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Purpose: To investigate case mix in relation to capsule complication, possible associations between case mix and operation volume, and change in case mix over time., Design: Register-based study., Participants: Swedish patients who underwent cataract surgery between 2007 and 2016., Methods: Demographics and data on ocular comorbidity, intraoperative difficulties, and capsule complications were registered from 2007 to 2016 and analyzed retrospectively in relation to coded data on individual surgeons' operation volume. Single factor analysis and logistic regression were performed, and a composite risk score was created., Main Outcome Measures: Risk of capsule complication, given as adjusted and composite odds ratio in relation to cataract surgery volume., Results: Preoperative and intraoperative variables significantly associated with capsule complications were best-corrected visual acuity (BCVA) ≤0.1 (decimal, adjusted odds ratio [aOR], 1.82; P < 0.001); pseudoexfoliation (PEX) (aOR, 1.53; P < 0.001); sight-threatening ocular comorbidity other than age-related macular degeneration (AMD), diabetic retinopathy, glaucoma, or cornea guttata (aOR, 1.35; P = 0.006); use of Trypan blue (aOR, 1.76; P < 0.001); mechanical pupil dilation (aOR, 1.36; P = 0.024); and iris hooks at the rhexis margin (aOR, 6.99; P < 0.001). The composite risk score was 3.09 ± 6.40 (mean ± standard deviation) for patients with capsule complication and 1.28 ± 1.66 for uncomplicated procedures (P < 0.001). High-volume cataract surgeons (≥500 procedures yearly) had a significantly lower composite risk score (mean risk score ≤1.28; range, 1.01-2.02) compared with low- and medium-volume cataract surgeons (1.34 ± 0.56; range, 1.00-4.55 and 1.49 ± 0.58; range, 1.01-5.19), respectively. During the period 2007-2016, the proportion of patients aged >88 years, patients with BCVA ≤0.1, and patients with intraoperative difficulties decreased., Conclusions: Case mix, as calculated from a composite risk score based on preoperative and intraoperative parameters registered in the National Cataract Register (NCR), may contribute to the decrease in capsule complications from 2007 to 2016 and the lower complication rate observed in cases managed by high-volume cataract surgeons., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze changes in intraocular pressure (IOP) after cataract surgery based on data from the Swedish National Cataract Register (NCR)., Setting: Ophthalmic surgery units in Sweden., Design: Prospective database study., Methods: Data for 2012 through 2014 were obtained prospectively from the NCR. The outcome register of the NCR has collected data on IOP before and a mean of 37.7 days ± 29.1 (SD) after cataract surgery since 2012., Results: The analyses were based on 20 437 cataract extractions reported during 1 month each year to the outcome registry of the NCR. Cataract surgery was found to reduce IOP by a mean of 1.46 mm Hg, which was statistically significant (P < .001). A larger IOP reduction was seen in cases with a higher preoperative IOP (r = 0.557, P < .001). Older patients and shorter eyes had a greater IOP reduction after surgery (P < .001 and P = .001, respectively). Women had a greater IOP reduction than men (P = .04) When high IOP was given as an indication for surgery, the IOP reduction after cataract surgery was 5.50 mm Hg compared with a reduction of 1.40 mm Hg in patients for whom this indication was not given (P < .001). Patients with glaucoma or pseudoexfoliation (PXF) had a more pronounced IOP reduction than patients without these diagnoses (P < .001)., Conclusion: Cataract surgery had an IOP-lowering effect, in particular in older patients, women, short eyes, eyes with high preoperative IOP, and eyes with glaucoma or PXF., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze changes over time in biometry prediction error (BPE) after cataract surgery with special reference to the impact of gender and the intra-ocular 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., (© 2014 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: To evaluate the efficacy of adding nepafenac 0.1% ophthalmic suspension to dexamethasone 0.1% eyedrops in controlling macular swelling and other manifestations of inflammation