.Day AC, Donachie PHJ, Sparrow JM, Johnston RL. The Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 1, visual outcomes and complications. Eye. 2015;29:552–60. doi: 10.1038/eye.2015.3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Ionides A, Minassian D, Tuft S. Visual outcome following posterior capsule rupture during cataract surgery. Br J Ophthalmol. 2001;85:222–4. doi: 10.1136/bjo.85.2.222. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Ang GS, Whyte IF. Effect and outcomes of posterior capsule rupture in a district general hospital setting. J Cataract Refract Surg. 2006;32:623–7. doi: 10.1016/j.jcrs.2006.01.047. [DOI] [PubMed] [Google Scholar]
- 6.Sokol DK, Wilson J. What is a surgical complication? World J Surg. 2008;32:942–4. doi: 10.1007/s00268-008-9471-6. [DOI] [PubMed] [Google Scholar]