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Purpose: To analyse trends of ISBCS reported to the Swedish National Cataract Register (NCR) over a 10‐year period. Methods: Since 2010 the NCR contains social security number of all individuals in the list of parameters reported to NCR after each cataract procedure. Bilateral surgeries were mapped out using social security numbers. When dates of both‐eye surgeries are identical for an individual it is classified as an immediate sequential bilateral cataract surgery (ISBCS). This study includes all data reported during the period 1st of January 2010 to 31st of December 2019. During the study period 113 cataract surgery clinics affiliated to the NCR reported their data on consecutive cataract cases. Results: For the whole period 54 194 ISBCS were reported. The total number of bilateral cataract extractions was 422 300. There was a significant trend of increasing ISBCS over time with linear regression (Beta = 1.75, p < 0.001). In ISBCS the occurrence of an ocular comorbidity decreased over time. The use of a capsular tension ring was significantly more common in ISBCS than in delayed sequential bilateral cataract surgery (DSBCS). All other measures taken during surgery were more common in DSBCS. The use of multifocal IOL was significantly more frequent in ISBCS compared to DSBCS (p < 0.001). Conclusions: The use of ISBCS has increased over the study period. The operated eyes have less risk factors than eyes going through a DSBCS, but both ocular comorbidities and surgical complications occur in ISBCS eyes. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the performance of different probabilistic classifiers to predict posterior capsule rupture (PCR) prior to cataract surgery. Methods: Three probabilistic classifiers were constructed to estimate the probability of PCR: a Bayesian network (BN), logistic regression (LR) model, and multi‐layer perceptron (MLP) network. The classifiers were trained on a sample of 2 853 376 surgeries reported to the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) between 2008 and 2018. The performance of the classifiers was evaluated based on the area under the precision‐recall curve (AUPRC) and compared to existing scoring models in the literature. Furthermore, direct risk factors for PCR were identified by analysing the independence structure of the BN. Results: The MLP network predicted PCR overall the best (AUPRC 13.1 ± 0.41%), followed by the BN (AUPRC 8.05 ± 0.39%) and the LR model (AUPRC 7.31 ± 0.15%). Direct risk factors for PCR include preoperative best‐corrected visual acuity (BCVA), year of surgery, operation type, anaesthesia, target refraction, other ocular comorbidities, white cataract, and corneal opacities. Conclusions: Our results suggest that the MLP network performs better than existing scoring models in the literature, despite a relatively low precision at high recall. Consequently, implementing the MLP network in clinical practice can potentially decrease the PCR rate. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the surgical and pharmacological management and outcomes of patients with cataract and concurrent uveitis. Methods: Data from the Swedish National Cataract Register, 2018–2019, were collected and analysed. Uveitic eyes were identified and eyes without uveitis were used as controls. Generalized estimating equations were used to adjust for intra‐individual correlation. Results: The study included 719 eyes with and 256 360 without uveitis. The mean age was 66.0 ± 13.5 (standard deviation [SD]) years in the uveitis group and 74.3 ± 8.7 years in the control group (p < 0.001). Surgery was associated with more intraoperative difficulties in eyes with uveitis (27.0%) than in control eyes (7.1%; p < 0.001). Posterior capsule rupture/zonular complications were registered in nine eyes with uveitis (1.3%) and in 1464 eyes without uveitis (0.6%; p = 0.02). Hydrophilic acrylic intraocular lenses (uveitis 3.6%, controls 1.2%) and subconjunctival steroids (uveitis 17.4%, controls 6.1%) were more frequently used in eyes with uveitis (p < 0.001). post‐operative best‐corrected visual acuity (BCVA) was 0.16 ± 0.38 logarithm of the minimum angle of resolution (logMAR, mean ± SD) in eyes with uveitis (n = 52) and 0.08 ± 0.20 in control eyes (n = 14 489; p = 0.008). Conclusion: In this large registry‐based Swedish cohort study, the findings demonstrate that cataract surgery in patients with uveitis poses more challenges and requires special surgical precautions. Eyes with concurrent uveitis had worse BCVA prior to and following surgery. Despite the intraoperative challenges, the visual improvement was greater in the uveitic group. [ABSTRACT FROM AUTHOR]

Purpose: Visual functioning evaluated by the Catquest-9SF questionnaire has shown to be a valid measure for assessing a patient's prioritization for cataract surgery. This study adapted Catquest-9SF for visual function outcomes post uni-lateral cataract surgery or bi-lateral cataract surgery.Methods: Visual functioning was assessed before and after uni-lateral or bi-lateral cataract surgery using the Catquest-9SF questionnaire. Patients were enrolled to this study prior to their cataract surgery between March 29 and April 30, 2021 at Shellharbour Hospital, Australia. Catquest-9SF questionnaires were completed prior to and 3 months post surgery. Resulting data were assessed for fit to a Rasch model using WINSTEPS software (version 4.2.0). Catquest-9SF data analysis of Chi-square, Wilcoxon sum test, and Fischer's test were performed in R (version 4.1.0). P value <.05 was considered statistically significant.Results: Sixty-one patients (mean age = 73.2 years, 62% female) were included for analysis. Catquest-9SF response thresholds, adequate precision (person separation index = 2.58, person reliability = 0.87, Cronbach's alpha = 0.74), uni-dimensionality, and no misfits (infit range 0.65-1.33; outfit range 0.64-1.31) were recorded. The mean of item calibration for patients was -0.22 post-operatively. There was significant (P <.05) improvement (16.3%) in visual functions across all nine Catquest 9-SF items. There was a significant mean visual function difference between patients with uni-lateral (10.1%) and bi-lateral cataract surgery (22.3%) pre-operatively and post-operatively.Conclusion: The Catquest-9SF questionnaire showed excellent psychometric properties and can assess visual functioning in an Australian population. There was a significant improvement in patient visual function post cataract surgery and higher functioning with bi-lateral cataract surgery. [ABSTRACT FROM AUTHOR]

Purpose: To analyse if patients with diabetic retinopathy (DR) subjected to cataract surgery differ in outcome compared to patients without DR with regard to best‐corrected visual acuity (BCVA), deviation from target refraction, intraoperative difficulties and risk of complications. Methods: A register‐based study from the Swedish National Cataract Register (NCR) during the years 2015–2017 including 358 040 cataract procedures. Patients with other ocular pathology than cataract and DR were omitted from outcome analyses. Results: Diabetic retinopathy was reported in 13 724 of all eyes (3.8%). Preoperative BCVA was significantly worse in DR patients than in patients without DR, 0.54 ± 0.33 compared to 0.40 ± 0.27 (logMAR, mean ± SD, p < 0.001). The same was evident for postoperative BCVA, 0.15 ± 0.25 for DR patients versus 0.06 ± 0.13 (p < 0.001). The improvement in BCVA was slightly better in DR than in non‐DR, −0.40 ± 0.32 (logMAR; mean ± SD) versus −0.35 ± 0.27, p < 0.001. The absolute mean biometry prediction error was 0.42 ± 0.50 diopters (D) in DR and 0.43 ± 0.71 D in non‐DR patients, p = 0.768. One or more intraoperative difficulties, including mechanical pupil dilation, capsular stain, hooks at capsulorhexis margin or capsular tension ring, had an adjusted odds ratio (OR) of 1.75 (95% confidence interval [CI] 1.61–1.90, p < 0.001) in DR versus non‐DR cases and the rate of posterior capsular tears (PCR) had an adjusted OR of 1.76 (95% CI 1.40–2.20, p < 0.001). Conclusion: Eyes with DR have inferior pre‐ and postoperative BCVA compared to non‐DR eyes. There is little difference in improvement of BCVA and no difference in absolute mean biometry prediction error. Importantly, intraoperative difficulties and PCRs are almost twice as common in DR patients, strongly indicating that these patients should be managed by experienced surgeons. [ABSTRACT FROM AUTHOR]

