Low-cost high-volume extracapsular cataract extraction with posterior chamber intraocular lens implantation in Nepal

Public health meets global surgery: a synergistic approach to better outcomes

Background

Global surgery (GS) aims to improve access to timely, quality, and affordable surgical care worldwide, yet it remains underrepresented in public health education.

Objective

This cross-sectional study assessed the awareness and knowledge of GS among 242 public health professionals.

Methods and results

Data collected via a self-structured questionnaire using SPSS 25 revealed significant gender and age diversity, with the majority being young professionals (76.4% aged 20-29). Most participants (71.5%) held a master's degree, and 55% had 1-5 years of public health experience. While 60% were familiar with the term "Global Surgery," a considerable portion lacked a comprehensive understanding. Participants emphasized the need to integrate GS into public health curricula through faculty development, practical training, scholarships, and research collaborations.

Conclusion

These strategies aim to bridge the knowledge gap and enhance the role of surgical care in global health. Despite being essential for addressing a significant portion of the global disease burden, surgical care remains inaccessible to many in LMICs due to systemic barriers. This study underscores the importance of fostering international partnerships and promoting a multidisciplinary approach to improve surgical care access, ultimately contributing to better health outcomes globally.

Humanitarian missions and visual outcomes in cataract surgery: A literature review

The limited accessibility to ophthalmological services in remote regions of developing countries poses a significant challenge in visual healthcare. Cataracts and refractive errors are prominent causes of visual impairment, and surgery, despite being an efficient option, faces barriers in developing countries due to financial and geographical constraints. Humanitarian missions play a vital role in addressing this issue. The improvement in the accuracy of calculating IOL power through techniques such as keratometry and biometry is a fundamental step towards optimizing surgical outcomes and the quality of life for patients in these underserved regions. In this context, the consideration of keratometry and immersion ultrasound biometry as preoperative assessment standards in cataract surgeries in developing countries is presented as a pertinent and advisable strategy.

Outcomes of Cataract Surgeries Performed in Makeshift Operating Rooms in Rural Camps, Compared to Hospital-based Surgeries in Nepal

PURPOSE

This study was undertaken to evaluate the complication rates and visual outcomes of outreach cataract surgeries done in makeshift operating rooms.

METHOD

In this retrospective study, surgical outcomes of consecutive Manual Small Incision Cataract Surgeries (MSICS) done in 11 rural camps in Nepal were compared with the results of consecutive hospital surgeries (MSICS and phacoemulsification) done by the same surgeon. Surgeries were done from September 2018 to March 2020.

RESULTS

Out of 1034 study population in each group, a significantly higher number (p < .001) of camp patients (27%, n = 279) were either blind or had severe visual impairment when compared to hospital patients (18.6%, n = 192). Around 88.9% (n = 919) of cases operated in camps and 85.7% (n = 886) in the hospital achieved uncorrected visual acuity (VA) of 6/18 or better on the first postoperative day. Poor outcome (VA<6/60) was seen in 3.7% (n = 38) of cases in camps and 3.9% (n = 40) in the hospital. The difference in visual outcomes was not significant (p = .162) when the results were controlled for other associated variables. There was no significant difference (p = .126) between complication rates in camps (1.9%, n = 20) and hospital surgeries (3.5%, n = 36) when preoperative conditions were statistically controlled. No cases of endophthalmitis were reported.

CONCLUSIONS

Makeshift operating rooms can be used for cataract surgeries in rural areas where no standard operating rooms are available. If appropriate patient selection criteria and standard surgical protocols are followed, good surgical outcomes can be achieved in camps by an experienced surgical team.

Visual outcomes of high-volume compared with low-volume manual small-incision cataract surgery in Nepal

PURPOSE

To study whether manual small-incision cataract surgery (MSICS) in a high-volume setting gives acceptable postoperative visual outcomes.

SETTINGS

Geta Eye Hospital, Kailali, Nepal.

DESIGN

Single-center retrospective study.

METHODS

One-year records of all MSICS in adult patients without any other ocular comorbidity were analyzed retrospectively. Surgical outcomes of cataract cases when surgeons performed more than 72 surgeries (high volume) in a single operating session (1 day) were compared with when fewer than 30 surgeries (low volume) were performed in a single operating session (1 day).

