CLINICAL PRACTICE IMPROVEMENT PROJECT 2009-2010
"Improving Pupil Dilation for Cataract Patients in SNEC"

1. Pei Hong, TIAN²
2. Huey Peng, LOH¹
3. Allan, FONG¹
4. Siew Hoon, NEO
5. Kit Ngoh, YICK

²Singapore National Eye Centre, Singapore
¹Singapore National Eye Centre, Singapore
¹Singapore National Eye Centre, Singapore

Introduction
One of the surgical challenges faced by Ophthalmologists is the miotic (small) pupil. It can make a routine procedure difficult, or complicate a difficult cataract case further. Adequate mydriasis (pupil dilatation) is critical for a smooth and successful surgery, as it gives adequate surgical access throughout the procedure.

Pre-operative pupil dilatation is usually achieved by topical administration of mydriasis drops. Whilst there are other intra-operative instruments and devices to manage miotic pupils, such approaches increased surgical time, and may potentially caused inadvertent complications such as permanently enlarged pupil or iris sphincter tear. Pharmacological dilatation remains less invasive than these intra-operative maneuvers and is the first step in the preparation of the pupil for surgery (Gholam et al, ND, & Aminollah N, 2007)

Background
A total of 380 patients were recruited to collect baseline data September to October 2009. Results showed that less than 40% of cataract patients achieve dilation of at least a 7mm or above. A desirable and adequate pupil size would be at least 7mm, as this would give a reasonable access to perform a 5.5 to 6mm capsulorhexis (Buratto L, ND).

Aim (Mission Statement):
The aim of this project is to achieve 80% all patients scheduled for cataract surgery to achieve a pupil dilation of at least 7mm or above by the time they reach operating induction room, within 6 months.

Method:
PDCA (Plan , Do, Check & Act) methodology and a series of quality improvement tools were used to guide the project from conceptualizing the work flow up to problem identification. Intervention was started in Jan 2110 and was completed at March 2010.

Data analysis
Results were presented in run chart and satistical process control chart to allow continious monitoring of trends and shift in practice. Paired T Test was used to determine the significance of pre and post pupil dilation.

Results
Post intervention results showed that 88% of the cataract patients achieved an average pupil dilation of 7.6mm when they reached the operating theatre. T Test showed a statistical significance between mean difference of pre and post pupil dilation, P= 0.001.