Purpose: To study the incidence, predictive factors, etiology, and visual consequences of postoperative endophthalmitis (PE) in relation to 3 intracameral (IC) antibiotic regimes. Setting: Swedish National Cataract Register entries from 2011 through 2017. Design: Observational retrospective study. Methods: PE incidence, influencing factors, bacteriology, and visual outcome were analyzed regarding the 3 major prophylactic IC protocols. Results: The overall incidence of PE was 0.023% or 177 cases in 764 513 cataract procedures. Analyzed per IC regime, the rates of PE were 0.024% (126 cases in 514 916 surgeries) for cefuroxime, 0.020% (25 cases in 122 340 surgeries) for moxifloxacin, and 0.017%(20 cases in 121 045 surgeries) for combined cefuroxime-ampicillin. Incidences were not statistically significantly different from one another. Grampositive bacteria caused 89.0% of culture positive cases. Enterococci as pathogens were significantly more frequent with IC cefuroxime than with moxifloxacin, P = .006, or cefuroxime-ampicillin, P < .001, while streptococci other than enterococci were more common with moxifloxacin than with cefuroxime, P < .001. Bacterial susceptibility to the given antibiotics was demonstrated in 21.3% of PE cases treated with cefuroxime, which was statistically significantly lower than proportions found with cefuroxime-ampicillin, 60.0%, P = .015, or with moxifloxacin, 88.2%, P < .001. Visual outcome worse than 20/200 was similar in the groups ranging from 42.0% to 53.7%. Conclusions: No statistically significant differences in PE incidence or visual outcome results between treatment groups were demonstrated. However, differences in etiology and bacterial sensitivity were found between the prophylactic IC treatments. [ABSTRACT FROM AUTHOR]

Background: The recent systematic adoption of intracameral antibiotic injection during cataract surgery in Sweden, India, and the US serves as a model for the successful transitioning of local quality improvement initiatives to organization-wide implementation. Although the delivery of eye care in the 3 countries is distinctly organized with differing governances and technological infrastructure, each contains elements of a learning organization (ie, an organization that has adopted a culture of creating, acquiring, and transferring knowledge into practice through system level and clinician-level change). Methods: We describe a retrospective and organizational implementation study of intracameral antibiotic injection in Sweden, through the efforts of the National Cataract Registry; in the US by Kaiser Permanente; and in India by the Aravind Eye Hospital System. Leadership structure, training in problem solving, benchmarking, sharing of technical knowledge, and data and workforce engagement are compared. Results: Each of the 3 organizations share the key elements of effective leadership, which values the exchange of ideas in the workforce, training and resourcing for change, and information management in the form of benchmarking and data sharing. In the case of intracameral antibiotic injection, a new technique was identified to improve quality and safety with a reduction in infections as evidence of the success of the programs. Conclusion: Committing to a culture of collective learning, and leveraging each stakeholder’s personal investment, health-care systems may improve care delivery and set new benchmarks in quality and safety. [ABSTRACT FROM AUTHOR]

Purpose: To characterize pre‐ and perioperative factors associated with treatment for wet age‐related macular degeneration (wet AMD) after cataract surgery. Methods: This register‐based cohort study with data from the Swedish National Cataract Register (NCR) and the Swedish Macula Register (SMR) from 2010 to 2017 compared eyes with and without preoperative AMD that had undergone cataract surgery and was subsequently treated for wet AMD to eyes not treated within the study period. All first‐eye surgeries registered in the NCR from 2010 to 2017 and matching eyes found in the SMR that had undergone treatment for wet AMD ≥ 1 year after the cataract procedure were included. Data for cataract surgery date, age and gender, use of a blue‐blocking IOL, preoperative visual acuity, ocular comorbidities, posterior capsule rupture and date of AMD treatment initiation were extracted. Results: The only independent factor associated with postoperative treatment of wet AMD in both groups was female gender (67.3% vs. 58.8%, p < 0.001 and 66.4% vs. 60.6%, p = 0.001, respectively). Older age was an independent factor in eyes without preoperative AMD (78.4 ± 6.5 vs. 73.4 ± 9.6 years, p < 0.001). A blue‐blocking IOL appeared to decrease the likelihood of subsequent wet AMD treatment slightly but not statistically significant in eyes with preoperative AMD (52.7% vs. 56.8%, p = 0.110). Conclusions: Some factors (female gender, high age) are associated with undergoing subsequent treatment for wet AMD to a higher extent. If the use of a blue‐blocking IOL offers any protection from undergoing AMD treatment after cataract surgery, such an effect must be very small. [ABSTRACT FROM AUTHOR]

Purpose: To study the test–retest reliability of the Catquest‐9SF questionnaire in cataract surgery. Methods: A single‐centre prospective non‐randomized test–retest study was conducted using the Swedish National Cataract Register and the Catquest‐9SF questionnaire, which is a valid patient‐reported outcome measurement tool developed and used for evaluating quality and visual disability outcome in cataract surgery. Consecutive patients (n = 144) scheduled for cataract surgery completed the Catquest‐9SF twice before surgery, with a minimum of 7 days and a maximum of 14 days between the two questionnaires. A rating scale model was constructed on the basis of the questionnaires from the first measurement and used to generate scores for both the first and second measurements. The consistency was investigated by calculating intraclass correlation, Pearson correlation and a Bland–Altman plot. Internal consistency was measured using Cronbach's alpha. Results: Analyses showed an intraclass correlation of 0.93 (95% confidence interval: 0.90–0.95), a Pearson correlation of 0.93 and Cronbach's alpha of 0.94. The results fit well in a Bland–Altman plot. Conclusion: The test–retest reliability of the Swedish Catquest‐9SF is excellent. Along with previous knowledge, this supports continued use of the Catquest‐9SF in evaluating quality and outcome in cataract surgery. [ABSTRACT FROM AUTHOR]

Purpose: The primary goal was to validate a Danish translated version of the Catquest‐9SF by Rasch analysis. The secondary goal was to investigate whether preoperative Catquest‐9SF scores, best‐corrected visual acuity, comorbidity, gender, age or corneal astigmatism could predict improvements in subjective outcome. Methods: In a prospective trial, 250 patients eligible for cataract surgery were included. Patients filled out the translated Catquest‐9SF questionnaire before surgery and again 3 months after surgery. Both preoperative and postoperative questionnaires were included in the Rasch analysis. A multiple reverse stepwise regression model was used to investigate the correlation between preoperative measurements and subjective improvement. Results: The preliminary Rasch analysis showed misfit of items 4 and 6. These items were removed, and the remaining seven items demonstrated a measurement precision of 2.78, a person reliability coefficient of 0.89, ordered response categories, infit of 0.69–1.22, outfit of 0.73–1.14, observed raw variance explained by measures of 70.4% and an eigenvalue of 1.7. Item 7 showed a mild DIF for gender (0.54 logits), and person mean Rasch score targeting was −1.69 logits. Preoperative Catquest score was the only parameter with a significant correlation to a gain in subjective outcome (p < 0.001). A preoperative Catquest‐9SF score of 0.5 carried a 95% likelihood of an increase in subjective outcome. Conclusion: The Danish version of the Catquest‐9SF fit the Rasch model. Only preoperative Catquest‐9SF score was correlated to subjective improvement, and a cut‐off value of 0.5 predicted an improvement in subjective outcome with 95% probability. [ABSTRACT FROM AUTHOR]

