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Background: Due to surgical capacity pressures, induced by the COVID-19 pandemic, immediate bilateral simultaneous cataract surgery (ISBCS) has been utilised increasingly throughout the U.K. This surgical method comes with both novel risks and benefits, so the consent process must be modified. Prior randomised trials have demonstrated that appropriate online information may act as an adjunct to the surgical consent process. This study aims to assess the quality of available internet information for ISBCS., Methods: Terms searched were 'bilateral cataract surgery patient information', 'double cataract surgery patient information', and 'immediate sequential bilateral cataract surgery patient information'. The Google search engine was used. The DISCERN instrument and JAMA benchmarks were used to assess healthcare information for quality. The Flesch Reading Ease Score (FRE), Flesch Kincaid Grade (FKG) Level and Gunning Fog Score (GFS) were used to assess for readability. HONcode certification was used to assess transparency and quality., Results: Forty-six websites were found. The average DISCERN score was 41.3, meaning a "fair" quality which is below what many patients would anticipate discovering when trying to find information. National Healthcare Service websites had higher DISCERN scores than private healthcare-provided websites ( p  < 0.01; 95% CI: 1.13-1.88.)., Conclusions: Fair patient information for ISBCS has been demonstrated. Specific internet information sources with appropriate information should be further developed, with cited sources, and patients signposted to them if felt appropriate., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction and Objectives: Cataract surgery is one of the most common procedures in outpatient surgery units. The use of information and communication technologies (ICT) in clinical practice and the advent of new health scenarios, such as the Covid pandemic, have driven the development of pre-anaesthesia assessment models that free up resources to improve access to cataract surgery without sacrificing patient safety. The approach to cataract surgery varies considerably among public, subsidised and private hospitals. This raises the need for guidelines to standardise patient assessment, pre-operative tests, management of background medication, patient information and informed consent., Results: In this document, the SEDAR Clinical Management Division together with the Major Outpatient Surgery Division SEDAR Working Group put forward a series of consensus recommendations on pre-anaesthesia testing based on the use of ITCs, health questionnaires, patient information and informed consent supervised and evaluated by an anaesthesiologist., Conclusions: This consensus document will effectivise pre-anaesthesia assessment in cataract surgery while maintaining the highest standards of quality, safety and legality., (Copyright © 2024 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

This study assessed the performance of automated machine learning (AutoML) in classifying cataract surgery phases from surgical videos. Two ophthalmology trainees without coding experience designed a deep learning model in Google Cloud AutoML Video Classification for the classification of 10 different cataract surgery phases. We used two open-access publicly available datasets (total of 122 surgeries) for model training, validation and testing. External validation was performed on 10 surgeries issued from another dataset. The AutoML model demonstrated excellent discriminating performance, even outperforming bespoke deep learning models handcrafter by experts. The area under the precision-recall curve was 0.855. At the 0.5 confidence threshold cut-off, the overall performance metrics were as follows: sensitivity (81.0%), recall (77.1%), accuracy (96.0%) and F1 score (0.79). The per-segment metrics varied across the surgical phases: precision 66.7-100%, recall 46.2-100% and specificity 94.1-100%. Hydrodissection and phacoemulsification were the most accurately predicted phases (100 and 92.31% correct predictions, respectively). During external validation, the average precision was 54.2% (0.00-90.0%), the recall was 61.1% (0.00-100%) and specificity was 96.2% (91.0-99.0%). In conclusion, a code-free AutoML model can accurately classify cataract surgery phases from videos with an accuracy comparable or better than models developed by experts., (© 2022. The Author(s).)

The eye care sector is well positioned to contribute to the advancement of universal health coverage within countries. Given the large unmet need for care associated with cataract and refractive error, coupled with the fact that highly cost-effective interventions exist, we propose that effective cataract surgery coverage (eCSC) and effective refractive error coverage (eREC) serve as ideal indicators to track progress in the uptake and quality of eye care services at the global level, and to monitor progress towards universal health coverage in general. Global targets for 2030 for these two indicators were endorsed by WHO Member States at the 74th World Health Assembly in May, 2021. To develop consensus on the data requirements and methods of calculating eCSC and eREC, WHO convened a series of expert consultations to make recommendations for standardising the definitions and measurement approaches for eCSC and eREC and to identify areas in which future work is required., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2021 World Health Organization; licensee Elsevier. This is an Open Access article published under the CC BY-NC-ND 3.0 IGO license which permits users to download and share the article for non-commercial purposes, so long as the article is reproduced in the whole without changes, and provided the original source is properly cited. This article shall not be used or reproduced in association with the promotion of commercial products, services or any entity. There should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.)

Purpose: To determine the effects of cataract surgery and preoperative factors on the vision-related quality of life (QOL) in patients with retinitis pigmentosa (RP)., Materials and Methods: This was a prospective, interventional study of 54 patients diagnosed with RP. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was used to determine the QOL before and after the cataract surgery. The correlations between the scores of the questionnaire and the best-corrected visual acuity (BCVA), macular structure, and degree of improvement of the NEI VFQ-25 scores were also determined., Results: Statistically significant improvements were observed in the BCVA and all of the NEI VFQ-25 subscale scores except for color vision. The improvement of general vision was the largest. The postoperative BCVA of the better-seeing eye was more strongly and significantly correlated with the postoperative NEI VFQ-25 scores than that of the worse-seeing eye. All of the postoperative NEI VFQ-25 scores were significantly correlated with the length of the ellipsoid zone (EZ) of the photoreceptors. No significant correlation was found between the preoperative general vision, near vision, mental health scores, and EZ length. All of the preoperative NEI VFQ-25 scores except the social function and mental health scores were negatively and significantly correlated with the degree of improvement of the NEI VFQ-25 score. The EZ length was significantly correlated with the degree of improvement of the NEI VFQ-25 scores of the general vision, distance vision, mental health, dependency, and composite 9 scores., Conclusions: Cataract surgery can significantly improve the NEI VFQ-25 scores in RP patients. The EZ length can be used to predict the postoperative VFQ scores. We conclude that the NEI VFQ-25 is a useful method to evaluate the impact of cataract surgery on the BCVA in patients with RP., Competing Interests: GM received grants from Novartis outside the submitted work. TB received personal fees from Bayer, Kowa, Santen, Senju, and Alcon and grants and personal fees from Novartis outside the submitted work. SY received grants and personal fees from HOYA, Senju, Pfizer, Santen, Alcon Japan, Alcon Pharma, Bayer, and Kowa and has personal fees from Nikon, Wakamoto, Chuo Sangyo, Daiichi Sankyo, Jamex, Sun Contact Lens, Finedex, Novartis, Chugai, and Abbvie outside the submitted work. The following authors declare no competing interests associated with this manuscript: TT and HY., (Copyright © 2021 Gen Miura et al.)

