Ontario Cataract Quality Outcome Initiative: appropriateness and prioritization of cataract surgery.

OBJECTIVE: To explore the utility of the Catquest 9SF visual function (VF) questionnaire along with visual acuity (VA) for determining appropriateness and priority for cataract surgery. To evaluate the feasibility of administering the Catquest-9SF in a clinical setting using web-based electronic data capture and interpretation. DESIGN: Prospective multicentred interventional observational study. PARTICIPANTS: Subjects undergoing sequential cataract surgery in both eyes at 4 sites in Ontario. METHODS: We recorded best-corrected VA (BCVA) and VA with current correction (CCVA) in each eye and both eyes (OU) and Catquest-9SF responses on a tablet before and after cataract surgery. Linear regression models were employed to test for associations between VA and visual function (VF). RESULTS: Preoperative BCVA and CCVA in the worse eye were significant predictors of change in VF (p = 0.006 and p = 0.008, respectively); subjects with worse VA had a greater improvement in VF after surgery. There was a significant association between improvement in VF and improvement in CCVA OU (p = 0.001). Fourteen of 151 subjects (9%) had no improvement or worse VF scores after surgery. Within this group, 10 of 14 subjects had a preoperative score ≤-3, which is suggestive of minimal visual disability. Within this subset, 4 of 14 subjects (2.6%) had a preoperative BCVA of 20/30 or better in their worse eye. CONCLUSIONS: For patient groups with equal VA, the Catquest-9SF score can help determine priority for surgery. Web-based data capture and interpretation allow for efficient virtual assessments of VF. A BCVA in the worse eye of 20/30 or better combined with a Catquest-9SF score <-3 can be used as a guideline for lowest priority.

Retinal nerve fiber layer in frontotemporal lobar degeneration and amyotrophic lateral sclerosis.

Purpose: Tauopathy and transactive response DNA binding protein 43 (TDP-43) proteinopathy are associated with neurodegenerative diseases. These proteinopathies are difficult to detect in vivo. This study examined if spectral-domain optical coherence tomography (SD-OCT) can differentiate in vivo the difference in peripapillary retinal nerve fibre layer (pRNFL) thickness and macular retinal thickness between participants with presumed tauopathy (progressive supranuclear palsy) and those with presumed TDP-43 proteinopathy (amyotrophic lateral sclerosis and semantic variant primary progressive aphasia). Study design: Prospective, multi-centre, observational study. Materials and methods: pRNFL and macular SD-OCT images were acquired in both eyes of each participant using Heidelberg Spectralis SD-OCT. Global and pRNFL thickness in 6 sectors were analyzed, as well as macular thickness in a central 1 mm diameter zone and 4 surrounding sectors. Linear mixed model methods adjusting for baseline differences between groups were used to compare the two groups with respect to pRNFL and macular thickness. Results: A significant difference was found in mean pRNFL thickness between groups, with the TDP-43 group (n = 28 eyes) having a significantly thinner pRNFL in the temporal sector than the tauopathy group (n = 9 eyes; mean difference = 15.46 µm, SE = 6.98, p = 0.046), which was not significant after adjusting for multiple comparisons. No other significant differences were found between groups for pRNFL or macular thickness. Conclusion: The finding that the temporal pRNFL in the TDP-43 group was on average 15.46 µm thinner could potentially have clinical significance. Future work with larger sample sizes, longitudinal studies, and at the level of retinal sublayers will help to determine the utility of SD-OCT to differentiate between these two proteinopathies.

A recommended "minimum data set" framework for SD-OCT retinal image acquisition and analysis from the Atlas of Retinal Imaging in Alzheimer's Study (ARIAS).

