Findings from a recent study published in the American Journal of Ophthalmology assessed the rate of unplanned operating room (OR) returns within 90 days of cataract surgery and identified the most common preoperative and intraoperative risk factors.
Give me some background.
The rate of return to the OR is considered a useful metric to assess surgical quality and understanding adverse surgical events are critical to improving the overall quality of patient care.
- Additionally: In ophthalmic surgery, unplanned returns to the OR have been associated with increased short- and long-term morbidity, costs, and intraoperative resource utilization.
And what has previous research into this shown?
Previous studies have evaluated the rate of unplanned OR visits after glaucoma surgery at the Johns Hopkins Wilmer Eye Institute in Baltimore, Maryland, and identified factors to improve the standard of care:
- One study on trabeculectomies found that nearly 10% of eyes returned to OR within 180 days and over 20% of eyes required reoperation at any time postoperatively with a mean follow-up of nearly 3 years
- Another on tube shunt surgery reported over 20% of eyes undergoing the procedure returned to the OR with a mean follow-up of nearly 3 years, and over 10% of eyes undergoing reoperation within the first 180 days
Consequently: A research team sought to report the rate of unplanned OR visits within 90 days of cataract surgery performed by residents, fellows, and attendings at the same institution to investigate the relevant preoperative and intraoperative risk factors.
Now talk about the study.
In this retrospective case-control study, participating patients included those aged ≥40 years undergoing cataract surgery between 2019 and 2022, with at least 90 days of postoperative follow-up data.
For each case, a time-matched control (i.e., cataract surgery within 1 month of the case’s surgery) was selected using a random number generator.
Main outcome measures: The rate and most common reasons for unplanned OR visits and the odds ratios of associated preoperative and intraoperative variables.
Findings?
Among 32,480 eyes, 175 (0.54%) had an unplanned return to the OR within 21 days of cataract surgery.
The most common reason for the visit was retained lens fragments in 88 (50%) eyes.
Patients with an unplanned return to the OR had a worse best-corrected visual acuity (BCVA) preoperatively and at last follow up (p≤0.001):
- Cases
- Preoperative BCVA: 20/100
- Last follow-up BCVA: 20/50
- Controls
- Preoperative BCVA: 20/50
- Last follow-up BCVA: 20/30
Anything else?
There were significantly higher odds of an unplanned return to the OR for specific patients, including:
- Those undergoing complex cataract surgery (odds ratio [OR]: 1.80, 95% confidence interval [CI]: 1.06-3.05)
- Individuals with prior tamsulosin use (OR: 2.00, 95% CI: 1.09-3.69)
Expert opinion?
Researchers determined that tamsulosin provides a systemic blockade of alpha-1-a adrenergic receptors, impacting receptors in the dilator smooth muscle of the iris, preventing mydriasis during ophthalmic surgery, and causing intraoperative floppy iris syndrome (IFIS).
Of note: One study found that when surgeons were informed preoperatively about potential IFIS and employed strategies for proper intraoperative management, the incidence of complications significantly decreased.
Limitations?
These included:
- The single-center design, which may have limited the sample heterogeneity or represented more challenging and complex cases
- The operative notes were limited in information regarding the involvement of a resident or fellow during each case
- The study used surrogate indicators for operative times, such as case complexity, intraoperative suture use, and surgeon level of training
- The rate of unplanned reoperation may have been influenced by additional factors, such as patients lost to follow up and surgeon preferences regarding surgical versus medical management of postoperative complications
Take home.
These findings suggest that patients undergoing complex cataract surgery and those with prior tamsulosin use had significantly higher odds of unplanned return to the OR.
The next step: Monitoring rates of unplanned postoperative OR visits at the institutional and national level using national clinical registers or a multicenter study are required to improve quality monitoring and enhance patient surgical outcomes.