Operated and unoperated cataract in Australia

A longitudinal analysis of factors associated with age-related cataract among older Australian women: a cohort study of 7851 older Australian women 79-90 years

BACKGROUND

Age-related cataracts are a significant global health issue due to population ageing. More than 70% of older Australians aged 80 or above have clinically significant age-related cataracts.

AIM

The study aimed to identify factors associated with age-related cataracts among older Australian women 79-90 years.

METHOD

A 6-year longitudinal analysis of the Australian Longitudinal Study on Women's Health (ALSWH) was conducted on 7117 women from surveys four to six. The women were asked whether they had been diagnosed or treated for cataracts 3 years before each survey. We used generalised estimating equation (GEE) modelling to identify factors independently associated with age-related cataracts.

RESULTS

At baseline (79-84 years), 44.8% lived in metropolitan Australia, 67.9% had good general health, 26.5% had private health insurance, 30.6% had cataracts, 28.8% had undergone cataract surgery, 12.0% had diabetes, 24.9% had skin cancer, 56.2% had hypertension, 24.0% had a history of falls, 63.0% had visited general practitioner (GP) frequently, and 48.8% were driving themselves as their main means of transport. In the final model, poor general health [adjusted odds ratio (AOR) = 1.23, 95% CI = 1.14, 1.33)], not driving (AOR = 1.09, 95% CI = 1.01, 1.18), having private health insurance (AOR = 1.13, 95% CI = 1.04, 1.23), frequent GP visits (AOR = 1.16, 95% CI = 1.07, 1.25), skin cancer (AOR = 1.26, 95% CI = 1.16, 1.37), hypertension (AOR = 1.13, 95% CI = 1.05, 1.21), and fall (AOR = 1.12, 95% CI = 1.04, 1.22) were significantly associated with the age-related cataracts.

CONCLUSIONS

Systemic diseases, poor quality of life, driving cessation, and health service use were significantly associated with age-related cataracts in older women.

Population-based assessment of visual acuity outcomes following cataract surgery in Australia: the National Eye Health Survey

AIM

To assess the visual outcomes of cataract surgery among a national sample of non-Indigenous and Indigenous Australians.

METHODS

This was a population-based study of 3098 non-Indigenous Australians (50-98 years) and 1738 Indigenous Australians (40-92 years), stratified by remoteness. A poor postoperative outcome in an eye that had undergone cataract surgery was defined as presenting distance visual acuity (PVA) <6/12-6/60, and a very poor outcome was defined as PVA <6/60. Effective cataract surgery coverage (eCSC; operated cataract and a good outcome (PVA ≥6/12) as a proportion of operable plus operated cataract) was calculated.

RESULTS

The sampling weight adjusted cataract surgery prevalence was 19.8% (95% CI 17.9 to 22.0) in non-Indigenous Australians and 8.2% (95% CI 6.0 to 9.6) in Indigenous Australians. Among the non-Indigenous population, poor and very poor PVA outcomes were present in 18.1% and 1.9% of eyes, respectively. For Indigenous Australians, these values were 27.8% and 6.3%, respectively. The main causes of poor vision were refractive error (non-Indigenous=41.8%; Indigenous=41.9%) and coincident disease (non-Indigenous=43.3%; Indigenous=40.3%). The eCSC rates in the non-Indigenous and Indigenous populations were 88.5% (95% CI 85.2 to 91.2) and 51.6% (95% CI 42.4 to 60.7), respectively.

CONCLUSION

Approximately half of eyes with a poor visual outcome postcataract surgery could be readily avoided through the appropriate refractive correction. The finding of a lower eCSC rate among Indigenous Australians suggests that improvements in access and quality of cataract services may be warranted in order to reduce cataract-related vision loss in the Indigenous population.

Multiple deprivation, vision loss, and ophthalmic disease in adults: global perspectives

The association between socioeconomic position and morbidity and mortality has long been recognized. We evaluate the evidence for an association between multiple aspects of deprivation and ocular health in a global context. This is a systematic review of studies that evaluated deprivation in the adult population in the context of the major acquired causes of visual loss such as cataract, diabetic eye disease, glaucoma, age-related macular degeneration, and ocular trauma. The search strategy identified relevant studies reported between 1946 and August 2016, with randomized control trials, case-control, cohort, and cross-sectional study designs being selected for inclusion. The studies identified in this review from across the world demonstrate the extent to which the common themes such as low educational attainment and low income may be associated with increased incidence of various sight-threatening conditions and may adversely affect access to specialist assessment and delivery of treatment. Health inequality may always persist, but an increased recognition of the importance of the various impacts of deprivation may empower policy makers to target limited resources to the most vulnerable groups in order to deliver the greatest benefit.

Cataract surgery coverage rates for Indigenous and non-Indigenous Australians: the National Eye Health Survey

OBJECTIVE

To determine cataract surgery coverage rates for Indigenous and non-Indigenous Australians.

DESIGN

National cross-sectional population-based survey.

SETTING

Thirty randomly selected Australian geographic sites, stratified by remoteness.

PARTICIPANTS

3098 non-Indigenous Australians aged 50 years or more and 1738 Indigenous Australians aged 40 years or more, recruited and examined in the National Eye Health Survey (NEHS) between March 2015 and April 2016.

METHODS

Participants underwent an interviewer-administered questionnaire that collected socio-demographic information and past ocular care history, including cataract surgery. For those with visual acuity worse than 6/12, anterior segment photography and slit lamp examinations were conducted.

MAIN OUTCOME MEASURES

Cataract surgery coverage rates according to WHO and NEHS definitions; associated risk factors.

RESULTS

Cataract surgery coverage rates calculated with the NEHS definition 1 of vision impairment (visual acuity worse than 6/12) were lower for Indigenous than non-Indigenous participants (58.5% v 88.0%; odds ratio [OR], 0.32; P < 0.001). According to the World Health Organization definition (eligibility criterion: best-corrected visual acuity worse than 6/18), coverage rates were 92.5% and 98.9% for Indigenous and non-Indigenous Australians respectively. Greater age was significantly associated with higher cataract surgery coverage in Indigenous (OR, 1.41 per 10 years; P = 0.048) and non-Indigenous Australians (OR, 1.58 per 10 years; P = 0.004).

