The Madurai Intraocular Lens Study. I: A randomized clinical trial comparing complications and vision outcomes of intracapsular cataract extraction and extracapsular cataract extraction with posterior chamber intraocular lens

Functional and visual acuity outcomes of cataract surgery in Timor-Leste (East Timor)

PURPOSE

To report functional outcomes following cataract surgery in Timor-Leste.

METHODS

Pre- and post-intervention study measuring visual function improvement following cataract surgery. Presenting visual acuity (VA) was measured and visual function documented using the Indian vision function questionnaire (IND-VFQ).

RESULTS

All 174 persons undergoing cataract surgery from November 2009 to January 2011 in Timor-Leste were included. Mean age was 65.4 years; 113 (64.9%) were male, 143 (82.1%) were from a rural background and 151 (86.8%) were illiterate. Pre-operatively, 77 of 174 patients (44.3%, 95% confidence interval, CI, 37.0-51.7%) were blind (VA ≤3/60), 77 (44.3%, 95% CI 37.0-51.7%) were visually impaired (VA <6/18->3/60), while 20 (11.5%, 95% CI 7.4-16.9%) had presenting acuity ≥6/18 in the better eye. Following surgery, significant improvement in visual function was demonstrated by an effect size of 2.8, 3.7 and 3.9 in the domains of general functioning, psychosocial impact and visual symptoms, respectively. Four weeks following surgery, 85 patients (48.9%, 95% CI 41.5-66.3%) had a presenting VA ≥6/18, 74 (42.5%, 95% CI 35.3-45.9%) were visually impaired and 15 (8.6%, 95% CI 5.0-13.6%) were blind. IND-VFQ improvement occurred even in patients remaining visually impaired or blind following surgery.

CONCLUSION

In this setting, cataract surgery led to a significant improvement in visual function but the VA results did not meet World Health Organization quality criteria. IND-VFQ results, although complementary to clinical VA outcomes did not, in isolation, reflect the need to improve program quality.

A pre- and post-treatment evaluation of vision-related quality of life in uveitis

Aim:

To study the effect of treatment on vision-related quality of life (VR-QOL) in uveitis patients.

Materials and Methods:

Interviewer-administered questionnaire-based evaluation of visual function and VR-QOL in Tamil-speaking adult patients with active uveitis at presentation and follow-up by the same interviewer.

Results:

Ninety-eight patients participated in this study. There was a statistically significant improvement in VR-QOL in all the scales following treatment (P < 0.001). Patients with chronic uveitis showed better improvement upon treatment than patients with acute uveitis. The visual symptoms scale showed moderate gains following treatment (effect size 0.56). Persons with bilateral disease had poorer mean scores compared to those with unilateral disease. Visual acuity was closely correlated with VR-QOL scores.

Conclusion:

The VR-QOL measurement has shown that it is sensitive to demonstrate the problems of patients with uveitis irrespective of their demographic profile. The scores improved significantly in patients with uveitis following treatment and have shown close correlation to visual acuity thus demonstrating that VR-QOL is effective in assessing the response to treatment.

Surgical interventions for age-related cataract

BACKGROUND

Cataract accounts for 50% of blindness globally and remains the leading cause of visual impairment in all regions of the world, despite improvements in surgical outcomes (WHO 2005). This number is expected to rise due to an aging population and increase in life expectancy. Although cataracts are not preventable, their surgical treatment is one of the most cost-effective interventions in healthcare.

OBJECTIVES

To compare the effects of different surgical interventions for age-related cataract.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE up to July 2006, NRR Issue 3 2005, the reference lists of identified trials and we contacted investigators and experts in the field for details of published and unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTS).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and discrepancies were resolved by discussion. Where appropriate, risk ratios, odds ratios and weighted mean differences were summarised after assessing heterogeneity between the studies.

MAIN RESULTS

We identified 17 trials that randomised a total of 9627 people. Phacoemulsification gave a better visual outcome than extracapsular surgery but similar average cost per procedure in Europe but not in poorer countries. Extracapsular surgery with posterior chamber lens implant and ICCE with or without an anterior chamber intraocular lens (IOL) implant gave acceptable visual outcomes but extracapsular surgery had less complications. Manual small incision surgery provides better visual outcome than ECCE but slightly inferior unaided visual acuity compared to phacoemulsification.

