Abstract
Purpose:
To study the incidence of re-surgery after manual small-incision cataract surgery (MSICS) at a tertiary eye-care center in South India and to compare the re-surgery rate between trainees and experts.
Methods:
A retrospective study was conducted at a tertiary eye-care center in Andhra Pradesh state of South India, which included 19,515 patients who underwent MSICS between 2012 and 2022 with 369 eyes of 369 patients who underwent re-surgery within 1 week of primary surgery. Factors included demographic data, type of re-surgery, that is, wound re-suturing, IOL repositioning, cortical wash, as well as anterior chamber (AC) wash.
Results:
19,515 eyes from the year 2012–2022 were analyzed. Most of the patients undergoing re-surgery belonged to the age group of 61–70 years (40.3%). Wound re-suturing was the more frequently performed re-surgery (47.6%). Wound re-suturing rates were comparable between the trainees and experts, whereas IOL repositioning, cortical wash, and AC wash were higher in the cases performed by trainees though statistically not significant.
Conclusion:
Careful pre-operative assessment, training under supervision, and other measures can be taken to reduce the re-surgery rates. Timely diagnosis and early treatment can give better outcomes and prevent devastating complications like endophthalmitis.
Keywords: AC wash, cortical wash, IOL repositioning, manual small-incision cataract surgery (MSICS), re-surgery, wound re-suturing
Cataract is the leading cause of preventable blindness worldwide. Therefore, cataract surgery is the most frequently performed ophthalmic surgical procedure worldwide. Given the large number of surgeries being performed, postsurgical complications are not uncommon.[1] Manual small-incision cataract surgery (MSICS) is principally employed in resource-poor settings, and the bulk of cataract surgeries are performed by this technique in the developing world. The results achieved by manual SICS are comparable with phacoemulsification in achieving excellent visual outcomes with low complication rates. The technique is faster, not expensive, and requires less technology.[2] Returns to the operating room after cataract surgery have implications for the quality of patient care, healthcare costs, and the effectiveness of resident surgical education. Risk factors for reoperation may provide additional factors to consider when evaluating patients for cataract surgery and in turn decrease the rates of reoperation.[3]
Early postoperative complications from cataract surgery include increased intraocular pressure (IOP), corneal edema, and corneal wound leakage. Corneal wound leakage is not uncommon, and early detection is important so that efforts to restore corneal integrity can immediately be implemented. If not caught early, patients are at risk of developing a cascade of sequelae, including endophthalmitis. A leaking clear corneal incision wound on the first day postoperatively has been associated with a 44-fold increased risk of endophthalmitis.[1] Retained lens fragments are another complication leading to re-surgery and may lead to significant patient morbidity including decreased visual acuity, corneal edema, glaucoma, retinal detachment, and cystoid macular edema.[4]
Although rare, intraocular lens (IOL) dislocation is one of the complications which will affect patients’ quality of life, worsening their visual acuity and adding cost to the treatment. IOL dislocation may occur after a few days to months. The incidence of IOL dislocation within the first week after operation is 0.2–2.8%.[5] Repositioning a dislocated posterior chamber IOL (PCIOL) is the preferred option for many surgeons in achieving optimal visual recovery for the patient. Repositioning the PCIOL in the ciliary sulcus allows the dislocated PCIOL to be restored to a position closest to its original fit[6]
Proficiency in cataract surgery is one of the main objectives of surgical training during ophthalmology training[7] Hence, this study aims to report the incidence of early re-surgery after MSICS at a tertiary eye-care center and also compare the rate between trainees (fellows) and experts. To our best knowledge, this is the first study in the literature to study the early re-surgery rates in MSICS and compare the same between the trainees and experts.
Methods
It was a retrospective study conducted at a tertiary eye-care center in Andhra Pradesh, India. Our hospital not only caters to the various districts within the state but also to the surrounding states of Telangana, Tamil Nadu, and Odisha. The study was performed after obtaining approval from the institutional ethics committee and adhered to the tenets of the Declaration of Helsinki. As a standard practice of our hospital, all subjects had previously given informed written consent for examination and for the medical records to be used for approved research purposes.