CONCLUSIONS

The cataract surgery coverage rate was higher for non-Indigenous than Indigenous Australians, indicating the need to improve cataract surgery services for Indigenous Australians. The WHO definition of the coverage rate may overestimate the cataract surgery coverage rate in developed nations and should be applied with caution.

Risk of cataract among subjects with acquired immune deficiency syndrome free of ocular opportunistic infections

PURPOSE

To evaluate the risk of cataract in the setting of AIDS.

DESIGN

Prospective cohort study.

PARTICIPANTS

Subjects with AIDS free of ocular opportunistic infections throughout catamnesis.

METHODS

From 1998 through 2008, subjects 13 years of age or older were enrolled. Demographic characteristics and clinical characteristics were documented at enrollment and semiannually.

MAIN OUTCOME MEASURES

Cataract was defined as high-grade lens opacity observed by biomicroscopy judged to be the cause of a best-corrected visual acuity worse than 20/40. Eyes that underwent cataract surgery during follow-up were considered to have developed cataract before the first visit when pseudophakia or aphakia was observed.

RESULTS

Among 1606 participants (3212 eyes) at enrollment, 1.9% (95% confidence interval [CI]: 1.3%-2.7%) were observed to have cataract or prior cataract surgery. Among the 2812 eyes initially free of cataract and followed longitudinally (median follow-up, 4.6 years), the incidence of cataract was 0.37%/eye-year (95% CI: 0.26%-0.53%). In addition to age, significant cataract risk factors included prior cataract in the contralateral eye (adjusted hazard ratio [aHR], 21.6; 95% CI: 10.4-44.8), anterior segment inflammation (aHR, 4.40; 95% CI: 1.64-11.9), prior retinal detachment (aHR, 4.94; 95% CI: 2.21-11.0), and vitreous inflammation (aHR, 7.12; 95% CI: 2.02-25.0), each studied as a time-updated characteristic. Detectable human immunodeficiency virus RNA in peripheral blood was associated with lower risk of cataract at enrollment (adjusted odds ratio, 0.32; 95% CI: 0.12-0.80) but not of incident cataract (aHR, 1.58; 95% CI: 0.90-2.76). After adjustment for other factors, neither the then-current absolute CD4+ T-cell count nor antiretroviral therapy status showed consistent association with cataract risk, nor did an additive diagnosis of other comorbidities. Compared with the available population-based studies that used similar definitions of cataract, the age-specific prevalence of cataract in our cohort was higher than in 1 of 2 such studies, and the age-specific incidence of cataract surgery was higher.

CONCLUSIONS

Our results suggest cataract may occur earlier among patients with AIDS free of ocular opportunistic infections than in the general population. Cataract risk was associated most strongly with age and with other ocular morbidity in this population. With improved survival, the burden of cataract likely will increase for persons with the human immunodeficiency virus or AIDS.

Radiation Dose Responses, Thresholds, and False Negative Rates in a Series of Cataract Surgery Prevalence Studies among Atomic Bomb Survivors

In order to find imperfect sensitivity or the false-negative rate of cataract surgery due to latent clinically significant or severe cataract and a dose-response threshold, cataract surgery prevalence data analysis was made for each of the two-year periods from 1986 through 2005 among atomic bomb survivors. Using the latent variable regression model published earlier, cataract prevalence studies allowing for false-negative and/or false-positive rates were conducted in each of the 10 two-year periods during 1986 to 2005. As the best statistical model for prevalence data, a logistic model with a non-negligible false negative rate was selected for analysis. The commonly used naïve logistic analysis resulted in an average odds ratio (OR) at 1 Gy of 1.33 (95%CI: 1.28, 1.38) for cataract surgery with no linear time trend (p = 0.334), and the OR at 1 Gy with the model allowing for sensitivity was 1.48 (95%CI: 1.40, 1.56) for clinically significant or severe cataract with no linear time trend (p = 0.263). Cataract surgery is an imperfect surrogate for clinically significant cataract, and the sensitivity increased from 0.15 to 0.50 during the 20 y with increasing rate of sensitivity per 2-y period of approximately 22%. The dose-response threshold based on a naïve logistic model for cataract surgery ranged from 0.04-1.03 Gy (simple average of 0.41 Gy) with no linear time trend (p = 0.620) in the 10 2-y periods compatible with the no dose response threshold model in all periods.

Cataract surgery in developing countries

PURPOSE OF REVIEW

To review the previous year's literature related to cataract surgery in developing countries and to provide fast, up-to-date information to the scientific world.

RECENT FINDINGS

Cataract is the leading cause of blindness, especially in developing countries. The prevalence of cataract increases with the aging population. Although cataract surgery is the most cost-effective intervention, its delivery in developing countries has many issues and challenges. A paradigm shift has occurred in the surgical techniques used for delivering cataract services and the outcomes have been positive in some countries compared to the scenario a decade ago. However, in some parts of Africa, it still continues to be a challenge. Apart from this, the issues related to ongoing supply of consumables and human resources continue to be a challenge in these countries.

SUMMARY

Although manual small incision cataract surgery is the most cost-effective intervention, there are other issues related to the delivery of services in developing countries. We need to plan a comprehensive strategy to deliver the services in developing countries if we want to achieve our goal of VISION 2020.

Prevalence of chronic ocular diseases in a genetic isolate: the Norfolk Island Eye Study (NIES)

PURPOSE

Over 40% of the permanent population of Norfolk Island possesses a unique genetic admixture dating to Pitcairn Island in the late 18(th) century, with descendents having varying degrees of combined Polynesian and European ancestry. We conducted a population-based study to determine the prevalence and causes of blindness and low vision on Norfolk Island.

METHODS

All permanent residents of Norfolk Island aged ≥ 15 years were invited to participate. Participants completed a structured questionnaire/interview and underwent a comprehensive ophthalmic examination including slit-lamp biomicroscopy.

