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Optimizing the cataract order of the list in modern surgery

Ruan, Claire W. BMedSc (Hons), MBBS(Hons); Win, Sai H. MBBS; Francis, Katherine E. MBBS, BE; Francis, Ian C. FRACS, PhD

Journal of Cataract & Refractive Surgery: May 2014 - Volume 40 - Issue 5 - p 842-843
doi: 10.1016/j.jcrs.2014.03.003
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Cataract surgery is typically highly successful. However, substantial complications may occur.1–4 The pathway to achieving cataract surgical success and reducing complication risk depends on myriad medical and surgical factors. However, the physical and psychological comfort of the surgical team is frequently overlooked.

Surgical-team comfort is likely to be affected by the characteristics of individual cataract patients. Therefore, the order in which patients are placed on the list is important. The authors have categorized surgical patient characteristics into 20 features on a pro forma known as “cataract order of the list” (Figure 1). This pro forma has been used for more than 4 years and was found by our surgical team to be simple to implement and inexpensive. It has led to improved surgical team experience.

Figure 1
Figure 1:
The pro forma.

The pro forma is divided into Groups 1, 2, and 3, which represent patient characteristics better suited to early, middle, or late placement on the operating list. The intended use is in a checklist format generated by the office computers. It can be used as an adhesive sticker (dimensions 9.8 cm × 3.8 cm) for the patient’s handwritten medical record or as a template for electronic medical records. It can also be used as an educational tool for neophyte surgeons. The pro forma is completed during the patient’s preoperative consultation. Thus, the abbreviations that are necessarily used in the patient’s presence are designed to eschew patient anxiety. Many surgeons have personal preferences for ordering their surgical lists but may benefit from using the pro forma as a template to optimize the order of their surgical list.

Group 1

Patients with medical conditions that benefit from surgery early in the day should be placed at the start of the operating list. These conditions include patients with insulin-dependent diabetes and chronic kidney disease. Low-maintenance patients are also suited for placement at the start of the list. These include calm patients with previous uneventful cataract surgery.

Group 2

The middle of the list should include patients whose operations may be more risky; ie, patients with higher levels of ametropia, higher grade nuclear sclerosis, those requiring a toric intraocular lens, pseudoexfoliation syndrome in association with small pupils, hearing-impaired patients, or an eye that has had laser in situ keratomileusis or similar surgery.

Group 3

Later in the course of the operating list, the surgical team is likely to have reached a mindset of optimal comfort and dexterity. This could enhance the team’s ability to deal more confidently with cases that are potentially more complex. Patients who may benefit from later placement include those with shallow anterior chambers, enophthalmos, dark brown eyes, high hyperopia, and very dark or dense cataracts requiring trypan blue dye. Those with poor pupil dilation requiring a Malyugin ring or iris retractors, division of posterior synechiae, or assisted local anesthesia should also be placed later on the list.

Later placement is also recommended for cases that may be more psychologically challenging for the surgeon. These cases include patients having cataract surgery for the first time, patients with only 1 eye with visual potential, or those who have had previous eventful cataract surgery. Patients who are familiar to the surgeon, including friends, family, and medical colleagues may fall into this category, depending on individual surgeon preference.

In the situation in which category placements conflict, the surgeon should review individual cases to determine priority. For example, in a patient with both diabetes and dense cataracts, systemic medical requirements should take precedence over cataract factors.

Quantitative evidence for the phenomenon of surgeon comfort is difficult to obtain. This is due to small numbers of overall cataract complications and the variable subjective nature of surgeon comfort. However, there is cognitive support for placing more complicated or potentially difficult patients later on the list when the surgeon’s performance level may be at its peak. This benefit has been seen across many performance-based professions.5,6 Further research into the association of ophthalmic surgeon comfort and surgical outcomes during cataract surgery could be valuable. In the meantime, the concept of use of the cataract order of the list may benefit our colleagues.


1. Riaz Y, Mehta JS, Wormald R, Evans JR, Foster A, Ravilla T, Snellingen T. Surgical interventions for age-related cataract, Cochrane Database Syst Rev. (4) (2006) CD001323.
2. Borovik AM, Skalicky SE, Masselos K, Brown TM, Dauber SL, Pandya VB, Figueira EC, Francis IC. The TAHITI approach to cataract surgery consent [letter]. J Cataract Refract Surg. 2008;34:180-181.
3. Rachmiel R, Trope GE, Chipman ML, Buys YM. Cataract surgery rates in Ontario, Canada, from 1992 to 2004: more surgeries with fewer ophthalmologists. Can J Ophthalmol. 2007;42:539-542.
4. Wormald RP, Foster A. Cataract surgery [editorial]. Br J Ophthalmol. 88, 2004, p. 601-602, Available at: Accessed February 9, 2014.
5. Yeo GB, Neal A. A multilevel analysis of effort, practice and performance: effects of ability, conscientiousness and goal orientation. J Appl Psychol. 2004;89:231-247.
6. Grill-Spector K, Henson R, Martin A. Repetition and the brain: neural models of stimulus-specific effects. Trends Cog Sci. 10, 2006, p. 14-22, Available at: Accessed February 9, 2014.
© 2014 by Lippincott Williams & Wilkins, Inc.