Purpose: To study associations between intraoperative difficulties and changes in patient‐perceived and postoperative visual function and visual satisfaction after cataract surgery. Methods: Swedish multicenter, prospective, cross‐sectional, nonrandomized, National Cataract Register study. A total of 10 979 patients (n = 10 979) who underwent cataract surgery from 2008 to 2011 completed the Catquest‐9SF questionnaire before and 3 months postoperatively. Using Rasch analysis, we converted the nonparametric grading of the answers to parametric data and performed parametric statistical analyses. Multiple regression models were used to examine possible predictors associated with self‐assessed visual function after cataract surgery. Results: Greater improvement in self‐assessed visual function was seen in patients in whom trypan blue dye was used; those without a posterior capsular tear or an ocular comorbidity; and those who were younger, female and had low preoperative corrected distance visual acuity (CDVA) or high postoperative CDVA compared with their counterparts. Significantly higher self‐assessed postoperative visual function was seen in patients in whom trypan blue dye was used and those with no posterior capsular tear or ocular comorbidity and no use of capsular hooks; and those who were younger and had low preoperative or high postoperative CDVA compared with their counterparts. The risk of general dissatisfaction after cataract surgery was significantly greater in patients with a posterior capsule tear, ocular comorbidity or low postoperative CDVA, and those in whom mechanical pupillary stretching was performed. Conclusion: Several intraoperative difficulties, posterior capsular tear, ocular comorbidity, age, gender, and preoperative and postoperative CDVAs affect patient improvement and self‐assessed visual function after cataract surgery. [ABSTRACT FROM AUTHOR]

Purpose: To explore the relationship between acquisition of new spectacles after routine cataract surgery and vision‐related activity limitation (VRAL) postoperatively. Methods: This cohort study with intervention (survey) included 1329 patients in Sweden who had undergone a second‐eye cataract surgery during March 2013. Data from the Swedish National Cataract Register were used, including evaluations of VRAL through the Catquest‐9SF questionnaire before and 3 months after cataract surgery. Five months after the second‐eye surgery, patients completed another five‐item questionnaire about spectacle use preoperatively and postoperatively including an item on surgeons' advice about the need for spectacles. These responses were linked to the Rasch‐analysed Catquest‐9SF data to identify correlations with VRAL. Results: A total of 1239 patients finally participated in the study after excluding those who did not fulfil the inclusion criteria. Patients who were advised about the need for spectacles postoperatively (n = 387) had a greater (p = 0.039) improvement in the postoperative VRAL compared to patients who were not advised (n = 691). Patients who obtained new spectacles postoperatively (n = 512) also had greater improvement (p = 0.032) compared to those who did not (n = 724). Conclusion: The average improvements in the VRAL after surgery were significantly higher for patients who obtained new distance spectacles postoperatively and for patients who were informed about the need for spectacles by their practitioners. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To explore patients' obtaining and use of spectacles after routine cataract surgery. Methods: The study included 1329 patients who underwent bilateral surgery with the second eye operated during March 2013 at 38 different clinics in Sweden. Five months after the second‐eye surgery, patients completed a five‐item questionnaire about their spectacle use preoperatively and postoperatively. The responses were linked to data from the registry on multiple variables including postoperative refraction, age and gender. Results: Of the 387 patients who were advised by their surgeons to obtain distance spectacles postoperatively, most did so (77.3%, n = 299), while of the 691 patients who were not so advised, most did not obtain spectacles (78.9%, n = 545). Nevertheless, almost 50% of patients with both spherical and cylindrical errors exceeding 1 dioptre (D) did not obtain new distance spectacles postoperatively, while about 25% of patients with bilateral emmetropia (spherical error <0.5 D, cylinder <1 D) obtained new distance spectacles postoperatively. Conclusion: Patients' choices regarding obtaining and using new spectacles postoperatively are strongly correlated with advice given by the surgeon about the need for distance correction. The large difference between groups who were and were not advised to obtain spectacles for distance correction was only partially reflected in the postoperative refractive errors. Similarly, the patterns of preoperative spectacle use and gender or age differences did not explain this difference. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The objective of this study was to compare patients with epiphora and cataract in terms of the activity limitations they experience in daily life due to their visual disability and to validate the use of the Catquest‐9SF questionnaire for epiphora patients. Methods: Seventy‐two consecutively encountered adult patients with confirmed lacrimal obstruction and listed for dacryocystorhinostomy (DCR) or lacrimal intubation at the St. Erik Eye Hospital, Stockholm, Sweden, completed the Catquest‐9SF questionnaire, which measures activity limitations in daily life due to visual disability. The psychometric qualities of the Catquest‐9SF results obtained from this group of patients were evaluated by Rasch analysis. Rasch analysis was further employed to convert the ordinal raw data to a Rasch score for comparison with the preoperative scores of patients registered in the Swedish National Cataract Register (NCR) during March 2013. Results: The Catquest‐9SF exhibited good psychometric qualities when investigating epiphora patients, with the exception of a misfit for Item 4, the item regarding facial recognition. On the Rasch scale (−5.43 = no activity limitations to +5.01 = severe activity limitations), the mean score for epiphora patients was −0.82 while for patients listed for 1st eye and 2nd eye cataract surgery it was −0.17 and −0.76, respectively. An equivalence test confirmed that the reported visual disability of epiphora patients was not significantly different from visual disability reported by patients waiting for 2nd eye cataract surgery. Conclusion: The Catquest‐9SF is a valid measure of visual disability in patients with epiphora. Epiphora patients experience visual disability to the same degree as patients awaiting 2nd eye cataract surgery. [ABSTRACT FROM AUTHOR]

Why do eye clinics differ in their waiting times for women’s and men’s access to cataract extraction (CE)/“grå starroperation”? Taking a doing-gender perspective as the starting point, this study explores how gender constructions embedded in Swedish eye clinics contribute to longer waiting times for women than for men. Focus group interviews were conducted with doctors at two Swedish eye clinics: one with a larger and another with a smaller than average gender difference in waiting times for CE. Several differences were found between the clinics regarding how gender was constructed: Women and men were constructed as different with respect to ascribed traits such as assertiveness and care-seeking behaviour. Their need for visual acuity in working life was perceived as different by the doctors, and the study indicates differences between the clinics regarding their interest and awareness concerning issues related to inequity, reflected in the dissimilar prevalence of jokes with racist and misogynist connotations at the two clinics. [ABSTRACT FROM AUTHOR]