RESULTS

We recruited 781 people aged ≥ 15, equal to 62% of the permanent population, 44% of whom could trace their ancestry to Pitcairn Island. No one was bilaterally blind. Prevalence of unilateral blindness (visual acuity [VA] < 6/60) in those aged ≥ 40 was 1.5%. Blindness was more common in females (P=0.049) and less common in people with Pitcairn Island ancestry (P<0.001). The most common causes of unilateral blindness were age-related macular degeneration (AMD), amblyopia, and glaucoma. Five people had low vision (Best-Corrected VA < 6/18 in better eye), with 4 (80%) due to AMD. People with Pitcairn Island ancestry had a lower prevalence of AMD (P<0.001) but a similar prevalence of glaucoma to those without Pitcairn Island ancestry.

CONCLUSIONS

The prevalence of blindness and visual impairment in this isolated Australian territory is low, especially amongst those with Pitcairn Island ancestry. AMD was the most common cause of unilateral blindness and low vision. The distribution of chronic ocular diseases on Norfolk Island is similar to mainland Australian estimates.

Cataract in indigenous Australians: the National Indigenous Eye Health Survey

BACKGROUND

To determine the prevalence of vision loss due to cataract in indigenous Australians.

METHODS

A national, stratified, random cluster sample was selected in 30 communities across Australia. Data collection was undertaken in 2008. Adults 40 years and older were examined using a standardized protocol that included a questionnaire. The presence of visually significant cataract was assessed.

RESULTS

Response rates were good and 1189 indigenous adults were examined and overall recruitment was 72%. Low vision (<6/12-6/60) due to cataract occurred in 2.52% (1.63-3.41%) and blindness (<6/60) in 0.59% (95% CI: 0.24-1.21%). The cataract coverage rate (proportion of those with visually significant cataract who had been operated on) was 65.3% (95% CI: 55.0-74.6%). Projections suggest that there are 3234 indigenous adults with vision loss from cataract.

CONCLUSIONS

Cataract remains a major cause of vision loss in Aboriginal and Torres Strait Islander peoples. There were no significant regional or state differences in the prevalence of cataract or of cataract surgical coverage, which suggests that increased cataract surgery services are required across the country to address cataract in indigenous Australians.

Psychometric properties of visual functioning index using Rasch analysis

PURPOSE

The visual functioning index (VFI) was one of the first questionnaires developed using classical test theory to assess outcomes of cataract surgery. However, it was not Rasch-validated. The objective of this study was to examine the psychometric properties of the VFI using Rasch analysis in patients with cataract.

METHODS

The 11-item VFI was self-administered to 243 patients (mean age 73.9 years) drawn from a cataract surgery waiting list. We examined the response category thresholds, item fit statistics, differential item functioning and unidimensionality for the VFI and its three subscales.

RESULTS

Category thresholds were ordered. The person separation and reliability were low, indicating the poor discriminatory ability of the VFI. No items misfit but there was suboptimal targeting of item difficulty to patient ability. On the whole the items in the VFI were too easy for the sample. Only one item showed moderate differential item functioning.

CONCLUSION

The VFI does not meet the stringent requirements of the Rasch model. However adding more items to suit the more able patients with cataract as well as those awaiting second-eye cataract surgery could optimize the VFI.

Prevalence of major eye diseases and causes of visual impairment in the adult Finnish population: a nationwide population-based survey

PURPOSE

To estimate the prevalence of cataract, glaucoma, age-related maculopathy (ARM) and diabetic retinopathy (DR) in the adult Finnish population.

METHODS

A representative cross-sectional sample of the Finnish population aged 30 years and older. Of the 7979 eligible people, 7413 (93%) were interviewed and/or examined. The interview included self-reported doctor-made diagnoses of cataract, glaucoma, degenerative fundus changes (mainly ARM) or DR. Information on self-reported eye diseases was complemented with data from national registers, and case records were gathered for non-participants and persons with visual acuity (VA) < 0.5 or reporting difficulties in vision or eye diseases without assessed VA.

RESULTS

Based on self-reported and/or register-based data the estimated total prevalences of cataract, glaucoma, ARM and DR in the study population were 10%, 5%, 4% and 1%, respectively. All these chronic eye diseases increased with age (p < 0.001). The corresponding prevalences for persons aged 65 and older were 34%, 13%, 12% and 2%, respectively. Cataract and glaucoma were more common in women than in men [odds ratio (OR) 1.55, 95% confidence interval (CI) 1.26-1.91; OR 1.57, 95% CI 1.24-1.98, respectively]. The most prevalent eye diseases in people with visual impairment (VA < or = 0.25) were ARM (37%), unoperated cataract (27%), glaucoma (22%) and DR (7%).

CONCLUSION

The high prevalence of these mainly age-related eye diseases, together with increasing life expectancy, mean that continuous efforts are needed to identify and treat eye diseases in order to maintain patients' quality of life and to alleviate the social and economic burden of serious eye diseases.

Cataract in central Sri Lanka: prevalence and risk factors from the Kandy Eye Study

PURPOSE

To estimate the prevalence of and risk factors for cataracts in the Kandy District of central Sri Lanka.

METHODS

A population-based, cross-sectional ophthalmic survey of the inhabitants of rural villages in central Sri Lanka was conducted; 1375 individuals participated (79.9%; age > or = 40 years, average age 57) and 1318 (95.9%) had an examinable lens in at least one eye. Data collection included district, age, occupation, education level, smoking history, height, weight and dilated lens assessment using Lens Opacities Classification System III grading: nuclear (> or =4), cortical (> or =2) and posterior subcapsular (> or =2) cataracts. Aphakic and pseudophakic eyes were included as operated cataracts for statistical analysis.

RESULTS

The prevalence of any cataract including operated eyes was 33.1% (95% Confidence Interval (CI), 22.4-43.7%): 26.0% cortical; 7.9% posterior sub-capsular and 4.5% nuclear cataracts. No significant association was found between cataract and gender, smoking or outdoor occupation. Low level of education (secondary or higher vs no education: Odds Ratio (OR) 0.6, CI 0.4-0.9, P = 0.04) and shorter stature were associated with a higher likelihood of any cataract (OR 1.7, CI 1.1-2.7, P = 0.02).

CONCLUSIONS

The overall prevalence of cataract in central Sri Lanka is similar to that in other developing Asian regions except for the unusually low prevalence of nuclear cataract. Illiteracy and height appear to be significant predictors for cataract in this population and further investigation is required to explore their influence.

