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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.

Unlabelled: Waterclefts and retrodots are independently associated with visual impairment, yet a review identified no data on risk factors., Purpose: To investigate risk factors for these two human lens cataract subtypes., Method: Two nested case-control studies: The host study comprised 1078 subjects (55 years) attending the Somerset and Avon Eye Study (SAES). In total, 197 watercleft cases (Oxford grade 0.2 in either eye) and 199 retrodot cases (Oxford grade 1.0 in either eye) were individually age/gender matched to controls. Detailed ophthalmic and potential risk factor data were collected, including body mass index (BMI), smoking, alcohol, diabetes, hypertension, analgesics, vitamin supplementation, nutrition, sunlight exposure, dehydration, hormonal (women), blood lipids, glucose, urea, creatinine, uric acid, and vitamin levels., Results: For waterclefts, univariable analysis identified BMI, alcohol intake, vitamin status, sunlight, urea, creatinine, and uric acid as possible risk factors. Multivariable analysis identified two independent associations. Total number of 'any' analgesics in the previous year: adjusted P<0.01 (U-shaped risk profile, unadjusted high vs medium use (=reference) OR 2.39, 95% CI 1.35-4.26 with medium use vs none (=reference) OR 0.43, 95% CI 0.26-0.72); total sunlight: adjusted P=0.03 (unadjusted highest exposure vs lowest (=reference) OR 3.25, 95% CI 1.11-9.50). For retrodots, univariable analysis identified alcohol, HRT, and lipids. Multivariable analysis identified two independent associations. Mean number of alcohol units consumed per month, adjusted P=0.02 and HDL cholesterol levels, adjusted P=0.02 (unadjusted ORs NS both)., Conclusion: This is the first available published information on risk factors for the human cataractous lens features waterclefts and retrodots.

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.

Follow-up ranging between 6 and 8 years of the survival of a cohort of 473 elderly nondiabetic subjects randomly selected from a small English town showed an age- and sex-adjusted association between nuclear cataract at the time of baseline examination and decreased survival (P = .002). Comparing those with and without nuclear cataract, the adjusted relative hazard for death was 1.52 (95% confidence interval, 1.15 to 1.99). This effect remained virtually unchanged when also adjusted for whether the subject reported ever having been a smoker.

Retrodots are common perinuclear features of age-related cataract. Clinical observation suggested that retrodots were associated with increased nuclear scatter. To test this hypothesis, retrospective data were analysed from 78 non-diabetic subjects (118 eyes), of at least 50 years of age, who had neither subscapsular nor axial spoke opacities. Retrodots were graded using the Oxford Clinical Cataract Classification and Grading system and central nuclear scatter was assessed by image analysis of Scheimpflug photographic negatives. Regression analysis in groups was performed according to the "intra-class correlation model" either considering retrodots as a graded feature (grades 0-5) or as a dichotomous variable (present or absent). After adjusting for age (treated as a co-variate), a highly significant association (P < 10(-6) was found between retrodots and increased nuclear scatter in each analysis. It is suggested that the co-existence of these two cataract types may reflect a common cataractogenic mechanism, possibly oxidative stress.

A single masked observer examined 55 non-diabetic patients chosen randomly from a population of patients who had undergone renal transplant. The mean age was 41 years and mean time from transplant was 4.4 years (1-10 years). Fourteen patients were found to have a posterior subcapsular cataract (PSC). The axial thickness of the right lens of the renal transplant population, even in the presence of a PSC, was significantly larger than in a control population of 99 patients with clear lenses. The PSC of renal transplantation is readily distinguished from age related PSC because the opacity lies in the superficial cortex at a depth proportional to time from transplant and the lens maintains a normal anterior clear zone. It is proposed that this type of cataract be called 'recovering' PSC. It is concluded that the cataractogenic insult occurs mainly during the peritransplant period. Maintenance doses of immunosuppressives or steroids are therefore probably not cataractogenic.

A modular system of acquisition and analysis of Scheimpflug, retro-illumination and fluorescence images of the in vivo human crystalline lens is described. Image analysis is directed towards the following goals: Scheimpflug slit-images are analysed for: (1) The optical density of nuclear cataract present; (2) The dimensions of the lens and the lenticular zones; (3) The curvatures of the lens and lenticular zones. Retro-illumination images are analysed for: (1) The percentage area which is occupied by cataract; (2) A combined measure (weighted integral) describing both the amount of cataract present and its optical density. Lenticular auto-fluorescence images are analysed for the mean density (fluorescence) of the lens as a whole. A pilot study of the repeatability of the methods is presented.

