Preoperative visual acuity among cataract surgery patients and countries' state of development: a global study

Changing patterns in cataract surgery indications, outcomes, and costs, 2012-2023: a retrospective study at Aravind Eye Hospitals, India

Background

Data on the evolving characteristics of patients seeking cataract surgery, surgical techniques used, preoperative vision, postoperative visual outcomes, and surgery costs provide critical insights for improving care delivery and making progress towards global eye care targets. We aimed to establish long-term trends in these factors.

Methods

Retrospective analysis of all cataract surgeries performed at Aravind Eye Hospitals during 2012-2023.

Findings

In 3.6 M cataract surgeries, the mean preoperative uncorrected visual acuity improved from 1.32 logMAR units (Snellen fraction ≈ 6/120) in 2012 to 1.15 (Snellen fraction ≈ 6/85) in 2023. The trend was observed in females and males, with females presenting with worse vision than males, in all age groups, and among outreach, subsidized and paying patients. Postoperative visual acuity outcomes steadily improved, with larger gains in Manual Small Incision Cataract Surgeries than in phacoemulsification. Mean prices for paying patients rose slightly faster than the Consumer Price Index for health. Surgeries supported by insurance and government assistance increased from 4.4% in 2012 to 28.7% in 2023. Male patients consistently paid about 10% higher prices than female patients because they chose more expensive intraocular lenses.

Interpretation

Over this period, patients sought cataract surgery sooner, received better surgical outcomes, and were willing to pay more for the improvements. However, female patients continued to face inequities, presenting with worse vision, and receiving lower expenditures for surgery, indicating the need for targeted approaches to address sex inequity both on the demand generation and treatment provision sides.

Funding

None.

Methods for a population-based Comprehensive Eye care Workload Assessment (CEWA) study in Southern India

Eye care programs, in developing countries, are often planned using the prevalence of blindness and visual impairment, often estimated from Rapid Assessment of Avoidable Blindness (RAAB) surveys. A limitation of this planning approach is that it ignores the annual overall eye care requirements for a given population. Moreover, targets set are arbitrary, often influenced by capacity rather than need. To address this lacunae, we implemented a novel study design to estimate the annual need for comprehensive eye care in a 1.2 million populations. We conducted a population-based longitudinal study in Theni district, Tamil Nadu, India. All permanent residents of all ages were included. We conducted the study in three phases, (i) household-level enumeration and enrollment, (ii) basic eye examination (BEE) at household one-year post-enrollment, and (iii) assessment of eye care utilization and full eye examination (FEE) at central locations. All people aged 40 years and above were invited to the FEE. Those aged <40 years were invited to the FEE if indicated. In the main study, we enrolled 24,327 subjects (58% aged below 40 years and 42% aged 40 years and above). Of those less than 40 years, 72% completed the BEE, of whom 20% were referred for FEE at central location. Of the people aged ≥40 years, 70% underwent FEE. Our study design provides insights for appropriate long-term public health intervention planning, resource allocation, effective service delivery, and designing of eye care services for resource-limited settings.

The Cost-Effectiveness of a Telemedicine Screening Program for Diabetic Retinopathy in New York City

Background

A telemedicine screening initiative was implemented by the Montefiore Health System to improve access to eyecare for a multi-ethnic, at-risk population of diabetic patients in a largely underserved urban community in the Bronx, New York. This retrospective, cross-sectional analysis evaluates the societal benefit and financial sustainability of this program by analyzing both cost and revenue generation based on current standard Medicare reimbursement rates.

Methods

Non-mydriatic fundus cameras were placed in collaboration with a vendor in eight outpatient primary care sites throughout the Montefiore Health Care System, and data was collected between June 2014 and July 2016. Fundus photos were electronically transmitted to a central reading center to be systematically reviewed and coded by faculty ophthalmologists, and patients were subsequently scheduled for ophthalmic evaluation based upon a predetermined treatment algorithm. A retrospective chart review of 2251 patients was performed utilizing our electronic medical record system (Epic Systems, Verona WI). Revenue was projected utilizing standard Medicare rates for our region while societal benefit was calculated using quality adjusted life years (QALY).

Results

Of the 2251 patient charts reviewed, 791 patients (35.1%) were seen by Montefiore ophthalmologists within a year of the original screening date. Estimated revenue generated by these visits was $276,800, with the majority from the treatment of retinal disease ($208,535), and the remainder from other ophthalmic conditions detected in the fundus photos ($68,265). There was a societal benefit of 14.66 quality adjusted life years (QALYs) with an estimated value of $35,471/QALY.

