Practice patterns of Canadian Ophthalmological Society members in cataract surgery: 2011 survey

Practice patterns of Canadian Ophthalmological Society members in cataract surgery: 2011 survey

Practice patterns of Canadian Ophthalmological Society members in cataract surgery: 2011 survey Lindsay Ong-Tone, FRCSC, Ali Bell, MSc, Yin Yin Tan AB...

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Practice patterns of Canadian Ophthalmological Society members in cataract surgery: 2011 survey Lindsay Ong-Tone, FRCSC, Ali Bell, MSc, Yin Yin Tan ABSTRACT ● RÉSUMÉ Objective: To establish the practice patterns of the members of the Canadian Ophthalmological Society (COS) in cataract surgery. Design: Web-based questionnaire. Participants: Members of the COS indicating practice focus to be cataract surgery. Methods: In January 2011 an e-mail with a link to Fluid Surveys was sent from the COS office to the 292 members who had indicated their practices’ focus to be cataract surgery. A reminder e-mail was sent 3 weeks later. Approval for the survey was obtained from the Regina Qu’Appelle Health Region Research Ethics Board. All responses were collected anonymously. Results: There were 92 responses (31.5%). In 2009, the response rate was 20.7%, and in 2010 it was 32.5%. The results of the 3 surveys were compared. There was a gradual increase in the use of topical-only anaesthesia, in the number of days during which the nonsteroidal anti-inflammatory drug (NSAID) eye drops were used preoperatively, and in the use of multifocal and toric intraocular lenses. Postoperatively, the use of an NSAID eye drop alone remained unchanged, but there was a decrease in the use of steroid eye drops alone and a corresponding increase in the use of a combination steroid and NSAID eye drop. Conclusions: Over the past 3 years the majority of the practice patterns in cataract surgery by the members of the Canadian Ophthalmological Society have remained unchanged. However, there were certain areas where definite trends were noted. Objet : Établir les modes de pratique des membres de la Société canadienne d’ophtalmologie (SCO) en chirurgie de la cataracte. Nature : Questionnaire en ligne. Participants : Les membres des COS indiquant la pratique se concentrer pour être chirurgie de la cataracte. Méthodes : En janvier 2011, le bureau de la SCO envoyait, avec un lien à Fluid Surveys (?), un courriel à 292 membres qui avaient indiqué que leur pratique se concentrait sur la chirurgie de la cataracte. Un rappel fut renvoyé 3 semaines après. Le conseil de déontologie en recherche de la Région Régina Qu’Appelle Santé avait approuvé le sondage. Les réponses ont été recueillies sous anonymat. Résultats : Il y eut 92 réponses (31,5 %). En 2009, le taux de réponses avait été de 20,7 % et, en 2010, de 32,5 %. La comparaison des trois sondages a donné les résultats que voici : il y a eu une hausse graduelle de l’utilisation de l’anesthésie topique seulement, du nombre de jours d’utilisation préopératoire de gouttes ophtalmiques anti-inflammatoires non stéroïdiennes (AINS) (?) et de lentilles intraoculaires multifocales et toriques. L’emploi postopératoire de gouttes ophtalmiques AINS seules n’avait pas changé, mais il y a eu une baisse d‘emploi des gouttes ophtalmiques stéroïdes seules avec une hausse correspondante d’utilisation de la combinaison de gouttes stéroïdes et AINS. Conclusions : Au cours des trois dernières années, chez les membres de la Société canadienne d’ophtalmologie, la majorité des modes de pratique en chirurgie de la cataracte n’avaient pas changé. Toutefois, on a noté certaines tendances définitives dans certains secteurs.

The practice patterns of Canadian Ophthalmological Society (COS) members in cataract surgery were first analyzed in a survey in 2009,1 and 2 subsequent annual surveys using the same questions, with minor modifications, were taken in 20102 and 2011. We performed an analysis of some of the major differences among the surveys.