This study evaluated the accuracy of total keratometry (TK) and standard keratometry (K) for intraocular lens (IOL) power calculation in eyes treated with femtosecond laser-assisted cataract surgery. The retrospective study included a retrospective analysis of data from 62 patients (91 eyes) who underwent uneventful femtosecond laser-assisted cataract surgery with Artis PL E (Cristalens Industrie, Lannion, France) IOL implantation by a single surgeon between May 2020 and December 2020 in Severance Hospital, Seoul, South Korea. The new IOLMaster 700 biometry device (Carl Zeiss Meditec, Jena, Germany) was used to calculate TK and K. The mean absolute error (MAE), median absolute error (MedAE), and the percentages of eyes within prediction errors of ± 0.25 D, ± 0.50 D, and ± 1.00 D were calculated for all IOL formulas (SRK/T, Hoffer-Q, Haigis, Holladay 1, Holladay 2, and Barrett Universal II). There was strong agreement between K and TK (intraclass correlation coefficient = 0.99), with a mean difference of 0.04 D. For all formulas, MAE tended to be lower for TK than for K, and relatively lower MAE and MedAE values were observed for SRK/T and Holladay 1. Furthermore, for all formulas, a greater proportion of eyes fell within ± 0.25 D of the predicted postoperative spherical equivalent range in the TK group than in the K group. However, differences in MAEs, MedAEs, and percentages of eyes within the above prediction errors were not statistically significant. In conclusion, TK and K exhibit comparable performance for refractive prediction in eyes undergoing femtosecond laser-assisted cataract surgery.

Background: The aim of our case control study was to evaluate the impact of glistening and tear film quality on visual performance after implantation of two different hydrophobic acrylic intraocular lenses (IOLs)., Materials and Methods: In our retrospective study we included cataract patients operated between January 1, 2011 and December 31, 2012, with follow-up controls between January 2016 and December 2019. Z-Flex 860FAB (Medicontur) and AcrySof IQ SN60WF (Alcon) monofocal IOLs were implanted during standard phacoemulsification. Best corrected distance visual acuity (BCDVA) and contrast sensitivity were monitored over the post-operative period of up to 6 years. Glistening was evaluated semi-quantitatively with slit-lamp biomicroscopy and quantitatively using Pentacam HR (Oculus). Using HD Analyzer OQAS (Visiometrics), total intraocular light diffusion was interpreted with the objective scatter index (OSI) and tear film quality was evaluated with the tear film related objective scatter index (TF-OSI)., Results: 26 eyes implanted with the Z-Flex and 25 eyes with the AcrySof IQ IOLs were included in the analysis. The slit-lamp evaluation of patients with the Z-Flex IOL (0.57 ± 0.60) revealed significantly less glistening (p<0.0001), compared to the AcrySof IQ group (1.82 ± 0.90), and these observations were confirmed by the Pentacam HR analyses, as well (Z-Flex group: 35.1 ± 1.63, Acrysof IQ: 39.6 ± 3.69, p<0.0001). TF-OSI differed between the two sets of patients remarkably (1.53 ± 1.03 vs. 2.51 ± 1.76 for AcrySof IQ and Z-Flex groups, respectively, p = 0.043). Both groups of patients provided similar results of BCDVA and contrast sensitivity., Conclusion: Glistening and tear film quality both contribute to visual performance outcomes after cataract surgery. In our study the advantage of less glistening in the Z-Flex IOL might have been masked by the adverse effects of the more pronounced tear film insufficiency of these patients, compared to the AcrySof IQ group. Among other factors, tear film quality should also be taken into consideration when comparing the impact of glistening on visual quality of patients implanted with different IOLs., Competing Interests: The authors have declared that no competing interests exist.

Construct: Authors investigated the perspectives of stakeholders on feasibility elements of workplace-based assessments (WBA) with varying designs. Background: In the transition to competency-based medical education, WBA are taking a more prominent role in assessment programs. However, the increased demand for WBA leads to new challenges for implementing suitable WBA tools with published validity evidence, while also being feasible and useful in practice. Despite the availability of published WBA tools, implementation does not necessarily occur; a more fulsome understanding of the perspectives of stakeholders who are ultimately the end-users of these tools, as well as the system factors that both deter or support their use, could help to explain why evidence-based assessment tools may not be incorporated into residency programs. Approach: We examined the perspectives of two groups of stakeholders, surgical teachers and resident learners, during an assessment intervention that varied the assessment tools while keeping the assessment process constant. We chose diverse exemplars from published assessment tools that each represented a different response format: global rating scales, step-by-step surgical rubrics, and an entrustability scale. The primary purpose was to investigate how stakeholders are impacted by WBA tools with varying response formats to better understand their feasibility for assessment of cataract surgery. Secondarily, we were able to explore the culture of assessment in cataract surgery education including stakeholders' perceptions of WBA unrelated to assessment form design. Semi-structured interviews with teachers and a focus group with the residents enabled discussion of their perspectives on dimensions of the tools such as acceptability, demand, implementation, practicality, adaptation, and integration. Findings: Three themes summarize teachers' and residents' experiences with the assessment tools: (1) Feedback is the priority; (2) Forms informing coaching; and (3) Forcing the conversation. The tools helped to facilitate the feedback conversation by serving as a reminder to initiate the conversation, a framework to structure the conversation, and a memory aid for providing detailed feedback. Surgical teachers preferred the assessment tool with a design that best aligned with their approach to teaching and how they wanted to provide feedback. Orientation to the tools, combined with established remediation pathways, may help preceptors to better use assessment tools and improve their ability to give critical feedback. Conclusions: Feedback, more so than assessment, dominated the comments provided by both teachers and residents after using the various WBA tools. Our typical assessment design efforts focus on the creation or selection of a robust assessment tool according to good design and measurement principles, but the current findings would encourage us to also prioritize the coaching relationship and include efforts to design WBA tools to function as a mediator to augment teaching, learning, and feedback exchange within that relationship in the workplace.