Purpose The Catquest-9 SF questionnaire is a unidimensional, reliable, valid and short patient-reported outcome measure for quantifying benefits in visual functioning from cataract surgery. Our aim was to develop a formal Dutch translation, calculate norm scores, assess its validity and test-retest reliability and provide an easy way for use in clinical practice. Methods Translation of the questionnaire was performed according to guidelines of the International Society for Pharmacoeconomics and Outcomes Research. Catquest-9 SF was obtained in 657 patients pre- and postcataract surgery. We applied Rasch and classical analyses to determine the questionnaire performance with characteristics such as unidimensionality, reliability, separation and differential item functioning. Test-retest reliability was assessed in another group of 145 patients. A cut-off value to discriminate between people with and without cataract, norm scores and a reliable change index ( RCI) were calculated using data from a sample of 916 'healthy' persons from the normal population. Results The Dutch Catquest-9 SF was unidimensional, and both person and item reliability were high; 0.87 and 0.99, respectively. Cronbach's alpha was 0.94, test-retest reliability was 0.85 and the intraclass correlation coefficient was 0.93. Catquest-9 SF showed to be responsive to the effect of cataract surgery (effect size = 1.27; p < 0.001). The cut-off value was −1.90, and RCI was 2.27. A quick-access table with norm scores and percentiles was established to facilitate clinical interpretation. Conclusion This investigation provides validity and reliability of the Dutch Catquest-9 SF as well as norm scores and a new tool to facilitate the clinical interpretation of patient scores. This makes Catquest-9 SF suitable for routine use in clinical practice. [ABSTRACT FROM AUTHOR]

Purpose To validate the Spanish Catquest-9SF and study patient-reported visual function after implantation of a trifocal versus a monofocal intraocular lens (IOL). setting Clinica Baviera, Valencia and Madrid, Spain. Design Prospective case series. Methods The Catquest-9SF was translated from English to Spanish according to a standard procedure. The Spanish version was validated through Rasch analysis. Patients completed the Catquest-9SF before cataract surgery and 3 months after the surgery. The change in patient-reported visual function caused by surgery, the level of achieved visual function, and satisfaction with vision after surgery were assessed for bilaterally implanted trifocal IOLs versus monofocal IOLs. Results The Spanish Catquest-9SF showed very good psychometric properties. Patient-reported achieved visual function was significantly better for those with a trifocal IOL than for those with a monofocal IOL ( P < .001). This was also true when the groups were matched for age and ocular comorbidity ( P = .006). In multivariate analyses of all cases and matched cases (the same age and no comorbidity), the reported visual function was significantly better with trifocal IOLs than with monofocal IOLs ( P = .001 and P = .008, respectively). There was greater improvement after trifocal IOL implantation in the matched cases, although not significant ( P = .103). Conclusions Results show the Spanish version of Catquest-9SF is a valid patient questionnaire with good psychometric properties. Patients with a trifocal IOL implanted bilaterally reported better visual function than those with a monofocal IOL implanted bilaterally. The change in visual function after surgery was also greater in patients with a trifocal IOL. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned. [ABSTRACT FROM AUTHOR]

Purpose To investigate visual outcome, bacteriology, and time to diagnosis in groups identified as being at risk for endophthalmitis following cataract surgery. Setting Swedish National Cataract Register. Design A retrospective review of postoperative endophthalmitis and control cases reported from 2002 to 2010. Methods Three identified risk groups for endophthalmitis confirmed in previous multivariate models were organized in such a way that the highest level of significance determined the allocation of cases that belonged to more than one group. Control cases of the entire database were arranged in the same manner. Results Of the 244 endophthalmitis cases occurring in 692 786 surgeries, 148 did not belong to any risk group, whereas the remaining cases were part of the following groups at risk: nontreatment with intracameral antibiotic (n = 22), communication with vitreous (n = 18), and age 85 years or more (n = 56). Cefuroxime was the intracameral antibiotic used in 99% of treated cases. Cases sustaining a communication with vitreous were found to have the worst visual prognosis. Among causative organisms, Gram-positive bacteria were significantly more frequent in cases with a communication with vitreous, whereas staphylococci and Gram-negative results were more common in patients aged 85 years or more than in nonrisk patients. Conclusion Limiting the size of the risk groups by giving a prophylactic intracameral antibiotic to every single patient and by intervening earlier in the course of cataract development appear to be first steps in further reducing the endophthalmitis rate. Adjustments of the intracameral regimen may be advantageous in some risk groups. Financial Disclosure None of the authors has any financial or propriety interest in any material or method mentioned. [ABSTRACT FROM AUTHOR]

Purpose To analyse the relationship between patient-reported outcome measures and clinical outcome measures in 42 individual Swedish cataract surgery settings. Methods The study material consisted of follow-up data on cataract extractions collected by the Swedish National Cataract Register in 2008-2011. Patient-reported outcome was measured using the Catquest-9 SF questionnaire. A total of 9707 pairs of questionnaires completed before and after a cataract extraction were analysed together with clinical data. The analyses were performed for each clinic. Results For almost all clinics, a factor related to a poor patient-reported outcome after surgery was a good preoperative self-assessed visual function. For some clinics, up to 50% of the patients stated that they were very satisfied with their vision before surgery. For single clinics, different factors such as large anisometropia (≥3D), capsule complications, biometry prediction error (≥3D) and ocular comorbidity were related to a poor patient-reported outcome. In situations where the clinical outcome was good and the patient-reported outcome was poor, problems with near-vision activities after surgery was the main factor noted. Conclusions Analysing factors related to a poor patient-reported outcome for each clinic showed large variation. Weak indication for surgery, refractive problems after surgery, surgical complications and a poor chance of visual recovery due to ocular comorbidity were among the reasons for a poor patient-reported outcome. Post-operative care in terms of establishing a good near vision seemed to be another problem for some clinics. [ABSTRACT FROM AUTHOR]

Purpose The aim of this study was to describe changes over time in the indications and outcomes of cataract surgery and to discuss optimal timing for the surgery. Design Database study. Participants Patients who had undergone cataract extraction in the Netherlands, Sweden, or Malaysia from 2008 through 2012. Methods We analyzed preoperative, surgical, and postoperative data from 2 databases: the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) and the Malaysian National Cataract Registry. The EUREQUO contains complete data from the national cataract registries in the Netherlands and Sweden. Main Outcome Measures Preoperative and postoperative corrected distance visual acuity, preoperative ocular comorbidity in the surgery eye, and capsule complications during surgery. Results There were substantial differences in indication for surgery between the 3 national data sets. The percentage of eyes with a preoperative best-corrected visual acuity of 20/200 or worse varied from 7.1% to 72%. In all 3 data sets, the visual thresholds for cataract surgery decreased over time by 6% to 28% of the baseline values. The frequency of capsule complications varied between the 3 data sets, from 1.1% to 3.7% in 2008 and from 0.6% to 2.7% in 2012. An increasing postoperative visual acuity was also seen for all 3 data sets. A high frequency of capsule complication was related significantly to poor preoperative visual acuity, and a high frequency of decreased visual acuity after surgery was related significantly to excellent preoperative visual acuity. Conclusions The 5-year trend in all 3 national data sets showed decreasing visual thresholds for surgery, decreasing surgical complication rates, and increasing visual outcomes regardless of the initial preoperative visual level. Cataract surgery on eyes with poor preoperative visual acuity was related to surgical complications, and cataract surgery on eyes with excellent preoperative visual acuity was related to adverse visual results. [ABSTRACT FROM AUTHOR]