Conclusion

This telemedicine initiative was successful in identifying many patients with diabetic retinopathy and other ophthalmic conditions who may otherwise not have been formally evaluated. Our analysis demonstrates the program to generate a downstream revenue of nearly $280K with a cost benefit below <50% of the threshold of $100,000/QALY, and therefore cost-effective in marginalized communities.

Cross-sectional study of intraocular cataract lens replacement, circadian rest–activity rhythms, and sleep quality in older adults

Study Objectives

Age-related cataract decreases light transmission at the most sensitive spectrum for circadian photoentrainment, with negative ramifications for human health. Here, we assessed whether intraocular lens replacement (IOL) in older patients with previous cataract was associated with increased stability and amplitude of circadian rest–activity rhythms, and improved sleep quality.

Methods

Our cross-sectional study included sixteen healthy older individuals without ocular diseases (controls; 55–80 years; 63.6 ± 5.6y; 8 women) and 13 patients with previous cataract and bilateral IOL (eight with blue-blocking [BB] lens and five with ultraviolet-only [UV] blocking lens; 55–80 years; 69.9 ± 5.2y; 9 women). The study comprised three weeks of at home rest–activity assessments using wrist-worn actigraphs, and each week preceded a laboratory protocol. Primary outcomes were actigraphy-derived interdaily stability, intradaily variability, and relative amplitude of circadian rest–activity rhythms. Secondary outcomes were actigraphy-assessed sleep quality (i.e. time in bed, sleep duration, sleep efficiency, mean wake bout time and fragmentation index).

Results

Patients with IOL had significantly higher interdaily stability (“Group” effect: pFDR =.001), but not intradaily variability (“Group” effect: pFDR = n.s.), and significantly higher relative amplitude of rest–activity rhythms (“Group” effect: pFDR &lt; .001). Moreover, patients with IOL had significantly higher activity levels during the day and lower levels during the evening, as compared to healthy older controls (“Group” effect: pFDR = .03). Analyses of actigraphy-derived sleep parameters yielded no significant differences across groups (“Group” effect: all pFDR &gt; .1).

Conclusions

Our cross-sectional study suggests that enhancing spectral lens transmission in patients with cataract may benefit their circadian health.

Visual outcomes of cataract surgery: An observational study of ten years from a tertiary eye care hospital in Pakistan

Objectives:

To observe and analyze the visual outcomes of cataract surgery of ten years at a tertiary eye care hospital, Karachi.

Methods:

An observational study with retrospective data search was conducted in Al Ibrahim Eye Hospital (AIEH), Karachi. Data of all adults (above 16 years) who underwent cataract surgery from 2010-2019 was retrieved from HIMS. Presence of opacity in the lens was labelled as cataract. Surgery was advised when patient’s BCVA was found to be ≤ 6/18. Visual assessments of the patients were done on day 01, one week and six weeks postoperatively. Postoperatively, 6/6 – 6/12 was considered as good, 6/18 as mild visual impairment, < 6/18 to 6/60 as moderate visual impairment and < 6/60 as severe visual impairment.

Results:

A total of 1,027,840 patients visited AIEH with different eye diseases. Among 1027840 individuals, cataract was identified in 88443 (8.6%). Surgery was advised to 58371 and performed in 38616. Records of operated cases (38616) were retrieved. Mean age of patients was 54.96±14.22 years. There were 20578 (53.29%) males and 18038 (46.71%) females who underwent surgery . At the end of sixth week, 3561 (18.4%), patients were found to have “good vision”, 12242 (63.43%) had mild visual impairment, 2676 (13.86%) had moderate visual impairment and 822 (4.26%) had severe visual impairment. Corneal Complications was the commonest cause (33.56%) at sixth week.

Conclusions:

The institution achieved WHO recommended criteria of “good visual outcome” (6/6 to 6/18) of 81.83% which is near to recommended ≥ 90% and severe visual impairment of 4.26%.

Comparison of safety and number of post-operative visits of patients in convenient day versus conventional first day follow-up after phacoemulsification

Objectives

To compare safety and number of post-operative visits of patients in convenient day versus conventional first day follow-up after phacoemulsification.

Methods

This observational cohort study was conducted in Department of ophthalmology, Sahiwal Medical College, Sahiwal from November 2019 to August 2020. There were 600 patients who underwent uncomplicated phacoemulsification with intraocular lens implantation. Patients were allocated into two groups. Group-I comprised of patients with convenient day follow-up during the first post-operative week. Group-II comprised of the patients with conventional first day follow-up. Rate of complications, number of visits during the first month and final visual acuity were recorded.

