Crossover clinical trial of pain relief in cataract surgery.

PURPOSE: To determine the effects of intra-operative Korean traditional music on pain experienced by Korean patients undergoing sequential bilateral cataract surgery. METHODS: This was a two-sequence, two-period, and two-treatment crossover study. Fifty-two patients with cataracts were divided into two groups by block randomization, and bilateral cataract surgery was performed. In group 1, patients listened to Korean traditional music (KTM) during their first but not second cataract surgery. This sequence was reversed for patients in group 2. After each surgery, patients scored their pain intensity (PI) using a visual analog scale (VAS) ranging from 0 to 10, where 0 was 'no pain' and 10 was 'unbearable pain.' RESULT: There was a statistically significant reduction in the mean VAS score with KTM (3.1 ± 2.0) compared to that without KTM (4.1 ± 2.2; p = 0.013). However, there were no statistically significant differences in blood pressure or pulse rates. CONCLUSION: KTM had a significant effect on reducing pain experienced by patients during cataract surgery. This may be useful in the context of other surgical procedures to reduce pain in Korean patients.

Safety and comparative costs of preoperative assessments for cataract surgery: traditional mandatory assessment versus a novel graded assessment system.

PURPOSE: We conducted this study to evaluate the safety and costs of traditional mandatory preoperative assessment for cataract surgery patients compared with a novel graded preoperative assessment system. METHODS: Patients were recruited at a high-volume surgical centre from May to November 2013. Patients completed a health-related questionnaire which allowed for a graded preoperative assessment of all participants. Based on responses to the questionnaire, patients were classified preoperatively into a) low-risk patients not requiring a preoperative assessment and b) high-risk patients requiring this assessment. Anesthesiologists still assessed all patients immediately before surgery but with staff blinded to preoperative assessment information for low-risk patients. Observed complication rates and costs were compared with those expected in the mandatory assessment system. RESULTS: We examined 3,347 cataract surgeries on 2,766 patients and categorized 59.9% of patients as low risk. In the graded system cohort, there were no major complications and a low rate of minor complications occurred. Wherever a complication occurred in a low-risk patient, the anesthesiologist doubted that the preoperative assessment information would have prevented the complication. If implemented, the graded system would save approximately 4,414 preoperative assessments per year in our region, with an associated cost of approximately $40.00 per surgery, or $359,000 in total. The cost to prevent a single minor complication with the mandatory system was approximately $8,976, with a number needed to treat of 223. CONCLUSION: The graded system resulted in no major complications and a low rate of minor complications. The information obtained from the mandatory assessment is unlikely to prevent complications. Additionally, the cost effectiveness of the mandatory system was poor. This novel graded preoperative assessment system for cataract surgery patients can save time and resources by eliminating unnecessary patient visits.

Updated inventory and projections for Canada's ophthalmology workforce.

OBJECTIVE: To update Canadian ophthalmology workforce data and provide future predictions. DESIGN: Cross-sectional study. PARTICIPANTS: Ophthalmologists working in Canada from 1968 to 2019. METHODS: Supply and demographics of physicians in Canada were obtained from the Canadian Institute for Health Information. Physician training numbers were obtained from the Canadian Post-MD Education Registry. Using Statistic Canada population projections, future predictions about Canada's ophthalmology workforce were determined. RESULTS: In 2020, there were 1323 ophthalmologists in Canada; 27.3% were female and 20.9% were aged ≥65 years. Overall, there were 3.48 ophthalmologists per 100,000 population. Provincial distributions varied from 2.32 in Manitoba to 5.00 in Nova Scotia. For the population aged ≥65 years, there were 19.35 ophthalmologists per 100,000 population. If the yearly change in ophthalmologists' numbers remains as during the past 10 years, the number of ophthalmologists per 100,000 population is predicted to be slightly reduced to 3.21 in 2068 in a high-growth scenario and increased to 4.08 and 5.08 in a medium- and low-growth scenario, respectively. For the population aged ≥65 years, corresponding predicted ratios are 14.00 in a high-growth scenario, 17.72 in a medium-growth scenario, and 18.40 in a low-growth scenario. CONCLUSIONS: The ratio of ophthalmologists to population aged ≥65 years, the predominant cohort treated by ophthalmologists, is projected to drop by 4.9% and 27.7% in the low- and high-growth scenarios, respectively, potentially creating a challenge to vision care delivery. A small increase in ophthalmology residency positions could protect against this.