METHODS In January 2011 an e-mail with a link to Fluid Surveys was sent from the COS office to its 292 members who had indicated their practice focus to be cataract surgery. A reminder e-mail was sent 3 weeks later. Approval for the survey was obtained from the Regina Qu’Appelle Health Region Research Ethics Board. All responses were collected anonymously. There was no financial reward for returning the questionnaire. The survey data were descriptively analyzed using the StatisPresented at the Canadian Ophthalmological Society annual meeting in Vancouver, B. C., June 10, 2011. From the Regina Qu’Appelle Health Region, Regina, Sask. Originally received Oct. 1, 2011. Final revision Nov. 13, 2011. Accepted Nov. 24, 2011 Correspondence to Lindsay Ong-Tone, Ste. 215, 2125 11th Ave., Regina S4P 3X3 Sask.; [email protected]

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tical Package for the Social Sciences (SPSS, Chicago, Ill) v 17.0 software.

RESULTS There were 92 responses, a response rate of 31.5%. Of the responses, 9 were incomplete, so 83 responses were analyzed. Most of the respondents had been in practice for more than 25 years (28.3%), followed by 20.7% who had been in practice for between 20 and 25 years, 18.5% between 15 and 19 years, 16.3% between 10 and 14 years, 13.0% between 5 and 9 years, and 3.3% for fewer than 5 years. The majority of the respondents were male (84.6%). Ophthalmologists in Ontario provided most of the responses: 40.2%. They were followed by those in British Columbia (17.4%); Alberta (14.1%); Quebec (10.9%); Saskatchewan and New Brunswick (4.3% each): Nova Can J Ophthalmol 2012;47:124 –130

0008-4182/11/$-see front matter © 2012 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.jcjo.2012.01.012

Survey of cataract surgery practice patterns—Ong-Tone et al. Scotia (3.3%); Manitoba and Prince Edward Island (2.2% each); Newfoundland and Labrador (1.1%). The response rates per province were also analyzed. There was a 100% response rate from Prince Edward Island. That was followed by New Brunswick, with 50% response rate, Alberta with 43.3%, Saskatchewan with 36.4%, Ontario with 33%, British Columbia with 32.7%, Quebec with 25.6%, Manitoba with 16.7%, Nova Scotia with 14.3%, and Newfoundland and Labrador with 12.5%. All the respondents performed phacoemulsification. The majority (76.7%) performed between 25 and 99 cataract surgeries per month. Topical anaesthesia was the most popular type of anaesthesia used by the respondents. Topical anaesthesia and intracameral xylocaine were used by 53.5% of the respondents; topical anaesthesia alone was used by 39.5%, retrobulbar anaesthesia by 4.7%, and peribulbar anaesthesia by 2.3%. None of the respondents routinely used subtenon or general anaesthesia. The vital signs of the patients undergoing cataract surgery were monitored by the majority of the respondents. The patients’ pulses were monitored by 94.2%, oxygen saturation by 91.9%, blood pressure by 81.4%, and electrocardiogram by 64.0%. Preoperative topical antibiotic drops were used by 87.2% of the respondents. The majority (38.7%) started the drops 2 days preoperatively, whereas 33.3% started them 3 days preoperatively, 16% started them 1 day preoperatively, 10.7% started them on the day of surgery, and 1.3% started them 4 days preoperatively. Only 1 respondent (1.2%) used an antibiotic in the irrigating solution during cataract surgery. Unfortunately, the respondent did not indicate which antibiotic was used. An intracameral antibiotic was used by 28.6% of the respondents. The most commonly used was vancomycin (54.2%); followed by