Results

In Group-I post-operative complications were noted in 12.67% cases on first follow up visit and in 2.67% cases on first month follow up visit. In Group-II post-operative complication were noted in 22 % cases on first follow up visit and in 4% cases on first month follow up visit. Common postoperative complications were corneal oedema, anterior segment intraocular inflammation, residual lens matter in anterior chamber and intraocular lens subluxation. There was no difference in presenting and postoperative visual acuity between the two groups. Mean follow-up visits were 2.23 ± 0.42 in Group-I and 3.55 ± 0.50 in Group-II.

Conclusion

Convenient day follow-up is as safe as conventional first day follow-up. Convenient day follow-up significantly reduces the number of post-operative visits. This would translate into cost reduction both for the patients and the health care facility.

Seven-year trends in cataract surgery indications and quality of outcomes at Aravind Eye Hospitals, India

PURPOSE

To report trends in cataract surgery indications, visual acuity outcomes, complication rates and reoperation rates at ten Aravind Eye Hospitals in Tamil Nadu, India.

METHODS

In this retrospective database study we analyzed seven years of data of cataract surgeries at Aravind during January 1, 2012 to December 31, 2018. Our main outcome measures were preoperative and 1-month postoperative uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA); and rates of intraoperative complications and reoperations. We performed Cochran-Armitage trend tests.

RESULTS

In 1.86 million eyes that underwent cataract surgery, the percentage of eyes undergoing phacoemulsification (PE) showed an increasing trend (p < 0.0001), from 26.8% in 2012 to 33.5% in 2018. The percentage of eyes undergoing manual small incision cataract surgery (SICS) showed a decreasing trend (p < 0.0001), from 70.0% in 2012 to 65.1% in 2018. For SICS, the percentages of eyes with good postoperative UCVA and BCVA showed increasing trends (p < 0.0001 for each), and the percentages of eyes with poor postoperative UCVA and BCVA showed decreasing trends (p < 0.0001 for each). Results for PE surgeries were mixed. For both PE and SICS rates of intraoperative complications showed a declining trend (p < 0.0001 for each) and a slight increasing trend for reoperations (PE p < 0.02; SICS p < 0.0001).

CONCLUSIONS

During this seven-year period there were noticeable trends in cataract surgeries performed at Aravind in terms of the mix of surgical procedures, preoperative vision, and cataract surgical outcomes.

Cataract surgical reach: Falling short to catch white cataracts!

Purpose:

The aim of this study was to know proportion of white cataracts from among patients coming for cataract surgery, and to find causes delaying uptake of cataract surgery.

Methods:

A hospital-based, prospective study enrolled patients of senile cataract between April 2018 and March 2019. The proportion of white cataract was calculated and underlying causes delaying uptake of cataract surgery studied.

Results:

White cataracts constituted 13.5% of total 3634 senile cataract patients, with gender disparity disfavoring women. Bilateral white cataract was presentation in 39 (8%) patients and lens-related glaucoma in 24 (5%) patients. Pseudophakia in the other eye was single most common cause of delay.

Conclusion:

A large proportion of white cataracts suggest that penetration of cataract surgical services in not reaching to the most eligible individual.

Door-to-Door Eye Health Education to Improve Knowledge, Attitude, and Uptake of Eyecare Services Among Elderly with Cataracts: A Quasi-Experimental Study in the Central Tropical Region, Myanmar

Introduction

Cataract-related blindness is routinely reported globally. This study aimed to measure the effect of door-to-door eye health education in improving knowledge and attitude toward cataracts and the use of eyecare services among the elderly residing in a rural area of Naypyitaw Union Territory, Myanmar.

Methods

A quasi-experimental study design that used intervention and control groups was employed in Lewe Township from November 2018 to April 2019. Stratified sampling method was used to select lists of patients diagnosed with cataracts via a township-wide prevalence survey of eye diseases. A total of 56 elderly people with cataracts were involved in each group. The intervention group received door-to-door eye health education for 3 consecutive months. The data were collected using pre- and post-intervention surveys. Descriptive statistics for general characteristics as well as Chi-squared tests and multivariate analysis of variance for significant differences between knowledge and attitude scores of the two groups were analyzed.

Results

Both groups represented similarities in socio-economic characteristics, pre-existing knowledge and attitude levels, and eyecare services use. During the baseline study, the mean knowledge score in the intervention group was 7.8 and after the intervention, it increased to 10.67. Attitude score increased from 4.51 to 7.55. Among the control group, the scores remained unchanged. For use of eyecare services in the intervention group, 35.7% of patients sought eyecare services before the intervention, but after, 85.7% accessed eyecare services. Among them, 78.6% were satisfied with the treatment outcome. Further, there was a significant difference in knowledge and attitude between the control group and the intervention group (p-value <0.05), representing a medium effect of the intervention on improving knowledge and attitude level.

Conclusion

Door-to-door eyecare education significantly increased knowledge and attitude toward cataracts and the use of eyecare services among the elderly with cataracts. Intervention might be effective in improving the use of eyecare services and reduction of avoidable blindness due to cataracts.

