Visual outcomes for remote Australian Aboriginal people after cataract surgery

Specialist clinics in remote Australian Aboriginal communities: where rock art meets rocket science

People in remote Aboriginal communities in the Northern Territory have greater morbidity and mortality than other Australians, but face considerable barriers when accessing hospital-based specialist services. The Specialist Outreach Service, which began in 1997, was a novel policy initiative to improve access by providing a regular multidisciplinary visiting specialist services to remote communities. It led to two interesting juxtapositions: that of “state of the art” specialist services alongside under-resourced primary care in remote and relatively traditional Aboriginal communities; and that of attempts to develop an evidence base for the effectiveness of outreach, while meeting the short-term evaluative requirements of policy-makers.

In this essay, first we describe the development of the service in the Northern Territory and its initial process evaluation. Through a Cochrane systematic review we then summarise the published research on the effectiveness of specialist outreach in improving access to tertiary and hospital-based care. Finally we describe the findings of an observational population-based study of the use of specialist services and the impact of outreach to three remote communities over 11 years.

Specialist outreach improves access to specialist care and may lessen the demand for both outpatient and inpatient hospital care. Specialist outreach is, however, dependent on well-functioning primary care. According to the way in which outreach is conducted and the service is organised, it can either support primary care or it can hinder primary care and, as a result, reduce its own effectiveness.

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.

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.

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.