The cumulative number of patients who underwent cataract surgery, that is, MSICS at our center from 2012 to 2022, was 19515 and they were included in the study. Out of these, 369 eyes underwent re-surgery in the form of wound re-suturing, IOL repositioning, cortical wash, and anterior chamber (AC) wash.
Patients who underwent re-surgery within 1 week from the day of primary surgery were included in the study. MSICS performed by trainees which needed re-surgery were identified and compared with those performed by experts. All re-surgeries were performed by consultants.
Data of all these patients were evaluated with the help of electronic medical records (EMRs). Factors studied included the type of re-surgery performed, that is, wound re-suturing, IOL repositioning, cortical wash as well as AC wash, and the rate was compared between trainees and experts.
The statistical analysis was performed using the software STATA v14.0 (StataCorp, College Station, TX, USA). Categorical data were described as proportions and continuous data as mean ± standard error. The data was analyzed by frequency, percentage, Chi-square test, and z-test of testing proportions. P < 0.05 was considered statistically significant.
Results
During the study, data from 19,515 eyes from the years 2012 to 2022 were analyzed. 369 eyes of 369 patients underwent re-surgery in the form of wound re-suturing, IOL repositioning, cortical wash, and AC wash. Table 1 summarizes the demographic data of the patients. Most of them were in the age group of 61–70 years (149/369) (P = 0.055) [Fig. 1]. There were 213 males and 156 females (P = 0.812), whereas 205 were from a rural background and 164 were from an urban background. (P = 0.147) [Fig. 2].
Table 1.
Demographic data
| Wound re-suturing | IOL reposition | Cortical wash | AC wash | Total | P | |
|---|---|---|---|---|---|---|
| Age | ||||||
| 20-30 | 2 (1.13%) | 0 | 0 | 0 | 2 (0.54%) | |
| 31-40 | 8 (4.54%) | 5 (3.75%) | 0 | 0 | 13 (3.52%) | |
| 41-50 | 27 (15.3%) | 32 (24.06%) | 4 (11.1%) | 3 (8.82%) | 66 (17.8%) | |
| 51-60 | 51 (28.97%) | 25 (18.79%) | 8 (22.2%) | 5 (20.8%) | 89 (24.1%) | |
| 61-70 | 67 (38.06%) | 49 (36.84%) | 20 (55.5%) | 13 (54.1%) | 149 (40.3%) | 0.055, NS |
| 71-80 | 20 (11.36%) | 22 (16.54%) | 2 (5.55%) | 3 (8.82%) | 47 (12.7%) | |
| 81-90 | 1 (0.56%) | 0 | 2 (5.55%) | 0 | 3 (0.81%) | |
| 91-100 | 0 | 0 | 0 | 0 | 0 | |
| Gender | ||||||
| Male | 102 (56.7%) | 75 (56.3%) | 20 (55.5%) | 16 (66.6%) | 213 (57.7%) | 0.812, NS |
| Female | 74 (43.2%) | 58 (43.6%) | 16 (44.4%) | 8 (33.3%) | 156 (42.2%) | |
| Place | ||||||
| Rural | 101 (57.3%) | 65 (48.8%) | 22 (61.1%) | 17 (70.8%) | 205 (55.5%) | 0.147, NS |
| Urban | 75 (42.6%) | 68 (51.1%) | 14 (38.8%) | 7 (29.1%) | 164 (42.5%) |
NS: Not significant
Figure 1.
Age distribution of various re-surgeries after MSICS
Figure 2.
Gender and population distribution of various re-surgeries after MSICS
Re-surgery rates of different procedures, that is, wound re-suturing, IOL repositioning, cortical aspiration, and AC wash are documented in Table 2.
Table 2.