Infection rate following elective oculoplastic surgery in a minor procedure setting: a single-centre retrospective study.

OBJECTIVE: A surgical site infection after oculoplastic surgery is a serious complication that can lead to endophthalmitis and vision loss. Although performing these procedures in a minor-surgery setting is common, there is a lack of evidence in the literature regarding the incidence of postoperative infections. The objective of this study was to determine the infection rate associated with elective outpatient oculoplastic procedures performed in a minor-surgery setting. METHODS: A retrospective review was completed for all patients who underwent elective oculoplastic surgery in the minor-procedure room at the Misericordia Health Centre in Winnipeg between April and December 2018. Operations were performed by 2 senior oculoplastic surgeons. Data collected included the type of procedure, number of surgical incisions, type and number of sutures, use of prophylactic antibiotics, time to follow-up, complications, and presence of surgical site infection. RESULTS: Review of 539 patients showed an infection rate of 0.37% (2 of 539). Infection cases were an exposed orbital implant using a temporalis fascia graft and ptosis repair using a frontalis sling. Thirteen complications were identified, corresponding to a complication rate of 2.41% (13 of 539). CONCLUSION: Study results show an infection rate of 0.37% for elective oculoplastic surgery in a minor-procedure setting.

Does eliminating the preoperative history and physical make a difference in low-risk cataract surgery patients? A before and after study of 30-day morbidity and mortality.

OBJECTIVE: To evaluate the safety of omitting the conventional preoperative history and physical examination (H&P) for low-risk cataract surgery patients. DESIGN: Comparison of outcomes before and after the January 1, 2015 system wide implementation of a program that eliminated the conventional preoperative H&P for low-risk patients as identified by a 12-item risk stratification questionnaire. PARTICIPANTS: Two separate groups of Winnipeg residents who had cataract surgery at the city's sole ophthalmological referral centre between July 1 and December 31, 2014 (preimplementation reference group) or between October 1, 2015 and March 31, 2016 (postimplementation intervention group). METHODS: A detailed chart review was completed for cataract surgery patients who experienced a postoperative medical event (a composite of death or hospital admission or emergency department visit, identified within administrative databases) within 30 days of surgery. Nonfatal events were captured for all 7 hospitals and urgent care centres in the city, including the ophthalmological referral centre. RESULTS: Postoperative medical events occurred in 114 of 2981 (3.82%) intervention group surgeries and 125 of 3037 (4.12%) reference group surgeries (Relative risk 0.92, 95% confidence interval 0.72 to 1.19, p = 0.6 Fisher exact test). Subgroup analyses of major medical events and medical events by affected organ system yielded no significant differences between the 2 groups. In the opinion of the physician chart reviewers, none of the events among low-risk patients in the intervention group were related to the omission of a conventional preoperative H&P. CONCLUSIONS: The risk of adverse medical events within 30 days of cataract surgery was not higher after the omission of the conventional preoperative H&P in patients screened to be low risk by a validated preoperative questionnaire.

Neural network and logistic regression diagnostic prediction models for giant cell arteritis: development and validation.

PURPOSE: To develop and validate neural network (NN) vs logistic regression (LR) diagnostic prediction models in patients with suspected giant cell arteritis (GCA). Design: Multicenter retrospective chart review. METHODS: An audit of consecutive patients undergoing temporal artery biopsy (TABx) for suspected GCA was conducted at 14 international medical centers. The outcome variable was biopsy-proven GCA. The predictor variables were age, gender, headache, clinical temporal artery abnormality, jaw claudication, vision loss, diplopia, erythrocyte sedimentation rate, C-reactive protein, and platelet level. The data were divided into three groups to train, validate, and test the models. The NN model with the lowest false-negative rate was chosen. Internal and external validations were performed. RESULTS: Of 1,833 patients who underwent TABx, there was complete information on 1,201 patients, 300 (25%) of whom had a positive TABx. On multivariable LR age, platelets, jaw claudication, vision loss, log C-reactive protein, log erythrocyte sedimentation rate, headache, and clinical temporal artery abnormality were statistically significant predictors of a positive TABx (P≤0.05). The area under the receiver operating characteristic curve/Hosmer-Lemeshow P for LR was 0.867 (95% CI, 0.794, 0.917)/0.119 vs NN 0.860 (95% CI, 0.786, 0.911)/0.805, with no statistically significant difference of the area under the curves (P=0.316). The misclassification rate/false-negative rate of LR was 20.6%/47.5% vs 18.1%/30.5% for NN. Missing data analysis did not change the results. CONCLUSION: Statistical models can aid in the triage of patients with suspected GCA. Misclassification remains a concern, but cutoff values for 95% and 99% sensitivities are provided (https://goo.gl/THCnuU).

