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Safety and  efficacy in the cataract surgery process
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Ophthalmology.
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

Cataract and age-related macular degeneration (AMD) are two major causes for visual impairment in the elderly. Cataract surgery is one of the most common surgical interventions performed in the western world. As a consequence of the increasing number of operations performed, postoperative visits are a large workload for surgical units. It is important that all parts of the cataract surgery procedure are appropriate and cost-effective. During the last 20 years the trend is towards fewer visits both pre- as well as postoperatively. The number and timing of postoperative visits are also a subject of an ongoing debate. Few studies have previously evaluated safety perspectives concerning the number and timing of post-operative visits.

The last decade, new treatments for wet AMD have evolved and the number of patients receiving treatment has increased. It has been debated if blue-blocking intraocular lenses (IOL) have a protective effect on the development of wet AMD and decreasing the need for AMD-treatment after cataract surgery.

Aims

To analyse parts of the modern cataract surgery process including peri- and post-operative routines from a safety and efficacy perspective. To analyse pre- and perioperative risk factors as well as protective factors associated with the need for wet AMD-treatment after cataract surgery.

Methods

I, II. These prospective, observational cohort studies included all cataract surgery cases (n=1249) during a 1-year period, at one institution. The cohort was analysed regarding the use of a standardized anaesthetic regimen and the safety perspectives, when the standard routine is no planned postoperative visit in uncomplicated cases without ocular comorbidity.

III. The above-mentioned cohort (study group), was compared with a cohort from another clinic (control group) with a different follow-up routine, i.e. each case with first eye cataract surgery had a planned postoperative visit. In the control group all patients (n= 1162 cases) had surgery during the same 1-year period. The number of planned and unplanned visits was recorded, and the surgical outcome from the two institutions was compared.

IV. A register-based cohort study included all patients registered in the Swedish National Cataract Register and the Swedish Macula Register in 2010 - 2017, to find all eyes with past cataract surgery that were subsequently treated for wet AMD. Complete registry data was used for comparisons and analyses of pre- and peri-operative risk- and protective factors for wet AMD treatment after cataract surgery.

Results

I. A standardized anaesthetic method with topical and intracameral anaesthetics without sedation was used in most cases (90%). Median pain score after surgery was 0.7 (VAS 0-10) and most patients (97%) would choose the same anaesthetic method again.

II, III. Evaluation of all medical records 2 years after the cataract surgery procedure, found no report of missed adverse events. Significantly less patients in the study group (9% vs 16%; p=0.000036) initiated a postoperative unplanned contact compared with the control group. Patients with 70 km or longer to the hospital were less inclined to seek unplanned care (p=0.016).

IV. Female gender and high age are associated with an increased risk of needing treatment for wet AMD ≥1 year after cataract surgery. Eyes with a diagnosis of AMD preoperatively, and subsequently treated for wet AMD, had a significantly (p=0.023) lower degree of blue-blocking IOLs implanted at their previous cataract surgery.

Conclusion

I. A standardized anaesthetic method with topical and intracameral anaesthetics without sedation seems well tolerated by the patients, and is effective at cataract surgery, also in cases when complications/adverse events occur.

II, III. Without compromising patient safety, it is possible to refrain from standard postoperative visits after cataract surgery in patients with uncomplicated surgery and no ocular comorbidity. A significant reduction in postoperative visits is only obtained if the standard routine applies to both first and second eye surgery.

IV. Patients without preoperative AMD have no benefit from the use of blue-blocking IOLs. In patients with preoperatively diagnosed AMD, blue-blocking IOLs may offer some protection from the subsequent development of AMD.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2018. , p. 60
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1989
Keywords [en]
Cataract, prospective cohort study, patient safety, age-related macular degeneration
National Category
Ophthalmology
Research subject
Ophtalmology
Identifiers
URN: urn:nbn:se:umu:diva-152946ISBN: 978-91-7601-955-9 (print)OAI: oai:DiVA.org:umu-152946DiVA, id: diva2:1259786
Public defence
2018-11-23, Hörsal D, Unod T9, plan 9 Tandläkarhögskolan, Norrlands Universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2018-11-02 Created: 2018-10-31 Last updated: 2018-11-08Bibliographically approved
List of papers
1. Intracameral anesthesia for cataract surgery: a population-based study on patient satisfaction and outcome
Open this publication in new window or tab >>Intracameral anesthesia for cataract surgery: a population-based study on patient satisfaction and outcome
2013 (English)In: Clinical Ophthalmology, ISSN 1177-5467, E-ISSN 1177-5483, no 7, p. 2063-2068Article in journal (Refereed) Published
Abstract [en]

PURPOSE: To evaluate if the standard anesthetic regimen - topical combined with intracameral anesthesia without sedation - in a population-based cohort of unselected cataract surgery cases is adequate, optimal, and good practice, or if improvements are necessary.

