Monday, June 5, 2023
|
Pre-operative VA |
Postoperative VA loss |
|---|---|
| <1.00 LogMAR | A loss of ≥0.30 LogMAR |
| ≥1.00 to <CF | Postoperative VA of HM, NPL or PL |
| CF | Postoperative VA of NPL or PL |
| HM | Postoperative VA of NPL |
| PL | VA loss not considered |
| NPL | VA loss not considered |
Table 1. Definition of visual loss.
CF count fingers, HM hand movements, PL perception of light, NPL no perception of light.
|
N (row %) |
AISH |
No AISH |
Overall |
p value |
|---|---|---|---|---|
|
Number of operations |
204 (0.03) |
708,879 |
709,083 |
|
|
Patient Factors |
||||
|
Gender |
||||
|
Male |
74 (0.02) |
299,023 |
299,097 |
|
|
Female |
130 (0.03) |
409,584 |
409,714 |
0.222 |
|
Not stated |
0 (0.00) |
272 |
272 |
|
|
Age at surgery in years |
||||
|
<70 |
20 (0.01) |
177,207 |
177,227 |
<0.001 |
|
70–74 |
31 (0.03) |
123,415 |
123,446 |
|
|
75–79 |
44 (0.03) |
150,801 |
150,845 |
|
|
80–84 |
41 (0.03) |
144,307 |
144,348 |
|
|
85–89 |
43 (0.05) |
85,022 |
85,065 |
|
|
>=90 |
25 (0.09) |
28,127 |
28,152 |
|
|
Diabetic Status |
||||
|
Not diabetic |
174 (0.03) |
558,239 |
558,413 |
0.022 |
|
Has diabetes mellitus |
30 (0.02) |
150,640 |
150,670 |
|
|
Anticoagulant Use |
||||
|
No |
131 (0.03) |
483,844 |
483,975 |
0.215 |
|
Yes |
73 (0.03) |
225,035 |
225,108 |
|
|
Eye Factors |
||||
|
Age |
||||
|
IOP |
||||
|
First/Second eye
|
||||
|
First treated eye |
118 (0.03) |
391,333 |
391,451 |
0.449 |
|
Second treated eye |
86 (0.03) |
317,546 |
317,632 |
|
|
Axial Length (mm) |
||||
|
<21 (short) |
28 (0.05) |
59,174 |
59,202 |
|
|
21–26 (normal) |
167 (0.03) |
615,001 |
615,168 |
0.021 |
|
>26 (long) |
9 (0.03) |
34,704 |
34,713 |
|
|
Glaucoma |
||||
|
No |
157 (0.02) |
639,398 |
639,555 |
0.001 |
|
Yes |
47 (0.07) |
69,481 |
69,528 |
|
|
Brunescent/white/mature cataract |
||||
|
No |
184 (0.03) |
674,976 |
675,160 |
0.001 |
|
Yes |
20 (0.06) |
33,903 |
33,923 |
|
|
IOP |
||||
|
<10 (low) |
4 (0.02) |
19,462 |
19,466 |
|
|
10–21 (normal) |
160 (0.02) |
653,709 |
653,869 |
<0.001 |
|
>21 (high) |
40 (0.11) |
35,708 |
35,748 |
|
|
Operative Factors |
||||
|
Surgeon’s grade |
||||
|
Consultants |
132 (0.03) |
503,647 |
503,779 |
<0.001 |
|
Career grade non-consultants |
7 (0.01) |
52,639 |
52,646 |
|
|
Experienced trainees |
62 (0.05) |
127,567 |
127,629 |
|
|
Inexperienced trainees |
3 (0.01) |
25,026 |
25,029 |
|
|
PCR |
||||
|
No |
159 (0.02) |
699,701 |
699,860 |
<0.001 |
|
Yes |
45 (0.49) |
9178 |
9223 |
|
|
Anaesthesia type |
||||
|
Topical |
32 (0.04) |
88,688 |
88,720 |
<0.001 |
|
Intracameral |
58 (0.02) |
326,610 |
326,668 |
|
|
Sub-Tenon’s |
103 (0.04) |
263,104 |
263,207 |
|
|
Peribulbar/Retrobulbar |
11 (0.04) |
30,477 |
30,488 |
|
|
Incision size (mm) |
||||
|
<22 mm |
10 (0.04) |
24,374 |
24,384 |
|
|
2.2–2.75 mm |
117 (0.03) |
427,918 |
428,035 |
<0.001 |
|
2.75–3.2 mm |
51 (0.02) |
221,537 |
221,588 |
|
|
>3.2 mm |
26 (0.07) |
35,050 |
35,076 |
|
Table 2. Univariate analysis of potential risk factors for suprachoroidal haemorrhage for patient, ocular and surgical covariates.