moxifloxacin (33.3%) and cefuroxime (12.5%). An antibiotic eye drop was used by all of the respondents postoperatively. Moxifloxacin was the most commonly used (58.5%); it was followed by gatifloxacin (28%); tobramycin (8.5%); and both ciprofloxacin and ofloxacin (2.4%). Povidone iodine was used preoperatively by all of the respondents, and only 8.3% used it postoperatively. A nonsteroidal anti-inflammatory drug (NSAID) drop was used preoperatively by 61.4% of respondents. Of these, 44% started the drops 3 days preoperatively, 36% started them 2 days preoperatively, 14% started them 1 day preoperatively, and 6% started the drops immediately preoperatively. After surgery, an NSAID drop was used by 73.5% of the respondents. The majority (46.7%) used it for 4 weeks; 20% used it for 3 weeks, 15% for 2 weeks, 11.7% for 1 week, 3.3% for 5 weeks, and another 3.3% for 6 weeks. A steroid drop was used postoperatively by 89% of the respondents. A steroid drop and an NSAID drop were used together postoperatively by 62.2% of the respondents, whereas 26.8% used a steroid drop alone, and 11% used an NSAID drop alone. Adrenaline was used in the irrigating solution by 80% of the respondents. This was used routinely by 98.5% of these respondents. The rest did so in selected cases. Clear corneal incision was the most popular type of incision. It was used by 92.9% of the respondents. The remainder preferred scleral tunnels. A temporal incision was preferred by 69.4% of the respondents; 12.9% preferred an incision at the steepest axis keratomy reading, 8.2% preferred a superior incision, another 8.2% preferred an oblique incision, and 1.2% preferred an incision at another location. At the end of the surgery, 94% of the respondents did not routinely suture the incision. 28.9

30 25 20.5

Percent

20 15

12 8.4

10

8.4 7.2

6 3.6

5 1.2

1.2

1.2

0

r ylic crylic locker crylic crylic licone licone licone ylic crylic ilte A A A A Acr Acr VF b Si Si Si ric hilic ophilic with U phobic phobic h Blue phobic phobic 1 pc heric p o r r phe p it o o o o c d d i r r r s r l S w y y d d d d y A c H H c Acr ric Hy ric Hy crylic ric Hy ric Hy 3p ric heric 3p hilic p phe cA he he he he c S pc As ydrop pc Sp c Asp phobi pc Sp c Asp 1p p o p H 1 r 3 1 1 3 yd eric ic H sph her cA Asp 1p c 1p

Fig. 1—The types of intraocular lenses used by members of the Canadian Ophthalmological Society as determined by the 2011 survey. CAN J OPHTHALMOL—VOL. 47, NO. 2, APRIL 2012

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Fig. 2—The types of anaesthesia used by members of the Canadian Ophthalmological Society as determined by the 2009, 2010, and 2011 surveys.

The most popular phacoemulsification technique used was chopping. The vertical chop was preferred by 25.9% of the respondents, whereas the horizontal chop was preferred by 20% of the respondents. The 4-quadrant divide-and-conquer technique was preferred by 38.8% of the respondents, and a combination of techniques was preferred by 14.8%. The majority of respondents preferred using a hydrophobic acrylic intraocular lens (IOL). A 1-piece hydrophobic acrylic lens was preferred by 50.6% of the respondents. A 3-piece hydrophobic acrylic lens was used by 10.8%, a hydrophilic acrylic lens by 26.4%, and a

silicone lens by 10.8% of the respondents. A 1-piece aspheric hydrophobic acrylic IOL with blue-blocker was preferred by 28.9% of the respondents, and a 1-piece aspheric hydrophilic acrylic IOL with UV filter was preferred by 12% (Fig. 1). Toric IOLs were used routinely by 73.5% of respondents. Multifocal IOLs were used routinely by 43.4%, and accommodating lenses were used by 12% of the respondents. Microincisional cataract surgery was performed by 8.5% of the respondents. Coaxial microincisional cataract surgery was the most popular, with 85.7% of these respondents preferring that technique.