INTRODUCTION: We propose a minimum data set framework for the acquisition and analysis of retinal images for the development of retinal Alzheimer's disease (AD) biomarkers. Our goal is to describe methodology that will increase concordance across laboratories, so that the broader research community is able to cross-validate findings in parallel, accumulate large databases with normative data across the cognitive aging spectrum, and progress the application of this technology from the discovery stage to the validation stage in the search for sensitive and specific retinal biomarkers in AD. METHODS: The proposed minimum data set framework is based on the Atlas of Retinal Imaging Study (ARIAS), an ongoing, longitudinal, multi-site observational cohort study. However, the ARIAS protocol has been edited and refined with the expertise of all co-authors, representing 16 institutions, and research groups from three countries, as a first step to address a pressing need identified by experts in neuroscience, neurology, optometry, and ophthalmology at the Retinal Imaging in Alzheimer's Disease (RIAD) conference, convened by the Alzheimer's Association and held in Washington, DC, in May 2019. RESULTS: Our framework delineates specific imaging protocols and methods of analysis for imaging structural changes in retinal neuronal layers, with optional add-on procedures of fundus autofluorescence to examine beta-amyloid accumulation and optical coherence tomography angiography to examine AD-related changes in the retinal vasculature. DISCUSSION: This minimum data set represents a first step toward the standardization of retinal imaging data acquisition and analysis in cognitive aging and AD. A standardized approach is essential to move from discovery to validation, and to examine which retinal AD biomarkers may be more sensitive and specific for the different stages of the disease severity spectrum. This approach has worked for other biomarkers in the AD field, such as magnetic resonance imaging; amyloid positron emission tomography; and, more recently, blood proteomics. Potential context of use for retinal AD biomarkers is discussed.

Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery.

CONTEXT: Both benign prostatic hyperplasia (BPH) and cataract formation are common in older men. The alpha-adrenergic receptor blocker tamsulosin is frequently prescribed to treat BPH, and research suggests this drug may increase the intraoperative difficulty of cataract surgery. No studies have documented whether use of tamsulosin or other alpha-blocker drug therapies affect the risk of serious postoperative adverse events. OBJECTIVE: To assess the risk of adverse events following cataract surgery in older men prescribed tamsulosin or other alpha-blocking drugs used to treat BPH. DESIGN, SETTING, AND PATIENTS: Nested case-control analysis of a population-based retrospective cohort study using linked health care databases from Ontario, Canada. We included all men aged 66 years or older who had cataract surgery between 2002 and 2007 (N = 96 128). MAIN OUTCOME MEASURES: A composite of procedures signifying retinal detachment, lost lens or lens fragment, or endophthalmitis occurring within 14 days after cataract surgery. The risk of these adverse events was compared between men treated with tamsulosin or other alpha-blockers and men with no exposure to these medications in the year prior to cataract surgery. We separately examined the association of drug exposure that was either recent (within the 14 days before surgery) or previous (15-365 days before surgery). RESULTS: Overall, 3550 patients (3.7%) in the cohort had recent exposure to tamsulosin and 7426 patients (7.7%) had recent exposure to other alpha-blockers. Two hundred eighty-four patients (0.3%) had an adverse event. We randomly matched 280 of the cases to 1102 controls according to their age, surgeon, and year of surgery. Adverse events were significantly more common among patients with recent tamsulosin exposure (7.5% vs 2.7%; adjusted odds ratio [OR], 2.33; 95% confidence interval [CI], 1.22-4.43) but were not associated with recent exposure to other alpha-blockers (7.5% vs 8.0%; adjusted OR, 0.91; 95% CI, 0.54-1.54) or to previous exposure to either tamsulosin (< or = 1.8% vs 1%; adjusted OR, 0.94; 95% CI, 0.27-3.34) or other alpha-blockers (2.9% vs 2.1%; adjusted OR, 1.08; 95% CI, 0.47-2.48). This corresponds to an estimated number needed to harm (NNH) of 255 (95% CI, 99-1666). CONCLUSIONS: Exposure to tamsulosin within 14 days of cataract surgery was significantly associated with serious postoperative ophthalmic adverse events. There were no significant associations with exposure to other alpha-blocker medications used to treat BPH.

Risk factors for acute endophthalmitis after cataract surgery: a population-based study.