Cataract is the second leading cause of preventable blindness on the globe. Several programs across the country have been running efficiently to increase the cataract surgical rates and decrease blindness due to cataract. The current COVID-19 pandemic has led to a complete halt of these programs and thus accumulating all the elective cataract procedures. At present with the better understanding of the safety precautions among the health care workers and general population the Government of India (GoI) has given clearance for functioning of eye care facilities. In order to facilitate smooth functioning of every clinic, in this paper, we prepared preferred practice pattern based on consensus discussions between leading ophthalmologists in India including representatives from major governmental and private institutions as well as the All India Ophthalmological Society leadership. These guidelines will be applicable to all practice settings including tertiary institutions, corporate and group practices and individual eye clinics. The guidelines include triage, use of personal protective equipment, precautions to be taken in the OPD and operating room as well for elective cataract screening and surgery. These guidelines have been prepared based on current situation but are expected to evolve over a period of time based on the ongoing pandemic and guidelines from GoI., Competing Interests: None

Purpose: To facilitate the development of standardized guidelines for the surgical management of patients with pediatric traumatic cataracts by assessing current ophthalmologists' practice patterns., Methods: This was a cross-sectional, observational, and retrospective study. A 24-question electronic survey of current practices pertaining to the surgical management of pediatric traumatic cataracts was sent to pediatric ophthalmologists worldwide. Preferences for pre-operative evaluation, surgical timing and techniques, and postoperative management were analyzed., Results: Of the 56 respondents, 62.5% practiced in academic settings. Of the 49 respondents (87.5%) who performed pediatric ruptured globe repair, 41.7% would perform simultaneous cataract extraction if anterior capsular violation existed, whereas 4.1% would do so without capsular violation (P < .001). Most respondents (50.9%) would remove visually significant cataracts within 4 weeks in patients within the amblyogenic age range (P = .02), whereas 63.6% would wait longer outside the amblyogenic range. Preferences for intraocular lens selection, primary posterior capsulotomy, and timing of amblyopia therapy differed., Conclusions: Individual management practices regarding pediatric traumatic cataracts vary depending on associated globe injuries and patient age. Trends exist in surgical planning, intraoperative techniques, and visual rehabilitation methods, but no single approach has achieved complete unanimity. Therefore, further investigation into optimal timing and the extent of surgical intervention, refractive correction, and postoperative care is necessary prior to developing evidence-based guidelines for enhancing visual outcomes in this population. [J Pediatr Ophthalmol Strabismus. 2020;57(3):190-198.]., (Copyright 2020, SLACK Incorporated.)

Background: A proactive risk assessment using the Healthcare Failure Mode and Effect Analysis (HFMEA) process was completed on the intraocular lens (IOL) selection and implantation process to analyze system vulnerabilities that could cause patient harm. The three largest ophthalmology clinics based on patient surgical volume were studied in the analysis. The analysis included in-clinic eye measurements needed for IOL selection through the actual implantation of the lens in the operating room., Methods: The HFMEA process was used for the analysis. A detailed process and subprocess diagram was created through interviews and observations. A multidisciplinary team met 12 times over a 14-week period, evaluating 170 discrete process and subprocess steps and identifying 177 failure modes and 75 failure mode causes for analysis., Results: A high degree of process variability and lack of a robust quality assurance process was found. Areas for improvement included reducing variability between and within clinics, reducing variability in processes used by surgeons, modifying equipment and software to better support the work processes, and implementing a quality assurance program requiring observation of staff performing their routine work as opposed to relying on self-reports of quality metrics., Conclusion: The HFMEA process provided a more complete understanding of all of the processes associated with cataract surgery. This allowed for the identification of a variety of risk factors to patient safety that had not previously been identified by the more traditional reactive analysis methods, which tend to focus only on vulnerabilities identified by a specific event., (Copyright © 2019. Published by Elsevier Inc.)

Introduction: This retrospective consecutive case series assessed 12-month effectiveness and safety of iStent ® or iStent inject ® trabecular micro-bypass implants with cataract surgery in patients with open-angle glaucoma (OAG) in a real-world clinical setting., Methods: Effectiveness outcomes consisted of intraocular pressure (IOP) reduction; glaucoma medication reduction; proportions of eyes achieving IOP < 18, < 15, or < 12 mmHg; and proportional analysis of medication usage. Safety outcomes included adverse events, secondary surgeries, and best-corrected visual acuity (BCVA)., Results: This evaluation included 58 eyes with OAG (35 iStent, 23 iStent inject), with 96.6% of eyes having mild or moderate glaucoma. Diagnoses included primary open-angle glaucoma (the majority; 72.4%), pseudoexfoliative glaucoma, and pigmentary glaucoma. Baseline mean IOP and medications were statistically comparable between groups: 16.1 ± 3.6 mmHg on a mean of 1.8 ± 0.8 medications in the iStent group, and 16.2 ± 3.1 mmHg on a mean of 1.7 ± 0.8 medications in the iStent inject group. Twelve months after stent-cataract surgery, mean IOP was significantly lower in the iStent inject group than in the iStent group (13.1 mmHg vs. 15.4 mmHg, respectively; p < 0.001), and the percent reduction in IOP from baseline was significantly greater in iStent inject eyes than in iStent eyes (19.1% vs. 4.3% reduction, respectively; p < 0.001). At 12 months postoperative, significantly greater proportions of iStent inject eyes than iStent eyes achieved IOP < 18 mmHg (100% vs. 80.0% of eyes, respectively; p = 0.035), IOP < 15 mmHg (73.9% vs. 34.3% of eyes, respectively; p = 0.003), and IOP < 12 mmHg (26.1% vs. 0% of eyes, respectively; p = 0.002). Meanwhile, both groups achieved significant medication reductions at 12 months vs. baseline (94.1% reduction in iStent inject eyes, p < 0.0001; and 72.2% reduction in iStent eyes, p < 0.0001), with the percent reduction being significantly greater in iStent inject eyes than in iStent eyes (p = 0.023). At 12 months, mean number of medications was significantly lower in iStent inject eyes than iStent eyes (0.1 vs. 0.5 medications, respectively; p = 0.021), and significantly more iStent inject eyes (95.7%) than iStent eyes (71.4%) were off medications entirely (p = 0.021). A similarly high safety profile was observed in both groups., Conclusion: iStent or iStent inject implantation with cataract surgery resulted in substantial and safe reductions in IOP and medications through 12 months postoperative. Consistent with prior observations, greater efficacy was observed with iStent inject than with iStent., Funding: The Rapid Service Fees were funded by Glaukos Corporation.