Changes in waiting lists over time.

BACKGROUND: Governments in Canada have committed $5.5 billion to shorten waiting lists. There is little information about changes in waiting lists over time except the perception that they are getting longer. METHODS: Monthly data from the Misericordia Cataract Waiting List Program from 2000 to 2006 were used to examine changes in the length of the waiting list per surgeon over time. The data were analyzed to see whether changes in the length of a surgeon's list from month to month appeared to influence his or her threshold for booking surgery. RESULTS: The overall length of the waiting lists decreased during the study period. Individual surgeons' lists fluctuated markedly. Surgeons were not found to adjust their threshold for booking surgery to maintain the length of their lists. INTERPRETATION: Committing extra resources to shorten waiting lists is successful. Surgeons do not appear to be manipulating their threshold for booking surgery to maintain the length of their waiting list. Individual surgeons' waiting list lengths are surprisingly dynamic. More study is needed on the variation in length of waiting lists and the longitudinal change over time if all patients are to receive their surgery within recommended benchmark wait times.

Ophthalmology human resource projections: are we heading for a crisis in the next 15 years?

BACKGROUND: Ophthalmology residency positions have increased in recent years. This study looks at whether the expansion is enough to avoid shortages in the future. METHODS: The Canadian Medical Association Physician Resource Evaluation Template was used to project the supply of ophthalmologists up to 2016, assuming a status quo scenario in terms of attrition and gain factors. RESULTS: The ratio of ophthalmologists to population is steadily declining but not as fast as previously projected. INTERPRETATION: With the scenario presented, the supply of ophthalmologists will be inadequate in the future. Expanding Canadian residency training programs to their maximum capacity will maintain the current national ophthalmologist-to-population ratio but will still not be enough to meet the demand for ophthalmology services because of the shift in demographics as baby boomers age.

Health care utilization for injury in cataract surgery patients.

BACKGROUND: Although visual impairment has been associated with falls, fractures, and other injuries, the relation between cataract surgery and injuries is unclear. This study assesses whether persons waiting for cataract surgery are at increased risk of requiring health care services for an injury compared with a control group, and, if so, whether the risk changes after cataract surgery. METHODS: This is a retrospective case-control study of first-eye cataract surgery recipients in Manitoba in fiscal 1999-2000. Health care administrative data and cataract waiting list registry data were the data sources. Cataract surgery recipients were matched 3:1 with controls on age, sex, and region. The outcome measure was a diagnosis of injury identified using International Classification of Diseases 9 (Clinical Modification) codes in the physician or hospital claims. Data were analyzed for 2 years before and after cataract surgery. A multivariate logistic regression adjusted for potential confounders, such as burden of illness, presence of diabetes, stroke or dementia, number of different medications, and use of psychoactive mediations. RESULTS: There were 3811 cases and 11,359 controls. Cases were found to be much more likely to have a history of stroke, diabetes, or dementia, and were more likely to have been prescribed multiple medications or a psychoactive drug. After adjustment for comorbidities and pharmaceutical use, cases had a significantly higher probability of an injury before surgery (0.2784 vs. 0.2538; chi2 = 5.01, p = 0.03). This decreased significantly after surgery to 0.2333 (chi2 = 18.05, p < 0.0001). After surgery, the adjusted probability of injury was lower among cases (0.2333) than controls (0.2385), though this was not significant. The adjusted odds ratio for having an injury was 1.032 (95% confidence interval 1.026, 1.039) per week of waiting. INTERPRETATION: Cataract patients have a significantly increased risk of injury compared with controls before surgery, but their risk decreases to that of controls following surgery. Given that cataract patients also bear a much heavier burden of illness, including conditions that are associated with a higher risk of falls and injuries, the imperative of performing cataract surgery without delay becomes even more pressing.