When NSAID started 44

45

42.9

40 36

36.2

35

Percent

30

29

28.6

25 20

17.4

2009 2010 2011

17.4

16.1 14

15

12.5

10 6

5 0 Immediately preop

1 day preop

2 days preop

3 days preop

Fig. 3—Distribution of times when NSAID drops were started preoperatively as determined by the 2009, 2010, and 2011 surveys of the members of the Canadian Ophthalmological Society.

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Survey of cataract surgery practice patterns—Ong-Tone et al. Duration of postop NSAID 70 62.5 57.8

60

Percent

50

46.7

40

2009 2010 2011

33.3 29.7

30 20

20

15 11.7 7.8

10

4.2

3.3 1.6

0

0

3.1 3.3 0

0

0 1 week

2 weeks

3 weeks

4 weeks

5 weeks

6 weeks

Fig. 4 —Distribution of the duration of usage of NSAID drops postoperatively as determined by the 2009, 2010, and 2011 surveys of the members of the Canadian Ophthalmological Society.

Immediate sequential bilateral cataract surgery was performed by 13.4% of the respondents. The majority of these respondents (81.8%) did so only occasionally or rarely. Astigmatism was corrected by 37.8% of the respondents at the time of surgery. A toric IOL was preferred by 67.7% of these respondents, whereas 25.8% preferred a limbal relaxing incision, 3.2% preferred an astigmatic keratotomy, and the remaining 3.2% preferred another technique to correct astigmatism.

DISCUSSION The response rate to the 2011 survey was 31.5%. This is similar to the rate of 32.5% in the electronic survey taken in 2010 but much better than the 20.7% rate elicited by the e-mail survey of 2009. The results of the 3 surveys were compared. The

majority of the practice patterns analyzed remained the same. However, there were definite trends in certain areas. There was an increase in the use of topical anaesthesia by the respondents in 2011. It was 79.7% in 2009, 84.2% in 2010, and 93% in 2011. The use of topical anaesthesia plus intracameral xylocaine stayed much the same, at 53.5%, but there was a moderate increase in topical-only anaesthesia, at 39.5% (Fig. 2). There was a slight increase in the use of intracameral antibiotics, from 23.1% in 2009 to 28.6% in 2011. The antibiotics used were similar: vancomycin (54.2%); moxifloxacin (33.3%); and cefuroxime (12.5%). In 2009, the percentages were 52%, 36%, and 12%, respectively. The fourth-generation fluoroquinolones were, again, the most commonly used antibiotic drops postoperatively.

Postoperative use of NSAID & Steroid eye drops 70 62.2 57.9

60 50.4

Percent

50 39.7

40 2009 2010 2011

32.6

30

26.8

20 9.9

9.5

11

10 0 NSAID only

Steroid eye drops only

NSAID & Steroid drops

Fig. 5—Use of NSAIDs and steroid eye drops postoperatively as determined by the 2009, 2010, and 2011 surveys of the members of the Canadian Ophthalmological Society. CAN J OPHTHALMOL—VOL. 47, NO. 2, APRIL 2012

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Survey of cataract surgery practice patterns—Ong-Tone et al. Phacoemulsification Techniques 38.9 38.8

40

37.4 34.1

35

30.5

30 25.9

Percent

25 20

20 13.8

15

14.7

13.8

14.7 11.8

2009 2010 2011

10 5

3 0.8 1.1

0 er qu on C d an ide v i D

Fig. 6 —Use of phacoemulsification techniques as determined by the 2009, 2010, and 2011 surveys of the members of the Canadian Ophthalmological Society.