RESULTS

Of 23 717 cases in the study, 20 574 patients (87%) had preoperative visual acuity of less than 3/60; 15 632 patients (66%) achieved good visual outcome (uncorrected distance visual acuity of 6/18 or better) postoperatively. Patients operated during high-volume months achieved good visual outcomes in 9930 cases (66.9%) as compared with 5702 (64.3%) in low-volume months. However, 6235 patients (61.7%) operated on during high-volume days had good visual outcomes as compared with 3053 (71.4%) during low-volume days; 175 patients in the high-volume group and 73 patients in the low-volume group (1.7% each) achieved visual acuity worse than 3/60. There were comparable posterior capsular rupture rates (423 [1.78%]) during high- and low-volume months, and 21 cases (0.09%) of postoperative endophthalmitis were noted.

CONCLUSIONS

MSICS can be used to reduce large cataract backlogs in developing countries as good visual outcomes could be achieved in high-volume settings if standard protocols for quality control are followed.

Improving productivity, costs and environmental impact in International Eye Health Services: using the 'Eyefficiency' cataract surgical services auditing tool to assess the value of cataract surgical services

Objective

Though one of the most common surgeries, there is limited information on variability of practices in cataract surgeries. ‘Eyefficiency’ is a cataract surgical services auditing tool to help global units improve their surgical productivity and reduce their costs, waste generation and carbon footprint. The aim of the present research is to identify variability and efficiency opportunities in cataract surgical practices globally.

Methods and Analysis

9 global cataract surgical facilities used the Eyefficiency tool to collect facility-level data (staffing, pathway steps, costs of supplies and energy use), and live time-and-motion data. A point person from each site gathered and reported data on 1 week or 30 consecutive cataract surgeries. Environmental life cycle assessment and descriptive statistics were used to quantify productivity, costs and carbon footprint. The main outcomes were estimates of productivity, costs, greenhouse gas emissions, and solid waste generation per-case at each site.

Results

Nine participating sites recorded 475 cataract extractions (a mix of phacoemulsification and manual small incision). Cases per hour ranged from 1.7 to 4.48 at single-bed sites and 1.47 to 4.25 at dual-bed sites. Average per-case expenditures ranged between £31.55 and £399.34, with a majority of costs attributable to medical equipment and supplies. Average solid waste ranged between 0.19 kg and 4.27 kg per phacoemulsification, and greenhouse gases ranged from 41 kg carbon dioxide equivalents (CO2e) to 130 kg CO2e per phacoemulsification.

Conclusion

Results demonstrate the global diversity of cataract surgical services and non-clinical metrics. Eyefficiency supports local decision-making for resource efficiency and could help identify regional or global best practices for optimising productivity, costs and environmental impact of cataract surgery.

Role of laser refractive surgery in cross-subsidization of nonprofit humanitarian eyecare and the burden of uncorrected refractive error in Nepal: Pilot project

PURPOSE

To establish a refractive surgery unit at Tilganga Institute of Ophthalmology through support from international donations and provide knowledge transfer for doctors and management to make the unit self-sustaining, nonprofit laser refractive surgery, and financial support for other eyecare projects at Tilganga.

SETTING

Tilganga Institute of Ophthalmology, Kathmandu, Nepal.

DESIGN

Retrospective study.

METHODS

A foundation was created to establish a refractive surgery unit using a cost-recovery model; that is, patients are charged according to their financial status to cover running costs, patients without funds to pay for surgery, and other eyecare projects for the underprivileged population of Kathmandu, Nepal. Donations were obtained to fund refurbishment within Tilganga Hospital and purchase equipment and technology. A Nepalese surgeon was selected from Tilganga and completed an 8-month fellowship and proctorship of the first series of surgeries. The refractive surgery unit was opened in January 2012, and the cost-recovery model was evaluated up to December 2016.

RESULTS

During the period evaluated, 74.8% of patients were treated at full cost, 17.2% at subsidized cost, and 8.6% free of charge. The refractive surgery unit generated a profit representing 28% of the running cost in this period, which was used to reduce the deficit of the main hospital. Surgical outcomes achieved were comparable to those reported by groups in the developed world.

CONCLUSION

A self-sustaining nonprofit laser refractive surgery clinic, operating with high quality, was successfully implemented supported by international donations for initial setup costs and a cost-recovery model thereafter.