Incidence of Re-surgery in MSICS
| Year | Total number of MSICS | Wound re-suturing | P | IOL reposition | P | Cortical wash | P | AC wash | P |
|---|---|---|---|---|---|---|---|---|---|
| 2012 | 870 | 5 | 5 | 0.025 | 0 | 0 | |||
| 2013 | 1044 | 7 | 0.013 | 5 | 0.025 | 0 | 0 | ||
| 2014 | 1397 | 12 | 0.004 | 10 | 0.002 | 1 | 0.317 | 1 | 0.317 |
| 2015 | 1869 | 19 | 0.000 | 16 | 0.000 | 2 | 0.157 | 1 | 0.317 |
| 2016 | 2400 | 44 | 0.000 | 21 | 0.000 | 0 | - | 1 | 0.317 |
| 2017 | 2668 | 24 | 0.000 | 19 | 0.000 | 10 | 0.002 | 4 | 0.045 |
| 2018 | 2220 | 21 | 0.000 | 19 | 0.000 | 5 | 0.025 | 3 | 0.083 |
| 2019 | 2054 | 20 | 0.000 | 11 | 0.001 | 7 | 0.008 | 5 | 0.025 |
| 2020 | 1724 | 6 | 0.000 | 8 | 0.005 | 2 | 0.157 | 1 | 0.317 |
| 2021 | 2197 | 10 | 0.007 | 11 | 0.001 | 5 | 0.025 | 6 | 0.014 |
| 2022 | 1072 | 8 | 0.001 | 8 | 0.005 | 4 | 0.045 | 2 | 0.157 |
| Total | 19515 | 176 | 0.002 | 133 | 0.000 | 36 | 0.000 | 24 | 0.000 |
Out of the 369 eyes, 176 eyes of 176 patients underwent wound re-suturing, 133 eyes underwent IOL repositioning, 36 eyes underwent cortical wash, and 24 eyes underwent AC wash. Wound re-suturing was the most frequently performed re-surgery as compared to the other procedures, which was statistically significant (P = 0.002) [Table 2].
In our study, we also compared the re-surgery rates between trainees and experts from 2018 to 2022 and found that wound re-suturing was comparable between the trainees (47.6%) and experts (52.3%) [Table 3]. Out of the 57 IOL reposition from 2018 to 2022, 36 (63.1%) were by trainees but were statistically insignificant. A total of 17 (73.9%) cases of cortical aspiration were in those performed by trainees out of the 23 cases, which was also statistically insignificant. However, out of the 17 cases of AC wash, 11 (64.7%) were in those performed by trainees (P = 0.048) [Table 3].
Table 3.
Re-surgery rates Trainees vs Experts
| Re-surgery | Number of cases | Percentage | Number of cases by trainees | Number of cases by Experts | P | |
|---|---|---|---|---|---|---|
| Total number of SICS | Wound Re-suturing | |||||
| 870 | 2012 | 5 | 0.57% | 0 | 5 | |
| 1044 | 2013 | 7 | 0.67% | 1 | 6 | |
| 1397 | 2014 | 12 | 0.85% | 2 | 10 | |
| 1869 | 2015 | 19 | 1.01% | 2 | 17 | |
| 2400 | 2016 | 44 | 1.83% | 5 | 39 | |
| 2668 | 2017 | 24 | 0.89% | 4 | 20 | |
| 2220 | 2018 | 21 | 0.94% | 10 | 11 | 0.759, NS |
| 2054 | 2019 | 20 | 0.97% | 13 | 7 | 0.065, NS |
| 1724 | 2020 | 6 | 0.34% | 4 | 2 | 0.275, NS |
| 2197 | 2021 | 10 | 0.45% | 2 | 8 | 0.015, sig |
| 1072 | 2022 | 8 | 0.74% | 2 | 6 | 0.065, NS |
| IOL Reposition | ||||||
| 870 | 2012 | 5 | 0.57% | 0 | 5 | |
| 1044 | 2013 | 5 | 0.47% | 1 | 4 | |
| 1397 | 2014 | 10 | 0.71% | 2 | 8 | |
| 1869 | 2015 | 16 | 0.85% | 6 | 10 | |
| 2400 | 2016 | 21 | 0.87% | 9 | 12 | |
| 2668 | 2017 | 19 | 0.71% | 8 | 11 | |
| 2220 | 2018 | 19 | 0.85% | 6 | 13 | 0.029, sig |
| 2054 | 2019 | 11 | 0.53% | 9 | 2 | 0.007, HS |
| 1724 | 2020 | 8 | 0.46% | 6 | 2 | 0.065, NS |
| 2197 | 2021 | 11 | 0.50% | 10 | 1 | 0.001, HS |
| 1072 | 2022 | 8 | 0.74% | 5 | 3 | 0.334, NS |
| Cortical Matter Aspiration | ||||||
| 1397 | 2014 | 1 | 0.07% | 0 | 1 | |
| 1869 | 2015 | 2 | 0.10% | 2 | 0 | |
| 2400 | 2016 | 0 | 0 | 0 | 0 | |
| 2668 | 2017 | 10 | 0.37% | 3 | 7 | |