There was a slight increase in the use of both moxifloxacin (58.5%) and gatifloxacin (28%) since 2009, when the percentages were 51.4% and 24.8%, respectively. A similar number of respondents used an NSAID drop preoperatively, 56.6% in 2009 and 61.4% in 2011. However, more respondents used it for longer periods preoperatively in 2011 (Fig. 3). There was a moderate increase in the use of NSAID drops postoperatively, from 59.8% in 2009 to 73.5% in 2011. There was a decrease in the use of the drops during the 2- and 4-week periods but an increase during the other time frames (Fig. 4). The use of postoperative steroid eye drops stayed much the same: 90.1% in 2009 and 89% in 2011. The use of an NSAID-only eye drop postoperatively stayed

100

the same over the 3 years, but there was a gradual decrease in the use of a steroid drop alone and a corresponding increase in the use of combination steroid and NSAID drops (Fig. 5). Together, horizontal and vertical phacoemulsification chops were the most popular phacoemulsification techniques in all 3 years: 51.2% in 2009, 45.2% in 2010, and 45.9% in 2011. This technique was followed by 4-quadrant divide-and-conquer, at 34.1% in 2009, 38.9% in 2010, and 38.8% in 2011. However, there was a gradual decrease in the use of the vertical chop and a corresponding increase in the use of the horizontal chop (Fig. 6). There was a marked increase in the use of toric and multifocal IOLs. Use of the toric lenses increased from

93

90 79.7

80

72.9 69.4

69.6

Percent

70

69.4 67.568.4

61.7

60

COS 2009 COS 2011

56.1

ASCRS 2008

50

ASCRS 2010 36.5 34.2

40

ESCRS 2008 ESCRS 2010

30 20 10 0 Topical Anaesthesia

Temporal Incisions

Fig. 7—Comparison of the frequency of use of topical anaesthesia and temporal incisions as determined by the Canadian Ophthalmological Society surveys of 2009 and 2011, the American Society of Cataract and Refractive Surgery surveys of 2008 and 2010, and the European Society of Cataract and Refractive Surgeons surveys of 2008 and 2010.

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Survey of cataract surgery practice patterns—Ong-Tone et al. When NSAID started 68.7 67.5

70 60 50

COS 2009

Percent

44

40

40.5

40.3

39

COS 2011

36.2

ASCRS 2008 28.8

30

28.1 22.622.6 21.5 20.5

ESCRS 2008

17.4

20

ASCRS 2010

ESCRS 2010

14 10

10

6

7.3

0 Started day of Started 1 day Started 3 days surgery preop preop

Fig. 8 —Comparison of when NSAID drops are started preoperatively according to the Canadian Ophthalmological Society surveys of 2009 and 2011, the American Society of Cataract and Refractive Surgery surveys of 2008 and 2010, and the European Society of Cataract and Refractive Surgeons surveys of 2008 and 2010.

47.5% in 2009 to 73.5% in 2011; use of multifocal lenses increased from 29.2% in 2009 to 43.4% in 2011. The use of the accommodating IOLs stayed much the same, at 12.3% in 2009 and 12% in 2011. There was a marked decrease in the number of respondents who performed microincisional cataract surgery. The numbers decreased from 23.8% in 2009 to 8.5% in 2011. The vast majority of these respondents performed coaxial microincisional cataract surgery: 79.2% in 2009 and 85.7% in 2011. The number of respondents who performed immediate sequential bilateral cataract surgery stayed much the same: 9.8% in 2009 and 13.4% in 2011. The vast majority of these respondents (83.3% in 2009 and 81.8% in 2011) did so only rarely or occasionally.

There was a slight decrease in the number of respondents who corrected astigmatism at the time of surgery: 43% in 2009 and 37.8% in 2011. A toric IOL was still the method of choice by the majority of the respondents: 57.7% in 2009 and 67.7% in 2011. The rate of response to the 2010 survey of the American Society of Cataract and Refractive Surgery (ASCRS)3 was 12% and the response to the European Society of Cataract and Refractive Surgeons (ESCRS) was 17%. In Canada, 88.4% of the respondents performed more than 25 cataract surgeries per month, compared to 65% in the United States and 66.8% in Europe. Topical anaesthesia was still gaining popularity in North America and Europe (Fig. 7) in these 3 most recent surveys. Temporal incisions also