Prevalence and outcomes of cataract surgery in Brazil: the São Paulo eye study

PURPOSE

To investigate the prevalence and visual acuity (VA) outcomes of cataract surgery in a low- to middle-income population in São Paulo, Brazil.

DESIGN

Population-based, cross-sectional study.

METHODS

Cluster sampling was used in randomly selecting those > or =50 years old for VA measurement, refraction, and ocular examination. Participants were queried as to the year and type of facility for previous cataract surgery. Surgical procedure and evidence of surgical complications were noted. Main outcome measures were presenting and best-corrected vision, and the principal cause for eyes presenting with VA < or =20/40.

RESULTS

A total of 4,224 eligible persons were enumerated and 3,678 (87.1%) were examined. The prevalence of cataract surgery was 6.28% (95% confidence interval [CI], 5.29% to 7.27%). Surgical coverage for presenting VA <20/63 in both eyes because of cataract was 61.4%. Unoperated cataract impairment/blindness was associated with older age and lack of schooling. Among the 352 cataract-operated eyes, 41.2% presented with VA >20/40, 28.1% with VA 20/40 to 20/63, 14.2% with VA <20/63 to 20/200, and 16.5% with VA <20/200. With best correction, the percentages were 61.9%, 17.6%, 8.2%, and 12.2%. Intraocular lenses were found in 90.6% of cataract-operated eyes; half appeared to have been operated by phacoemulsification. Refractive error and retinal disorders were the main cause of vision impairment/blindness in operated eyes.

CONCLUSIONS

Cataract surgery has increased in São Paulo, but many remain visually impaired/blind because of cataract. Refractive error and other causes of impairment are common in cataract-operated eyes. Emphasis on the quality of VA outcomes and sustained government subsidy to provide access to affordable modern cataract surgery are needed.

The Etiology of Steroid Cataract

Steroid-induced posterior subcapsular cataracts (PSCs) exhibit three main distinctive characteristics: (i) association only with steroids possessing glucocorticoid activity, (ii) involvement of aberrant migrating lens epithelial cells, and (iii) a central posterior location. The first characteristic suggests a key role for glucocorticoid receptor activation and subsequent changes to the transcription of specific genes. Glucocorticoid receptor activation is associated in many cell types with proliferation, suppressed differentiation, a reduced susceptibility to apoptosis, altered transmembrane transport, and enhancement of reactive oxygen species activity. Glucocorticoids may be capable of inducing changes to the transcription of genes in lens epithelial cells that are related to many of these cellular processes. This review examines the various mechanisms that have been proposed to account for the development of PSC in the context of recent DNA array studies. Additionally, given that the glucocorticoid receptor can also engender wide-ranging indirect activities, glucocorticoids could also indirectly affect the lens through the responses of other cells within the ocular compartment and/or through effects on cells at more remote locations. These indirect mechanisms, which, for example, could be mediated through alterations to the intraocular levels of growth factors that normally orchestrate lens development and maintain lens homeostasis, are also discussed. Although the mechanism of steroid cataract induction remains unknown, glucocorticoid-induced gene transcription events in lens epithelial cells, and also other intraocular or systemic cells, likely interact to generate steroid cataracts. Finally, although evidence for glucocorticoid-protein adduct formation in the lens is inconclusive, the generation of such adducts cannot yet be discounted as a contributing factor and must necessarily be retained in discussions of the etiology of steroid cataract.

Ten-year incidence of age-related cataract and cataract surgery in an older Australian population. The Blue Mountains Eye Study

PURPOSE

To estimate the 10-year incidence of cataract and cataract surgery in an older Australian population.

DESIGN

Prospective population-based study.

PARTICIPANTS

Persons at least 49 years old living in 2 postcode areas west of Sydney, Australia.

METHODS

Eye examinations were performed at baseline and at 5- and 10-year follow-up visits. Lens photographs were taken and graded by masked graders using the Wisconsin Cataract Grading System.

MAIN OUTCOME MEASURES

Incidences of nuclear cataract, cortical cataract, posterior subcapsular cataract (PSC), and cataract surgery.

RESULTS

Ten-year person-specific incidences were 36.0% for nuclear cataract, 28.0% for cortical cataract, 9.1% for PSC, and 17.8% for cataract surgery. Corresponding rates were 31.7%, 24.4%, 8.2%, and 14.4%, respectively, in men and 39.3%, 30.8%, 9.8%, and 20.1%, respectively, in women. The incidence for each type of cataract and cataract surgery was positively associated with age (P<0.0001). Women had a significantly higher incidence than men for nuclear cataract (P = 0.04), cortical cataract (P = 0.007), any cataract (P = 0.0006), and cataract surgery (P = 0.03) after adjusting for age. There was no significant gender difference for PSC. The mean age at cataract surgery was 75.8 years, and there was no significant gender difference (P = 0.9). Among persons who developed any cataract, 22% had more than one type and 1.3% had all 3 types present. Nuclear cataract and PSC were significantly associated with visual impairment (visual acuity worse than 20/40).

CONCLUSION

Age- and gender-specific cataract incidences in this study were similar to those reported from the U.S. Beaver Dam Eye Study. In this study, 72% of the participants were affected by cataract or had had cataract surgery over the 10-year follow-up period.

Remote Indigenous Australians with cataracts: they are blind and still can't see

Aboriginal and Torres Strait Islander people are three times more likely than non-Indigenous Australians to report vision loss due to cataracts, but are four times less likely to have cataract surgery. To increase access for Aboriginal and Torres Strait Islander people to cataract surgery, we need to identify the barriers to current services and trial strategies to overcome these barriers. Barriers to cataract surgery exist at the health service, community and individual level. Health service factors include infrastructure, cost, and provision of interpreters, escorts and transport. Community factors include social support, perceptions about the success of surgery, and beliefs about the causes of cataracts. Individual factors include ignorance that cataracts can be cured, fear of surgery or poor outcome, and comorbidity. Strategies proven to increase uptake of cataract surgery in other countries could be trialled in remote Australia.

Socioeconomic and rural differences for cataract surgery in Western Australia

BACKGROUND

To examine the relationship between socioeconomic factors, residential locality and cataract surgery incidence.