| 2220 | 2018 | 5 | 0.22% | 2 | 3 | 0.545, NS |
| 2054 | 2019 | 7 | 0.34% | 5 | 2 | 0.135, NS |
| 1724 | 2020 | 2 | 0.11% | 2 | 0 | 0.184, NS |
| 2197 | 2021 | 5 | 0.22% | 5 | 0 | 0.013, sig |
| 1072 | 2022 | 4 | 0.37% | 3 | 1 | 0.207, NS |
| AC wash | ||||||
| 1397 | 2014 | 1 | 0.07% | 0 | 1 | |
| 1869 | 2015 | 1 | 0.05% | 0 | 1 | |
| 2400 | 2016 | 1 | 0.04% | 0 | 1 | |
| 2668 | 2017 | 4 | 0.14% | 2 | 2 | |
| 2220 | 2018 | 3 | 0.13% | 2 | 1 | 0.23, NS |
| 2054 | 2019 | 5 | 0.24% | 3 | 2 | 0.272, NS |
| 1724 | 2020 | 1 | 0.05% | 1 | 0 | -- |
| 2197 | 2021 | 6 | 0.27% | 4 | 2 | 0.138, NS |
| 1072 | 2022 | 2 | 0.18% | 1 | 1 | 0.5, NS |
|
| ||||||
| Re-surgery | Number of Cases | Percentage | Number of cases by trainees | Number of cases by Experts | P | |
|
| ||||||
| Total number of SICS | Wound Re-suturing | |||||
| 2220 | 2018 | 21 | 0.94% | 10 | 11 | 0.759, NS |
| 2054 | 2019 | 20 | 0.97% | 13 | 7 | 0.065, NS |
| 1724 | 2020 | 6 | 0.34% | 4 | 2 | 0.275, NS |
| 2197 | 2021 | 10 | 0.45% | 2 | 8 | 0.015, sig |
| 1072 | 2022 | 8 | 0.74% | 2 | 6 | 0.065, NS |
| IOL Reposition | ||||||
| 2220 | 2018 | 19 | 0.85% | 6 | 13 | 0.029, sig |
| 2054 | 2019 | 11 | 0.53% | 9 | 2 | 0.007, HS |
| 1724 | 2020 | 8 | 0.46% | 6 | 2 | 0.065, NS |
| 2197 | 2021 | 11 | 0.50% | 10 | 1 | 0.001, HS |
| 1072 | 2022 | 8 | 0.74% | 5 | 3 | 0.334, NS |
| Cortical Matter Aspiration | ||||||
| 2220 | 2018 | 5 | 0.22% | 2 | 3 | 0.545, NS |
| 2054 | 2019 | 7 | 0.34% | 5 | 2 | 0.135, NS |
| 1724 | 2020 | 2 | 0.11% | 2 | 0 | 0.184, NS |
| 2197 | 2021 | 5 | 0.22% | 5 | 0 | 0.013, sig |
| 1072 | 2022 | 4 | 0.37% | 3 | 1 | 0.207, NS |
| AC Wash | ||||||
| 2220 | 2018 | 3 | 0.13% | 2 | 1 | 0.23, NS |
| 2054 | 2019 | 5 | 0.24% | 3 | 2 | 0.272, NS |
| 1724 | 2020 | 1 | 0.05% | 1 | 0 | -- |
| 2197 | 2021 | 6 | 0.27% | 4 | 2 | 0.138, NS |
| 1072 | 2022 | 2 | 0.18% | 1 | 1 | 0.5, NS |
NS: Not significant
Discussion
Returns to the operating room after resident-performed cataract surgery have implications for the quality of patient care, healthcare costs, and the effectiveness of resident surgical education. Risk factors for reoperation may provide additional factors to consider when evaluating patients for cataract surgery and seeking to decrease rates of reoperation. The most common indications for reoperation include retained nuclear fragmentation, intraocular lens dislocations, and incision leaks.[3]
The data on the association of the resident training level and complication rate have been variable, with some studies reporting no increased risk, whereas others suggest that experience plays a larger role.[8,9] Randleman et al.[10] showed that there were decreasing rates of complications after the first 80 resident cases. The effect of surgeon experience upon outcomes may persist as another study suggests that complication rates decrease over the first 300 to 3,000 cases in independent practice.[3] Our data add to this that early trainee cases are at the greatest risk for reoperation, especially IOL repositioning (63.1%), cortical wash (73.9%), and AC wash (64.7%). However, wound re-suturing in cases performed by trainees was comparable with that performed by experts (47.6%).