Introduction: Cataract surgery is the most commonly performed surgery in the world, and its success depends in part on the quality of mydriasis., Purpose: To compare, for the same eye, the pupillary dilation obtained with Mydrane® (standardized intracameral solution of 0.02% tropicamide, combined with 0.31% phenylephrine and 1% lidocaine) intraoperatively versus Mydriasert® (0.28mg tropicamide insert and 5.4mg phenylephrine) with a contact time between 45 and 60 minutes in the preoperative period., Methods: Single center prospective study from November 2016 to January 2018 at the Laveran Army Instructional Hospital in Marseille. Patients referred for surgery were dilated at the preoperative consultation with Mydriasert®. The pupillary diameter after 45-60 minutes of contact with the insert was manually measured, by two different examiners, through the "iris image" tab of the Pentacam® elevation topography. Patients were dilated on the day of their cataract surgery with 0.2cc of Mydrane® injected in the anterior chamber through a paracentesis. Thirty seconds later, prior to injection of viscoelastic, an eye photograph was taken by screen capture. The pupillary diameter was evaluated by two different examiners with to the Piximeter 5.9 metrology software. The difference in pupil dilation between Mydriasert® and Mydrane® was tested with the paired series Student t-test., Results: A hundred and eleven eyes of 82 patients were included. Mydriasert® achieved a mean pupillary dilation of 7.21±0.79mm. The mydriasis obtained with Mydrane® averaged 6.35±0.8mm. This difference of 0.86mm was statistically significant (P<0.001) with a confidence interval of 95% [-0.97; -0.74]., Conclusion: On average, Mydrane® dilates the pupil less than Mydriasert®. However, the mydriasis obtained with Mydrane® remains comfortable for the performance of the capsulorhexis. It helps save preoperative time and affords additional anesthetic to the cataract surgery. Nevertheless, the use of Mydriasert® is beneficial when extra mydriasis is required., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Introduction: In 2017, over 75,000 cataract surgeries were performed within the Veterans Health Administration System (VHA). Previous reports of outcomes of cataract surgery in veterans include patients with pre-existing ocular disease, which can affect vision. To exclude the confounding factor of pre-existing ocular comorbidities, we investigated the long-term visual outcomes and complications associated with small incision cataract surgery performed on veterans without any pre-existing eye disease., Materials and Methods: Institutional Review Board approved cohort study with detailed retrospective chart review of all phacoemulsification (small incision) cataract surgeries performed at the Veterans Affairs Medical Center in Washington D.C. over 11 years, including all pre-and postoperative visits until postoperative month 12., Results: A total of 1,513 consecutive surgical cases without any pre-existing ocular disease except the cataract were included. Vision improved significantly after cataract surgery compared to the preoperative best-corrected visual acuity (BCVA) (p = 0.0001) and remained stable over the first intra- and postoperative year. All eyes without complicated surgery and 99.1% of eyes with complications achieved 20/40 or better final vision postoperatively. The most common intra-and postoperative complications were vitreous loss (3.1%) and cystoid macular edema (CME; 1.4%). Patients with complications achieved final mean BCVA of 0.04 (20/22, vitreous loss) and 0.06 (20/23, CME) mean logMAR (Snellen)., Conclusion: Analysis of 11 years of small incision cataract surgery in eyes without pre-existing ocular disease within the VHA showed significant improvement in vision and stability 12 months after uncomplicated and complicated surgery in veterans., (Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2018.)

Objective: To evaluate preoperative testing for cataract surgery, implement stakeholder-driven change, and increase the number of patients who arrived for surgery with complete preoperative requirements, for the purpose of delivering safe, high-quality, and cost-effective care for patients., Design: Quality improvement., Participants: Cataract surgery patients, health care staff in Ophthalmology Day Surgery, an Ophthalmology improvement team, the Clinical Section Heads of Ophthalmology and Anaesthesia, Quality Consultants, and members of the Quality Council participated in this study., Methods: A lean quality improvement approach was used to define and build understanding of the problem. Between July and November 2016, a chart-based reporting system captured all patients who arrived for cataract surgery with expired or incomplete preoperative requirements. A cost analysis was completed, and evidence was reviewed to ensure alignment with best practice preoperative recommendations., Results: On average, 25% (619/2451 over a 17-week period) of patients per day arrived at the Ophthalmology Day Surgery for cataract surgery with incomplete and/or expired physical history forms and ECGs. An improvement team worked to implement a radical improvement idea and relied on an existing questionnaire to ensure patient safety preoperatively., Conclusions: Based on the literature, best practice guidelines, and a cost analysis, it was decided that patients undergoing routine cataract surgery in Edmonton Zone Hospitals under regional anaesthesia would no longer require physician history and physicals and ECGs. Elimination of the preoperative requirements for all but select high-risk patients meant that 100% of patients who arrived for cataract surgery would not have outstanding presurgery requirements., (Copyright © 2018 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Cataract surgery is the most common operation performed in most developed countries, including Canada. Nuanced, evidence-driven policies are needed to ensure appropriate access to this sight-saving operation while maintaining the highest standards in quality of care. The Vision Health Services Research Program at Queen's University, in partnership with members of the Ontario Provincial Vision Task Force, has developed evidence to inform policies aimed at optimizing both access and quality across the eye care spectrum., (Copyright © 2019 Longwoods Publishing.)