AUTHORS' CONCLUSIONS

This review provides evidence from seven RCTs that phacoemulsification gives a better outcome than ECCE with sutures. We also found evidence that ECCE with a posterior chamber lens implant provides better visual outcome than ICCE with aphakic glasses. The long term effect of posterior capsular opacification (PCO) needs to be assessed in larger populations. The data also suggests that ICCE with an anterior chamber lens implant is an effective alternative to ICCE with aphakic glasses, with similar safety. Phacoemulsification provides the best visual outcomes but will only be accessible to the poorer countries if the cost of phacoemulsification and foldable IOLs decrease. Manual small incision cataract surgery provides early visual rehabilitation and comparable visual outcome to PHACO. It has better visual outcomes than ECCE and can be used in any clinic that is currently carrying out ECCE with IOL. Further research from developing regions are needed to compare the cost and longer term outcomes of these procedures e.g. PCO and corneal endothelial cell damage.

Outcomes of high volume cataract surgeries in a developing country

AIM

To analyse the outcome of high volume cataract surgery in a developing country, community based, high volume eye hospital.

METHODS

In a non-comparative interventional case series, the authors reviewed the surgical outcomes of 593 patients with cataract operated upon by three high volume surgeons on six randomly selected days. There were 318 female (54%) and 275 male (46%) patients. Their mean age was 59.57 (SD 10.13) years. The majority of the patients underwent manual small incision cataract surgery (manual SICS). Extracapsular cataract extraction with posterior chamber intraocular lens (ECCE-PCIOL) and intracapsular cataract extraction (ICCE) were also done on a few patients as clinically indicated.

RESULTS

Best corrected visual acuity of >or=6/18 was achieved in 94% of the 520 patients who could be followed up on the 40th postoperative day (88% follow up rate). Intraoperative and immediate postoperative complications as defined by OCTET occurred in 11 (1.9%) and 75 (12.6%) patients, respectively. Average surgical time of 3.75 minutes per case (16-18 cases per hour) was achieved. Statistically significant risk factors for outcomes were found to be age >60, sex, and surgeon.

CONCLUSION

High volume surgery using appropriate techniques and standardised protocols does not compromise quality of outcomes.

The Sivaganga eye survey: II. Outcomes of cataract surgery

PURPOSE

To assess the clinical outcomes of cataract surgery in rural southern India.

METHODS

Cluster sampling was used in randomly selecting a cross-sectional sample of persons 50 years of age or older for visual acuity measurement, refraction, and ocular examination in 1999. Subjects were queried as to the date and place of surgery for each cataract-operated eye. Surgical complications were noted and the principal cause of reduced vision was identified for eyes with presenting visual acuity worse than 6/18.

RESULTS

Within the cataract-operated sample of 682 persons, 13.8% had presenting visual acuity worse than 6/60 in both eyes, 25.2% better than or equal to 6/18 in both eyes, and 37.8% were bilaterally operated on. For aphakic eyes, 50.5% presented with visual acuity better than or equal to 6/18; 82.6% with best-correction. For pseudophakic eyes, the corresponding percentages were 78.0% and 94.5%. Over one-third of all eyes were pseudophakic, and nearly three-fourths had been operated on in non-governmental facilities. Uncorrected aphakia and other refractive error were the main causes of vision impairment. In multiple logistic regression modeling, poor presenting visual acuity in aphakic eyes was associated with illiteracy, rural residence, and surgery in government facilities; gender and time period of surgery were not predictors of vision outcomes. None of these variables were associated with best-corrected outcomes in aphakic eyes, nor with presenting and best-corrected outcomes in pseudophakic eyes.

CONCLUSIONS

Visual acuity outcomes in pseudophakic eyes were good. More attention must be given to needless vision impairment among the cataract-operated because of inadequate aphakic correction, especially among those operated on in government facilities, the illiterate, and those living in rural villages.

Surgical interventions for age-related cataract

BACKGROUND

Cataract is the major cause of global blindness, accounting for 40 to 80% of all blindness in developing countries. The number of people blind from cataract is expected to rise due to the changing age distribution and increasing life expectancy. There is currently no proven intervention to prevent cataract and surgery is the only form of treatment.

OBJECTIVES

The objective of this review is to compare the effects of different surgical interventions for age-related cataract.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register - CENTRAL/CCTR, which contains the Cochrane Eyes and Vision Group specialised register (Cochrane Library Issue 3 2001), MEDLINE (1966 to August 2001), EMBASE (1980 to September 2001), the reference lists of identified trials, and we contacted investigators and experts in the field for details of published and unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials evaluating surgical treatment for people with age-related cataract.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and discrepancies were resolved by discussion. Where appropriate, relative risks, odds ratios and weighted mean differences were summarised after assessing heterogeneity between the studies. We used a fixed effect model due to the low number of trials in each comparison.