METHODS

This was a population-based study using the Western Australian Data Linkage System to identify all cataract operations performed in patients aged 50+ years in 1996 and 2001. Patients' residential addresses at the time of operation were geocoded to census localities. Using census-derived indices, procedures were categorized into socioeconomic groups and residential locations (metropolitan and rural). Poisson regression was used to analyse for differences in procedure rates.

RESULTS

The crude cataract surgery rate in Western Australia increased from 4458 to 6631 procedures per million person-years between 1996 and 2001. Female and older patients underwent more surgery. Metropolitan residents were more likely to undergo surgery compared with rural residents; a difference that increased by 17% between 1996 and 2001 (1996: incidence rate ratio [IRR] 1.07, 95% confidence interval [CI] 1.02-1.13; 2001: IRR 1.24, 95% CI 1.18-1.29). A pronounced 'U-shaped' pattern of difference had developed for socioeconomic disadvantage by 2001. The most advantaged underwent 9% more surgery than the most disadvantaged. Rates in the middle two groups were less than the lowest one.

CONCLUSION

There was growing inequity in the rates of cataract surgery for rural and poorer patients between 1996 and 2001. These differences partly reflect the increasingly two-tiered Australian health system with more privately provided cataract surgery in urban areas.

Public versus private patient priorities and satisfaction in cataract surgery

BACKGROUND

Despite strong stereotypes of differences, few studies have compared private and public patient priorities and satisfaction, and none in the context of cataract surgery. The objective of this study was to compare samples of private and public patients undergoing day-stay cataract surgery.

METHODS

Forty-two public patients and 39 private patients were asked to rate the importance of 13 domains that prior research has shown to influence patient satisfaction. Patients were also asked about their waiting time, amount of information they received, and current and expected VF-14 functional ability. One month after surgery, patients recorded their satisfaction with each of the 13 domains.

RESULTS

Public patients waited ninefold longer for surgery and had lower preoperative visual function. Nonetheless both groups expected, and achieved, the same level of postoperative outcome. Although 90% of private patients were satisfied with the information they received regarding the surgery, 45% of public patients wanted more. There were significant differences in priorities between private and public patients. After surgery, public patients were less satisfied than private patients, although when accounting for the importance as well as satisfaction of each factor, the level of satisfaction between groups was not different.

CONCLUSIONS

The dearth of information received by public patients raises important questions whether their surgery decision was sufficiently individualized or adequately consented. Patient satisfaction is an important health outcome, and understanding both the domains of satisfaction, as well as their relative importance to patients, is necessary to improve the overall quality of patient care.

Utilization of eye care services by Victorians likely to benefit from eye care

AIM

To assess the utilization of eye care services by Australians most likely to benefit from eye assessment.

METHODS

The Melbourne Visual Impairment Project was a population-based study that collected demographic, health and vision-related information including use of eye care services. A standardized detailed ophthalmic examination was performed. Utilization of eye care services by those who might most benefit from eye care was assessed and compared to the general population. These participants include those with undiagnosed glaucoma, unoperated visually significant cataract, undercorrected refractive error, diabetes mellitus, age-related macular degeneration and visual acuity < 6/12. Sociodemographic characteristics were assessed for their influence on eye care utilization among these participants.

RESULTS

A total of 4744 urban and rural residents participated (86% of those eligible) and 4612 (83% of total eligible) of these had a complete data set for the use of eye care services and were included. There were 933 participants (20.2%) who did not report eye assessment in the previous 5 years, and 891 participants (19.3%) had one or more aforementioned conditions potentially benefiting from eye care. Of these, between 34.4% and 59.4% reported no examination in the previous year and between 9% and 25% reported no examination within the previous 5 years. These participants were more likely to seek eye care within the short term (1 year) if they had a family history of eye disease, otherwise a noticed change in vision was the main influence in the longer term (2-5 years). Male participants, younger participants and those whose main spoken language was not English were less likely to seek eye care in the longer term.

CONCLUSIONS

In Victoria 19% of those >40 years of age have potentially unmanaged eye disease including glaucoma, unoperated visually significant cataract, undercorrected refractive error, age-related macular degeneration, diabetes mellitus or visual acuity < 6/12. A substantial proportion of these report no eye assessment in the previous 1, 2 or 5 years or ever before. Younger age, male sex and main language other than English make assessment less likely. Many may have these conditions despite having had a recent eye assessment.

Systemic and ocular comorbidity of cataract surgical patients in a western Sydney public hospital

BACKGROUND

This study aimed to assess the frequency of major systemic and ocular comorbidities among cataract surgical patients attending a large general public hospital.

METHODS

Consecutive patients aged 60+ years who had undergone cataract surgery at Westmead Hospital from July 2001 to December 2002 were included. Preoperative information was obtained from patient medical records.

RESULTS

A total of 773 cataract surgical procedures were performed during the 18-month period, including 668 (86.4%) aged 60+ years. Complete data were available for 653 eyes (97.8%); 62.2% were women. The mean age at surgery was 74.6 (+/- 7.2) years. Frequent systemic comorbidities included: angina (20.2%), previous myocardial infarct (15.0%), diabetes (27.5%) and hypertension (56.3%); 12.5% were current smokers. Major preoperative ocular comorbidities included age-related maculopathy (12.6%), diabetic retinopathy (9.0%) and glaucoma (10.6%). Preoperatively, 21.7% of this group had severe visual impairment (visual acuity [VA] <6/60), 30.6% had moderate impairment (VA <6/24 ->or=6/60) and 30.6% had mild impairment (VA <6/12 ->or=6/24); 28.5% had presenting VA >or=6/12.

CONCLUSION

The data indicate a high frequency of comorbid systemic and ocular diseases among cataract surgical patients.

Risk factors for age related cataract in a rural population of southern India: the Aravind Comprehensive Eye Study

AIM

To determine risk factors for lens opacities and age related cataract in an older rural population of southern India.

METHODS

A cross sectional population based study of 5150 people aged 40 years and above from 50 clusters from three districts in southern India. The lens was graded and classified after dilation using LOCS III system at the slit lamp for cataract. Definite cataract was defined as nuclear opalescence >/=3.0 and/or cortical cataract >/=3.0 and/or PSC >/=2.0.