OBJECTIVE: To identify risk factors for suspected acute endophthalmitis after cataract surgery. DESIGN: Population-based retrospective cohort. PARTICIPANTS: Administrative data from more than 440,000 consecutive cataract surgeries in Ontario, Canada, from April 1, 2002, to March 31, 2006. METHODS: Consecutive physician billing claims for cataract surgery and specific intraoperative and postoperative procedures related to complications of cataract surgery were identified. Acute endophthalmitis was defined using surrogate markers for intraocular infection, including vitrectomy, vitreous injection, or aspiration procedures not in combination with air/fluid exchange or dislocated lens extraction, performed 1 to 14 days after cataract surgery. Anterior vitrectomy performed on the day of surgery was used as a surrogate marker for capsular rupture. MAIN OUTCOME MEASURES: Overall rates of endophthalmitis were calculated and grouped by patient demographics, surgical facility, season, year, and association with capsular rupture. RESULTS: There were 617 suspected acute endophthalmitis cases of 442,177 cataract surgeries over the 4 years. The overall unadjusted and adjusted rates of suspected acute endophthalmitis were both 1.4 per 1000 cataract surgeries. Men had higher rates than women (1.70 vs. 1.19/1000 surgeries, P<0.0001) with an adjusted odds ratio of 1.40 (95% confidence interval, 1.19-1.64).The oldest age group (>or= 85 years) had the highest rate (2.18/1000), and the youngest group (20-64) had the second highest rate (1.76/1000). The endophthalmitis rates for these age groups were significantly different from those aged 65 to 84 years. The endophthalmitis rate was approximately 10-fold higher in those with capsular rupture compared with those without (13.11 vs. 1.34/1000, P<0.0001), with an adjusted odds ratio of 9.56 (95% confidence interval, 6.43-14.2). CONCLUSIONS: The overall rates of suspected acute endophthalmitis are low but significantly higher in certain patient groups. Our population-based analysis can be used as a benchmark for quality-improvement initiatives and can assist clinicians in educating their patients regarding the risks associated with cataract surgery. Future work is required to address the higher rate of endophthalmitis in men, those with capsular rupture, and the oldest patients undergoing cataract surgery.

A 10-year population-based cohort analysis of cataract surgery rates in Ontario.

BACKGROUND: We studied the rates and distribution of cataract surgery throughout Ontario using population-based administrative data. METHODS: We identified patients who had had cataract surgery performed between April 1, 1994, and March 31, 2005. We calculated crude cataract surgery rates, overall and regional adjusted rates per 100,000 residents aged 65 and over, and age- and sex-specific rates. RESULTS: The number of cataract surgeries performed on patients over 65 more than doubled, from 43,818 to 90,183, over the 10-year period and accounted for approximately 81% of all cataract surgeries in Ontario. Age- and sex-adjusted rates varied considerably among health administrative geographic regions. For 2004-2005, rates including all cataract surgeries ranged from 4272 to 6563 cataract surgeries per 100,000 residents aged 65 or older. INTERPRETATION: There has been a significant increase in the number of cataract surgeries performed over the past decade in Ontario with considerable regional variation. Observed rates were higher than those reported for other countries.

Comparison of glaucoma progression evaluated with Heidelberg retina tomograph II versus optic nerve head stereophotographs.

BACKGROUND: To compare disease progression in glaucoma evaluated by means of the Heidelberg retina tomograph (HRT II) or by expert clinical assessment of colour stereophotographs of the optic nerve head (ONH). METHODS: One eye each of 54 subjects with glaucoma was reviewed using the HRT II and ONH stereophotographs. The ONH stereophotographs were assessed twice each for glaucomatous progression by 2 expert observers (Drs. Buys and Trope). They were considered to be in agreement if their results were the same in 3 of 4 assessments. Progression on the HRT II was defined by using the topographic change analysis (TCA). The clinical assessments were the reference standard used to determine sensitivity and specificity of the HRT II TCA. RESULTS: The expert observers were in agreement in 50 subjects (92%). Concordance between the HRT II and ONH stereophotographs assessments was obtained in 35 patients (65%); 16 patients (30%) showed progression on HRT II only, while 3 patients (6%) showed progression on stereophotographs only. When these results were used to perform a post hoc analysis, HRT II sensitivity increased from 70% to 78% and specificity increased from 63.6% to 70%. The positive predictive value of the HRT II rose from 30.4% to 47.8%, while the negative predictive value remained at 90.3%. INTERPRETATION: Our results demonstrate only fair agreement between HRT II and clinical judgment of ONH stereophotographs for progression in glaucomatous eyes. At present, HRT II progression alone should not indicate a treatment change. HRT II change must be evaluated in conjunction with other clinical features of deterioration before altering therapy.

Surgeon volumes and selected patient outcomes in cataract surgery: a population-based analysis.