after uneventful cataract surgery., Setting: Ophthalmology Department, Mölndal Hospital, Gothenburg, and St. Erik Eye Hospital, Stockholm, Sweden., Design: Randomized double-masked clinical trial., Methods: Patients at low risk for postoperative inflammation were recruited and randomized to the nepafenac group or to the control group. Postoperative swelling of the macula was assessed with ocular coherence tomography. Laser flare intensity, corrected distance visual acuity, ocular discomfort, and visual complaints were also recorded., Results: The analysis of intent-to-treat population comprised 75 patients in the nepafenac group and 77 patients in the control group. Compared with the control regimen, add-on nepafenac resulted in statistically significant reductions in the following parameters: change in macular volume at 3 weeks and 6 weeks (P<.001), proportion of patients with more than 10 μm of swelling in the central macula at 3 weeks (P<.0001) and 6 weeks (P=.02), mean laser flare intensity at 1 day (P=.029), pain during the first 24 hours postoperatively (P<.0001), and ocular discomfort and photophobia during the first 3 postoperative weeks (P=.0058 and P=.0052, respectively)., Conclusion: The combination of topical nepafenac and steroid treatment reduced subclinical macular swelling and inflammation as well as subjective complaints, indicating it is an efficient antiinflammatory regimen after cataract surgery., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2014 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To define the incidence of capsule complication and its risk factors in Sweden over an 8-year period., Setting: Fifty-two ophthalmic surgery units in Sweden., Design: Database study., Methods: Data were collected prospectively in the Swedish National Cataract Register (NCR) from 2002 through 2009. The NCR contains 97.3% of the total number of cataract extractions in Sweden over the 8-year study period. One mandatory variable in the register is capsule complications during surgery. As a means to validate the accuracy of register data on capsule complications, a randomly selected sample of 2400 registrations was compared with corresponding medical records., Results: The analyses were based on 602,553 cataract extractions reported to the NCR. A capsule complication was reported in 12,574 cataract extractions, corresponding to a frequency of 2.09%. The incidence of this complication consistently decreased each year from 2002 to 2006, after which it stabilized. Poor corrected distance visual acuity in the surgical eye (≤ 0.1), the occurrence of glaucoma, diabetic retinopathy, and age were among the parameters significantly related to a capsule complication. Some of these parameters also decreased over time. However, even after adjusting for this, there was an obvious decrease in capsule complications over time. The validity test showed a certain underreporting of capsule complications to the registry, but it was not significant and did not change over time., Conclusion: The incidence of capsule complications decreased over time. This may be partly the result of fewer risk factors and of better surgical quality., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the long-term outcomes after cataract extractions with a capsule rupture included in the Swedish Capsule Rupture Study., Setting: Ten ophthalmic surgery departments in Sweden., Methods: From the cohort of patients originally selected for inclusion in the Swedish Capsule Rupture Study, cases with a capsule complication (study group) and cases without a complication (control group) were examined approximately 3.5 years postoperatively. Visual acuity and objective and subjective parameters were registered., Results: The study group comprised 171 patients and the control group, 198 patients. Patients with a capsule complication had a significantly worse visual outcome and a doubled risk for no improvement in preoperative visual acuity. Pupil distortion, iris damage, synechias, and subjective complaints related to the eye were significantly more common in patients with a capsule complication., Conclusion: Capsule complications decreased the probability of good postoperative visual acuity and in general yielded a worse long-term outcome after phacoemulsification surgery.

