Purpose To determine the association between hospital and surgeon volume with the incidence of postoperative endophthalmitis. Methods A prospective cohort study was conducted to analyse the national health insurance claims data of those patients receiving cataract surgery in 2000 in Taiwan. A total of 108 705 patients who received cataract surgery by 1004 surgeons at 494 hospitals were followed to the end of 2002. Stepwise Cox regression was used to analyse the effects of hospital and surgeon volume of cataract surgery on postoperative endophthalmitis after adjustment for patient's age, gender, education, ophthalmic comorbidities, general comorbidities, and surgical factors including operative methods, different types of intraocular lenses, and surgeon's age. Results The 2-year incidence of postoperative endophthalmitis at high-volume hospitals (0.90%) was lower than low-volume hospitals (1.16%). The incidence of postoperative endophthalmitis by highvolume surgeons (0.59%) was lower than those by middle-high-volume (0.73%), middle-lowvolume (0.80%), or low-volume surgeons (1.16%). After controlling for case mix, the risk of postoperative endophthalmitis of the lowvolume hospitals (hazard ratio (HR) ¼ 1.39) was higher than that of the high-volume hospitals. The risk of postoperative endophthalmitis of low-volume surgeons (HR ¼ 1.67) was higher than that of the highvolume surgeons. ConclusionsThe provider volume (hospital and surgeon volume) is associated with the risk of postoperative endophthalmitis. The patients who receive cataract surgery at lowvolume hospitals or by low-volume surgeons have significantly higher risk of postoperative endophthalmitis than at high-volume hospitals or by high-volume surgeons. Provider volume can be considered in further postoperative endophthalmitis study as a risk factor. Eye (2006) 20, 900-907.
During toric intraocular lens (IOL) implantation, surgeons must take particular care to ensure that inaccurate preoperative measurement and intraoperative misalignment do not cause unexpected postoperative residual astigmatism. This retrospective, comparative case series study aimed to analyze the rotational deviation, or cyclotorsion, of three corneal marking methods: VERION digital marker (VDM; reference), horizontal slit beam marking (HSBM), and subjective direct visual marking (SDVM) on the table (using a bevel knife tip). Subjects included 81 eyes of 61 patients (mean age: 65.70±13.14 years; range: 32–91 years) undergoing scheduled cataract surgery. A preoperative reference image was taken of each eye. Subsequently, a slit lamp with the light beam turned to the horizontal meridian was used to align the seated patient’s head, and two reference marks were placed at the 3- and 9-o’clock positions of the corneal limbus using a 27-gauge needle and marking pen (HSBM). Upon transfer to the surgical table, the VDM was used to display a real-time dial scale on the patient’s eye, with the entrance of the temporal clear corneal incision (CCI) at 0° (horizontal meridian). Simultaneously, a bevel knife tip was used to create a marker based on the surgeon’s visual determination of the temporal 0° point (SDVM). We used the VDM to quantitatively evaluate the accuracy of axis alignment via deviation from the horizontal reference meridian. Compared with the reference meridian, the SDVM (−3.46°±7.32°, range: −18° to 13°) exhibited greater average relative cyclotorsion versus the HSBM (0.41°±4.92°, range: −10° to 10°). Furthermore, the mean average misalignment was significantly less in the HSBM group versus the SDVM group (t=4.179, P<0.001). The VDM is likely a reliable marking method, similar to the HSBM. In contrast, the SDVM is not entirely reliable. The VDM usage may prevent inaccurate preoperative manual marking during toric IOL implantation.
adjusting for length of stay and other factors, we found that a hospital's cumulative cataract surgery volume was not associated with endophthalmitis risk. 5 Despite the limitations of the administrative data used by Fang et al, we applaud their investigative approach. Such population-based methodologies provide large unbiased samples that are necessary to properly investigate uncommon but serious problems such as postoperative endophthalmitis. 2,6References We thank Dr Ng et al. for their interest and comments on our report. In our study, we use a broader definition as: codes of endophthalmitis in subsequent outpatient visits or admissions, or at the index cataract surgery were considered as the occurrence of postoperative endophthalmitis. Concerning the use of this definition, for we believe that postoperative endophthalmitis is not necessarily treated in admission, and this condition can also be treated in outpatient visits. Unlike EPSWA study and other previous studies using hospital-based data or define admission for endophthalmitis as the occurrence of postoperative endophthalmitis. 1-3 If we use the definition as EPSWA study for endophthalmitis as the index of occurrence, we would exclude patients that were only treated in outpatient clinics but not in hospitals. Therefore, the incidence of postoperative endophthalmitis will be underestimated. The 2-year incidence of postoperative endophthalmitis in Taiwan will be 0.26%. It is similar to Dr Ng's report.Different from what Dr Ng pointed out, we did consider the length of stay as an important factor and control this variable in Cox regression analysis in our study, as presented in Table 4 of our previous article. 4In our study population, there were 88.1% outpatient cataract surgery and 11.9% inpatient cataract surgery with 1.5370.80 days of the mean length of stay. As the percentage of inpatient cataract surgery was relatively low and the length of stay was short, we used 'site of operation' as the variable and divided patients into the outpatient and inpatient cataract surgery categories. Even after we adjusted site of operation and other factors, we found that hospital volume and surgeon volume were still significantly associated with endophthalmitis risks. Unlike EPSWA report, 5 we found that inpatient cataract surgery posed a higher risk for postoperative endophthalmitis than outpatient cataract surgery in hospital volume model (HR ¼ 1.33, P ¼ 0.014), but not in surgeon volume model (HR ¼ 1.25, P ¼ 0.065).
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