In January 2015 Zilveren Kruis, the largest health insurer in The Netherlands, engaged in a new three-year, unlimited volume contract with five carefully selected providers of cataract surgery. Zilveren Kruis used a novel method, designed to identify the top expert providers in a certain discipline. This procedure for provider selection uses the principles of Best Value Procurement (BVP), and puts the provider in charge of defining key performance indicators for health care quality. The procedure empowers the professional and acknowledges that the provider, not the purchaser, is the true expert in defining what is high quality care. This new approach focuses purely on provider selection and is thus complementary to innovations in health care reimbursement, such as value-based hospital purchasing or outcome-based financing. We describe this novel approach to preferred provider selection and show how it makes affordable quality the core topic in negotiations with providers., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: A cataract is a common cause of vision impairment that requires surgery in older subjects. The Optical Quality Analysis System (OQAS, Visiometrics SL, Terrassa, Spain) assesses the optical quality of the eye in cataract patients. This study shows the role of the optical quality evaluation system for decision-making in cataract surgery. We investigated the clinical utility of the OQAS for decision-making in cataract surgery., Methods: Sixty-seven eyes from 67 patients undergoing cataract surgery and 109 eyes from 109 control subjects were compared. The best corrected visual acuity (BCVA) was measured. The objective scatter index (OSI), modulation transfer function (MTF), Strehl ratio, predicted visual acuity (PVA) 100%, PVA 20%, and PVA 10% were measured using the OQAS. The sensitivity and specificity of the different parameters were analyzed using the receiver operating characteristic (ROC) curve. The main parameters measured were sensitivity and specificity., Results: The BCVA, OSI, PVA 100%, PVA 20%, and PVA 10% were higher in the cataract group compared to those in the control group, while the MTF and Strehl ratios were lower (p <  0.001 for all). ROC analysis showed that the OSI had the largest area under the curve and that the sensitivity and specificity of the OSI were 83.9 and 84.6%, respectively, at the optimal cut-off point of 2.35., Conclusion: The MTF, OSI, Strehl ratio, PVA 100%, PVA 20% and PVA 10% may be useful parameters for preoperative decision-making in cataract surgery. The OSI appears to be the most effective parameter for this purpose.

Aim: To provide a quantitative assessment of cataract theatre lists focusing on productivity and staffing levels/tasks using time and motion studies., Methods: National Health Service (NHS) cataract theatre lists were prospectively observed in five different institutions (four NHS hospitals and one private hospital). Individual tasks and their timings of every member of staff were recorded. Multiple linear regression analyses were performed to investigate possible associations between individual timings and tasks., Results: 140 operations were studied over 18 theatre sessions. The median number of scheduled cataract operations was 7 (range: 5-14). The average duration of an operation was 10.3 min±(SD 4.11 min). The average time to complete one case including patient turnaround was 19.97 min (SD 8.77 min). The proportion of the surgeons' time occupied on total duties or operating ranged from 65.2% to 76.1% and from 42.4% to 56.7%, respectively. The correlations of the surgical time to patient time in theatre was R 2 =0.95. A multiple linear regression model found a significant association (F(3,111)=32.86, P<0.001) with R 2 =0.47 between the duration of one operation and the number of allied healthcare professionals (AHPs), the number of AHP key tasks and the time taken to perform these key tasks by the AHPs., Conclusions: Significant variability in the number of cases performed and the efficiency of patient flow were found between different institutions. Time and motion studies identified requirements for high-volume models and factors relating to performance. Supporting the surgeon with sufficient AHPs and tasks performed by AHPs could improve surgical efficiency up to approximately double productivity over conventional theatre models., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: To objectively measure head drift during cataract surgery, and subjectively simulate eye movements and assess impact on surgical technique., Materials and Methods: Twelve consecutively recorded routine cataract operations in the Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, were reviewed. The speculum was used as a fixed point and correlated with a superimposed virtual ruler to measure maximum head drift in each direction throughout the operations. To simulate intraoperative eye movement, we attached string to the cataract surgical simulator (Eyesi) eye and manually induced abduction and adduction. A calibrated scale secured to the Eyesi head ensured 5 mm eye movements were consistently created. Ophthalmology trainees performed the continuous curvilinear capsulorhexis (CCC) exercise without and with sequential eye movements. Movements were induced every three seconds. Scores were compared using a paired Student's T-test., Results: Mean head drift in the surgical recordings was 3.1 mm medially (range 2-7 mm), 2.9 mm laterally (range 2-4 mm), 2.6 mm superiorly (range 1-5 mm), and 1.9 mm inferiorly (range 1-4 mm). In 11 of 12 cases, the operating microscope had to be adjusted for head drift. Six junior trainees completed the CCC module on the Eyesi without then with eye movements. After introducing eye movements the mean Eyesi score reduced from 92.7 to 76.9 (P = 0.014), 'roundness of rhexis' score reduced from 89.4 to 57.5 (P = 0.020), and trainees operated 17 s faster (P = 0.016)., Conclusion: This study objectively demonstrates the under-reported clinical scenario of head drift during cataract surgery. By manipulating the Eyesi we have shown that eye movements reduce the quality of cataract surgery.