Review of manual small-incision cataract surgery

Cataract surgery has undergone many changes with the size of incision progressively decreasing over time with an incision of 12.0 mm for intracapsular cataract extraction to 2.2–2.8 mm in phacoemulsification. However, phacoemulsification due to high cost and equipment maintenance cannot be employed widely in developing countries. Manual small-incision cataract surgery (MSICS) offers similar advantages with the merits of wider applicability, less time consuming, a shorter learning curve, and lower cost. MSICS can be performed in high-volume setups due to fast technique. Here, we review the various techniques, safety and efficacy of MSICS, and its progress and utility in developing and underdeveloped countries.

Cataracts

An estimated 95 million people worldwide are affected by cataract. Cataract still remains the leading cause of blindness in middle-income and low-income countries. With the advancement of surgical technology and techniques, cataract surgery has evolved to small-incisional surgery with rapid visual recovery, good visual outcomes, and minimal complications in most patients. With the development of advanced technology in intraocular lenses, the combined treatment of cataract and astigmatism or presbyopia, or both, is possible. Paediatric cataracts have a different pathogenesis, surgical concerns, and postoperative clinical course from those of age-related cataracts, and the visual outcome is multifactorial and dependent on postoperative visual rehabilitation. New developments in cataract surgery will continue to improve the visual, anatomical, and patient-reported outcomes. Future work should focus on promoting the accessibility and quality of cataract surgery in developing countries.

Value innovation: an important aspect of global surgical care

Introduction

Limited resources in low- and middle-income countries (LMICs) drive tremendous innovation in medicine, as well as in other fields. It is not often recognized that several important surgical tools and methods, widely used in high-income countries, have their origins in LMICs. Surgical care around the world stands much to gain from these innovations. In this paper, we provide a short review of some of these succesful innovations and their origins that have had an important impact in healthcare delivery worldwide.

Review

Examples of LMIC innovations that have been adapted in high-income countries include the Bogotá bag for temporary abdominal wound closure, the orthopaedic external fixator for complex fractures, a hydrocephalus fluid valve for normal pressure hydrocephalus, and intra-ocular lens and manual small incision cataract surgery. LMIC innovations that have had tremendous potential global impact include mosquito net mesh for inguinal hernia repair, and a flutter valve for intercostal drainage of pneumothorax.

Conclusion

Surgical innovations from LMICs have been shown to have comparable outcomes at a fraction of the cost of tools used in high-income countries. These innovations have the potential to revolutionize global surgical care. Advocates should actively seek out these innovations, campaign for the financial gains from these innovations to benefit their originators and their countries, and find ways to develop and distribute them locally as well as globally.

Outcome of an outreach microsurgical project in rural Nepal

PURPOSE

This study is aimed at evaluation of the outcome of an outreach program conducted in the remote Himalayan part of Nepal. Conclusions will be used to improve blindness prevention projects in this country.

METHODS

A temporary outreach microsurgical clinic was established in Diktel, Nepal. All patients who reported to the clinic were examined. Cases requiring surgical treatment, mostly cataracts, were operated on. Minor ocular diseases were treated on the spot, while the complicated ones were diagnosed, given initial treatment and referred to the nearest eye hospital.

RESULTS

Examination was performed on 1296 patients; 84 subjects underwent manual small incision cataract surgery with intraocular lens implantation. Intraoperative complications included 1 posterior capsule rupture (1.2%). Six weeks following the treatment 98.6% of the operated patients achieved corrected distance visual acuity of 0.3 or better. Out of all 1296 examined individuals, 224 (17.3%) presented visual impairment; 634 (24.5%) of the total number of eyes presented visual acuity of <0.3. In 90.2% of eyes the determinant of loss of sight was avoidable.

CONCLUSION

High percentage of avoidable blindness, with the majority caused by cataract and refractive errors alone, indicate that appropriate programs focused on these diseases should be implemented. High volume cataract surgery in a camp setting with the application of appropriate surgical techniques and standardized protocols of disinfection and sterilization do not have to compromise on the quality of the outcome.

Comparison of hospital versus rural eye cAMP based pediatric cataract surgery

Purpose:

To compare the outcomes of pediatric cataract surgery with intraocular lens (IOL) implantation in an eye camp setting and tertiary care center.