Purpose: To analyze changes over time in biometry prediction error (BPE) after cataract surgery with special reference to the impact of gender and the intraocular lens (IOL) calculation formula. Methods: About 65% of Swedish cataract surgery units participating in the outcome registration of the National Cataract Register (NCR) were included in this prospective register study. Data for planned and postoperative refraction and keratometry during the month of March 2004-2013 were analyzed, divided by gender. The newly introduced variables axial length and IOL calculation formula were analyzed for March 2013. Gender differences in BPE with correct sign (BPESign) and absolute biometry prediction error (BPEAbs) were compared for the Haigis' and Sanders-Retzlaff-Kraff T (SRK/T) formulas. Results: The BPEAbs decreased throughout the study period. In 2004-2006, the BPEAbs was larger in women than in men (p < 0.05), but this difference disappeared from 2007. For 2004 through 2009, the mean BPESign was -0.105 ± 0.79D for women, but -0.003 ± 0.73D for men. After 2009, this myopic error for women gradually diminished. The Haigis' formula performed better in women than the SRK/T formula (p < 0.001); the SRK/T formula rendered a BPESign similar to that from 2004 to 2009 in women. Women had steeper corneas and shorter axial lengths than men (p < 0.001). Conclusion: The myopic BPE in women - associated with steeper corneas and shorter axial lengths - is decreasing, possibly owing to an increased use of the Haigis' formula. Using the Haigis' formula to a higher extent can potentially further reduce the BPEs after cataract surgery. [ABSTRACT FROM AUTHOR]

. Purpose: The purpose of this study was to investigate national indication criteria tool for cataract extraction (NIKE), a clinical tool for establishing levels of indications for cataract surgery, in relation to gender differences in waiting times for cataract extraction (CE). Methods: Data were collected by The Swedish National Cataract Register (NCR). Eye clinics report to NCR voluntarily and on regular basis (98% coverage). Comparisons regarding gender difference in waiting times were performed between NIKE-categorized and non-NIKE-categorized patients, as well as between different indication groups within the NIKE-system. All calculations were performed in spss version 20. Multivariate analyses were carried out using logistic regression, and single variable analyses were carried out by Student's t-test or chi square as appropriate. Results: Gender, age, visual acuity and NIKE-categorization were associated with waiting time. Female patients had a longer waiting time to CE than male, both within and outside the NIKE-system. Gender difference in waiting time was somewhat larger among patients who had not been categorized by NIKE. In the non-NIKE-categorized group, women waited 0.20 months longer than men. In the group which was NIKE-categorized, women waited 0.18 months longer than men. Conclusions: It is reasonable to assume that prioritizing patients by means of NIKE helps to reduce the gender differences in waiting time. Gender differences in waiting time have decreased as NIKE was introduced and there may be a variety of explanations for this. However, with the chosen study design, we could not distinguish between effects related to NIKE and those due to other factors which occurred during the study period. [ABSTRACT FROM AUTHOR]

Purpose To study the epidemiology and risk factors of early- and late-onset postoperative endophthalmitis ( PE) and severe blebitis following trabeculectomy. Methods Retrospective, single-centre, observational study with a case-control design in part. Patients sustaining PE and severe blebitis following trabeculectomy or a combined trabeculectomy with a cataract extraction procedure performed from 1990 through 2008 and diagnosed from 1990 through 2012 were recorded at St Erik Eye Hospital. Incidence data were calculated with help from the hospital records. Notes data of cases and of six randomly selected but procedure matched control patients for each case were compared. Results The joint rate of infection was 0.46% or 34 incidents in 7402 procedures. The frequency of early (occurring <6 weeks after surgery) onset PE was 0.19%, late PE was 0.19% and severe blebitis was 0.08%. Dominating aetiologies were staphylococci and streptococci. Overall, the infection severely impaired the visual function. Combined cataract and fistulating operations were less prone to develop late infections, p = 0.04, but no other decisive factors were identified in the case-control study. Data collection for all trabeculectomy surgeries from 1998 and onward identified an increased rate for late infection with the use of mitomycin C ( MMC), 8 in 1171 surgeries or 0.7%, versus no such use, 0 case of late PE in 2136 surgeries, p < 0.001. Conclusions Postoperative endophthalmitis is a devastating complication after trabeculectomy. The use of MMC increases the risk for delayed infection. Early PE after trabeculectomy is clearly more common than PE after cataract surgery. Developing efficacious prophylactic antibiotic regimens to reduce early PE after penetrating filtering procedures should be a major priority in ophthalmic surgery. [ABSTRACT FROM AUTHOR]

. Purpose: To evaluate waiting times for first-eye cataract surgery in Sweden following widespread adoption of the Nationell Indikationsmodell for Kataraktextraktion (NIKE) tool for prioritizing patients for cataract surgery. Methods: Waiting times for all first-eye cataract surgeries in Sweden in 2009-2011 were identified from the Swedish National Cataract Register. Waiting times were compared according to demographic, clinical and NIKE indication group for surgery. Multivariate logistic regression modelling was used to determine factors associated with waiting times less than the 3-month Government guarantee period. Results: There were 141 070 first-eye cataract surgeries in 2009 to 2011; an annual increase of around 6%. Over the study period, mean waiting times decreased across all NIKE groups. The proportion waiting <3 months for surgery also increased across all NIKE groups. Surgery within 3 months of waitlisting was more likely for patients with a NIKE 1 indication classification (most need for surgery), in later years, male patients, younger patients and patients with a preoperative visual acuity in the better eye worse than 6/24. Conclusions: Prioritizing patients for cataract surgery using NIKE reduces waiting times for those with the greatest need. [ABSTRACT FROM AUTHOR]

. Purpose: To evaluate the posterior capsule opacification (PCO) rates in three different modern standard intraocular lenses (IOL) and analyse the related cost. Methods: Retrospective study of medical records from 1527 patients who underwent uneventful cataract surgery by phacoemulsification with posterior chamber implantation of either AcrySof SN60 ( n = 375), Akreos Adapt ( n = 350) or Tecnis Acryl IOL ( n = 801). All surgeries were performed by the same surgeon using the same surgical technique and equipment. Primary end-point was neodymium:yttrium-aluminium-garnet (Nd:YAG) capsulotomy for visual impairment secondary to PCO. Cost of IOL material and Nd:YAG capsulotomy for PCO was then evaluated and compared between the IOLs. Results: Mean follow-up was 41.5 months, and the only statistically significant variable of developing PCO was IOL type and individual follow-up time. Nd:YAG capsulotomy was performed in 7.47% in the AcrySof group, 17.71% in the Akreos group and 3.75% in the Tecnis group. Average cost for Nd:YAG capsulotomy per surgery was €18.75 in the AcrySof SN60 group, €44.25 in the Akreos Adapt group and €9.25 in the Tecnis Acryl group. The combined cost of cataract surgery and PCO treatment was €9.81 higher in for the Akreos Adapt group than the other two combined. Conclusions: This retrospective study shows that the risk of PCO and Nd:YAG capsulotomy is significantly higher in hydrophilic Akreos IOL compared with both AcrySof and Tecnis hydrophobic IOLs. The increased risk of PCO in the hydrophilic IOL is related to higher total average costs for cataract surgery. [ABSTRACT FROM AUTHOR]

Background: To validate the Catquest-9SF questionnaire in Italian, assess the change in visual disability with cataract surgery and determine the correlation between pre-operative Catquest-9SF scores and Lens Opacities Classification System (LOCS) III cataract grading. Methods: Prospective, questionnaire validation study. The Catquest-9SF questionnaire was forward and back translated and completed by 209 Italian patients before and three months following cataract surgery. Rasch analysis was used to assess its psychometric properties. Results: The Italian Catquest-9SF demonstrated ordered response categories, unidimensionality (item fit statistics range: 0.73–1.34), adequate person separation (2.04), and no differential item functioning. Mistargeting was evident with a mean difference in item difficulty and person ability of 2.04 logits but improved with inclusion of pre-operative data only. There was a statistically significant (Friedman tests, p < 0.001) median improvement in visual disability of 1.92, 3.57, 1.44 and 2.94 logits in patients undergoing first eye surgery with and without ocular comorbidity, and second eye surgery with and without ocular comorbidity respectively. There was no statistically significant difference in the improvements among the four groups (Kruskal-Wallis H test, X2(3) = 5.445, p = 0.142). There was no correlation between Catquest-9SF scores and nuclear opalescence (rs = 0.049, p = 0.478), nuclear colour (rs = 0.008, p = 0.909), cortical (rs = 0.066, p = 0.341), and posterior subcapsular components (rs = 0.048, p = 0.494). Conclusions: The Italian Catquest-9SF demonstrated good psychometric properties and is suitable for use in Italian speaking patients. There were similar improvements in visual disability in patients undergoing first or second eye surgery, with or without ocular comorbidity. There was no correlation between pre-operative Catquest-9SF scores and LOCS III cataract grading.