N = 709 083 operations performed in 65 centres by 2680 surgeons.
aAll ISBCS cases are included with first treated eyes.
|
Risk factor estimates |
Odds Ratio |
Odds Ratio 95% CI |
Coefficient |
p value |
|---|---|---|---|---|
|
PCR |
17.562 |
(12.402, 24.869) |
2.866 |
<0.001 |
|
Age |
||||
|
>70
|
REF |
|||
|
70–74 |
2.276 |
(1.265, 4.097) |
0.823 |
0.006 |
|
75–79 |
2.616 |
(1.456, 4.702) |
0.962 |
0.001 |
|
80–84 |
2.445 |
(1.321, 4.527) |
0.894 |
0.004 |
|
85–89 |
4.069 |
(2.203, 7.516) |
1.403 |
<0.001 |
|
>=90 |
6.675 |
(3.469, 12.842) |
1.898 |
<0.001 |
|
IOP |
||||
|
Normal
|
REF |
|||
|
Low |
0.740 |
(0.245, 2.236) |
−0.301 |
0.593 |
|
High |
3.723 |
(2.506, 5.532) |
1.315 |
<0.001 |
|
Incision size |
||||
|
2.2–2.75 mm
|
REF |
|||
|
<22 mm |
1.388 |
(0.701, 2.748) |
0.328 |
0.347 |
|
2.75–3.2 mm |
0.804 |
(0.565, 1.142) |
−0.219 |
0.223 |
|
>3.2 mm |
2.087 |
(1.332, 3.269) |
0.736 |
0.001 |
|
Axial Length |
||||
|
22–26 mm
|
REF |
|||
|
<22 mm |
1.572 |
(1.061, 2.328) |
0.452 |
0.024 |
|
>26 mm |
1.236 |
(0.560, 2.729) |
0.212 |
0.599 |
|
Surgeon’s grade |
||||
|
Consultants
|
REF |
|||
|
Career grade non-consultants |
0.486 |
(0.170, 1.115) |
−0.831 |
0.083 |
|
Experienced trainees |
0.935 |
(1.060, 2.066) |
0.392 |
0.021 |
|
Inexperienced trainees |
0.810 |
(0.121, 1.082) |
−1.016 |
0.069 |
|
Glaucoma |
1.704 |
(1.189, 2.440) |
0.533 |
0.004 |
|
Anaesthesia type |
||||
|
Topical
|
REF |
|||
|
Intracameral |
0.486 |
(0.301, 0.785) |
−0.721 |
0.003 |
|
Subtenon |
0.935 |
(0.594, 1.470) |
−0.068 |
0.770 |
|
Peribulbar/Retrobulbar |
0.810 |
(0.351, 1.871) |
−0.211 |
0.622 |
|
Diabetic Status |
0.643 |
(0.441, 0.938) |
−0.442 |
0.022 |
|
Constant |
<0.001 |
(<0.001, <0.001) |
−9.200 |
<0.001 |
|
N (row %) |
AISH |
No AISH |
Overall |
p value |
|
Number of operations |
204 (0.03) |
708,879 |
709,083 |
|
|
Patient Factors |
||||
|
Gender |
||||
|
Male |
74 (0.02) |
299,023 |
299,097 |
|
|
Female |
130 (0.03) |
409,584 |
409,714 |
0.222 |
|
Not stated |
0 (0.00) |
272 |
272 |
|
|
Age at surgery in years |
||||
|
<70 |
20 (0.01) |
177,207 |
177,227 |
<0.001 |
|
70–74 |
31 (0.03) |
123,415 |
123,446 |
|
|
75–79 |
44 (0.03) |
150,801 |
150,845 |
|
|
80–84 |
41 (0.03) |
144,307 |
144,348 |
|
|
85–89 |
43 (0.05) |
85,022 |
85,065 |
|
|
>=90 |
25 (0.09) |
28,127 |
28,152 |
|
|
Diabetic Status |
||||
|
Not diabetic |
174 (0.03) |
558,239 |
558,413 |
0.022 |
|
Has diabetes mellitus |
30 (0.02) |
150,640 |
150,670 |
|
|
Anticoagulant Use |
||||
|
No |
131 (0.03) |
483,844 |
483,975 |
0.215 |
|
Yes |
73 (0.03) |
225,035 |
225,108 |
|
|
Eye Factors |
||||
|
Age |
||||
|
IOP |
||||
|
First/Second eyea |
||||
|
First treated eye |
118 (0.03) |
391,333 |
391,451 |
0.449 |
|
Second treated eye |
86 (0.03) |
317,546 |
317,632 |
|
|
Axial Length (mm) |
||||
|
<21 (short) |
28 (0.05) |
59,174 |
59,202 |
|
|
21–26 (normal) |
167 (0.03) |
615,001 |
615,168 |
0.021 |
|
>26 (long) |
9 (0.03) |
34,704 |
34,713 |
|
|
Glaucoma |
||||
|
No |
157 (0.02) |
639,398 |
639,555 |
0.001 |
|
Yes |
47 (0.07) |
69,481 |
69,528 |
|
|
Brunescent/white/mature cataract |
||||
|
No |
184 (0.03) |
674,976 |
675,160 |
0.001 |
|
Yes |
20 (0.06) |
33,903 |
33,923 |
|
|
IOP |
||||
|
<10 (low) |
4 (0.02) |
19,462 |
19,466 |
|
|
10–21 (normal) |
160 (0.02) |
653,709 |
653,869 |
<0.001 |
|
>21 (high) |
40 (0.11) |
35,708 |
35,748 |
|
|
Operative Factors |
||||
|
Surgeon’s grade |
||||
|
Consultants |
132 (0.03) |
503,647 |
503,779 |
<0.001 |
|
Career grade non-consultants |
7 (0.01) |
52,639 |
52,646 |
|
|
Experienced trainees |
62 (0.05) |
127,567 |
127,629 |
|
|
Inexperienced trainees |
3 (0.01) |
25,026 |
25,029 |
|
|
PCR |
||||
|
No |
159 (0.02) |
699,701 |
699,860 |
<0.001 |
|
Yes |
45 (0.49) |
9178 |
9223 |
|
|
Anaesthesia type |
||||
|
Topical |
32 (0.04) |
88,688 |
88,720 |
<0.001 |
|
Intracameral |
58 (0.02) |
326,610 |
326,668 |
|
|
Sub-Tenon’s |
103 (0.04) |
263,104 |
263,207 |
|
|
Peribulbar/Retrobulbar |