Corneal wound leakage is not uncommon; in a study by Chee et al.,[11] almost one-third of incisions leaked. This was comparable to our study where 47.6% of the re-surgeries were of wound re-suturing.
IOL dislocation is one of the complications after cataract surgery that may occur after a few days to months.[5] Repositioning a dislocated PCIOL is the preferred option for many surgeons in achieving optimal visual recovery for the patient.[6] The incidence of IOL dislocation within the first week after operation is 0.2–2.8%.[5] However, in our study, 36.04% of re-surgeries were for IOL repositioning, that is, 0.6% of total MSICS performed. Our results were consistent with a study by Greenberg et al.,[12] in which 0.9% of patients presented with IOL dislocation or underwent IOL exchange in a 90-day postoperative period.
Retained lens fragments or cortex may lead to significant patient morbidity including decreased visual acuity, corneal edema, glaucoma, retinal detachment, and cystoid macular edema. According to Moshirfar et al.,[4] the incidence of retained lens fragments is only 0–1.5%; similarly, in our study, about 16.2% of re-surgeries were due to retained lens fragments, cortex material, and hyphema.
In a study by Menda et al.,[3] the reoperation rate after resident-performed cataract surgery was 2.11%. Similarly, in our study, out of the re-surgeries, 58.6% were those performed by trainees during the years 2018–2022.
We utilize the International Council of Ophthalmology’s Ophthalmology Surgical Competency Assessment Rubric (ICO-OSCAR) score to assess the trainee’s performance and in turn the impact of a surgical training program.[13] To monitor and reduce the incidence of re-surgery, postoperative assessment is performed by consultants. Trainees do the surgery under the supervision of a well-experienced consultant until they are confident.
In this study, we analyzed the incidence of re-surgery after MSICS and also studied if the trainees had any significant role in the incidence of early re-surgery after MSICS. After analysis of the data for 10 years, we started a retrospective evaluation of surgical videos for each trainee and discussed theoretical and practical approaches toward improvement in surgical competence of the respective trainee/fellow. The surgery should be strictly performed under the supervision of the consultant, it should be evaluated by the consultant at the end of the case, and intervention should be performed by the consultant, if necessary, to avoid re-surgery.
Limitations
The limitations of the study include that of a retrospective study. Also, we did not include the pre-operative and intraoperative factors leading to re-surgeries in MSICS.
Conclusion
In a developing country like India, MSICS is a major surgical procedure undertaken in ophthalmology. Careful pre-operative assessment, training under supervision, and other measures can be taken to reduce the re-surgery rates. Timely diagnosis and early treatment can give better outcomes and prevent devastating complications like endophthalmitis.
Financial support and sponsorship
Hyderabad Eye Institute and Hyderabad Eye Research Foundation, Hyderabad, India.
Conflicts of interest
There are no conflicts of interest.
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