Preoperative visual acuity of cataract patients at a tertiary hospital in sub-Saharan Africa: a 10-year review

Purpose:

To determine the preoperative visual acuity of cataract patients over a 10-year period in a tertiary facility as a means of auditing the cataract surgical services.

Methods:

A retrospective study of patients with age-related cataracts who had cataract surgery performed between January 2007 and December 2016 at the University College Hospital, Ibadan. Systematic random sampling and probability proportionate to size were used to recruit a representative sample. Information on sociodemographic characteristics, preoperative visual acuity, ocular and systemic comorbidities were retrieved and analysed.

Results:

Of the 499 patients studied, males were 268 (53.7%) and their mean age was 67.69 (±9.51) years. The predominant visual acuity was hand motion 184 (36.9%) and yearly mean preoperative visual acuity was in the range of 0.0037–0.04 decimal.

Conclusion:

The mean preoperative visual acuity of patients in this facility did not change over the 10-year study period. Mean value of preoperative visual acuity remained within the range of blindness and did not improve over the decade. This could either be a reflection of visual impairment at which our patients seek care or an indication of the range of visual acuities at which surgeons are willing to offer cataract surgery in our environment. This trend has negative implications on the burden of cataract blindness as it reflects poor coverage of surgery for other levels of visual impairment due to cataract.

Outcomes of cataract surgery performed by non-physician cataract surgeons in remote North Cameroon

OBJECTIVE

To report the outcomes of cataract surgery performed by non-physician cataract surgeons due to lack of ophthalmologists in remote areas of North Cameroon.

DESIGN

Prospective cohort study.

SETTING

The main centre of the non-governmental organisation Ophtalmo Sans Frontières in Lagdo.

PARTICIPANTS AND INTERVENTIONS

Age-related cataract surgery performed between 28 November 2016 and 17 May 2017.

MAIN OUTCOMES MEASURES

The main outcome measure was presenting visual acuity (PVA) 1-4 weeks after surgery, classified according to the WHO as good (PVA ≥6/18), borderline (PVA 6/60-6/18) and poor (PVA <6/60). The WHO definition of blindness (visual acuity <3/60) and severe visual acuity (visual acuity 3/60-6/60) was used to assess the proportion of patients with a change in WHO category.

RESULTS

We included 474 eyes of 474 patients; the mean (SD) age was 63.9 (15) years (42.2% female). At 1-4 weeks after surgery, the surgical outcome was good for 170 patients (41.1%), borderline for 213 (51.5%) and poor for 31 (7.5%). In all, 224 patients (47.2%) had blindness or severe visual impairment before cataract surgery and 22 (5.3%) at 1-4 weeks after surgery. Poor visual outcome was associated with older age (p=0.018), preoperative blindness or severe impairment (p=0.012) and surgical complications (p=0.019).

CONCLUSION

Blindness and severe visual impairment were significantly decreased in the early postoperative period. Poor outcomes were associated with older age, low preoperative binocular visual acuity and intraoperative complications. Non-physician cataract surgeons may compensate for the lack of ophthalmologists in remote areas of low-income and middle-income countries.

Visual outcome after phacoemulsification with lens implant in diabetic and non-diabetic patients; A comparative study

Objective:

To compare the visual outcomes of phacoemulsification surgery with intraocular lens (IOL) in persons with and without diabetes at end of follow-up.

Methods:

This was a comparative, cross sectional, observational study with Non-probability, purposive sampling. After approval from “Research Ethical Committee of Isra Post-graduate Institute of Ophthalmology Karachi, 92 patients with cataract in one eye were selected. Patients were divided into two groups. Group A consisted of 48 diabetics and group B consisted of 44 non- diabetics with or without diabetes in the age group ≥ 30 years were included. Patients with small Pupil, Pseudo exfoliation Syndrome, Diabetic Retinopathy, and positive history of Uveitis, Glaucoma, and Macular Degeneration were excluded. Data analysis was performed by SPSS Version 20.0.

Results:

Best Corrected Visual Acuity (BCVA) in diabetic patients improved from 0.813 ± 0.181 Log MAR pre operatively to 0.183 ± 0.143 after the period of six months post-operatively. Corresponding results in non-diabetics were 0.66 ± 0.31 and 0.08 ± 0.092 Log Mar (P value = 0.001). If WHO criteria was considered, 87.5% diabetics and 92% non-diabetics achieved normal vision (Log Mar 0 to 0.5; ≥ 6/12,) on the first post-operative day. Remaining 12.5% diabetics and 8% non-diabetics achieved moderate vision (0.6 to 1 Log MAR) on first post-operative day improving to normal vision within a week.