Purpose: To analyze the visual outcome after cataract surgery. Setting: Cataract surgery clinics in 15 European countries. Design: Database study. Methods: Data were drawn from case series of cataract extractions reported to the European Registry of Quality Outcomes for Cataract and Refractive Surgery database. These data were entered into the database via the Web by surgeons or by transfer from existing national registries or electronic medical record systems. The database contains individual anonymous data on preoperative, intraoperative, and postoperative measurements. Results: Data on 368 256 cataract extractions were available for analysis. The best visual outcome was achieved in age groups 40 to 74 years, and men showed a higher percentage of excellent vision (1.0 [20/20] or better) than women. A corrected distance visual acuity (CDVA) of 0.5 (20/40) or better and of 1.0 (20/20) or better was achieved in 94.3% and 61.3% of cases, respectively. Ocular comorbidity and postoperative complications were the strongest influences on the visual outcome; however, surgical complications and ocular changes requiring complex surgery also had a negative influence. Deterioration of visual acuity after the surgery (n= 6112 [1.7% of all cases]) was most common in patients with a good preoperative visual acuity. Conclusions: The visual outcomes of cataract surgery were excellent, with 61.3% of patients achieving a corrected distance visual acuity of 1.0 (20/20) or better. Age and sex influenced the visual outcomes, but the greatest influences were short-term postoperative complications, ocular comorbidity, surgical complications, and complex surgery. A weakness of the study could be that some of the data is self-reported to the registry. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. [ABSTRACT FROM AUTHOR]

Purpose: To report the nationwide incidence and risk factors for endophthalmitis after cataract surgery in Sweden. Setting: Swedish National Cataract Register containing reports on cataract operations from all Swedish ophthalmic surgical units. Design: Prospective epidemiologic study. Methods: Endophthalmitis case reports were collected from 2005 through 2010. Case and control parameters pertaining to patient characteristics and surgical technique were generated from the database. In addition, information from annual surveys regarding the topical prophylactic protocol was analyzed. Results: The reports showed 135 endophthalmitis cases in 464 996 operations, equaling an incidence of 0.029%. Patient age over 85 years, perioperative communication with the vitreous and, above all, nonuse of intracameral cefuroxime showed a statistically significant association with endophthalmitis in the logistic regression. Short-term topical antibiotics given as add-on prophylaxis to the intracameral regimen before, after, or before and after the operation did not confer a clear-cut benefit. Groups with topical treatment were small, comprising 14% of the sample. Conclusions: The incidence of endophthalmitis after cataract surgery in Sweden is declining, which appears to be explained by a fall in the frequency of major risk factors. Operating earlier in the cataract course, avoiding capsule breakage, and giving intracameral antibiotics universally should further reduce the endophthalmitis rate. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. [ABSTRACT FROM AUTHOR]

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. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. [ABSTRACT FROM AUTHOR]

. Purpose: To investigate the functional outcome, as defined using the Catquest questionnaire, for patients with posterior capsule opacification (PCO) and low corrected distance visual acuity (CDVA), after capsulotomy. Methods: Thirty-one patients with PCO and visual acuity ≥0.6 (logMAR, ≤0.25 decimal notation) in the PCO eye were examined before and 1 month after capsulotomy. An ophthalmic examination, procuring of a digital image of the posterior lens capsule and completion of Catquest were carried out. Results: Mean CDVA (p < 0.001), disabilities in daily life (p = 0.004), activity (p = 0.012), symptoms of glare (p = 0.003) and satisfaction with vision (p < 0.001) all improved after capsulotomy. Sixty-five per cent of patients had good or very good benefit and 23% questionable or no benefit. The group with moderate benefit was only 6%. Compared with patients with PCO and better visual acuity, the number of patients with good benefit was greater than the number with moderate benefit. Conclusions: Most patients with PCO and low CDVA reported improved visual function in daily life as defined using Catquest, after capsulotomy. The group with moderate benefit was small, indicating that the improvement was either substantial or negligible. [ABSTRACT FROM AUTHOR]

Objective: To determine the preoperative or postoperative patient-related factors that make patients benefit more or less from cataract surgery. Design: Multicenter, prospective, cross-sectional Swedish National Cataract Register study. Participants: A total of 14 817 patients who underwent cataract surgery from 2000 to 2006 in 42 Swedish ophthalmology departments. Methods: The patients completed the Catquest questionnaire before and 6 months postoperatively. The 9 questions in the revised Catquest-9SF were selected from the Catquest and recoded by Rasch analysis, which makes it possible to use parametric statistics when analyzing the study data. The change from preoperative to postoperative, the postoperative mean subjective visual function, and satisfaction with vision were assessed with multiple regression or logistic regression with dummy variables where appropriate, in relation to waiting time, age, preoperative and postoperative corrected distance visual acuity (CDVA), ocular comorbidity, a first- or second-eye surgery, gender, achieved postoperative refraction, correct sign biometry prediction error, and absolute biometry prediction error. Main Outcome Measures: Three outcome measures from Catquest-9SF of patient self-assessed visual function after cataract surgery. Results: Young age (P<0.001), low preoperative CDVA (P<0.001), high postoperative CDVA (P<0.001), no ocular comorbidity (P<0.001), and postoperative myopia (−2 to 0 diopters [D]) instead of hyperopia (>0 to +2 D; P<0.05) led to significantly greater improvement in subjective visual function and a better postoperative subjective visual function than the counterparts. Women (P<0.001) and patients who underwent a first-eye surgery (P<0.001) had greater improvement but lower postoperative subjective visual function (P<0.001) than men and patients who underwent a second-eye surgery. A correct sign biometry prediction error of plus instead of minus led to greater improvement in subjective visual function (P<0.01) but no difference in postoperative subjective visual function. The absolute biometry prediction error had no effect on the change in subjective visual function, the subjective mean visual function or satisfaction with vision. Conclusions: Several patient preoperative and postoperative factors are related to the self-assessed benefit of cataract surgery. Age, preoperative and postoperative CDVAs, ocular comorbidity, a first- or second-eye surgery, gender, and achieved postoperative refraction were related to changes in subjective visual function, subjective visual function, and satisfaction with vision. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article. [Copyright &y& Elsevier]

Patient-reported outcome is an important part of the evaluation of a surgical procedure. Numerous questionnaires for patient’s self-assessed activity limitation because of cataract have been published. The technique for constructing and evaluating questionnaires has changed over time. This review evaluates the psychometric properties of patient questionnaires that have been published since 1992. The evaluation includes questionnaires constructed according to classical test theory and item-response theory. Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned. [Copyright &y& Elsevier]