Materials and Methods:

Children aged 5-16 years with visually significant cataract underwent phacoaspiration with IOL implantation in an eye camp (eye camp group) or tertiary care center (TCC group). All surgeries incorporated contemporary microsurgical techniques with implantation of polymethyl-methacrylate (PMMA) IOL. Major postoperative complications were managed at a tertiary care center. Postoperative complications, visual acuity and compliance were evaluated using the Chi-square test. A P value less then 0.05 was considered as statistically significant.

Results:

The cohort comprised 59 children in the eye camp group and 48 children in the TCC group. Thirty two of fifty nine (54.23%) eyes in the eye camp group and 30/48 (62.5%) eyes in the TCC group achieved 20/40 or better best corrected visual acuity (BCVA) postoperatively. Postoperatively, 36 (61%) eyes in the eye camp group and 22 (45.83%) eyes in the TCC group required Nd: YAG laser capsulotomy or a pars plana membranectomy. (P> 0.05) The most striking feature was loss to follow up. In the eye camp group, loss to follow was 20% at one year, 49% at two years, 62% at 3 years and 67% at 4 years compared to 12.5, 21, 27 and 33% respectively in the TCC group (P<0.05, all cases).

Conclusions:

The outcomes of camp and tertiary care center (hospital) based pediatric cataract surgery were similar. However, the major drawback of camp based surgery was loss to follow up which eventually affected the management of amblyopia and postoperative complications.

Preoperative visual acuity of people undergoing cataract surgery in rural and urban Nepal

BACKGROUND

Preoperative presenting visual acuity (PPVA) is not a commonly reported indicator for the delivery of cataract services. This study aimed to evaluate the PPVA of patients undergoing cataract surgery in rural and urban areas of Nepal.

DESIGN

A prospective, non-interventional study conducted from October 2007 to March 2008 in a tertiary hospital and outreach clinics of Nepal.

PARTICIPANTS

A total of 3023 consecutive subjects from urban and rural settings (1323 from the tertiary hospital and 1700 from outreach clinics) with cataract were included.

METHODS

Visual acuity was tested with a Snellen E-chart at 6 m by ophthalmic assistants. All Outreach Microsurgical Eye Clinic patients were examined by either ophthalmologists or senior ophthalmic assistants. Patients at the Tertiary Eye Care Centre were examined only by ophthalmologists.

MAIN OUTCOME MEASURES

Preoperative presenting visual acuity of patients undergoing cataract surgery was measured in both the settings.

RESULTS

The sex ratio was 0.96 (male/female). Based on PPVA, 11.5% of patients operated were blind (PPVA < 3/60 in the better eye). The proportion of blind people operated was similar in rural (11.4%) to urban (11.6%) areas. The proportion of blind eyes operated was higher in rural (50.7%) compared to urban (38.9%) areas.

CONCLUSION

Despite a comparatively high volume of cataract surgery carried out in Nepal every year, only about one in eight patients operated for cataract in the sample population was blind. PPVA is an important indicator for the progress towards eliminating cataract blindness.

Visual outcome of manual small-incision cataract surgery: comparison of modified Blumenthal and Ruit techniques

AIM

To compare the efficacy and visual results of the modified Blumenthal and Ruit techniques for manual small-incision cataract surgery (MSICS).

METHODS

This was a prospective, non-randomized comparison of 129 patients with senile cataracts scheduled to undergo routine cataract surgery via either a superior scleral tunnel incision, i.e., the Blumenthal technique (group 1, n=64) or a temporal scleral tunnel incision, i.e., the Ruit technique (group 2, n=65). MSICS and intraocular lens implantation were performed through an unsutured 6.5- to 7.0-mm scleral tunnel incision. Uncorrected and corrected visual acuity, intraoperative and postoperative complications, and surgically induced astigmatism calculated by simple subtraction were compared. Patients were examined at 1 day, 1 week, 1 month, and 3 months after surgery.

RESULTS

Both groups achieved good visual outcome with minor complications. Three months after surgery, the corrected visual acuity was 0.73 in the Blumenthal group and 0.69 in the Ruit group (P=0.29). The average (SD) postoperative astigmatism was 0.87 (0.62) diopter (D) for the Blumenthal group and 0.86 (0.62) D for the Ruit group. The mean (SD) surgically induced astigmatism was 0.55 (0.45) D and 0.50 (0.44) D for the Blumenthal and Ruit groups, respectively (P=0.52). Common complications were minimal hyphema and corneal edema. There was no statistically significant difference in the complication rate between the groups (P>0.05).