Conclusion:

Visual outcomes in diabetics after phacoemulsification with intra ocular lens implant is almost as good as that in non-diabetic patient if the diabetics have no retinopathy and have good glycemic control.

Socioeconomic Disparity in Global Burden of Cataract: An Analysis for 2013 With Time Trends Since 1990

PURPOSE

To assess socioeconomic disparity in global burden of cataract, by using disability-adjusted life years (DALYs).

DESIGN

International, comparative burden-of-disease study.

METHODS

Published data on national age-standardized DALY rates caused by cataract and human development index (HDI) between 1990 and 2013 were obtained. The association between age-standardized DALY rates and HDI in 2013 was analyzed. The health-related Gini coefficients and the concentration indexes were calculated to explore the trends in between-country inequality in cataract burden from 1990 to 2013.

RESULTS

Multiple comparison revealed that lower-HDI countries had higher age-standardized DALY rates caused by cataract. Age-standardized DALY rates were inversely associated with HDI (β = -0.522, P < .01). From 1990 to 2013, global age-standardized DALY rates showed a trend of decline, whereas the Gini coefficients increased from 0.409 to 0.439. The concentration indexes indicated that socioeconomic-associated inequality declined in the 1990s and subsequently increased since 2000, with values of -0.259 in 1990, -0.244 in 2000, and -0.273 in 2013.

CONCLUSIONS

Global health progress in cataract was accompanied by widening inequality, with cataract burden being more concentrated in countries with lower socioeconomic status. The findings highlight the need to provide more cataract services for developing countries, to combat global vision loss caused by cataract.

Intraoperative Complications of Cataract Surgery in Tehran Province, Iran

PURPOSE

To determine the prevalence and types of intraoperative complications of cataract surgery and examine potential risk factors.

METHODS

Data were obtained from the 2011 Iranian Cataract Surgery Survey in which information about cataract surgeries throughout the nation was collected. In the Province of Tehran, 55 centers and 1 week per season per center were randomly selected for sampling. In each center, the charts of all patients who underwent cataract surgery during the selected weeks (total of 20 weeks per center) were reviewed for data extraction. The prevalence of different types of intraoperative cataract surgery complications were determined, and their relationships with age, sex, surgical method, surgeon, and hospitalization time were examined.

RESULTS

The prevalence of intraoperative complications of cataract surgery was 4.15% (95% confidence interval, 0.94 to 7.36). The prevalence of posterior capsular rupture with vitreous loss, posterior capsular rupture without vitreous loss, retrobulbar hemorrhage, suprachoroidal effusion/hemorrhage, intraocular lens drop, and nucleus drop was 2.86, 0.69, 0.06, 0.39, 0.03, and 0.11%, respectively. The prevalence of cataract surgery complications decreased from 6.95% in 2006 to 3.07% in 2010. The results of multiple logistic regression showed that surgery by residents, nonphacoemulsification methods of surgery, and patient age less than 10 years and more than 70 years were the risk factors for complications.

CONCLUSIONS

This study evaluated the prevalence of intraoperative complications of cataract surgery for the first time in Tehran Province. The prevalence of complications was high in this study. To achieve the goals of the Vision 2020 Initiative and improve surgical quality, it is necessary to minimize complication rates. Factors to note for decreasing complication rates include type of surgery, surgeon experience, and patient age.

People with diabetic peripheral neuropathy display a decreased stepping accuracy during walking: potential implications for risk of tripping

AIM

To examine the stepping accuracy of people with diabetes and diabetic peripheral neuropathy.

METHODS

Fourteen patients with diabetic peripheral neuropathy (DPN), 12 patients with diabetes but no neuropathy (D) and 10 healthy non-diabetic control participants (C). Accuracy of stepping was measured whilst the participants walked along a walkway consisting of 18 stepping targets. Preliminary data on visual gaze characteristics were also captured in a subset of participants (diabetic peripheral neuropathy group: n = 4; diabetes-alone group: n = 4; and control group: n = 4) during the same task.

RESULTS

Patients in the diabetic peripheral neuropathy group, and patients in the diabetes-alone group were significantly less accurate at stepping on targets than were control subjects (P < 0.05). Preliminary visual gaze analysis identified that patients diabetic peripheral neuropathy were slower to look between targets, resulting in less time being spent looking at a target before foot-target contact.

CONCLUSIONS

Impaired motor control is theorized to be a major factor underlying the changes in stepping accuracy, and potentially altered visual gaze behaviour may also play a role. Reduced stepping accuracy may indicate a decreased ability to control the placement of the lower limbs, leading to patients with neuropathy potentially being less able to avoid observed obstacles during walking.