MAIN RESULTS

We identified six trials that randomised a total of 7828 people. Phacoemulsification gave a better visual outcome than extracapsular surgery and gave a similar average cost per procedure in one trial conducted in the UK. Extracapsular surgery with posterior chamber lens implant and intracapsular surgery with or without an anterior chamber intraocular lens implant gave acceptable visual outcomes at 12 to 24 months after surgery. In three large trials in south Asia, best-corrected visual acuity of less than 6/60 ranged from 0.5 to 4%. Higher rates of poor outcome were observed in a multicentre study with 19 surgeons compared to a single-centre study with two surgeons.

REVIEWER'S CONCLUSIONS

This review provides evidence from one randomised controlled trial that phacoemulsification gives a better visual outcome than extracapsular extraction with sutures. However, this trial was conducted in a developed country specialised hospital setting and extrapolation to other settings must be made with caution. This review also found evidence that extracapsular cataract extraction with a posterior chamber lens implant provides better visual outcome than intracapsular extraction with aphakic glasses. This finding is also based on the results of a single trial. The long term effects of posterior capsular opacification need to be assessed in larger populations. The data in the review suggest that intracapsular extraction with an anterior chamber lens implant is an effective alternative to intracapsular extraction with aphakic glasses, with similar safety. Further data from developing regions are needed to compare all aspects of intraocular lens surgery with the three main surgical procedures - intracapsular extraction with an anterior chamber lens, extracapsular surgery with a posterior chamber lens with or without sutures.

Visual acuity and quality of life outcomes in cataract surgery patients in Hong Kong

BACKGROUND

Visual acuity, visual functioning, and vision related quality of life outcomes after cataract surgery were assessed in a population based study in a suburban area of Hong Kong.

METHODS

A cluster sampling design was used to select apartment buildings within housing estates for enumeration. All enumerated residents 60 years of age or over were invited for an eye examination and visual acuity measurement at a site within each estate. Visual functioning (VF) and vision related quality of life (QOL) questionnaires were administered to interview subjects who had undergone cataract surgery and to unoperated people with presenting visual acuity less than 6/60 in either eye, and a sample of those with normal visual acuity.

RESULTS

36.6% of the 310 cataract operated individuals had presenting visual acuity 6/18 or better in both eyes, and 40.0% when measured by pinhole. 4.5% were blind, with presenting visual acuity less than 6/60 in both eyes. Of operated eyes, 59.6% presented with visual acuity 6/18 or better. 11.2% of the operated eyes were blind with vision less than 6/60. Visual acuity outcomes 6/18 or better were marginally associated with surgery in private versus public hospitals. Lens status (pseudophakic versus aphakic) and surgical period (within the most recent 3 years versus before) were not significantly related to vision outcomes. Mean VF and QOL scores decreased consistently with decreasing vision status. Spearman correlation with vision status was 0.420 for VF scores and 0.313 for QOL scores. Among VF/QOL subscales, correlation was strongest for visual perception (r = 0.447) among VF subscales and weakest for self care (r = 0.171) among QOL subscales. Regression adjusted VF and QOL total scores for cataract operated individuals were slightly lower than for those of visually comparable unoperated individuals (p<0.05).

CONCLUSIONS

Cataract operations in Hong Kong did not consistently produce good presenting visual acuity outcomes, suggesting that postoperative monitoring would be useful to minimise visual impairment in this population. Although vision outcomes were consistently correlated with all VF/QOL subscale scores, there was a differential impact with VF subscales usually being affected more by reduced acuity than the more general QOL subscales.

Outcomes of extracapsular surgery in eye camps of eastern Nepal

BACKGROUND

Extracapsular cataract (ECCE) surgery is becoming increasingly popular in surgical eye camps of developing countries. This study assesses the outcome of 166 eyes at 6 weeks and 14 and 32 months after ECCE with and without implantation of intraocular lens in refugee camps of eastern Nepal.

METHOD

All patients operated on in seven refugee camps during the 3 years before the assessment were included in the study population. Visual acuity, examination of anterior segment and posterior segments, and grading of capsular opacification using a standardised grading system were performed.

RESULTS

Of 166 eyes examined, of which 49.4% were aphakic, 58% of eyes had very poor functional vision (WHO severe visual impairment-VA <6/60). After refraction and best correction 19% still had very poor vision. The aphakic eyes had both significantly poorer functional and best corrected vision than the pseudophakic eyes. In patients with intact posterior capsule clinically significant posterior capsular opacification was observed in over 10% of eyes at 14 months and 30% at 32 months.