CONCLUSION

In MSICS, both the Blumenthal and Ruit techniques achieved good visual outcomes, with low complication rates.

Sutureless large-incision manual cataract extraction using the kongsap technique: outcome of a prospective study

AIM

To report the short- and medium-term outcomes of sutureless large-incision manual cataract extraction using the Kongsap (SLIMCE-K) technique.

METHODS

This prospective study included 73 eyes of 73 patients who underwent cataract surgery performed by using the SLIMCE-K technique. The postoperative visual acuity, intraoperative and postoperative complications, and endothelial cell loss were evaluated. A follow-up visit, at least 6 months after the surgery, was included in the study.

RESULTS

All patients had improved visual acuity after surgery. Uncorrected visual acuity (UCVA) was 6/18 or better in 55 eyes (75.3%) at 1 week postoperatively and in 64 eyes (87.6%) at 6 weeks postoperatively (P=0.09). The best corrected visual acuity (BCVA) was 6/18 or better in 67 eyes (91.8%) at 1 week postoperatively and in 70 eyes (95.9%) at 6 weeks postoperatively. The results remained stable at 3 months and 6 months postoperatively. No significant intraoperative complications were encountered. The endothelial cell loss was 4.8% at the 3-month follow-up examination.

CONCLUSION

When performed by an experienced surgeon, SLIMCE-K is a safe and effective procedure that can be performed independent of phacoemulsification machines. It can be used in any nuclear grading of cataract hardness that is common in developing countries.

Intraocular lens power requirements for humanitarian missions

PURPOSE

To develop a generalized method to determine an optimum set of intraocular lens (IOL) powers for humanitarian missions.

SETTING

Humanitarian missions to Central America, South America, and Southeast Asia.

METHODS

Biometric data of adults who had cataract surgery on 2 humanitarian missions were reviewed, and the ideal emmetropic IOL power for each eye was calculated. Using statistical modeling, the number of extra IOLs required at each power to account for natural variation inherent in random population samples was calculated. To limit the total number of IOLs and maximize availability of suitable IOLs for each patient, a tolerance strategy for choosing IOL powers was developed and the ideal proportion of extra IOLs required at each power was empirically determined.

RESULTS

Data of 103 patients were reviewed. The mean IOL power was 20.38 diopters (D) +/- 2.32 (SD). Applying a tolerance strategy to accept IOLs with powers 0.5 D below or 1.0 D above the emmetropic IOL power, the number of extra IOLs required at each power was decreased to a fraction of the fourth root of the number of eyes anticipated to require that IOL power. The model predicted that with this strategy, fewer than 2% of all patients would be rejected due to lack of an IOL with a suitable power.

CONCLUSIONS

The spreadsheet-based IOL power prediction model calculated an ideal distribution of IOLs to order for humanitarian cataract surgery. It is generalizable to missions of any size and should help planners minimize costs while ensuring excellent refractive outcomes.

Cataract surgery for the developing world

PURPOSE OF REVIEW

To review surveys published within the last year concerning the prevalence of cataract blindness, rates of cataract surgical coverage and visual outcomes of cataract surgery in various developing countries, and to review recent studies that compare the different cataract surgical techniques used in developing countries.

RECENT FINDINGS

Up to 75% of blindness (visual acuity below 20/400) is due to cataract. Cataract remains the most common treatable cause of blindness. Reported cataract surgical coverage is low, and visual outcomes are poor and necessitate improvement. Phacoemulsification is the preferred technique for cataract surgery in developed countries, but large-scale implementation in developing countries may prove to be a challenge. An alternative surgical technique, manual sutureless small incision extracapsular cataract surgery, has been increasing in popularity, as the technique has been shown to yield similar surgical outcomes as phacoemulsification.

SUMMARY

Treating cataract blindness worldwide continues to be a formidable challenge. Significant barriers include cost, lack of population awareness, shortage of trained personnel and poor surgical outcomes. Both phacoemulsification and manual small incision extracapsular cataract surgery achieve excellent visual outcomes with low complication rates, but manual small incision extracapsular cataract surgery is significantly faster, less expensive and requires less technology. Therefore, manual small incision extracapsular cataract surgery may be the preferred technique for cataract surgery in the developing world.

