| Summary: | 碩士 === 國立陽明大學 === 醫務管理研究所 === 92 === Objective:
The purpose of this study is to explore current practice styles of cataract surgery and to investigate the incidence and risk factors of postoperative complications, including endophthalmitis, posterior capsular opacification and retinal detachment in Taiwan.
Methods:
longitudinal data analysis.
Participants:
108,736 patients who received cataract extraction and intraocular lens implantation in 2000 were identified from Bureau National Health Insurance(BNHI) claimed dataset, and followed up to the end of 2002. The stepwise Cox regression was used for risks analysis.
Results:
Approximately 54% of the patients received cataract surgery were female, 41.2% were aged between 70 and 79 years, followed by 35.5% between 60 and 69 years. The most common ophthalmic comorbidities of these patients are retinopathy (9.9%), glaucoma (8.2%), and keratitis (4.6%), and the medical comorbidities are hypertension (38%), arthritis (23.5%) and diabetic mellitus (20.1%).
Extracapsular cataract extraction was used in 41.8% of patients, followed by phacoemusification (13.2%) and intracapsular cataract extraction(5.7%). 99.5% method of anesthesia were retrobulbar anesthesia. As for the material of intraocular lens, PMMA (69.4%) is the most common, followed by acrylic (5.7%), HSM PMMA (5.2%) and silicone(4.4%). 85.9% patients received cataract surgery in the private medical institutions,57.2% in the clinics, and 64.8% in the institutions with high surgical volume. 84.3% patients performed by male surgeons, 62.7% by surgeons whose age between 36 and 45 years, and 68.1% by surgeons with high surgical volume.
The overall one year incidence of endophthalmitis was 0.71%, and rate of admitted postoperative endophthalmitis was 0.24%. The stepwise cox proportional hazard model that simultaneously evaluated the effects of many variables was used, and showed that male patients, under age 50, with proliferative diabetic retinopathy, glaucoma, choroidopathy, psychotic disorders and non-senile cataract, operated in the hospitals with middle-lower surgical volume and by male doctors were positively associated with the likelihood of endophthalmitis. Conversely, patients receiving acrylic intraocular lens were protected against endophthalmitis compared to those implanted with ordinary PMMA lenses.
After excluded patients under age of 50, the two year incidence of posterior capsular opacification was 19%, and the two year utilization rate of YAG Laser capsulotomy was 15.2%. Male patients, with background diabetic retinopathy, proliferative diabetic retinopathy, glaucoma, choroidopathy, high myopia, keratitis, non-psychotic mental disorders and immune disorders, in-patient surgery, performed in middle-lower volume hospitals, and operated by older doctors associated with higher risk of utilization of YAG capsulotomy. However, patients above 80 year of age, with psychotic disorders, use phacoemusification surgery, using acrylic and HSM PMMA intraocular lenses were less likely to receive YAG laser capsulotomy.
The two year incidence of retinal detachment after cataract surgery was 0.90%, and the two year incidence of retinal detachment and/or retinal breaks was 1.11%. Those patients which were males, young age, with background diabetic retinopathy, high myopia, retinal detachment, and maculopathy, received in-patient surgery, operated by doctors of middle surgery volume or by older doctors were with higher risks of developing post-operative retinal detachment or retinal breaks.
Suggestions:
We recommend that doctors should carefully choose surgery method and intraocular lends material to avoid surgical complications and should pay attention to high risks patients. The BNHI should set up clinical database and establish quality index to monitor the quality of cataract surgery. In Taiwan, the one year incidence of YAG laser capsulotomy is too high, and the BNHI should evaluate its propriety of medical services.
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