Background: The Catquest questionnaire was developed using traditional methodology to enable cataract surgery outcomes assessment in European countries. Recently, it has been validated using Rasch analysis in a Swedish population resulting in the Catquest-9SF. The aim of the present study was to assess the performance of the Catquest and the Catquest-9SF questionnaires using Rasch analysis in Australian cataract patients. Methods: A total of 217 cataract patients awaiting surgery at Flinders Medical Centre, Adelaide, South Australia self-administered the Catquest questionnaire. This is a 19-item instrument containing frequency, difficulty, symptoms and global rating items. Rasch analysis was undertaken to assess the unidimensionality (whether all the items are measuring a single underlying construct using principal components analysis or PCA), person separation (ability of the questionnaire to distinguish between strata of patient ability) and targeting of item difficulty to person ability. Results: Similar to the previous validation study, the original Catquest questionnaire required revision because of misfit and multidimensionality necessitating removal of the frequency items. The revised version was similar to the Catquest-9SF although an extra driving item was a valid optional inclusion. The Catquest-9SF performed well in the Australian cohort satisfying all criteria for valid measurement including unidimensionality. However, targeting of item difficulty to person ability was marginally worse compared with the Swedish cataract population indicating the Australian cataract patients present for surgery at lower levels of visual disability. Conclusions: The Catquest-9SF is a reliable and valid measure of visual disability in the Australian cataract population. [ABSTRACT FROM AUTHOR]

Purpose: To compare resource utilization of two different strategies for bilateral cataract surgery: immediate sequential cataract surgery (ISCS) versus delayed sequential cataract surgery (DSCS). The purpose was also to analyse the value for the patient of undergoing ISCS versus DSCS. Methods: Differences in routines and resource utilization between ISCS ( n = 17) and DSCS ( n = 80) were studied in a cohort of cataract surgery patients at our clinic in Karlskrona, Sweden. Costs were extracted from an earlier publication by the same clinic. The value for the patient was studied using the capability index, based on published data on the benefit to the patient of ISCS or DSCS using the Catquest questionnaire. Results: Operating both eyes of a patient was 1.14 times more expensive with DSCS than with ISCS including all surgical costs. The value to the patient of undergoing ISCS depended on the time between first- and second-eye surgery in DSCS and the remaining lifetime after both-eye surgery. A long waiting time for second-eye surgery and a short remaining lifetime decreased the patient value of DSCS compared to ISCS. Conclusion: DSCS is 14% more expensive than ISCS. The value for the patient of ISCS compared to DSCS depends on how long the period will be between first- and second-eye surgery in DSCS and also on the patient’s survival time after surgery. [ABSTRACT FROM AUTHOR]

Purpose: To analyze which factors influence the mean absolute prediction error after cataract surgery. Setting: Forty-nine eye departments participating in the Swedish National Cataract Register (NCR). Methods: In this prospective multicenter comparative nonrandomized study, ophthalmology departments in Sweden voluntarily reported to the NCR the outcomes of every cataract extraction performed during the month of March from 2000 through 2005. During this period, 49 of 55 ophthalmology departments in Sweden reported data. Perioperative data describing visual acuity, sex, age, other eye diseases, target postoperative refraction, and achieved postoperative refraction were included in the study. Factors that could be related to the mean absolute prediction error were evaluated. Of the cataract extractions, 23244 were eligible for analyses. Statistical analyses were performed using multiple regression and logistic regression. Results: During the study years, the mean absolute prediction error decreased significantly (P<.0001). The mean absolute prediction error was larger in women than in men (P<.001) and in patients with low preoperative visual acuity (P<.0001). Glaucoma in the surgical eye was also significantly related to a large deviation from the target refraction. The precision in reaching the target refraction was not better in second-eye surgery than in first-eye surgery. Some clinics had a significantly smaller mean absolute prediction error than other clinics (P<.0001). Conclusions: Some preoperative factors were related to less success in reaching the planned postoperative refraction. Taking this into consideration, extra care is warranted in cases with these preoperative risk factors. [Copyright &y& Elsevier]

Purpose: To establish the nationwide rate of postoperative endophthalmitis (PE) after cataract extraction (CE) and to study the relationship between PE and type of incision and other possible risk factors. Design: Prospective, multicenter, comparative, nonrandomized, observational study. Participants: All cataract surgeries in Sweden performed from January 2002 through December 2004 and all endophthalmitis cases in the same period that were reported to the Swedish National Cataract Register (NCR). Methods: Through a standard reporting form sent to the NCR, patient and operation technique data were recorded. In addition, PE cases with a traceable number to the main register were collected. Various parameters with a possible impact on endophthalmitis development were evaluated. Univariate analyses and logistic regression were statistical methods. Main Outcome Measures: The rate and etiology of PE; possible risk factors pertaining to patient history and operation technique, with a special emphasis on incision type and location; use of injector for the intraocular lens implantation; kind of prophylaxis; and presence of peroperative communication between the anterior chamber and vitreous. Results: The overall rate of PE was 0.048% (109 cases in 225 471 CEs). Incidences of PE were 0.053% with clear corneal incisions and 0.036% with sclerocorneal incisions (P = 0.14, logistic regression analysis). The corresponding results were 0.040% for superior incisions and 0.055% for temporal incisions (P = 0.14). Communication between the anterior segment and vitreous was found to be a highly significant independent risk factor for PE (P<0.001), as were patient age ≥ 85 years (P<0.001) and the nonuse of intracameral cefuroxime (P<0.001). Conclusions: The overall rate of PE after cataract surgery is low in Sweden, which may be a consequence of the widespread use of prophylactic intracameral cefuroxime. Only a trend for an increased risk of PE was detected for clear corneal and temporal wounds. The present data indicate that the use of clear corneal and/or temporal approaches will result in 1 additional PE case in approximately 5500 procedures on top of the PE rate after sclerocorneal or superior incisions, which was approximately 1 case in 2400 operations. [Copyright &y& Elsevier]

Objective: To evaluate the effects of the Maximum Waiting-time Guarantee (MWG) policy for cataract surgery on volume, indications, waiting times and priority setting in Sweden. Methods: Comparison between 1993 and 1994, when the guarantee had been in force for one year, and 1998 and 1999, when the policy had been terminated for one year. Data from the National Cataract Registry covering 156,657 cataract operations for the years studied. Results: The number of operations increased by 43% between the two study periods. Of this increase, 61% were patients with a visual acuity above 0.5 in the better eye, i.e. low-priority patients. Waiting times were longer for all patient categories in the later period and differences in waiting times between patients with differing priority diminished. Variations among the units in priority setting and waiting times were substantial, and increased after the Guarantee was terminated. Conclusions: The Guarantee with its explicit indications was an effective policy instrument to limit waiting times and improve access for patients with the greatest need. It is unlikely that the Guarantee caused any 'crowding out' of other patient groups. When the Guarantee was not in force, indications for surgery widened. This, however, resulted in longer waiting times for all patient groups. After the Guarantee was terminated, the already substantial differences in access and indications among ophthalmic units became even greater. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to construct a new clinical tool for establishing levels of indications for cataract surgery, and to validate this tool. Methods: Teams from nine eye clinics reached an agreement about the need to develop a clinical tool for setting levels of indications for cataract surgery and about the items that should be included in the tool. The tool was to be called ‘NIKE’ (Nationell Indikationsmodell för Kataraktextraktion). The Canadian Cataract Priority Criteria Tool served as a model for the NIKE tool, which was modified for Swedish conditions. Items included in the tool were visual acuity of both eyes, patients' perceived difficulties in day-to-day life, cataract symptoms, the ability to live independently, and medical/ophthalmic reasons for surgery. The tool was validated and tested in 343 cataract surgery patients. Validity, stability and reliability were tested and the outcome of surgery was studied in relation to the indication setting. Results: Four indication groups (IGs) were suggested. The group with the greatest indications for surgery was named group 1 and that with the lowest, group 4. Validity was proved to be good. Surgery had the greatest impact on the group with the highest indications for surgery. Test-retest reliability test and interexaminer tests of indication settings showed statistically significant intraclass correlations (intraclass correlation coefficients [ICCs] 0.526 and 0.923, respectively). Conclusions: A new clinical tool for indication setting in cataract surgery is presented. This tool, the NIKE, takes into account both visual acuity and the patient's perceived problems in day-to-day life because of cataract. The tool seems to be stable and reliable and neutral towards different examiners. [ABSTRACT FROM AUTHOR]