RESULTS

Definite cataracts were found in 2449 (47.5%) of 5150 subjects and the prevalence of cataract increased with age. The age adjusted prevalence of cataract was significantly lower in males (p = 0.0002). Demographic risk factors-increasing age and illiteracy-were common for the three subtypes of cataract; females were more likely to have cortical cataracts and nuclear cataracts. Additionally, nuclear cataracts were associated with moderate smoking (OR:1.28, 95% CI:1.01 to 1.64), lean body mass indices (OR: 1.37, 95% CI: 1.17 to 1.59) and higher waist to hip ratios (OR: 0.67, 95% CI: 0.54 to 0.82); cortical cataracts with hypertension (OR: 1.39 95% CI:1.11 to 1.72), pseudoexfoliation (OR:1.53,95% CI:1.17 to 2.01), and moderate to heavy smoking; and posterior subcapsular cataracts with diabetes (OR:1.55, 95% CI:1.12 to 2.15), lean body mass (OR:1.32, 95% CI:1.11 to 1.57), and high waist to hip ratios (OR: 0.77, 95% CI: 0.62 to 0.94).

CONCLUSIONS

Risk factors for age related cataract in this population do not appear to be different from those reported in other populations. Further studies are required to identify the reason for the high prevalence of age related cataract and to understand better the role of each risk factor for cataractogenesis in this population.

Cataract surgery in Australia: a profile of patient-centred outcomes

BACKGROUND

Few studies have addressed quality of life or satisfaction outcomes for patients undergoing cataract surgery, particularly in Australia. The purpose of this study was to describe a sample of patients undergoing cataract surgery in typical metropolitan practices in Sydney, with a particular focus on the impact upon quality of life and satisfaction with vision.

METHODS

One hundred and eleven patients were recruited prior to surgery and followed through 3 months postoperatively. Patients reported basic demographic information, VF-14 visual disability and SF-36 quality of life information, along with the degree of satisfaction and trouble with vision they experienced. Surgeons' records provided information about type and severity of cataract, refractive error, ocular comorbidity and visual acuity.

RESULTS

Patients enjoyed strongly significant improvement in visual acuity, disability, trouble and satisfaction with vision, with a median postoperative Snellen acuity of 6/7.5, and 82% within 1 D refraction. Not wearing glasses was the most commonly stated patient goal for undergoing surgery. Prior to surgery 23% of all driving patients did so illegally due to poor vision; after surgery 21% of non-drivers began driving again, all legally. Nonetheless, quality of life did not improve. Those who failed to achieve improvements in satisfaction with vision were more likely to be female, have lower educational attainment or have high visual function preoperatively. Change in visual acuity was not predictive.

CONCLUSIONS

The findings from this study indicate that cataract surgery outcomes in Australia compare well with international standards, and emphasize the inadequacy of visual acuity to measure relevant surgical outcomes. Increased preoperative counselling may be required in those groups less likely to attain high levels of satisfaction. Finally, the role of cataract surgery to improve quality of life must be investigated further, as this is the ultimate goal of the procedure.

Surgeons' perceptions of their patients' priorities

PURPOSE

To compare cataract surgeons' predictions of patient responses to patients' actual responses on 13 factors that are important to patients about to have cataract surgery and are likely to affect their satisfaction.

SETTING

Day-stay cataract surgery units at a large private hospital and a large public hospital.

METHOD

Patients (private and public) were asked to rate the importance of 13 factors regarding their cataract treatment. All cataract surgeons who regularly treated cataract patients in a large metropolitan city were randomized to a public or private group and sent the same 13 factors. The surgeons were asked to rate how important each factor is to their public or private patients, as appropriate.

RESULTS

Eighty-one patients and 77 doctors responded to the survey. Overall, doctors predicted that all items would be more important to private patients than to public patients, even though no significant difference existed between the patient groups. Doctors correctly identified public patients' priorities but underestimated the magnitude of overall importance. In contrast, doctors recognized the magnitude of overall importance to private patients but misjudged many priorities. Doctors underestimated the importance to patients of nonsurgical characteristics such as seeing the same doctor, having a pleasant location for appointments, and waiting time for surgery.

CONCLUSIONS

This study demonstrates significant discordance between patients' priorities when having cataract surgery and their doctors' perception of those priorities. These differences could be explained by doctors' stereotypes of public patients and insufficient appreciation of the nonmedical aspects of patient care.

Incidence and progression of cataract in the Melbourne Visual Impairment Project

PURPOSE

To determine the 5-year incidence and progression of cataract and cataract surgery in the Melbourne Visual Impairment Project.

DESIGN

Prospective cohort study. methods: Demographic information including race, sex, age, and education level was collected at baseline. Cortical cataract was defined as 4/16 or greater opacity; progression was defined as a more than 2/16 increase. Nuclear cataract was defined as Wilmer standard grade 2 or higher; progression was defined as more than 0.5 increase. Posterior subcapsular (PSC) cataract was defined as opacity 1 mm(2) or greater; progression was defined as greater than 1 mm(2) increase. results: Of the 3040 participants eligible to attend follow-up examinations, 2594 (85% of those eligible) participated. The mean age of participants at follow-up was 62.5 years, and 55% were female. The percentage of patients who had at least one lens extracted over 5 years increased from 0.5% of those aged 40 to 49 years at baseline to 35.7% of those aged 80 years or more at baseline. The overall incidence of the three types of cataract was as follows: cortical 7.7% (95% confidence limits [CL] = 5.8-9.8), nuclear 16.4% (95% CL = 12.1-20.8), and PSC 7% (95% CL = 5.3-8.7). The overall progression of cataract was cortical 14.3% (95% CL = 10.2-18.3), nuclear 19.3% (95% CL = 15.9-22.7), and PSC 20% (95% CL = 8.7-31.1). The incidence and progression rates increased significantly by age, but the rates were not significantly different by sex.

CONCLUSION

These cataract incidence data confirm the public health importance of cataract in Australia. The data also support the need to plan both primary prevention program and adequate surgical services to meet the anticipated increase in demand with the aging population.