Future trends in ophthalmology health human resources in Canada.

Projections of future Canadian ratios of ophthalmologists to population have fluctuated because of changes in numbers of residency spots and retirement rates. Although this ratio plateaued in recent years, the ratio of ophthalmologists to the population over 65 years of age is projected to steadily deteriorate. All graduating residents are going to be needed to meet the upcoming workload, yet current graduates are finding increasing difficulty obtaining full-time positions with operating room privileges. This problem is affecting all specialties who require hospital facilities, and exploration of this problem by the Royal College, Canadian Medical Association (CMA), Resident Doctors of Canada, and council of the Provincial Deputy Ministers of Health is presented. Proposed solutions to the current job shortages include residents starting in positions outside of major metropolitan areas, clinicians in practice giving up some operating room time to make way for new graduates, government increasing infrastructure commensurate with the increased number of medical school positions, and optimizing use of current resources by running operating rooms for longer hours and on the weekends.

The underemployed ophthalmologist-results of a survey of recent ophthalmology graduates.

OBJECTIVE: To survey recent graduates of Canadian ophthalmology residency programs with regard to current employment, fellowship, job finding strategies, operating room time and resources, scope of practice, and reasons for difficulty in finding a job. DESIGN: Cross-sectional survey. PARTICIPANTS: Graduates of Canadian ophthalmology residency programs between 2009 and 2013 inclusive. METHODS: An electronic survey in English and French distributed via Surveymonkey to Canadian ophthalmology graduates from 2009 to 2013. RESULTS: Of the eligible ophthalmologists, 72% responded, and 81% of respondents had what they considered a job placement. The class of 2009 had the highest (100%) and the class of 2012 had the lowest (55%) employment rate. Of the respondents, 68% completed or were completing a fellowship, with retina being the most popular. Eighty percent of those with a job had operating room time with a median of 4 days per month, and 61% stated that their practice was open to all consultations, with cataract being the most common. Respondents felt adequately trained within the CanMEDS roles with the exception of manager. Only 11% felt they were adequately trained to run a business. CONCLUSIONS: It is important that an ophthalmology health human resources strategy is developed to ensure that newly trained ophthalmologists can practice their skills to serve health-care needs now and in the future.

Why are patients with no visual symptoms on cataract waiting lists?

BACKGROUND: Some patients waiting for cataract surgery report limited or no visual symptoms when responding to standardized visual function questions. This has led some to argue that too many patients are undergoing cataract surgery. METHODS: One hundred and forty-nine consecutive patients who reported no symptoms on the Visual Function Index questionnaire (VF-14) were asked if they had any visual symptoms not included in the VF-14, why they thought they were on the waiting list, and what they expected to gain from surgery. They were interviewed after their surgery to see if they were satisfied with the procedure and if their vision had improved. RESULTS: Of 149 patients, 108 described some degree of visual impairment, 28 stated they were undergoing surgery at their doctor's suggestion, and 13 did not describe any reason for their surgery. By the second interview, 105 patients had had surgery, of whom 85% were very or extremely satisfied and 75% felt their vision was markedly improved. There was no statistically significant difference in satisfaction rates between the symptomatic, asymptomatic, or doctor's suggestion groups, or between patients undergoing first or second eye surgery. INTERPRETATION: Patients on cataract waiting lists who scored 100 (no complaints) on the VF-14 are likely to have some visual complaints not identified by the test and are likely to experience significant visual gain after undergoing cataract surgery. The adoption of the VF-14 questionnaire to determine the threshold for cataract surgery would be detrimental, because many patients who clearly could benefit from surgery would be denied appropriate health care.

The Misericordia Health Centre cataract comfort study.