Socioeconomic Disparities in Cataract Prevalence, Characteristics, and Management

PURPOSE

To review the current literature on socioeconomic disparities relationship with cataract prevalence, characteristics, and management.

SUMMARY

Cataracts are an important cause of preventable visual impairment in both the developing and industrialized world. Cataract surgery is a highly effective operation with an excellent risk profile. Furthermore, cataract surgery has been shown to have significant positive functional, social, and economic implications for patients. Several medical conditions have been shown to have correlation with socioeconomic factors and cataract is among several forms of visual impairment that demonstrate this relationship. Disparities in prevalence, clinical characteristics, and management are documented in the ophthalmic literature. A better understanding of these socioeconomic factors and their clinical relevance is critical to alleviating the burden of cataract-related visual impairment in an aging population.

Incidence and associated factors of posterior capsule opacification in pseudophakic patients at Cipto Mangunkusumo Hospital

Background: Posterior capsule opacification (PCO) is the most common postoperative consequence of cataract surgery which may cause visual acuity reduction, yet the incidence in Indonesia has not been reported. The objectives of this study were to evaluate three years cumulative incidence of PCO and factors associated with PCO formation at Cipto Mangunkusumo Hospital, Jakarta.Methods: This was a retrospective descriptive study on patients with uneventful senile cataract surgery during year 2010. All related data were retrieved from medical records in year 2013, which included patient demographics, type of surgery, intraocular lens (IOL) characteristics (material, optic edge design and diameter). Moreover, time to first PCO diagnosis (month), and best corrected visual acuity (BCVA) pre-operatively, at time PCO was diagnosed and two weeks after Neodymium-doped yttrium aluminum garnet (Nd:YAG) laser were noted (decimal).Results: A total of 578 eyes (485 patients) were involved in this study. Three years cumulative incidence of the PCO was 8.82% (51 eyes). Phacoemulsification surgery was performed in 496 (85.8%) eyes. The median time to PCO diagnosis was 21 months (range 1 to 34 months), mean of BCVA was 0.50 ± 0.26. Age (<65 and >65 years old) was not associated to PCO. Higher incidence of PCO was found in patients using hydrophilic acrylic IOL (10.7%) than in hydrophobic acrylic (6.2%). After Nd:YAG laser was performed, BCVA was improved to 1.00.Conclusion: Three years cumulative incidence of PCO was 8.82% and there was no defined factor related to PCO formation, but higher percentage of PCO occured in patients using hydrophilic acrylic IOL than in hydrophobic acrylic. 

Retinopathy in type 1 diabetes mellitus: Major differences between rural and urban dwellers in northwest Ethiopia

AIM

To audit levels of diabetes-related eye disease in Type 1 diabetes mellitus (T1DM) patients in northwest Ethiopia. In particular to establish whether, despite identical clinical goals, major differences between the physically demanding life-style of rural subsistence farmers and the sedentary life-style of urban dwellers would influence the prevalence of diabetes-related eye complications.

METHODS

A robust infrastructure for chronic disease management that comprehensively includes all rural dwellers was a pre-requisite for the investigation. A total of 544 T1DM were examined, representing 80% of all T1DM patients under regular review at both the urban and rural clinics and representative of patient age and gender (62.1% male, 37.9% female) of T1DM patients from this region; all were supervised by the same clinical team. Eye examinations were performed for visual acuity, cataract and retinal changes (retinal photography). HbA1c levels and the presence or absence of hypertension were recorded.

RESULTS/CONCLUSIONS

Urban and rural groups had similar prevalences of severe visual impairment/blindness (7.0% urban, 5.2% rural) and cataract (7.3% urban, 7.1% rural). By contrast, urban dwellers had a significantly higher prevalence of retinopathy compared to rural patients, 16.1% and 5.0%, respectively (OR 2.9, p<0.02, after adjustment for duration, age, gender and hypertension). There was a 3-fold greater prevalence of hypertension in urban patients, whereas HbA1c levels were similar in the two groups. Since diabetic retinopathy is closely associated with microvascular disease and endothelial dysfunction, the possible influences of hypertension to increase and of sustained physical activity to reduce endothelial dysfunction are discussed.

Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate

BACKGROUND

Surgery is a foundational component of health-care systems. However, previous efforts to integrate surgical services into global health initiatives do not reflect the scope of surgical need and many health systems do not provide essential interventions. We estimate the minimum global volume of surgical need to address prevalent diseases in 21 epidemiological regions from the Global Burden of Disease Study 2010 (GBD).

METHODS

Prevalence data were obtained from GBD 2010 and organised into 119 disease states according to the WHO's Global Health Estimate (GHE). These data, representing 187 countries, were then apportioned into the 21 GBD epidemiological regions. Using previously defined values for the incident need for surgery for each of the 119 GHE disease states, we calculate minimum global need for surgery based on the prevalence of each condition in each region.