Projected prevalence of age-related cataract and cataract surgery in Australia for the years 2001 and 2021: pooled data from two population-based surveys

This study aimed to estimate the number of Australians over 50 with cataract in the years 2001 and 2021. Data from two population-based studies were pooled: the Blue Mountains Eye Study and Melbourne Visual Impairment Project and Australian Bureau of Statistics population projections were used. Similar definitions for the three cataract types were used in the two studies (nuclear >/= grade 4, posterior sub-capsular >/= 1 mm, cortical >/= 10% lens area or >/= 25% circumference). Combining the three types and prior surgery, it was estimated that in 2001, 1.7 million Australians had clinically significant cataract in either eye and 320,000 had previously undergone cataract surgery. It was estimated that the number of persons with cataract will rise to 2.7 million by 2021 (over 500,000 will have had cataract surgery). The number of Australians with cataract will grow by two-thirds during the next 20 years, reflecting continued population ageing. Health care delivery systems will need to develop methods to handle this increased workload.

Previous cataract surgery in a defined Swedish population

PURPOSE

To study the prevalence of previous cataract surgery (PCS) in different age groups in a defined Swedish population.

SETTING

Department of Ophthalmology, Blekinge Hospital, Karlskrona, Sweden.

METHODS

This investigation of the population of Blekinge County, Sweden, was performed in June 2001. All previous cataract extractions in the district were performed at a single surgical unit, and the register of this unit contains data on all consecutive operations since 1980. The population register in the district was studied to ascertain the number of female and male individuals in different age groups for each year from 1980 though 2000. Included were data about deceased patients and those who moved from the area.

RESULTS

During 21 calendar years, 10,538 patients had cataract surgery; 6,697 of them (63.6%) were alive in June 2001. The survival rate for patients having cataract surgery during the period shows a linear curve for patients operated on during the past 13 years. Among those in the district aged 70 or older, 23.9% of women and 14.0% of men had cataract extraction in 1 or both eyes. In the population aged 40 years and older, 6.43% had a history of PCS. The annual surgery volume is increasing because of a backlog of cataract cases and because of the yearly incidence. With an increase in the annual surgery volume, it is estimated that given the present indications for surgery, it will take 5 to 10 years to reach a level that means further surgery only in patients having new cataract.

CONCLUSION

Even though there is already a much higher prevalence of PCS than is known from the literature, the annual surgery volume continues to increase, even in older age groups.

Eye health in rural Australia

A review of the current literature relating to eye health in rural Australia was conducted. Few studies have been undertaken, with most information provided by the Australian Institute of Health and Welfare databases, The National Trachoma and Eye Health Program of 1980 and the Visual Impairment Project in Victoria in the mid 1990s. Key findings were that the rural population has an increased prevalence of pterygium, cataract, ocular trauma and glaucoma, but no difference in refractive error or diabetic retinopathy (although data are limited). Rural residents are more likely to have seen an optometrist but less likely to have seen an ophthalmologist. Interventions have been undertaken in ophthalmologist training to increase the rural workforce and tele-ophthalmology to provide city-based metropolitan ophthalmological support for rural practitioners. Further epidemiological data and evaluated interventions are urgently required to help identify and address the needs of rural Australian communities.

Posterior capsule opacification after cataract surgery in remote Australian Aboriginal patients

PURPOSE

The aim of this retrospective study was to determine the rate of visually significant posterior capsular opacification formation after cataract surgery for Australian Aborigines living in rural or remote areas in the 'Top End' of the Northern Territory, Australia, and then to assess these patients' outcomes after capsulotomy.

METHODS

Aboriginal patients living in remote areas of the Top End of the Northern Territory who underwent cataract surgery between 1994 and 1999 were identified from records at the three major hospitals in the region. The presence of posterior capsular opacification (PCO) was determined by clinical examination. The primary endpoint for this study was the presence of axial opacification of the posterior capsule and the need for subsequent Nd:YAG posterior capsulotomy to improve sight. Linear regression analysis of the time from surgery to follow up and the number of eyes requiring Nd:YAG capsulotomy was performed. Operated eyes were grouped according to the interval between surgery and follow up (Group 1: follow up within 1 year of surgery, n= 25; Group 2: follow up 1-3 years after surgery, n= 42; Group 3: follow up 3-5 years after surgery, n= 51).

RESULTS

One hundred and eighteen operated eyes were examined. Eyes in Group 3 were found to have the highest incidence of visually significant PCO (27.5%). There were more eyes requiring capsulotomy after 3 years than after 1 year following surgery. Linear regression analysis revealed an odds ratio of 1.4 (P = 0.07). All nine eyes in the 1-3 year group that had developed visually significant PCO had undergone extra-capsular cataract extraction.

CONCLUSIONS

For the remote Aboriginal patient who has undergone cataract surgery, there is a relatively minor chance of developing PCO within the first postoperative year regardless of the type of surgery undertaken. This study illustrates that the longer the time after surgery the greater the chance of developing visually significant PCO. For the remote Aboriginal patient there is a high chance (approximately 28%) of developing visually significant PCO within 5 years after cataract surgery. These figures are lower than those reported from other parts of Australia.

Fred Hollows lecture. Eye care for the community

Eye disease is a huge and largely unrecognized problem in our community, especially in the elderly. The Visual Impairment Project, an intensive epidemiological study conducted by the Centre for Eye Research Australia (CERA) from 1991 to 1999, determined the prevalence, causes and risk factors for eye disease in Australia, and helped identify a series of specific, often simple, steps and strategies to significantly reduce its impact. A distillation of CERA"s findings has highlighted the growing problem of eye disease in our community. In addition, CERA has joined with other interested bodies to form Vision 2020: the Right to Sight Australia. This partnership was established in response to the Global Initiative to Eliminate Avoidable Blindness by the year 2020 - Vision 2020: the Right to Sight. This Global Initiative was established by the World Health Organization and the International Agency for the Prevention of Blindness. Vision 2020 Australia aims to be the peak body for all those involved in vision care in its broadest sense in Australia, and to put vision on the national agenda.