CONCLUSION

It was found that ECCE surgery in eye camps in this setting gave unacceptable outcomes because of a high rate of capsular rupture and posterior capsular opacification. Careful consideration should be given to the quality of the surgical set up and available resources and possibilities of postoperative follow up when ECCE is introduced in eye camps.

Visual outcomes after cataract surgery and cataract surgical coverage in India

Visual outcomes of 2369 cataract operated persons(3655 eyes) across seven major Indian states were assessed in 1998. This is the largest ever study over the past decade in the country. 9.54 per cent of the examined population had undergone operation for cataract in one or both eyes. Intra-capsular cataract extraction was the commonest surgical modality adopted (91.62%). Intraocular lens implants resulted in better visual outcomes with 71.4 per cent of such patients achieving a good visual outcome (> or = 6/18 in operated eyes). Visual outcome was also good if ICCE operated patients were provided good quality aphakic spectacles. There were no gender differentials in surgical uptake rates. The risk of poor postsurgical visual outcome was strongly associated by type of surgery (Adjusted OR for ICCE-2.78; 95% CI: 1.41-5.49) and the non-availability or poor quality aphakic spectacles (Adjusted OR for poor/no spectacles 4.59-95% CI: 3.53-5.97). Duration since surgery and the source of surgery did not influence visual outcomes. Half the cataract blind remained unoperated in the study population.

The madurai intraocular lens study IV: posterior capsule opacification

PURPOSE

To estimate the cumulative incidence of posterior capsule opacification 4 years after surgery in patients who participated in the Madurai Intraocular Lens Study and had extracapsular cataract extraction with posterior chamber intraocular lens implantation.

METHODS

In the Madurai Intraocular Lens Study, 1,700 patients with best-corrected visual acuity 20/120 or worse in the better eye had extracapsular cataract extraction with posterior chamber intraocular lens implantation, and 1,474 (86.7%) of these completed the 1-year follow-up examination. From this group of 1,474 pseudophakic patients, 400 were randomly selected for reexamination 4 years after the original surgery. The eye that was operated on was examined by an ophthalmologist who was involved in the 1-year follow-up examinations and posterior capsule opacification grading. A grading of I to III was used to reflect the degree of opacification. With grades II and III, posterior capsule opacification detectable with an undilated pupil was present in the central axis.

RESULTS

Three hundred twenty-seven (81.8%) of the selected population were examined between October 1997 and December 1998. Thirty-four (8.5%) were confirmed as being deceased, and 39 (9.8%) were unavailable for follow-up. The median age was 60 years, and 57.2% were women. The 4-year incidence of grade II or III posterior capsule opacification, including eyes already treated with laser capsulotomy, was 13.1% (95% confidence interval [CI], 9.7% to 17.3%). Each year of increased age was associated with a decreased risk of posterior capsule opacification (odds ratio, 0.96; 95% CI, 0.92 to 1.00). Based on best-corrected visual acuity of 20/40 or worse without co-existing pathology, the 4-year incidence of posterior capsule opacification was 13.5%.

CONCLUSION

Because patients with relatively mature cataracts routinely receive extracapsular cataract extraction with posterior chamber intraocular lens implantation instead of the traditional intracapsular extraction, the subsequent need for laser capsulotomy may be less than that anticipated, based on previous reports.

Outcomes of cataract surgery: implications for the developing world

Cataract surgery has virtually eliminated cataract blindness in the developed world. However, in the economically developing areas of the world it is a staggering and escalating problem where it is the leading cause of blindness affecting 16-20 million people. Outcomes research has clearly shown that modern cataract surgery with intraocular lens implantation is a safe and effective means of restoring visual function and improving vision-related quality of life. Several recent developments provide hope in the global fight against cataract blindness: decrease in the cost of modern surgery; available models of infrastructure development; and a global plan for the elimination of avoidable blindness.

Cataract--a global perspective: output, outcome and outlay

There are approximately 20 million people blind from cataract in the world, the majority of whom do not have access to affordable cataract surgery. This article will briefly address three questions regarding service delivery: How many cataracts need to be operated on? What are satisfactory results? How can cataract surgery be made affordable?

Vision-specific function and quality of life after cataract extraction in south India

PURPOSE

To assess visual and overall patient function after intracapsular (ICCE) and extracapsular (ECCE) cataract extraction in rural South India.

SETTING

Aravind Eye Hospital, Tirunelveli, Tamil Nadu, South India, and the Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Baltimore, Maryland, USA.