Massachusetts health care facilities reported a series of cataract surgery-related adverse events (AEs) to the state in recent years, including 5 globe perforations during eye blocks performed by 1 anesthesiologist in a single day. The Betsy Lehman Center for Patient Safety, a nonregulatory Massachusetts state agency, responded by convening an expert panel of frontline providers, patient safety experts, and patients to recommend strategies for mitigating patient harm during cataract surgery. The purpose of this article is to identify contributing factors to the cataract surgery AEs reported in Massachusetts and present the panel's recommended strategies to prevent them. Data from state-mandated serious reportable event reports were supplemented by online surveys of Massachusetts cataract surgery providers and semistructured interviews with key stakeholders and frontline staff. The panel identified 2 principal categories of contributing factors to the state's cataract surgery-related AEs: systems failures and choice of anesthesia technique. Systems failures included inadequate safety protocols (48.7% of contributing factors), communication challenges (18.4%), insufficient provider training (17.1%), and lack of standardization (15.8%). Choice of anesthesia technique involved the increased relative risk of needle-based eye blocks. The panel's surveys of Massachusetts cataract surgery providers show wide variation in anesthesia practices. While 45.5% of surgeons and 69.6% of facilities reported increased use of topical anesthesia compared to 10 years earlier, needle-based blocks were still used in 47.0% of cataract surgeries performed by surgeon respondents and 40.9% of those performed at respondent facilities. Using a modified Delphi approach, the panel recommended several strategies to prevent AEs during cataract surgery, including performing a distinct time-out with at least 2 care-team members before block administration; implementing standardized, facility-wide safety protocols, including a uniform site-marking policy; strengthening the credentialing and orientation of new, contracted and locum tenens anesthesia staff; ensuring adequate and documented training in block administration for any provider who is new to a facility, including at least 10 supervised blocks before practicing independently; using the least invasive form of anesthesia appropriate to the patient; and finally, adjusting anesthesia practices, including preferred techniques, as evidence-based best practices evolve. Future research should focus on evaluating the impact of these recommendations on patient outcomes.

Background: It is critical to consult patients to develop patient-centred cataract surgery care. We aimed to identify attributes patients consider when making decisions about cataract surgery in an Australian context, where both publicly and privately funded surgery are available. This is the first step in investigating how decisions are made about cataract surgery services., Methods: This observational qualitative study was undertaken in two public hospitals and one private practice in Sydney, Australia. The study involved 19 women and men with age-related cataracts and no previous cataract surgery, aged > 18 years, able to speak conversational English or Mandarin. A multi-stage attribute development process was followed, including: literature review, semi-structured interviews with surgery candidates in three eye clinics, and review by an expert panel. The main outcome measures were primary attributes for making choices about cataract surgery., Results: Wait time, cost, institutional reputation, surgeon experience and travel time were identified as principal attributes; lower value was placed on consultation length and accessibility. Non-English speaking participants indicated greater interest in pre-operative information than English speakers, but expressed trust in the Australian healthcare system., Conclusions: Findings suggest individuals prioritise attributes which consume time or incur costs when accessing care (wait time, cost and travel time). They also consider factors associated with the outcome of their cataract surgery (surgeon experience and institutional reputation). Similar to other decision-making processes, patients are likely to trade between these different attributes depending on their personal preferences and circumstances., (© 2018 Optometry Australia.)

In order to fight against blindness in the central region of Togo, a project was implemented in a partnership between the Ministry of Health and an international Non-Governmental Organization: the Swiss Red Cross. Cataract surgery underwent an annual audit of the research-action type, in order to improve the functional results of patients. One of the recommendations of these audits was the introduction of manual small incision surgery in place of the classic extracapsular technique. This study had for its objective to evaluate the functional results and follow-up of patients undergoing the new technique compared with quality standards of cataract surgery according to the World Health Organization. This study was carried out by retrospective analysis of records and operative reports of patients over twenty years of age undergoing manual small incision cataract surgery from June 2012 to June 2015. Out of a total of 1292 patients undergoing cataract surgery in the five districts covered by the project during the same period, 1003 patients met the inclusion criteria (77.63 %). Among the 1003 cases, 504 (50.25 %) were male, while 499 (49.75 %) were female. The overall mean age was 62 years. The cataract was total in 84.65 % of cases and partial in 15.35 % of cases where visual acuities were quantifiable. Postoperative complications were dominated by corneal edema (22 %). On the first postoperative day, the good results (visual acuity≥3/10), the average results (visual acuity between 3/10 and 1/10) and the poor results (visual acuity<1/10) were respectively 41.2 %, 50.60 % and 8.2 % without optical correction, changing to 64.40 %, 28.90 % and 6.70 % after optical correction. Between the first and third week, 855 patients (85 %) were seen again. The good, average and poor results were respectively 61.90 %, 35.70 % and 2.40 % without correction, going to 85.30 %, 12.70 % and 2 % after optical correction. Among the 85.30 % good results, 53 % had a visual acuity≥5/10. Residual ametropias are the main cause of poor functional results and the introduction of biometry can contribute to their improvement. Cataract surgery through a well-controlled manual small incision is a promising alternative to the technique of choice, phacoemulsification, which is not yet widely accessible in our low-income countries., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Diabetes is a chronic systemic disease that affects nearly one in eight adults worldwide. Ocular complications, such as cataract, can lead to significant visual impairment. Among the worldwide population, cataract is the leading cause of blindness, and patients with diabetes have an increased incidence of cataracts which mature earlier compared to the rest of the population. Cataract surgery is a common and safe procedure, but can be associated with vision-threatening complications in the diabetic population, such as diabetic macular edema, postoperative macular edema, diabetic retinopathy progression, and posterior capsular opacification. This article is a brief review of diabetic cataract and complications associated with cataract extraction in this population of patients.

Accurate intraocular lens (IOL) power calculation is always a challenge in ophthalmology, and unoptimized process may lead to inaccurate refractive outcomes. Quality control circle (QCC) has shown its success in many fields as a process management tool. However, its efficacy in ophthalmology remains unclear. Here we utilized the QCC method to optimize the process and evaluate its efficacy in improving the accuracy of IOL power calculation. After the QCC application, the percentage of eyes with achieved refractive outcomes within 0.5 diopter significantly increased from 63.2% to 80.8% calculated by Haigis formula and 59.2% to 75.8% by SRK/T formula in patients with normal axial length (AL) (22 mm ≤ AL < 26 mm). Although there were no statistically significant differences in patients with long AL by the two formulas (p = 0.886 and 0.726), we achieved an accuracy of 75% with the application of the PhacoOptics software, which was significantly higher than that using the other two formulas (p < 0.001). Our findings indicated that QCC optimized and standardized the process of IOL power calculation, thus improved the accuracy of IOL power calculation in patients who underwent cataract surgery.