FINDINGS

We estimate that at least 321·5 million surgical procedures would be needed to address the burden of disease for a global population of 6·9 billion in 2010. Minimum rates of surgical need vary across regions, ranging from 3383 operations per 100 000 in central Latin America to 6495 operations per 100 000 in western sub-Saharan Africa. Global surgical need also varied across subcategories of disease, ranging from 131 412 procedures for nutritional deficiencies to 45·8 million procedures for unintentional injuries.

INTERPRETATION

The estimated need for surgical procedures worldwide is large and addresses a broad spectrum of disease states. Surgical need varies between regions of the world according to disease prevalence and many countries do not meet the basic needs of their populations. These estimates could be useful for policy makers, funders, and ministries of health as they consider how to incorporate surgical capacity into health systems.

FUNDING

US National Institutes of Health.

Assessment of visual outcomes of cataract surgery in Tujia nationality in Xianfeng County, China

AIM

To evaluate the visual outcome and factors influencing visual outcome of manual small incision cataract surgery (MSICS) in the rural area in the Xianfeng County.

METHODS

Eighty-two eyes of 82 patients who underwent cataract surgery performed by using MSICS technique were identified. Data collected included each patient's age, gender, the level of education. Uncorrected and corrected distance visual acuity (UDVA and CDVA) at presentation and at 1, 6, 8wk postoperatively, pre-existing eye disease, operative findings and complications, the risk factors were evaluated.

RESULTS

In 82 patients, the average age was 69.6±0.6y, illiterate were 52 (63.4%). Of 82 eyes, pseudophakia was present in 77 eyes (93.9%). At 1wk postoperatively, 47 eyes (57.3%) had the UDVA of ≥6/18, and 52 eyes (63.4%) had the CDVA of ≥6/18. At 6 to 8wk postoperatively, 50 eyes (61.0%) had UDVA of ≥6/18, and 57 eyes (69.5%) had the CDVA of ≥6/18. Postoperative visual status was significantly related to the co-morbidities, such as corneal pathology, glaucoma (P<0.001). Operative complications, such as posterior capsule opacity and cystoid macular edema were main operative cause for the poor visual outcome.

CONCLUSION

MSICS provides a good visual recovery in our study but the vision outcome did not fulfill the standards proposed by WHO, which highlights the need for an improvement in local socioeconomic understanding, population education and surgery quality.

Prevalence of blindness and cataract surgical outcomes in Takeo Province, Cambodia

PURPOSE

To estimate the prevalence of blindness and cataract surgical outcomes in persons 50 years or older above in Takeo Province, Cambodia.

DESIGN

A population based survey.

METHODS

A total of 93 villages were selected through probability proportionate to size using the Rapid Assessment of Avoidable Blindness methodology. Households from 93 villages were selected using compact segment sampling. Visual acuity (VA) of 4650 people 50 years or older was tested and lens status and cause of visual impairment were assessed.

RESULTS

The response rate was 96.2%. The age- and sex-adjusted prevalence of bilateral blindness [presenting visual acuity (PVA) <3/60 in the better eye] was 3.4% (95% confidence interval, 2.8%-4.0%), resulting in an estimated 4187 people blind in Takeo Province. The age- and sex-adjusted prevalence of low vision (PVA <6/18 to 3/60) was 21.1%, an estimated 25,900 people. Cataract surgical coverage in the bilaterally blind was 64.7% (female 59.5%, male 78.1%). Cataract surgical outcome was poor (best-corrected visual acuity <6/60) in only 7.7% and good in 88.7% (best-corrected visual acuity ≥6/18) of eyes operated in the last 5 years before the survey.

CONCLUSIONS

The cataract surgical coverage for women is less than that for men. The increased life expectancy in Cambodia and the fact that women constitute 60.6% of the population (aged ≥50 years) at Takeo Province could have had an impact on cataract workload and high prevalence of blindness. A repeated survey using the same methodology after 8-12 years might be helpful in proving genuine change over time.

[Clinical practice variation in cataract surgery]

PURPOSE

Cataract surgery rates have dramatically increased in the last two decades. However, clinical practice variation in cataract surgery has not been thoroughly studied. The aim of this review is to analyze clinical practice variation, including the causes and consequences of this phenomenon. Then, its role in health care planning and health care quality is focused, emphasizing the importance of reducing it and providing several practical strategies to accomplish it.

RECENT FINDINGS

The latest researches are presented in this article. They identify the development and implementation of clinical practice guidelines as the best tool to standardize care processes.

CONCLUSION

Managing unwarranted or unwanted variation would improve quality of care and may lead to a significant saving in health care spending.

