Refractive error following cataract extraction with the implantation of a standard power intraocular lens in a rural African blindness prevention programme

Outcomes of manual small-incision cataract surgery using standard 22 dioptre intraocular lenses at Nkhoma Eye Hospital, Malawi

The aim of this study was to investigate the outcomes of sutureless, manual small-incision cataract surgery (SICS) in rural sub-Saharan Africa using standard intraocular lenses (IOLs). In order to assess the quality of surgery, we prospectively evaluated the visual outcomes of 1455 consecutive cataract operations performed in 2006 in patients ≥40 years at Nkhoma Eye Hospital, Malawi. All operations used standard 22-dioptre IOLs without pre-operative biometry. Outcomes were categorised according to the World Health Organization criteria, and causes of a poor outcome were recorded. Mean age of patients was 71.5 ± 9.5 years, and 53 % were female. Pre-operatively, 64 % of eyes had a visual acuity (VA) <6/60, and 41.3 % of eyes were blind (VA < 3/60). Without correction (uncorrected VA), nearly eighty percent (78.7 %) achieved a 'good' outcome (VA 6/6-6/18), 19.8 % were 'borderline' (VA < 6/18-6/60), and 1.5 % had a poor (VA < 6/60) outcome. With pinhole-correction, the proportion of good outcomes increased to 89.4 %, and poor outcomes decreased to 0.9 %. Poor outcomes were most commonly due to ocular co-morbidities (54.5 %) and refractive error (36.4 %). Older age and pre-operative blindness were strongly associated with borderline or poor visual outcomes. The most common surgical complication was posterior capsule tear (without vitreous loss). In a rural African environment, using standard IOL power plus SICS can lead to a high proportion of good outcomes and a low frequency of surgical complications. A comparative study is required to determine if any additional benefit in visual outcomes can be gained by the addition of biometry.

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.