Purpose: Medical processes can be modeled using different methods and notations. Currently used modeling systems like Business Process Model and Notation (BPMN) are not capable of describing the highly flexible and variable medical processes in sufficient detail., Methods: We combined two modeling systems, Business Process Management (BPM) and Adaptive Case Management (ACM), to be able to model non-deterministic medical processes. We used the new Standards Case Management Model and Notation (CMMN) and Decision Management Notation (DMN)., Results: First, we explain how CMMN, DMN and BPMN could be used to model non-deterministic medical processes. We applied this methodology to model 79 cataract operations provided by University Hospital Leipzig, Germany, and four cataract operations provided by University Eye Hospital Tuebingen, Germany. Our model consists of 85 tasks and about 20 decisions in BPMN. We were able to expand the system with more complex situations that might appear during an intervention., Conclusion: An effective modeling of the cataract intervention is possible using the combination of BPM and ACM. The combination gives the possibility to depict complex processes with complex decisions. This combination allows a significant advantage for modeling perioperative processes.

In 2013, the Danish Health and Medicines Authorities published a National Clinical Guideline on the treatment of age-related cataracts. The guideline provided evidence-based recommendations on the indication for cataract surgery, cataract surgery in patients with age-related macular degeneration, on the use of toric intraocular lenses (IOLs) to correct preoperative corneal astigmatism, the use of intracameral and topical antibiotics to prevent endophthalmitis, choice of anti-inflammatory medication to control postoperative inflammation and prevent cystoid macular oedema, the use of immediate sequential bilateral cataract surgery and on the postoperative check-up of patients. A questionnaire was sent to all members of the Danish Ophthalmological Society before and after publication of the guideline. The responses showed that the guideline had changed practice patterns so that surgeons were more likely to prescribe non-steroidal anti-inflammatory eye drops and to not prescribe topical antibiotic eye drops after the guideline was published. Other parameters, most notably the use of toric IOLs and use of postoperative examinations were more guided by reimbursement standards than by evidence-based medicine. Thus, evidence-based guidelines do change practice patterns unless they are counteracted by the reimbursement system., (© 2016 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose Quality control is particularly important in invasive medicine. As cataract surgery is the most frequently performed and most successful ophthalmic surgery, quality control should become mandatory. Patients and Methods Retrospective analysis of all cataract procedures performed in a 12 months period (01. 07. 2014 - 30. 06. 2015) at our hospital, using an internet-based EUREQOU database. This database is easy to use and allows local results to be compared with all participants in Switzerland and elsewhere in Europe. Results During one year, 904 cataract procedures were performed at our hospital. Of these, 892 with complete data were compared to 2918 operations performed in Switzerland and 274,644 in other European countries. Our sample contained more patients with markedly reduced visual acuity (< 0.1; 8.4/4.8/3.5 %; KSW/Switzerland/Europe), more patients with glaucoma (28.1/13.9/7.1 %) and more patients with pseudoexfoliation (22.8/11.5/0.56 %). Despite our training of young ophthalmic surgeons, the rate of capsular complications was as low (0.67/0.34/0.67 %) as in other series. Four to 6 weeks after surgery, the majority of patients achieved a best corrected visual acuity of ≥ 0.8 (79.2 vs. 87.4 % in Europe, not enough data from Switzerland). Biometric prediction error (79.2 % within ± 0.75 D) was within the target range, but in the lower quartile. Conclusions Despite the relatively high number of complex patients in our hospital, quality control reveals that we performed cataract surgery with low complication rates and good results. Although quality control is rapid and easy, only three centres in Switzerland are participating., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Monitoring the visual acuity following cataract surgery is used as a measure of the quality of the surgery in blindness prevention programs in middle- and low-income countries. While the day 1 visual acuity is usually available, the (final) visual acuity after several weeks may not be available, as the majority of patients may not return for review. This study was undertaken to ascertain if the early and late visual acuities are correlated and if the day 1 visual acuity can be used to predict the likely final visual acuity., Methods: A retrospective case note review was undertaken of all eyes having cataract surgery over a 6-month period., Results: There was a positive correlation between the day 1 and week 6 visual acuities in both the World Health Organization categories (Spearman coefficient = 0.4666, P = 0.001) and the logMAR visual acuity scores (Spearman coefficient = 0.5425, P = 0.001)., Conclusion: In blindness prevention programs in middle- and low-income countries with poor postoperative follow-up where it is not possible to document the final visual acuity in all the operated cases, there is merit in documenting and monitoring the day 1 visual acuity as a quality control measure., Competing Interests: There are no conflicts of interest.

PurposeThe purpose of this study was to establish benchmarks for outcome indicators that may help ascertain the quality of pediatric cataract surgery with primary intraocular lens (IOL) implantation.Patients and methodsA retrospective chart review of patients older than 2 years undergoing cataract surgery with primary IOL implantation, by multiple surgeons in a tertiary-care center, from November 2005 to February 2016 was conducted. Patients with ocular comorbidities that would affect the outcomes were excluded. The outcome measures chosen were as follows: (1) final best corrected Snellen visual acuity (BCVA) in patients who had bilateral cataract surgery analyzed at the last clinic visit; (2) prediction error (PE)=expected refraction-actual refraction. Mean PE and mean absolute PE were assessed 1 month postoperatively, irrespective of age or laterality.ResultsMean age at surgery was 8.3±4.6 years and mean follow-up duration was 3.7±2.7 years. The results of outcome measures were as follows: (1) BCVA was 20/40 or better in 96% (n=124 eyes, mean patient age: 8.3±4.6 years). Remaining five eyes had amblyopia with two eyes having BCVA worse than 20/100 that did not respond to amblyopia treatment. (2) Mean PE was 0.3±1.1 D and mean absolute PE was 0.9±0.7 D. PE was within ±0.5 D in 43.0%, ±1.0 D in 66%, and ±2.0 D in 95% (n=235 eyes).ConclusionGood visual acuity after cataract surgery should be expected for children with bilateral cataracts, setting a high benchmark similar to that recommended in adult cataract surgery. Prediction error is greater in pediatric eyes than in adult eyes, setting a lower benchmark. This study establishes benchmark for outcome indicators in pediatric patients older than 2 years undergoing cataract surgery with primary IOL implantation.