BACKGROUND: All surgery provokes various degrees of anxiety for patients. The environment leading up to surgery can affect anxiety levels. We performed a prospective randomized study to compare environmental factors around the time of cataract surgery in order to identify interventions that would minimize stress for patients. METHODS: Patients scheduled to undergo cataract surgery at a university-affiliated hospital in Winnipeg were randomly assigned to 1) receive orally administered lorazepam or a placebo before surgery; 2) listen to relaxing music through headphones or routine background noise before surgery; 3) walk (or go by wheelchair if unable to walk) to the operating room or go by stretcher; and 4) listen to relaxing music through headphones or routine background noise during surgery. Randomization for part 1 was double blind; for parts 2 and 3 the surgeon and anesthetist were blinded, but the patient was not. Patients were asked to rate their anxiety, sedation, nausea and pain on arrival at the preoperative area, about 30 minutes after arrival, on arrival in the operating room and on arrival in the postoperative area, on a visual analogue scale graded from 0 ("None" [or "Wide awake" in the case of sedation]) to 10 ("Worst possible" [or "Asleep" in the case of sedation]). Patient satisfaction and willingness to repeat the exact same form of treatment were also rated. RESULTS: Of the 19 surgeons in the department 18 agreed to participate; I withdrew during the study. Data were collected for 144 patients aged 26 to 93 years. Anxiety was highest on arrival at the institution and decreased progressively thereafter. Oral sedation and listening to music before surgery were associated with decreased anxiety and increased levels of sedation (p = 0.002). Walking to the operating room provided no benefit over going by stretcher. Listening to music through headphones during surgery was not accepted by many patients and, when used, negatively affected the surgeon's assessment of the patient's ability to cooperate. Surgeons reported movement more often among patients who received oral sedation than among those who did not (chi2 = 0.01). Levels of pain and nausea were extremely low in all patients, and satisfaction was very high. Patients who received regional local anesthesia had less pain and higher satisfaction than those who received topical anesthesia. Willingness to repeat the same treatment was extremely high. INTERPRETATION: For patients undergoing cataract surgery, efforts should be directed toward reducing anxiety on arrival at the institution, when it is highest, and not just during surgery. Oral sedation and listening to music before surgery appear to be beneficial. Listening to music through headphones during surgery was not found to be advantageous.

The impact of allocation of additional resources on the waiting time for cataract surgery.

In 2001, the ophthalmology community in Manitoba lobbied the regional health authority to allocate additional resources for cataract surgery because of unacceptably long waits. Approval was given in principle for a partial increase in resources and this was implemented in March 2002. Cataract surgery in the region is monitored by a waiting list program that is used to track and prioritize all patients waiting. This monitored increase in funding provided an opportunity to measure exactly what impact additional resources would have on a cataract waiting list.

The landscape of ophthalmologists in Canada: present and future.

OBJECTIVE: To describe the current national and regional population distribution of ophthalmologists in Canada and provide national predictions up to 2030. DESIGN: Cross-sectional, study. PARTICIPANTS: Ophthalmologists listed in the Canadian Medical Association (CMA) database and Canadian population. METHODS: The CMA database was used to determine the number and location of currently licensed ophthalmologists in Canada. Using Statistics Canada population data, we determined the ratio of ophthalmologists to 100,000 population. Projections were also made for the supply of ophthalmologists up to 2030 using the CMA Physician Resource Evaluation Template and assuming a status quo scenario in terms of attrition and gain factors. RESULTS: In Canada, there are currently 3.35 ophthalmologists per 100,000 population. There is, however, significant regional disparity; provincial ratios vary from 5.40 (Nova Scotia) to 1.96 (Saskatchewan) and 0.89 in the territories. If 3 ophthalmologists per 100,000 is the ideal ratio, then 4 provinces and the territories were below this ratio, and of the 104 regions with an ophthalmologist, 22 were below the ratio. The national projection to 2030 is a slight increase to 3.38; however, the full-time equivalent ratio is expected to decrease from 3.29 in 2012 to 3.06 in 2030. For the population ≥ 65 years old, with a projected growth 4 times greater than that of ophthalmologists, the ratio of ophthalmologists to population ≥ 65 years old is projected to decline by 34%. CONCLUSIONS: Although national estimates appear stable, there is significant regional variation. The projected marked growth of the population ≥ 65 years old may compromise our future ability to provide care at the current standard.