Socioeconomic status and incident cataract surgery: the Blue Mountains Eye Study

The aim of this study was to assess whether socioeconomic status influenced the incidence of cataract surgery in a defined population of older Australians. The Blue Mountains Eye Study examined 3654 residents during 1992-1994, then 2334 survivors (75.1%)during 1997-1999. Interviewers collected information on principal occupation, which was analysed using Australian Bureau of Statistics categories (stratified into four groups) and the Daniel Occupational Prestige Scale. Cataract surgical history was confirmed at both visits from clinical examinations. There were no statistically significant associations for any of the occupational categories with the 5-year incidence of cataract surgery. In summary, this study could not confirm any major socioeconomic associations with incident cataract surgery, supporting the view that cataract surgery is largely patient driven and that its primary incentive is patient benefit.

Does prospective monitoring improve cataract surgery outcomes in Africa?

AIMS

To determine if prospective monitoring influences cataract surgical outcomes in east Africa.

METHODS

A prospective observational study of all routine extracapsular cataract extractions with posterior chamber lens implants carried out at Kikuyu Eye Unit, Kenya, between 1 January 1999 and 31 December 1999.

RESULTS

Out of 1845 eligible eyes 1800 were included in the study. Two months' follow up was available in 67.2% of patients. The proportion achieving a good outcome increased steadily from 77.1% in the first quarter to 89.4% in the fourth quarter (chi(2) for trend, p<0.001). There was no change in the incidence of operative complications; however, the proportion of patients achieving a good visual outcome following vitreous loss increased from 47.2% in the first 6 months to 71.0% in the last 6 months (chi(2) p<0.05). Of the eyes with poor outcome (best corrected acuity <6/60 at 2 months) half were due to pre-existing eye diseases. The proportion of patients with known ocular comorbidity decreased from 10.2% in the first quarter to 5.9% in the fourth quarter (chi(2) for trend, p<0.05). Poor outcome was associated with age over 80 years, known diabetes, preoperative bilateral blindness, any ocular comorbidity, and intraoperative vitreous loss.

CONCLUSIONS

This study demonstrates improvement in visual outcome results after cataract surgery over a 1 year period. Monitoring of outcomes appears to be associated with a change in surgeons' attitudes, leading to greater emphasis on appropriate case selection, better management of surgical complications, and improved visual outcomes.

Predictors of falls in the Melbourne visual impairment project

OBJECTIVE

To assess factors associated with falls in the past month, including visual acuity and other vision-related variables.

METHODS

A household census was used to recruit permanent residents aged 40 years and older for baseline examinations of the Melbourne Visual Impairment Project conducted from 1992-94. At the five-year follow-up examinations, returning participants were asked to recall all falls that they had ever experienced and also how many falls they had experienced in the past month. Falls history was divided into those that occurred at home and away from home. Standardised examination of visual acuity was performed.

RESULTS

Of the original cohort of 3,271, 231 (7.1%) were reported to have died, leaving 3,040 eligible. Of these, 2,594 (85%) were examined, 51 (2%) had moved interstate or overseas, 83 (3%) could not be traced, and 312 (10%) refused to participate. A history of having ever fallen at home was reported by 466 (20%) participants, and 406 (17.3%) reported having fallen away from home at least once. Five per cent of the cohort (129/2,343) had fallen in the previous month. Factors significantly related to falls at home in the past month in a multivariate logistic regression model included age (OR=1.56 for 10-year age groups) and nuclear cataract (OR=2.87).

CONCLUSIONS

Irrespective of visual acuity, cataract is major risk factor for falls at home.

IMPLICATIONS

Interventions aimed at decreasing the incidence of falls in the community should include assessment of both visual acuity and cataract status and referral for treatment if functional impairment is evident.

Trends in health service delivery for cataract surgery at a large Australian ophthalmic hospital

PURPOSE

To evaluate trends in health service delivery for cataract surgery at the Royal Victorian Eye and Ear Hospital, Melbourne, Australia.

METHODS

A retrospective study was conducted of computerized hospital admissions for cataract surgery from July 1994 through June 1999. Main outcome measures included the annual number of cataract surgeries, waiting time, percentage of patients hospitalized overnight, length of overnight hospitalization, type of cataract surgery, surgery duration and total time in the operating theatre.

RESULTS

Although the annual number of patients undergoing cataract surgery increased from 3395 to 4796 over the 5-year study interval, there was a 13-day reduction in mean waiting time for public patients, a 30% reduction in overnight hospitalizations and a half-day reduction in length of hospitalization for all patients. There was also an increasing trend in use of phacoemulsification cataract extraction.

CONCLUSIONS

The health-care delivery for cataract surgery appears to have improved during the past 5 years at the Royal Victorian Eye and Ear Hospital.

Cataract extraction in a major ophthalmic hospital: day-case or overnight stay?

PURPOSE

Cataract surgery is increasing in Australia and represents a significant burden on limited health resources. This study examines the frequency and outcomes of cataract surgery for patients who were hospitalized overnight compared with those treated as day surgery cases.

METHODS

Medical records of 671 consecutive admissions for cataract surgery at the Royal Victorian Eye and Ear Hospital were reviewed. Data analysed included demographic features, insurance status, length of hospitalization, ophthalmic conditions, medical conditions, social problems and planned surgical technique. Ophthalmic and anaesthetic complications, active ophthalmic and medical interventions were also studied.

RESULTS

Of the 671 patient admissions for cataract during the study period, 226 (33.4%) were hospitalized overnight. Factors significantly associated with overnight hospitalization in univariate analyses include older age, female sex, country residence, Veterans' Affairs insurance, monocular vision status, pre-existing ischaemic heart disease, pre-existing asthma/chronic obstructive lung disease, absence of carer, transportation problems, planned extra-capsular cataract extraction technique, ophthalmic complications and active ophthalmic and/or medical interventions. After adjusting for possible confounding factors using backwards stepwise multivariate logistic regression models all except pre-existing ischaemic heart disease and ophthalmic complications were significantly associated with overnight admission for cataract surgery. In total, 14 cases (2.1%) needed active ophthalmic and/or medical interventions, 13 overnight cases and one day case.

CONCLUSIONS

These data suggest that many patients who are hospitalized overnight for cataract surgery could be safely treated as day cases. Such a shift in the pattern of care for cataract surgery could provide a significant potential for health care savings.