Global Cost-effectiveness of Cataract Surgery

OBJECTIVE

To determine the cost-effectiveness of cataract surgery worldwide and to compare it with the cost-effectiveness of comparable medical interventions.

DESIGN

Meta-analysis.

PARTICIPANTS

Approximately 12,000 eyes in the studies selected.

METHODS

Articles were identified by searching the literature using the phrase cataract surgery, in combination with the terms cost, cost-effectiveness, and cost-utility. Terms used for the comparable medical interventions search included epileptic surgery, hip arthroplasty, knee arthroplasty, carpal tunnel surgery, and defibrillator implantation. The search was restricted to the years 1995 through 2006. Cataract surgery costs were converted to 2004 United States dollars (US$). Cost-utility was calculated using: (1) costs discounted at 3% for 12 years with a discounted quality-adjusted life years (QALY) gain of 1.25 years, and (2) costs discounted at 3% for 5 years with a discounted QALY gain of 0.143 years. The Cataract Surgery Affordability Index (CSAI) for each country was calculated by dividing the cost of cataract surgery by the gross national income per capita for the year 2004.

MAIN OUTCOME MEASURES

Cost-utility in 2004 US$/QALY and affordability of cataract surgery relative to the United States.

RESULTS

Cost-utility values for cataract surgery (first eye) varied from $245 to $22,000/QALY in Western countries and from $9 to $1600 in developing countries. In developed countries, the cost-effectiveness of cataract surgery estimated by Choosing Interventions That Are Cost Effective ranged from, in international dollars (I$), I$730 to I$2400/disability-adjusted life years (DALY) averted, and I$90 to I$370/DALY averted in developing countries. The CSAI varied from 17% to 189% in developed countries and 29% to 133% in developing countries compared with the United States. The cost-utility of other comparable medical interventions was: epileptic surgery, $4000 to $20,000/QALY; hip arthroplasty, $2300 to $4800/QALY; knee arthroplasty, $6500 to $12,700/QALY; carpal tunnel surgery, $140 to $280/QALY; and defibrillator implantation, $700 to $23,000/QALY.

CONCLUSIONS

The cost-utility of cataract surgery varies substantially, depending how the benefit is assessed and on the duration of the assumed benefit. Cataract surgery is comparable in terms of cost-effectiveness to hip arthroplasty, is generally more cost-effective than either knee arthroplasty or defibrillator implantation, and is cost-effective when considered in absolute terms. The operation is considerably cheaper in Europe and Canada compared with the United States and is affordable in many developing countries, particularly India.

The surgical management of cataract: barriers, best practices and outcomes

Cataract is the leading cause of blindness in the world. Cataract surgery has been shown by multiple studies to be one of the most cost-effective health interventions, and leads to a dramatic increase in quality of life and productivity for many patients. Though there has been marked improvement in the last several decades, surgical delivery services in developing nations are still suboptimal, and a large backlog in cataract cases continues to grow. To decrease this backlog, barriers to surgery, such as direct and indirect patient costs, geographic access to surgical facilities and surgeons, cultural factors, and patient education, must be addressed. In particular, access to services by women and rural patients needs to be improved. It is clear that extracapsular techniques are cost-effective and lead to better post-operative outcomes than intracapsular cataract extraction with aphakic correction. In addition, monitoring surgical outcomes is essential for improving the quality of surgical services. However, other issues regarding the delivery of cataract surgical services, including the role of average power intraocular lenses and the role of non-physician surgeons, are yet unresolved. Information about the true cost of surgery, including costs of surgeon training, equipment, and patient outreach programs, is needed so that the goal of self-sustaining programs may be obtained.

A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal

PURPOSE

To compare the efficacy and visual results of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery (SICS) for the treatment of cataracts in Nepal.

DESIGN

Prospective, randomized comparison of 108 consecutive patients with visually significant cataracts.

METHODS

settings: Outreach microsurgical eye clinic. patients: One hundred eight consecutive patients with cataracts were assigned randomly to receive either phacoemulsification or SICS. intervention Cataract surgery with implantation of intraocular lens. main outcome measures: Operative time, surgical complications, uncorrected and best-corrected visual acuity (BCVA), astigmatism, and central corneal thickness (CCT).