METHODS: We conducted a prospective, observational study on all cases of cataract surgery during a 1-year period at one institution (n=1249). Data were collected from the patients' records. Outcome measures were use of preoperative sedation, type of anesthesia, complications, and adverse events. In a subgroup of patients (n=124) satisfaction with the anesthetic regimen was evaluated using a short questionnaire.

RESULTS: Most cases (90%, 1125/1249) had combined topical and intracameral anesthesia without sedation. Patients who chose preoperative sedation (midazolam hydrochloride sublingually) were significantly younger and more often female (P=0.0001 and P=0.011, respectively). In the questionnaire subgroup, the median pain score after surgery was 0.7 (visual analog scale, 0-10). A pain score of 1.9 or less was reported by 76% of the patients. Patients reporting a pain score of 2 or more had sedation and additional anesthetics more often. No significant difference was found regarding age, sex, pulse rate, oxygen saturation, first or second eye surgery, or adverse intraoperative events for patients with pain scores of 1.9 or less and 2 or more.

CONCLUSION: This large population-based series of small-incision phacoemulsification surgery shows that combined topical and intracameral anesthesia without sedatives is well tolerated for most phacoemulsification patients. It is also effective in cases when complications or adverse events occur. It is important to be responsive to the individual patient's needs and adjust operating procedures if necessary, as there were a few patients who experienced insufficient anesthesia.

Place, publisher, year, edition, pages
Dove Medical Press Ltd, 2013
Keywords
anesthesia, local/methods, phacoemulsification, cataract extraction, humans, prospective observational studies
National Category
Ophthalmology
Identifiers
urn:nbn:se:umu:diva-90954 (URN)10.2147/OPTH.S51409 (DOI)24204107 (PubMedID)
Available from: 2014-07-04 Created: 2014-07-04 Last updated: 2018-10-31Bibliographically approved
2. Optimizing number of postoperative visits after cataract surgery: Safety perspective
Open this publication in new window or tab >>Optimizing number of postoperative visits after cataract surgery: Safety perspective
2017 (English)In: Journal of cataract and refractive surgery, ISSN 0886-3350, E-ISSN 1873-4502, Vol. 43, no 9, p. 1184-1189Article in journal (Refereed) Published
Abstract [en]

Purpose: To evaluate safety perspectives when the standard routine after cataract surgery is no planned postoperative visit.

Setting: Eye Clinic, Sunderby Hospital, Lulea, Norrbotten County, Sweden.

Design: Prospective case series.

Methods: All cataract surgery cases during a 1-year period were included. The study group had the standard routine at the clinic, that is, no planned postoperative visit for patients without comorbidity and uneventful surgery. For the control group, patients who had surgery during 1 month of the 1-year period were chosen. All these patients had a planned postoperative visit. All surgeons involved were experienced. The outcome measures were any planned postoperative visit, any complication and/or adverse event, postoperative corrected distance visual acuity (CDVA), and any postoperative control/contact initiated by the patient.

Results: The study comprised 1249 patients (1115 in the study group and 134 in the control group). No significant differences in demographics, postoperative CDVA, frequency of planned visits because of ocular comorbidity, or postoperative patient-initiated contacts were found between the 2 groups. Of the 1249 patients, 9% (117 patients) initiated a postoperative contact, of whom 26% (30 patients) also had a scheduled visit. The reasons for the patient-initiated contacts were visual disturbance, redness and/or chafing, pain, and anxiety. An evaluation of all medidal records 2 years postoperatively found no reports of missed adverse events.

Conclusions: It was possible to refrain from planned,postoperafive visits for patients having uncomplicated cataract surgery. However, preoperatively, patients with comorbidities should be provided with individual planning of their postoperative follow-up. Preoperative counseling is important, and the clinic must have resources to answer questions from patients and be prepared for additional unplanned postoperative visits.

Place, publisher, year, edition, pages
Elsevier, 2017
National Category
Ophthalmology Surgery
Identifiers
urn:nbn:se:umu:diva-142002 (URN)10.1016/j.jcrs.2017.06.042 (DOI)000413889000010 ()28991615 (PubMedID)
Available from: 2017-11-21 Created: 2017-11-21 Last updated: 2018-10-31Bibliographically approved
3. Optimizing follow-up after cataract surgery: comparison of two institutions
Open this publication in new window or tab >>Optimizing follow-up after cataract surgery: comparison of two institutions
(English)Manuscript (preprint) (Other academic)
National Category
Ophthalmology
Identifiers
urn:nbn:se:umu:diva-152956 (URN)
Available from: 2018-10-31 Created: 2018-10-31 Last updated: 2018-10-31
4. Treatment of Age-Related Macular Degeneration after Cataract Surgery: A Study from the Swedish National Cataract and Macula Registers
Open this publication in new window or tab >>Treatment of Age-Related Macular Degeneration after Cataract Surgery: A Study from the Swedish National Cataract and Macula Registers
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Ophthalmology
Identifiers
urn:nbn:se:umu:diva-152955 (URN)
Available from: 2018-10-31 Created: 2018-10-31 Last updated: 2018-10-31

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