OBJECTIVE: To study the association of annual surgeon volume of cataract procedures with the risk of postoperative adverse events. DESIGN: We used population-based administrative health records to conduct a retrospective cohort study from 2001 through 2003. PARTICIPANTS: The number of surgeons who performed more than 50 cataract surgeries annually ranged from 231 to 243 over the 3 years. There were 284 797 cataract surgeries in patients older than 20 years performed at 70 hospitals or eye surgery centers in the province of Ontario, Canada. METHODS: We calculated cataract surgery volume for each surgeon and tested for the presence of a volume-outcome association. We used generalized estimating equations to account for the effect of clustering of patients according to individual surgeons and to adjust estimates for the potential confounding effects of patient age and gender. MAIN OUTCOME MEASURES: We used a composite outcome of postoperative adverse events from cataract surgery that included billing claims for vitrectomy, vitreous aspiration or injection of medication, vitreous air or fluid exchange, and dislocated lens extraction performed by any ophthalmologist between 1 and 14 days after cataract surgery. These procedures are surrogate markers for the outcomes of retinal detachment, lost lens or lens fragment, and suspected endophthalmitis. RESULTS: In each year, fewer than 1 in 200 patients experienced an adverse event (range, 0.33%-0.41%). Surgeons performing 50 to 250 cataract surgeries per year had an adverse event rate of 0.8%. Surgeons performing 251 to 500 cataract surgeries per year had an adverse event rate of 0.4% and an adjusted odds ratio of postoperative adverse events of 0.52 (95% confidence interval [CI], 0.39-0.69) compared with surgeons performing 50 to 250 procedures per year. Surgeons performing 501 to 1000 cataract surgeries per year had an adverse event rate of 0.2% and an adjusted odds ratio of 0.31 (95% CI, 0.22-0.43), and surgeons performing more than 1000 cataract surgeries per year had an adverse event rate of 0.1% and an adjusted odds ratio of 0.14 (95% CI, 0.09-0.23). CONCLUSIONS: Selected adverse event rates for surgeons performing more than 50 cataract surgeries per year are low. There is a volume-outcomes relationship for cataract surgery, and this relationship persists even for very high-volume surgeons.

Waiting times for eye surgery at a Toronto teaching hospital.

BACKGROUND: Waiting times for eye surgery in Ontario have increased dramatically in recent years. We performed a study to compare the waiting times, the amount of operating time and the number of cases performed for various eye surgical procedures in 1999, 2000 and 2001 at a major Toronto teaching hospital. METHODS: For 3 months (May, June and July) of 1999, 2000 and 2001, eye surgeons at the hospital reported how long their patients had to wait for surgery and how many patients they had waiting for surgery. The number of operating hours for eye surgery and the number of eye surgery cases in fiscal years 1999-2000, 2000-01 and 2001-02 were collected from a hospital database. Surgical procedures that were captured were cataract extraction, corneal transplantation, trabeculectomy (including phacotrabeculectomy), vitreoretinal surgery and adult strabismus surgery. RESULTS: All surgeons responded to the survey. Median waiting times increased for all types of eye surgery between 1999 and 2001. The median wait for cataract extraction increased by 92%, from 3.0 to 5.8 months. For corneal transplantation the median wait doubled, from 5.5 to 11.0 months. The median wait for trabeculectomy increased by 60%, from 2.5 to 4.0 months. The median wait for vitreoretinal surgery almost tripled (191%), from 1.2 to 3.4 months. For adult strabismus surgery the median wait increased by 56%, from 8.0 to 12.5 months. Operating time was cut by over 1000 hours (from 5481 to 4434) from 1999-2000 to 2000-01 and then again, by 255 hours, from 2000-01 to 2001-02. Despite this, the number of surgical procedures performed decreased only slightly over the study period, from 4292 to 4099. INTERPRETATION: The waiting times for all eye operations increased substantially between 1999 and 2001 at this Toronto teaching hospital. In addition, for each type of surgery the median waiting time was longer than the Ontario median, by 13% (cataract surgery) to 191% (vitreoretinal surgery). The fact that the number of cases performed decreased only slightly despite a dramatic decrease in operating time indicates that there was an increase in efficiency. Possible ways to reduce the long waits include implementing prioritization programs, increasing operating time and moving cataract surgery out of the hospital to a day surgical centre.