RESULTS

Both surgical techniques achieved excellent surgical outcomes with low complication rates. On postoperative day 1, the groups had comparable uncorrected visual acuity (UCVA) (P = 0.185) and the SICS group had less corneal edema (P = 0.0039). At six months, 89% of the SICS patients had UCVA of 20/60 or better and 98% had a best-corrected visual acuity (BCVA) of 20/60 or better vs 85% of patients with UCVA of 20/60 or better and 98% of patients with BCVA of 20/60 or better at six months in the phaco group (P = 0.30). Surgical time for SICS was much shorter than that for phacoemulsification (P < .0001).

CONCLUSION

Both phacoemulsification and SICS achieved excellent visual outcomes with low complication rates. SICS is significantly faster, less expensive, and less technology dependent than phacoemulsification. SICS may be the more appropriate surgical procedure for the treatment of advanced cataracts in the developing world.

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.

Treatment of vitreoretinal disorders in the developing world

PURPOSE

To examine the outcomes of vitreoretinal surgery for retinal disorders at Tilganga Eye Centre in Kathmandu, Nepal.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Records of 255 patients undergoing vitreoretinal surgery from December 2000 to January 2003 were reviewed.

METHODS

Demographics, diagnoses, duration of symptoms, vision, and examination findings were noted before and after vitreoretinal surgery.

MAIN OUTCOME MEASURES

Postoperative data were categorized by surgery type and analyzed by anatomic success, symptoms, and visual acuity (VA).

RESULTS

Sixteen percent of patients had >6/60 vision preoperatively, and the mean duration of vision loss before presentation was 4.9 months. Major indications for surgery were retinal detachment (RD) (75%) and vitreous hemorrhage (19%). Anatomic success was achieved in 74.5% of patients. Postoperatively, 39% of patients experienced improved VA, with 33% obtaining >6/60 vision.

CONCLUSIONS

Despite prolonged duration of vision loss at presentation, vitreoretinal surgery in the developing world can restore useful vision in many patients with RD and vitreous hemorrhage.

Optimal single intraocular lens power for the Nepali population

AIM

To evaluate optimal standard intraocular lens power for Nepalese eye camp cataract patients.

METHOD

A retrospective case series of 5109 preoperative cataract patients.

RESULTS

Average axial length of 23.08 (SD 1.26). Average dioptre intraocular lens power 21.37 (3.04).

CONCLUSION

An increase in the intraocular lens power used at Nepalese eye camps from +21.0 to 22.5 dioptres would improve overall visual outcome.

Pediatric cataract surgery in Nepal

PURPOSE

To describe the first pediatric cataract surgery case series report from Nepal.

SETTING

Tilganga Eye Center, Kathmandu, Nepal.

METHODS

This study comprised a consecutive series of 112 eyes of 85 children having cataract surgery with intraocular lens (IOL) implantation. General anesthesia of ketamine combined with peribulbar block was used in all patients. Patients' demographics, cataract type and presenting symptoms, surgical intervention, preoperative and postoperative visual acuities, and follow-up clinical examinations were recorded.

RESULTS

Seventy-three eyes (65.2%) of 53 patients had extracapsular cataract extraction with posterior capsulotomy, anterior vitrectomy, and posterior chamber IOL implantation (ECCE+PCAP+AV+PCIOL), and 39 eyes (34.8%) of 32 patients had cataract extraction and IOL implantation with an intact posterior capsule (ECCE+PCIOL). Of all patients, the mean age at surgery was 6.2 years +/- 4.3 (SD). The median age in the ECCE+PCAP+AV+PCIOL group was 4.7 years and in the ECCE+PCIOL group, 11.0 years. The mean follow-up was 5.4 +/- 5.3 months. The most common postoperative complication in the ECCE+PCIOL group was visual axis/posterior capsule opacification, which was seen in 18 eyes (46.2%) compared to 4 eyes (5.5%) in the ECCE+PCAP+AV+PCIOL group. Visual acuity improved with surgery in both groups. The leading cause of poor outcomes was deprivation amblyopia. There were no anesthesia-related complications.

CONCLUSIONS

Implantation of an IOL at the time of cataract extraction under combined systemic ketamine and peribulbar lidocaine anesthesia appeared to be well tolerated and produced significant visual improvement in pediatric patients in Nepal. Primary posterior capsulotomy and AV helped prevent visual axis opacification without a significant increase in complications.

Willingness to pay for cataract surgery in Kathmandu valley

AIM

A cross sectional study was carried out on 78 screened cataract patients of two screening camps in Kathmandu valley, Nepal, to assess the willingness to pay for cataract surgery.

