Ten years of EUREQUO

In 2007, European ophthalmology took a bold step toward making evidence-based medicine a reality. Led by the ESCRS, 11 national ophthalmic societies won a European Union grant to create a European registry of surgical outcomes for the purposes of studying, benchmarking and improving cataract and refractive surgery – one of the first international outcomes registries attempted by any specialty. Thus, the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) was born. A decade later EUREQUO has met and even exceeded many of its initial goals, said Mats Lundström MD, PhD, of Karlskrona, Sweden. His pioneering work founding the Swedish National Cataract Registry (NCR) in 1992, and extending its activities throughout Europe in 1995 through 2008 as the European Cataract Outcome Study (ECOS), laid the groundwork for EUREQUO. HUNDREDS OF CENTRES That EUREQUO’s cataract outcomes database continues to attract active participation from hundreds of centres worldwide is itself a great success, because it makes possible international studies that help advance surgical practice. As of December 2016, the EUREQUO database included more than 2.2 million cataract extraction cases. “The logistics of setting up the database was a major achievement,” said Paul Rosen FRCS, FRCOphth, London, UK. Because EUREQUO interfaces directly with many electronic medical record systems, most datasets are filed without the need for manual entry – though a manual web interface is also available. Over 10 years, EUREQUO data has shown a slow but steady trend toward better cataract surgery visual outcomes. In 2008, post-op corrected distance visual acuity was a mean 0.088 logMAR, improving nearly continuously to a mean 0.041 in 2016. Over the same period, mean spherical equivalent biometry error also improved slowly from 0.48D, with 67.3% within ±0.5D, to 0.412D, with 73.5%, within ±0.5D. Dr Rosen, who sits on the EUREQUO steering committee with Dr Lundström and five others, believes that the registry’s use as a benchmarking tool is responsible for some of this improvement. “It is very good for an individual surgeon to carry out their personal audits. If you are an individual surgeon, you can enter your outcomes on the web and compare your results anonymously with national, regional and international benchmarks.” Dr Rosen believes more surgeons will find this valuable as national health systems require audits for re-certification. Dr Lundström credits ESCRS’s support for the project’s continuing success. “EUREQUO survived the three-year EU project period due to the interest and financing from the ESCRS. It is because of the ESCRS this project sustained after the EU financing stopped.” PRACTICE GUIDELINES Developing evidence-based practice guidelines for cataract surgery was a major EUREQUO goal, and a first round of these was published in 2012 (Lundström M et al., J Cataract Refract Surg 2012; 38:1086–1093). Based on more than 500,000 surgeries reported from 2009 through 2011, these include recommendations on second-eye surgery, outpatient procedures, pre- and postoperative visual tests and refractive outcomes, managing co-morbidities and complex cases, anaesthesia, phaco v ECCE approach, IOL lens type and materials, reporting follow-up data and managing postoperative complications. Dr Lundström considers the neutral nature of EUREQUO studies as one of their greatest strengths. “There is a great benefit to the general ophthalmic society to be able to follow trends and real-world outcomes without any personal or company related influences. This is also true for the benchmark opportunity.” The breadth, and perceived neutrality and credibility of EUREQUO data makes it useful for studying new technologies, such as femtosecond laser-assisted cataract surgery (FLACS). EUREQUO data supported the largest study to date comparing visual, refractive and safety outcomes of 2,814 patients undergoing FLACS procedures, with 4,987 patients undergoing conventional phaco cataract surgery matched for age, preoperative visual acuity and similar number of ocular co-morbidities and surgical difficulty variables. It found visual and refractive outcomes were similar between the two groups, although FLACS patients had slightly more postoperative complications (Manning S et al., J Cataract Refract Surg Dec 2016; 42:1779-1790). However, the study also identified differences in patient populations and expectations, such as younger age and higher incidence of previous corneal refractive surgery among FLACS patients. Similarly, EUREQUO data are valuable for assessing relatively low-incidence complications, such as “refractive surprise”. Dr Lundström’s analysis of 2014 EUREQUO data, including more than 142,000 cases, found that 1.8% had refractive outcomes 2.0D or more off target, and more than half of these were associated with intraoperative surgical complications, most often capsule-related, and post-op complications, mostly corneal oedema. Errors of 4.0D or more usually involved rare and complex circumstances. Going forward, the value of EUREQUO will be as much in refining its data collection to reflect evolving practice as its breadth and volume, Dr Lundström said. Mats Lundström: mats.lundstrom@karlskrona.mail.telia.com Paul Rosen: phrosen@rocketmail.com