Purpose: To identify preoperative and intraoperative factors associated with a capsule complication; that is, a capsule tear or a zonular dehiscence during cataract surgery., Setting: Ten ophthalmic surgery departments in Sweden., Methods: A retrospective review of files of patients with a capsule complication and control patients with no complication operated on in 2003 was performed., Results: The review comprised 324 patients with a capsule complication and 331 control patients. In the logistic regression analyses, preoperative conditions associated with a capsule complication were previous trauma, white and brunescent/hard cataract, and phacodonesis. The intraoperative factors of loose zonules, the use of trypan blue, and miosis were all statistically significantly overrepresented in the capsule complication group. The same was true for eyes operated on by surgeons with the least experience., Conclusions: By preoperatively identifying cataract cases with the identified risk factors and allocating them to surgeons with the longest experience, the number of capsule complications could be kept low. Operating early in the course of the disease to prevent the cataract from becoming a poor surgical risk and improving training of junior surgeons should further reduce the frequency of capsule complications.

Purpose: To study the incidence, characteristics, and results of retinal detachment (RD) after cataract surgery with a capsule complication., Setting: Ten ophthalmic surgery departments in Sweden., Methods: In this case-control study, data on cataract surgery cases with a capsule complication (study group) or with no complication (control group) in 2003 were extracted from the Swedish National Cataract Register. Patients with RD during a 3-year follow-up were identified., Results: The study group comprised 324 patients and the control group, 331 patients. Retinal detachment occurred in 13 study group patients, for a 3-year incidence of 4.0%. In the control group, 1 patient (0.3%) had RD. Multivariate analysis showed an adjusted odds ratio (OR) of 14.8 for RD after capsule complication (95% confidence interval [CI], 1.9-114; P = .01). Subgroup analysis of the study group using a binary logistic regression model showed that male sex (OR, 8.5; 95% CI, 1.7-43.8; P = .001) and lens remnants in the vitreous (OR, 14.4; 95% CI 2.6-78.8; P = .002) were additional risk factors. Axial myopia was significantly associated with an increased risk as a single factor but not as a multiple factor. In general, the final visual outcome for RD after a capsule complication was poor; 3 eyes had a visual acuity of 0.50 or better. Eight eyes (62%) had a final visual acuity worse than 0.10 and 6 eyes, 0.02 or worse., Conclusions: The risk for RD after cataract surgery increased significantly when a capsule complication occurred, leading to poor final visual acuity in most cases.

Purpose: To report the selection procedure of complicated and uneventful cataract extractions included in the Swedish Capsule Rupture Study and to describe the additional care required after a capsule complication during cataract surgery., Setting: Ten ophthalmic surgery departments in Sweden., Methods: Consecutive cataract extractions with a reported capsule complication were selected from the national database. Surgical data and data from the matching ophthalmic records at the participating clinics were analyzed. Controls were selected as the first uneventful procedure in the database after each procedure with a complication., Results: Data on 655 cataract extractions were studied for evaluation of risks and additional care; a capsule complication occurred in 324 procedures and no complication in 331 procedures. Using these records, 369 patients were recruited for a follow-up examination of the outcomes 3 years after the original cataract extraction. The records showed a substantial increase in additional care after a capsule complication, including more visits after surgery, increased need for in-patient care, and a significantly greater percentage of reoperations than after the uneventful surgery. With additional care, the average cost of a procedure with a capsule complication was approximately double the cost of an uneventful cataract extraction., Conclusions: The combined study of the database and matching medical records showed a substantial increase in additional care after a capsule complication. Using the database allowed identification of a large number of capsule complication cases and uneventful cases, indicating that national databases are excellent sources of data for studying unusual complications.

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 > or = 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.

Purpose: 1) To evaluate the effects on the conjunctival flora of gentamicin ophthalmic eye drops 0.3%, given four times in 45 minutes, and a conjunctival rinse with 10 ml chlorhexidine 0.05% solution. 2) To investigate retrospectively the rate of endophthalmitis after cataract operations when these antimicrobials were applied preoperatively., Methods: Seventy-six patients undergoing standard phacoemulsification operations were enrolled in the experimental part of the study. Cultures were taken preoperatively, 5 minutes after prophylaxis with either chlorhexidine or gentamicin. To assess the combined effects of chlorhexidine and gentamicin, cultures were taken after the cataract operation. Hospital charts were reviewed for cases of endophthalmitis in 1994 and 1995, when this prophylactic protocol was used at the St Erik's cataract surgery department., Results: The conjunctival microflora was significantly suppressed by chlorhexidine rinsing alone (p = 0.001), while no other significant anti-bacterial effects were observed with the experimental prophylaxis. The endophthalmitis rate was 32/12. 806 operations (0.25%)., Conclusions: Topical rinsing with chlorhexidine solution suppresses conjunctival flora in the short term. Combined topical chlorhexidine and gentamicin prophylaxis does not eliminate postoperative endophthalmitis caused by gram-positive bacteria.