Preferred Lens Material 78.1

80 69.3

70 61.4

60

Percent

50

COS 2011 ASCRS 2010 ESCRS 2010

40 30

26.4 20.4

19.1

20 9.4

10.8

10 2.6

0 Hydrophobic Acrylic

Hydrophilic Acrylic

Silicone

Fig. 9 —Comparison of preferred lens material according to the Canadian Ophthalmological Society survey of 2011, the American Society of Cataract and Refractive Surgery survey of 2010, and the European Society of Cataract and Refractive Surgeons survey of 2010. CAN J OPHTHALMOL—VOL. 47, NO. 2, APRIL 2012

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Survey of cataract surgery practice patterns—Ong-Tone et al. Premium IOLs 90 82.6

80

74.1

73.5

70

Percent

60.1

COS 2009

59.6

60 50

COS 2011 47.5

ASCRS 2008

46.6 43.4

42.5

ASCRS 2010 40

34.2

33.3

ESCRS 2008

29.2

30

ESCRS 2010

20 10 0

Toric

Multifocal

Fig. 10 —Comparison of use of toric and multifocal intraocular lenses as determined by the Canadian Ophthalmological Society surveys of 2009 and 2011, the American Society of Cataract and Refractive Surgery surveys of 2008 and 2010, and the European Society of Cataract and Refractive Surgeons surveys of 2008 and 2010.

were more popular in North America than in Europe (Fig. 7). The use of an NSAID drop preoperatively stayed much the same: 61.4% in Canada, 78.8% in the United States, and 35.1% in Europe. However, there was a trend toward using the drops for longer periods preoperatively (Fig. 8). In Canada there was a marked increase in the use of NSAID drops for 2 days preoperatively, from 17.4% in 2009 to 36% in 2011. There was no report of the use of the drops for that length of time in the ASCRS and ESCRS surveys. However, 1.5% of the American and 12.5% of the European respondents started the drops 1 day postoperatively. None of the respondents in the Canadian survey reported this as an option. In North America the fourthgeneration fluoroquinolones were the most popular antibiotics used postoperatively. These were used by 86.5% of the Canadian respondents and 92.5% of the Americans. Only 14.4% of the European respondents used these antibiotics. The most popular antibiotics used in Europe were tobramycin, 39.6%, and the second-generation fluoroquinolones, 36.9%. The hydrophobic acrylic IOLs were the most popular lenses used in all 3 surveys (Fig. 9). There was an increase in the use of both the multifocal and the toric IOLs in both North America and Europe (Fig. 10). The use of the accommodating IOLs was recorded in all 3 surveys only in the past 2 years. Their usage stayed essentially unchanged in all 3 surveys. In 2009, usage was 11.8% in Canada, 39.6% in the United States, and 9.5% in Europe. In 2010, usage was 12%, 32.1%, and 9.6%, respectively.

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CONCLUSION The practice patterns of members of the COS when performing cataract surgery were, for the most part, unchanged over the past 3 years. Nonetheless, some definite trends were observed. The use of NSAID drops for longer periods preoperatively continued to increase. There was also an increase in the use of topical-only anaesthesia. There was a decrease in the use of steroid drops only postoperatively and a corresponding increase in the use of combination steroid and NSAID drops. There was an increase in the use of multifocal and toric IOLs, but there was a marked decrease in microincisional cataract surgery.

Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. REFERENCES 1. Ong-Tone L, Bell A. Practice patterns of Canadian Ophthalmological Society members in Cataract Surgery: 2009 Survey. Can J Ophthalmol. 2010;45:121-4. 2. Ong-Tone L, Bell A, Tan Y. Practice patterns of Canadian Ophthalmological Society members in Cataract Surgery: 2010 Survey. Can J Ophthalmol. 2011;46:139-42. 3. Leaming D. Comparisons of 2010 ESCRS and ASCRS practice style survey of members. Paper presented at the XXIX Congress of the ESCRS in Vienna, Austria, September 2011. Available online at www. leamingsurveys.com. Accessed September 2011.