Cataract Refractive Outcomes More Dependent on Patient Factors Than Surgeon

BETHESDA, MD – August 21: Opthamologist Dr. Daniel Pluznik uses a LensX state-of-the-art laser to perform part one of a two-step cataract surgery on Milford Best, 82 at Palisades Eye Surgery Center in Bethesda, MD on August 21, 2012. Cataracts are the most common surgery performed in Medicare and is the most common cause of blindness in the world. Pluznik performs about 350 of these surgeries a year, sometimes 12-15 a day at a length of 15 minutes each. (Photo by Linda Davidson / The Washington Post via Getty Images)
Surgeon choice accounts for very few unexplained variance in visual outcomes, a report suggests.

A patient’s sex and comorbidities have a stronger influence on the refractive outcomes of cataract surgery than variances between surgeons, according to a study published in the British Journal of Ophthalmology.

The researchers used the UK national ophthalmic cataract database to gather patients data for cataract operations conducted between April 1, 2010, and August 31, 2018. They examined the relationships between refractive outcomes and number of variables, including sex, age, diabetic retinopathy, glaucoma, high myopia, inherited retinal disease, optic nerve disease, uveitis, pseudoexfoliation, vitreous opacities, retinal pathology, cataract type, previous surgery, and posterior capsular rupture. 

The researchers reported that a total of 490,987 cataract operations were performed on 351,864 patients (median age, 76.6 years; interquartile range, 69.6-82.3) by 2567 surgeons. They found that myopic and astigmatic errors were associated with posterior capsule rupture (posterior mean error of expected refractive outcome, -0.38/+0.04×72), glaucoma (-0.10/+0.05×95), previous vitrectomy (-0.049/+0.03×66) and high myopia (-0.07/+0.03×57). They also found that hyperopic and astigmatic errors were associated with diabetic retinopathy (+0.08/+0.03×104), pseudoexfoliation (+0.07/+0.01×158), male gender (+0.12/+0.05×91), and age (-0.01/+0.06×97 per increasing decade). The team reported no significant impact of inherited retinal disease, optic nerve disease, previous trabeculectomy, uveitis, or brunescent/white cataract on the refractive outcome. 

They found that the effects of patient gender and comorbidity were additive and that surgeons only accounted for 4% of the unexplained variance in refractive outcome.

“It appears that further progress and refinements in IOL power formulae will probably come about through many small refinements in both formula design and discovery of new variables,” researchers report. “We believe that the incorporation of comorbidity and gender is one such step and it should be considered when developing and validating future IOL power formulas.”


Hughes R, Aristodemou P, Sparrow JM, Kaye S. Surgeon effects on cataract refractive outcomes are minimal compared with patient comorbidity and gender: an analysis of 490 987 cases Br J Ophthalmol. Published online November 11, 2021. doi:10.1136/bjophthalmol-2021-320231