Purpose: To compare patients'' self-assessed visual function after bilateral surgery performed on the same day with visual function after surgery in 1 eye at a time. Setting: Department of Ophthalmology, Blekinge Hospital, Karlskrona, Sweden. Methods: Patients with bilateral cataract were assigned randomly to 2 groups, patients having bilateral surgery on the same day and patients with 2 surgeries done 2 months apart. Both groups were examined before and 2 months and 4 months after surgery. All patients completed the Catquest questionnaire at each ophthalmic examination. Results: Until both eyes were operated on, patients having surgery in 1 eye had significantly more difficulties performing daily life activities (P<.001) and a worse binocular contrast sensitivity (P<.01) than patients who had bilateral surgery on the same day. Four months after surgery of both eyes in both groups, there was no difference in visual function. Conclusions: Bilateral cataract surgery on the same day allowed rapid rehabilitation of the patient and helped avoid suboptimal visual function in daily life while waiting for second-eye surgery. However, there was no extra long-term benefit of self-assessed visual function compared with cataract surgery in 1 eye at a time. [Copyright &y& Elsevier]

Purpose: To describe the functional outcome, as defined using the Catquest questionnaire, for patients with posterior capsule opacification (PCO) after capsulotomy. Methods: A total of 47 patients with PCO were examined before and 1 month after capsulotomy. In addition to the ophthalmic examination, Catquest was completed and a digital image of the posterior lens capsule acquired. Results: Capsulotomy resulted in a good level of benefit, as defined using Catquest, for 77% of the patients. No subgroup of patients who derived an exceedingly good or poor level of benefit was identified. Disabilities in daily life, satisfaction with vision and symptoms of glare improved from treatment (p < 0.001, p < 0.001 and p = 0.002, respectively). The results were comparable with the benefits of cataract surgery. Conclusions: Self-assessed visual function as defined using Catquest improved after capsulotomy for the vast majority of patients with PCO. No group of patients with exceptionally good or poor levels of benefit could be identified with certainty. However, the majority of those with a poor outcome were elderly individuals with ocular comorbidity. The overall functional results from treatment of PCO were very similar to those achieved after cataract surgery. [ABSTRACT FROM AUTHOR]

Purpose: To study the incidence of aphakia after cataract surgery, the surgical complications that can lead to it, and the visual outcome.Setting: Six community-run eye clinics participating in the Swedish National Cataract Register.Methods: Data on cataract extractions were collected prospectively from 1997 through 2001. The data also covered the type of surgery and type of intraocular lens, including a “no lens implanted” option. All data were stored in a database. These data were supplemented with data on the intended type of surgery, type of complications, possible second surgery, and visual outcome.Results: The overall incidence of postoperative aphakia was 0.65%. In 87.1% of cases, the aphakia was not planned, corresponding to an incidence of 0.48%. Unplanned aphakia was significantly related to poor preoperative vision, old age, and the presence of ocular comorbidity. The most frequent reasons for unplanned aphakia were intraoperative capsule problems and vitreous loss. In two thirds of cases, a second operation was performed. In 41% of all cases, the final visual acuity was 0.5 or better and in 27.7%, worse than 0.1.Conclusions: During the study period, 1 of every 200 routine cataract surgeries ended in unplanned aphakia. The incidence of surgical complications leading to unplanned aphakia and a final visual acuity worse than 0.1 (20/200) was 7.8 per 10000 operations in cases with no ocular comorbidity and 27.6 per 10000 operations in cases with ocular comorbidity. [Copyright &y& Elsevier]

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 287951 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 (≤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 (≤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 (≤0.1) in the eye to be operated on combined with ocular comorbidity was the highest risk factor for postoperative aphakia. [Copyright &y& Elsevier]

: PurposeTo study the prevalence of previous cataract surgery (PCS) in different age groups in a defined Swedish population.: SettingDepartment of Ophthalmology, Blekinge Hospital, Karlskrona, Sweden.: MethodsThis investigation of the population of Blekinge County, Sweden, was performed in June 2001. All previous cataract extractions in the district were performed at a single surgical unit, and the register of this unit contains data on all consecutive operations since 1980. The population register in the district was studied to ascertain the number of female and male individuals in different age groups for each year from 1980 though 2000. Included were data about deceased patients and those who moved from the area.: ResultsDuring 21 calendar years, 10 538 patients had cataract surgery; 6697 of them (63.6%) were alive in June 2001. The survival rate for patients having cataract surgery during the period shows a linear curve for patients operated on during the past 13 years. Among those in the district aged 70 or older, 23.9% of women and 14.0% of men had cataract extraction in 1 or both eyes. In the population aged 40 years and older, 6.43% had a history of PCS. The annual surgery volume is increasing because of a backlog of cataract cases and because of the yearly incidence. With an increase in the annual surgery volume, it is estimated that given the present indications for surgery, it will take 5 to 10 years to reach a level that means further surgery only in patients having new cataract.: ConclusionEven though there is already a much higher prevalence of PCS than is known from the literature, the annual surgery volume continues to increase, even in older age groups. [Copyright &y& Elsevier]

: PurposeTo develop a method to estimate the cost per quality-adjusted life year (QALY) gained with cataract surgery using large patient registries.: SettingFour centers in Sweden.: MethodsFive 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.: ResultsVisual 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 45 000 SKr (4500 US$) using the Swedish Cataract Registry.: ConclusionsThe 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. [Copyright &y& Elsevier]

ABSTRACT. 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. [ABSTRACT FROM AUTHOR]

ABSTRACT. Purpose: To investigate the morbidity of postoperative endophthalmitis (POE) following cataract surgery in Sweden in 1998. Methods: Clinically presumed cases of POE were reported in a prospective survey in which all Swedish ophthalmic surgical units except one had agreed to participate. Data on intraocular cultures and visual outcomes at 3 months after infection were supplied. Surgical cases that became infected were identified in the Swedish National Cataract Register, thereby enabling screening for various putative risk factors. Results: The nationwide incidence of POE amounted to 58 cases out of 54 666 cataract operations, or 0.1% of surgical cases. The predominant aetiology was gram-positive bacteria, which comprised 57% of the material. Acrylic intraocular lenses were found to decrease the risk of POE significantly in comparison to hydrogel and polymethylmethacrylate lenses. Conclusions: The incidence of POE after cataract surgery in Sweden is similar to that currently reported elsewhere in the developed world. We hope that continued registration of cases of POE in Sweden will shed light on the possible influences of various prophylactic measures and different intraocular lens materials on the development of postoperative infection. [ABSTRACT FROM AUTHOR]