Coding accuracy is an important factor in ensuring hospitals receive adequate reimbursement from the government for healthcare services rendered. A retrospective review of 100 charts, the purpose of this study was to determine the degree of coding accuracy from the surgeon perspective, for outpatient procedures performed for ophthalmic services at St. Joseph's Healthcare Hamilton from July to December 2016. Using ICD-10-CA, Canadian Classification of Health Interventions, Quality-Based Procedures criteria where applicable, and the 3M Coding and Reimbursement system, this paper reveals three primary sources of coding errors and presents recommendations to increase accuracy of reimbursement for the benefit of both the Ministry of Health and hospital organizations.

Purpose: The purpose of this study is to examine explanatory factors of perceived quality of care among cataract surgery patients., Methods: This study was administered to 264 cataract patients within one eye hospital located in Ankara, Turkey. The study was designed to determine the latent structure of quality of care. In order to assess cataract surgery patients' views about quality of care, the QUOTE-Cataract survey was used. The questionnaire's internal consistency was assessed using Cronbach's Alpha (0.96) and appropriateness of the factor analytic model was assessed using KMO (0.50) and Bartlett's test ([Formula: see text]=2004.959, p<0.001). Explanatory factor analysis with Varimax rotation was performed in order to determine the underlying factors in the model., Results: Four factors emerge from the explanatory factor analysis: relaying information about care process and behaviors; diagnosis and treatment process; accessibility/punctuality of physicians; and hospital facilities. The four factors explain 86% of total variance., Conclusion: The results of this study highlight the importance of sharing information with patients about treatment processes and accessibility/punctuality of physicians in the perception of quality of care among cataract surgery patients.

Purpose: To survey the surgical routines with regards to prophylactic strategies in a sample of Italian hospitals and compare these with European Society for Cataract and Refractive Surgery (ESCRS) guidelines., Methods: Six private and 18 public hospitals were included in this clinical-based retrospective study. The overall volume of cataract operations in the 24 centers in 2013 was 43,553. Main outcome measure was incidence of endophthalmitis per 1,000. An incidence of less than 0.13% was considered acceptable., Results: Our study provides the first Italian data on the use of intracameral antibiotics in cataract surgery as recommended by the ESCRS. Thirteen centers (54%) used intracameral cefuroxime at the end of surgery. Of the 13 centers that used cefuroxime, 8 (62%) had an incidence of endophthalmitis less than 0.13%. Of the 7 (29%) centers that did not use intracameral cefuroxime, all had an endophthalmitis rate of greater than 0.13%. This difference was statistically significant (p&lt;0.05). Among the 4 centers not included, 2 used vancomycin in the infusion bottle, 1 a fluoroquinolone, and the last a combination of antibiotics. The majority of surgeons (71%) used preoperative antibiotic eyedrops, but this measure was not shown to be significantly protective., Conclusions: Slightly more than half of the centers surveyed in this study adhered to the recommendations of the ESCRS and routinely employed prophylactic intracameral cefuroxime. An incidence of endophthalmitis greater than 0.13% was encountered significantly more frequently among centers that did not employ intracameral cefuroxime.

Objectives: To describe the initial outcomes following installation of a cataract surgery laser system., Setting: National Health Service cataract surgery day care unit in North London, UK., Participants: 158 eyes of 150 patients undergoing laser-assisted cataract surgery., Interventions: Laser cataract surgery using the AMO Catalys femtosecond laser platform., Primary Outcome Measure: intraoperative complications including anterior and posterior capsule tears., Secondary Outcome Measures: docking to the laser platform, successful treatment delivery, postoperative visual acuities., Results: Mean case age was 67.7±10.8 years (range 29-88 years). Docking was successful in 94% (148/158 cases), and in 4% (6/148 cases) of these, the laser delivery was aborted part way during delivery due to patient movement. A total of 32 surgeons, of grades from junior trainee to consultant, performed the surgeries. Median case number per surgeon was 3 (range from 1-20). The anterior capsulotomy was complete in 99.3% of cases, there were no anterior capsule tears (0%). There were 3 cases with posterior capsule rupture requiring anterior vitrectomy, and 1 with zonular dialysis requiring anterior vitrectomy (4/148 eyes, 2.7%). These 4 cases were performed by trainee surgeons, and were either their first laser cataract surgery (2 surgeons) or their first and second laser cataract surgeries (1 surgeon)., Conclusions: Despite the learning curve, docking and laser delivery were successfully performed in almost all cases, and surgical complication rates and visual outcomes were similar to those expected based on national data. Complications were predominately confined to trainee surgeons, and with the exception of intraoperative pupil constriction appeared unrelated to the laser-performed steps., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Purpose: To assess interrater reliability in grading cataract surgery performance of ophthalmology residents and attending physicians before and after rater skill training., Setting: Metropolitan Chicago, Illinois, USA., Design: Prospective interventional test design., Methods: Video versions of a previously validated scoring key for rating cataract surgery were created for participant training. All participants received 2 frame-of-reference training sessions lasting 2 hours each. Participants graded 4 videorecorded cataract surgeries before training (pretest) and 4 more after training (posttest). Intraclass correlation coefficients (ICCs), which measured the degree of rater agreement, were calculated before and after training. Participants completed a subjective confidence questionnaire at the beginning and at the end of the study., Results: The study participants included 9 postgraduate year (PGY)-3 residents, 8 PGY-4 residents, and 5 ophthalmology attending physicians from 4 medical centers in metropolitan Chicago. The rater training sessions had the greatest increase in ICCs among PGY-3 residents. The ICC improvement between the PGY-4 residents and attending physicians was uneven. After training, all residents felt more confident about their ability to rate and to perform cataract surgery., Conclusions: Learning to effectively grade performance of cataract surgery by reviewing video clips has the potential to be an important part of ophthalmology residency education. The benefit of such a protocol was greatest in the early stages of residency education and might provide a guideline for quality assessment that accelerates surgical skill development., Financial Disclosure: None of the authors has a financial or proprietary interest in any material or method mentioned., (Copyright © 2016 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)