Updated cataract surgery complexity stratification score for trainee ophthalmic surgeons.

ABSTRACT

PURPOSE: To devise a comprehensive cataract surgery complexity score system for the selection of appropriate cases for trainees using evidence-based, validated risk factors for posterior capsule rupture, patient-specific factors, and complexity stratification recommendations to minimize complications, optimize outcomes, and maximize patient safety. SETTING: Epsom and St. Helier University National Health Service Trust, London, United Kingdom. DESIGN: Retrospective cohort study. METHODS: Patients having primary phacoemulsification cataract surgery from January 1, 2011 until December 31, 2016 were included; combined corneal, glaucoma, or posterior segment procedures were excluded. Anonymized data on demographics, pupil size, pupil expander use, intraoperative and postoperative complications, and postoperative distance visual acuity were extracted. Patients were stratified by complexity score and surgeon grade (consultant, junior, intermediate, and senior trainee, and fellow). RESULTS: From 11 468 included cases, 8200 (71.5%) had a complexity score. Small pupil, pupil expander use, iris damage during phacoemulsification, zonular dialysis, postoperative raised intraocular pressure, and corneal edema (odds ratio, 3.17; 95% confidence interval, 2.05-4.92) were significantly associated with increasing complexity. Appropriate case allocation by complexity and surgeon grade resulted in no association between posterior capsule rupture and complexity score. Increasing complexity scores were associated with lower postoperative distance visual acuity. CONCLUSIONS: The updated evidence-based comprehensive cataract complexity score system is a useful tool for the stratification of case complexity and guides appropriate case selection to match trainee experience. Higher complexity scores were associated with greater intraoperative and postoperative complications and lower postoperative distance visual acuity. Patients with higher scores should be made aware of the guarded prognosis when obtaining consent.