11 (0.04) |
30,477 |
30,488 |
|
|
Incision size (mm) |
||||
|
<22 mm |
10 (0.04) |
24,374 |
24,384 |
|
|
2.2–2.75 mm |
117 (0.03) |
427,918 |
428,035 |
<0.001 |
|
2.75–3.2 mm |
51 (0.02) |
221,537 |
221,588 |
|
|
>3.2 mm |
26 (0.07) |
35,050 |
35,076 |
|
Table 3. Suprachoroidal haemorrhage risk factor model estimates.
N = 709,083 operations performed in 65 centres by 2680 surgeons.
aReference category.
Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™
This activity is intended for ophthalmologists and other healthcare professionals who participate in cataract surgery.
The goal of this activity is for learners to be better able to understand the prevalence and risk factors for intraoperative suprachoroidal hemorrhage.
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CME Released: 5/12/2023
Valid for credit through: 5/12/2024
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OBJECTIVE: To establish the incidence of acute intraoperative suprachoroidal haemorrhage (AISH) during cataract surgery and identify the risk factors for this complication.
METHODS: Data from the Royal College of Ophthalmologists ‘National Ophthalmology Database was analysed. During the 11-year study period, from 01/04/2010 to 31/03/2021, 709 083 operations performed on 498 170 patients from 65 centres were eligible for inclusion.
RESULTS: AISH occurred in 0.03% (204/709 083, approximately 1 in 3 500) of eligible cataract operations performed during the study period. Posterior capsule rupture was the risk factor most strongly associated with AISH (OR: 17.6, 95% CI: 12.4–24.9, p < 0.001). Other ocular risk factors identified were raised intraocular pressure (IOP) preoperatively (OR: 3.7, 95% CI: 2.5–5.5, p < 0.001), glaucoma (OR: 1.7, 95% CI: 1.2–2.4, p = 0.004). Risk increased with age and patients aged over 90 years were at greatest risk (OR: 6.7, 95% CI: 3.5–12.8, p < 0.001). The addition of intracameral anaesthetic when performing surgery under topical anaesthetic appears to be protective (OR: 0.5, 95 % CI: 0.3–0.8, p = 0.003), compared to topical anaesthetical one. There was a 16 fold increase in the incidence of vision loss when AISH occurred.
CONCLUSIONS: The risk of AISH during modern cataract surgery is approximately 1 in 3500 and is associated with a significant increase in the risk of vision loss should it occur. Posterior capsule rupture is the risk factor most strongly associated with AISH. Preoperative IOP control is a modifiable risk factor. The use of intracameral anaesthesia may reduce the risk of AISH.
Acute intraoperative suprachoroidal haemorrhage (AISH) is a rare but sight-threatening complication of cataract surgery [1–3]. Acute hypotony during surgery can cause a ciliochoroidal effusion and subsequent rupture of stretched posterior ciliary arteries [4–7]. Multiple risk factors for AISH have been identified, including older age, cardiovascular disease, glaucoma, increased axial length and posterior capsule rupture [7, 8]. AISH is a cause of irreversible vision loss following cataract surgery: a large epidemiological study found that a final visual acuity of 6/12 or better was achieved in only 40% of patients who developed this complication [3].
Previous studies have reported an incidence of 0.03–0.06% for AISH occurring during cataract surgery using phacoemulsification [1, 9]. However, there have been substantial changes in surgical and anaesthetic techniques in the past two decades since these studies were published. The administration of oral anticoagulants to our patient population has also changed, with an increase in direct oral anticoagulant (DOAC) prescriptions and a corresponding decrease in warfarin use [10].
This study aims to establish an estimated incidence of AISH occurring during modern cataract surgery and identify risk factors for this complication, using data submitted to the Royal College of Ophthalmologists (RCOphth) National Ophthalmology Database (NOD).
