Menda SA, Driver TH, Neiman AE, Naseri A, Stewart JM. Return to the Operating Room After Resident-Performed Cataract Surgery. JAMA Ophthalmol. 2014;132(2):223-224. doi:10.1001/jamaophthalmol.2013.5675
Cataract surgery is one of the most commonly performed operations during ophthalmology residency training, and its complications have been well described.1- 3 While returns to the operating room within 30 days after routine surgery serve as a benchmark for surgical quality in other specialties such as neurosurgery and general surgery, reoperation after cataract surgery has not been investigated.4,5 The aim of this study was to examine the rate and indications for reoperation after resident-performed cataract surgery at 30 and 90 days.
This was a retrospective study approved by the institutional review boards of the University of California, San Francisco/San Francisco General Hospital and the San Francisco Veterans Affairs Medical Center. The requirement for informed consent was waived by the institutional review boards. Billing codes were used to identify all patients at 2 teaching hospitals within a single residency program who underwent resident-performed cataract surgery from January 1, 2005, to December 31, 2010. Any return to the operating room within 90 days of the surgery was identified as a reoperation. Variables studied included age, type of cataract surgery, training level of the resident, time to reoperation, indication for reoperation, and type of reoperation. Univariate analyses were conducted with Microsoft Excel (Microsoft Corp) to gather descriptive data about the reoperation cases. A χ2 test was conducted to determine whether differences in reoperation rates among residency year quarters were statistically significant.
There were a total of 3310 resident-performed cataract operations and 70 reoperations within 90 days, for a reoperation rate of 2.11%. The reoperation rate at San Francisco General Hospital was 2.25%, while the reoperation rate at the San Francisco Veterans Affairs Medical Center was 1.99%. The mean (SD) age of patients requiring reoperation was 67.3 (13.5) years. Sixty percent of reoperations involved the right eye, while 40% involved the left eye. The most common primary procedure performed was phacoemulsification (88.6%), followed by manual cataract extraction (11.4%). The rate of return to the operating room following manual cataract extraction was 4.70%, while the rate of return to the operating room after phacoemulsification was 1.94%. The rate of reoperation in the first quarter of the academic year was 1.49%, followed by 2.37% in the second quarter, 2.45% in the third quarter, and 1.78% in the final quarter of the academic year. Fifty-two reoperations (74.3%) occurred within 30 days of the primary cataract surgery, while an additional 18 (25.7%) occurred 31 to 90 days after cataract surgery. The most common indications for reoperation included retained nuclear fragment, dislocated intraocular lens, incision leak, and retinal detachment (Table). The most common reoperation procedures were pars plana vitrectomy with pars plana lensectomy, incision repair, pars plana vitrectomy with membrane peel, intraocular lens exchange, and intraocular lens repositioning (Table). For the 9 patients undergoing pars plana vitrectomy with membrane peel, the indications included epiretinal membrane, macular hole, and retinal detachment repair.
Proficiency in cataract surgery is one of the main objectives of surgical training during ophthalmology residency. In addition to complication rates, the need for reoperation may reflect suboptimal surgical management and serves as an additional marker for outcomes assessment. Reported rates of unplanned return to the operating room within 30 days after surgery vary from 3.5% in general surgery to 28% in pediatric neurosurgery.4,5 In this study, the reoperation rate after resident-performed cataract surgery was 2.11%. Interestingly, the rate of return to the operating room was lowest in the first quarter of the academic year, which may reflect greater supervision at the beginning of the academic year. The rate of retained lens fragment was 0.7%, which is comparable to the previously published rate of 0.8% after resident-performed cataract surgery.6 Reoperations after cataract surgery can have important implications for visual prognosis, morbidity, and health care costs. Additional investigation is required to elucidate the perioperative risk factors associated with reoperation. The reasons for reoperation can provide another method for evaluating surgical skills and can help identify surgical competencies that require improvement.
Corresponding Author: Jay M. Stewart, MD, Department of Ophthalmology, University of California, San Francisco, 10 Koret Way, K301, San Francisco, CA 94143 (firstname.lastname@example.org).
Published Online: November 28, 2013. doi:10.1001/jamaophthalmol.2013.5675.
Author Contributions: Drs Menda and Stewart had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Menda, Naseri, Stewart.
Acquisition of data: Menda, Driver, Neiman.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: Menda, Driver.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Driver, Neiman, Naseri.
Administrative, technical, or material support: Menda, Neiman, Naseri, Stewart.
Study supervision: Naseri, Stewart.
Conflict of Interest Disclosures: None reported.