METHODS

This study evaluated preoperative visual acuity and demographic information and postoperative visual acuity and functional status measures in 71 patients having ECCE with posterior chamber intraocular lens (IOL) placement and 73 patients having ICCE with aphakic spectacle correction at Aravind-Tirunelveli Eye Hospital, Tamil Nadu, India. The principal outcomes assessed were visual acuity; quality-of-life score (possible range 0 to 100%); visual function measurement (possible range 0 to 100%).

RESULTS

Patients in the ECCE group scored 10.17 (P = .0001) points higher than those in the ICCE group on the visual function scale after adjustment for differences in age, sex, level of education, marital status, residence, and type of employment. The ECCE group scored 7.69 points higher on visual function when adjusting for the differences in best corrected visual acuity, which was also better in the ECCE group. In the quality-of-life assessment, 77.1% in the ECCE group and 46.6% in the ICCE group scored 90% or better (OR 3.85; P = .006).

CONCLUSIONS

Patients in rural south India having ECCE with posterior chamber IOL implantation obtained better postoperative visual function, quality of life, and visual acuity than those receiving ICCE with aphakic spectacle correction. These differences, which were not significantly affected by adjustment for age, sex, education, marital status, type of residence, and occupation, indicate that ECCE is clearly superior to ICCE.

The Madurai Intraocular Lens Study. II: Clinical outcomes

PURPOSE

To evaluate the safety and efficacy of extracapsular cataract extraction with posterior chamber intraocular lens (ECCE/PC-IOL) compared with intracapsular cataract extraction with aphakic glasses (ICCE-AG).

METHODS

In a nonmasked randomized controlled clinical trial, 3,400 bilaterally vision-impaired patients aged 40 to 75 years with operable cataract were randomly assigned to receive either ICCE-AG or ECCE/PC-IOL at the Aravind Eye Hospital in India. The surgery was performed by one of four study surgeons. Patients were hospitalized for 5 postoperative days, with follow-up visits at 2, 6, and 12 months after discharge. Postsurgery evaluations were conducted by two independent study ophthalmologists.

RESULTS

At any single postoperative follow-up time point, there were no statistically significant differences of clinical relevance between treatment groups for any complication of a serious nature except cystoid macular edema, which was more common with ICCE (4.2% vs 1.6%). In general, whether of a trivial, intermediate, or serious nature, complication rates were low at each evaluation time point. Cumulatively, the incidence of serious complications of all types throughout the 1-year study period was 14.5% for patients in the ICCE-AG group and 7.7% in the ECCE group (P < .001). Best-corrected visual acuity of 20/40 or better at 12 months was attained by 90.7% of ICCE-AG patients and 96.3% of ECCE/PC-IOL patients (P < .001).

CONCLUSION

Although both operative procedures are safe and effective for cataract patients with bilateral impairment, ECCE/PC-IOL is superior to ICCE-AG in terms of both visual acuity restoration and safety.

The Madurai Intraocular Lens Study. III: Visual functioning and quality of life outcomes

PURPOSE

To compare the effects of extracapsular cataract extraction with posterior chamber intraocular lens (ECCE/PC-IOL) vs intracapsular cataract extraction with aphakic glasses (ICCE-AG) on everyday visual functioning and quality of life.

METHODS

In a nonmasked randomized controlled clinical trial, 3,400 bilateral vision-impaired patients, aged 40 to 75 years, with operable cataract were randomly assigned to receive one of the two treatment options. One half in each group were randomly selected for interviewer administration of visual functioning and quality of life questionnaires before surgery and at 6 and 12 months after surgery.

RESULTS

Both ICCE-AG and ECCE/PC-IOL produced dramatic improvements in visual functioning and quality of life scores. Patients receiving ECCE/PC-IOL reported larger beneficial changes than did those receiving ICCE-AG, compatible with additional beneficial effects of a moderate magnitude for visual functioning and of a smaller beneficial magnitude for quality of life. All between-group differences were highly statistically significant (P < .00001). The additional benefits of ECCE/PC-IOL are not explained by visual acuity differences. A higher proportion of patients in the ICCE-AG group reported problems on a vision problem checklist at 6 months (more than 50%) than did patients in the ECCE/PC-IOL group (approximately 30%).

CONCLUSIONS

In this developing-country setting, ICCE-AG and ECCE/PC-IOL were associated with substantial benefits in improved everyday vision function and vision-related quality of life. Patients who received ECCE/PC-IOL reported greater benefits and fewer problems with vision than did patients who received ICCE-AG.