METHODS

A non-probability sampling technique with open ended and close ended questionnaires was used.

RESULTS

The average age of patients was 68.8 years. The ratio of men and women was 0.9:1. 42.3% (33) of patients were willing to pay for cataract surgery. Among them 48.5% (16) of people were willing to pay less than dollars 13 and 51.5% (17) were willing to pay more than dollars 13. The mean was dollars 2.3 (SD dollars 15.5) per case. Patients with bilateral cataract were more willing to pay than unilateral cases. Poverty (44.4%, 20) was the main barrier for unwillingness to pay for cataract surgery. Other reasons were the lack of family support (28.9%, 13), lack of knowledge of surgery and belief that it was an unnecessary procedure (15.6%, seven), and waiting for a free surgical service (11.1%, five).

CONCLUSION

This study clearly indicates that although there was awareness of the availability of treatment and services provided within the reach, people are not willing to pay for the surgery and use the facility primarily because of poverty. Hence, to change patients' attitudes, a more holistic approach is needed, keeping in view the cultural, social, and economic background of the society.

Extracapsular cataract surgery compared with manual small incision cataract surgery in community eye care setting in western India: a randomised controlled trial

AIM

To study "manual small incision cataract surgery (MSICS)" for the rehabilitation of cataract visually impaired and blind patients in community based, high volume, eye hospital setting; to compare the safety and effectiveness of MSICS with conventional extracapsular cataract surgery (ECCE).

METHODS

In a single masked randomised controlled clinical trial, 741 patients, aged 40-90 years, with operable cataract were randomly assigned to receive either MSICS or ECCE and operated upon by one of eight participating surgeons. Intraoperative and postoperative complications were graded and scored according to the Oxford Cataract Treatment and Evaluation Team recommendations. The patients were followed up at 1 week, 6 weeks, and 1 year after surgery and their visual acuity recorded.

RESULTS

This paper reports outcomes at 1 and 6 weeks. 706 of the 741(95.3%) patients completed the 6 week follow up. 135 of 362 (37.3%) of ECCE group and 165 of 344 (47.9%) of MSICS group had uncorrected visual acuity of 6/18 or better after 6 weeks of follow up. 314 of 362 (86.7%) of ECCE group and 309 of 344 (89.8%) of MSICS group had corrected postoperative vision of 6/18 or better. Four of 362 (1.1%) of ECCE group and six of 344 (1.7%) of MSICS group had corrected postoperative visual acuity less than 6/60. There were no significant differences between the two groups for intraoperative and severe postoperative complications.

CONCLUSION

MSICS and ECCE are both safe and effective techniques for treatment of cataract patients in community eye care settings. MSICS needs similar equipment to ECCE, but gives better uncorrected vision.

Small-incision manual extracapsular cataract surgery in Ghana, West Africa

PURPOSE

To evaluate the results of small-incision manual extracapsular cataract extraction surgery (ECCE) in a district hospital in West Africa.

SETTING

Margret Marquart Catholic Hospital, Ghana, West Africa.

METHODS

This prospective study consisted of 200 eyes of 193 patients who had small-incision manual ECCE between January 1999 and May 2000. For comparison, the charts of 32 patients (32 eyes) operated on between July and December 1998 using a limbal incision (control group) were retrospectively analyzed. Outcome measures included intraoperative and postoperative complications, postoperative visual acuity, and refractive astigmatism.

RESULTS

In the small-incision ECCE group, self-sealing wounds were achieved in 129 eyes (64.5%). Vitreous loss occurred in approximately 3% of eyes in both the small-incision and control groups. The final visual acuities were similar between the 2 groups, with more than 90% of eyes in both groups achieving a final best corrected visual acuity of at least 20/60. Eyes in the small-incision group had faster visual recovery (P <.001), a lower incidence of fibrinous iritis (P =.02), and were more likely to have round pupils (P <.001) than eyes in the control group. The main complication of small-incision surgery was moderate corneal edema, which persisted until at least the 1-week visit in 14 eyes (7%). At the most recent visit, 1 eye in the small-incision group (0.5%) had bullous keratopathy.

CONCLUSION

In a district hospital in West Africa, small-incision manual ECCE surgery yielded faster visual rehabilitation and had a lower incidence of fibrinous iritis than standard ECCE surgery.