Intra-observer (within observers) and inter-observer (between observers) variability of the Oxford Clinical Cataract Classification and Grading System were studied. Twenty cataracts were examined and scored independently by four observers. On a separate occasion two of the observers repeated the assessments of the same cataracts in the absence of information from the initial observations. The chance corrected and weighted kappa statistics for observer agreement, both for inter-observer and intra-observer variability demonstrated satisfactory repeatability of the cataract grading system. The overall intra-observer mean weighted kappa was kappa w = +0.68 (range SE kappa = 0.012-0.052) and the overall inter-observer mean weighted kappa was kappa w = +0.55 (range SE kappa = 0.011-0.043).

A composite slit-lamp based system for the clinical classification and grading of cataract is described. Cataract features are classified morphologically, and individual features are graded by comparison with standard diagrams mounted adjacent to the slit-lamp. Attention has been paid to relevant aspects of measurement theory, with equal interval steps between the grades. The image degrading effect of the cataract is assessed using a 'resolution target projection ophthalmoscope'. The method may be used in conjunction with photographic and image analysing techniques.

Posterior subcapsular cataracts were studied in 10 patients (19 eyes) and were photographed at four to 12 weeks intervals by the Oxford Retroillumination Camera. Changes in the fine structure of PSC may occur in as short a time as four weeks. Posterior subcapsular cataracts are shown to be in a state of flux and are not, as might be assumed, slowly but relentlessly progressive. This could imply the existence of a repair mechanism in the lens.

The lens growth through life is the net result of surface accretion partially offset by central compaction. Compaction has previously been shown to affect the cortex. The present study examines compaction in the nucleus by measuring the change in dimensions of congenital lamellar cataract with time and by comparing the different dimensions of dominantly inherited lamellar cataract in individuals of different ages in the same family. It is now shown that compaction affects the nucleus at a decreasing rate with increasing age and that the rate of compaction of lamellar cataracts is faster the greater diameter of the affected lamella. It is concluded that compaction of lens fibres towards the centre of the lens affects all regions of the cortex and nucleus in youth and that the compaction becomes largely or completely confined to the cortex in middle age and beyond. The shape of the lamellar cataract changes from a lenticular shape in youth to a rounded shape with increasing age. This accounts for the development of the peripheral divergence of the zones of discontinuity of the cortex, which allows the lens to remain emmetropic with increasing age in spite of changes in surface curvature.

AimTo 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.MethodsParticipating 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 11 618 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).ResultsThe 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.ConclusionVR 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. [ABSTRACT FROM AUTHOR]

AimsTo demonstrate variations in posterior capsule rupture (PCR) rate between surgeons of the same and different grades as a by-product of routine clinical care.MethodNHS 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.ResultsData 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.ConclusionsConsiderable 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. [ABSTRACT FROM AUTHOR]

AimsTo compare the quality of referrals and listing rates of direct optometric referrals vstraditional GP referrals for cataract surgery.MethodsA 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.ResultsOptometric referrals, relative to GP referrals, were more likely to include information relating to objective visual loss (100 vs87%, P=0.0061) and to counsel the patient (97 vs18%, P=0.0001). GP referrals, relative to optometric referrals, were more likely to comment on personal circumstances (32 vs3%, P=0.0001), past medical history (95 vs68%, P=0.0001), and drug history (94 vs69%, P=0.0009). Operative rates were higher for the optometric direct referrals relative to GP referrals (87 vs69%, P=0.0284). There was no difference in the visual acuity before or after surgery between the pathways.ConclusionsOptometric 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.Eye (2009) 23, 309–313; doi:10.1038/sj.eye.6703075; published online 8 February 2008 [ABSTRACT FROM AUTHOR]

AimsTo 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.MethodsThe 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.ResultsOverall ‘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 26.0 mm, the use of the α-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.ConclusionsHigher-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.Eye (2009) 23, 31–37; doi:10.1038/sj.eye.6703049; published online 7 March 2008 [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]