The changing pattern of cataract surgery indications: a 5-year study of 2 cataract surgery databases

PURPOSE

The aim of this study was to describe changes over time in the indications and outcomes of cataract surgery and to discuss optimal timing for the surgery.

DESIGN

Database study.

PARTICIPANTS

Patients who had undergone cataract extraction in the Netherlands, Sweden, or Malaysia from 2008 through 2012.

METHODS

We analyzed preoperative, surgical, and postoperative data from 2 databases: the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) and the Malaysian National Cataract Registry. The EUREQUO contains complete data from the national cataract registries in the Netherlands and Sweden.

MAIN OUTCOME MEASURES

Preoperative and postoperative corrected distance visual acuity, preoperative ocular comorbidity in the surgery eye, and capsule complications during surgery.

RESULTS

There were substantial differences in indication for surgery between the 3 national data sets. The percentage of eyes with a preoperative best-corrected visual acuity of 20/200 or worse varied from 7.1% to 72%. In all 3 data sets, the visual thresholds for cataract surgery decreased over time by 6% to 28% of the baseline values. The frequency of capsule complications varied between the 3 data sets, from 1.1% to 3.7% in 2008 and from 0.6% to 2.7% in 2012. An increasing postoperative visual acuity was also seen for all 3 data sets. A high frequency of capsule complication was related significantly to poor preoperative visual acuity, and a high frequency of decreased visual acuity after surgery was related significantly to excellent preoperative visual acuity.

CONCLUSIONS

The 5-year trend in all 3 national data sets showed decreasing visual thresholds for surgery, decreasing surgical complication rates, and increasing visual outcomes regardless of the initial preoperative visual level. Cataract surgery on eyes with poor preoperative visual acuity was related to surgical complications, and cataract surgery on eyes with excellent preoperative visual acuity was related to adverse visual results.

Mapping human resources for eye health in 21 countries of sub-Saharan Africa: current progress towards VISION 2020

BACKGROUND

Development of human resources for eye health (HReH) is a major focus of the Global Action Plan 2014 to 2019 to reduce the prevalence of avoidable visual impairment by 25% by the year 2019. The eye health workforce is thought to be much smaller in sub-Saharan Africa than in other regions of the world but data to support this for policy-making is scarce. We collected HReH and cataract surgeries data from 21 countries in sub-Sahara to estimate progress towards key suggested population-based VISION 2020 HReH indicators and cataract surgery rates (CSR) in 2011.

METHODS

Routinely collected data on practitioner and surgery numbers in 2011 was requested from national eye care coordinators via electronic questionnaires. Telephone and e-mail discussions were used to determine data collection strategies that fit the national context and to verify reported data quality. Information was collected on six practitioner cadres: ophthalmologists, cataract surgeons, ophthalmic clinical officers, ophthalmic nurses, optometrists and 'mid-level refractionists' and combined with publicly available population data to calculate practitioner to population ratios and CSRs. Associations with development characteristics were conducted using Wilcoxon rank sum tests and Spearman rank correlations.

RESULTS

HReH data was not easily available. A minority of countries had achieved the suggested VISION 2020 targets in 2011; five countries for ophthalmologists/cataract surgeons, four for ophthalmic nurses/clinical officers and two for CSR. All countries were below target for optometrists, even when other cadres who perform refractions as a primary duty were considered. The regional (sample) ratio for surgeons (ophthalmologists and cataract surgeons) was 2.9 per million population, 5.5 for ophthalmic clinical officers and nurses, 3.7 for optometrists and other refractionists, and 515 for CSR. A positive correlation between GDP and CSR as well as many practitioner ratios was observed (CSR P = 0.0042, ophthalmologists P = 0.0034, cataract surgeons, ophthalmic nurses and optometrists 0.1 > P > 0.05).

CONCLUSIONS

With only a minority of countries in our sample having reached suggested ophthalmic cadre targets and none having reached targets for refractionists in 2011, substantially more targeted investment in HReH may be needed for VISION 2020 aims to be achieved in sub-Saharan Africa.

The safety and efficacy of day care cataract surgery

Purpose:

To evaluate safety and efficacy of day care cataract surgery in developing country.

Patients and Methods:

This prospective study included 200 patients planned for cataract surgery during October and November 2012 divided in to two groups, day care cataract surgery (DCCS) and inpatient cataract surgery (ICS), with same number of male and female patients right and left eyes. All patients had same operative conditions and postoperative follow up.

Results:

The average age of patients in this study was 68.4 ± 7.47 years. Visual acuity before cataract extraction was 0.1754 where 44.5% of patients had severe visual impairment and another 23% had complicated cataract. Posterior capsule rupture was noted in 4.5% of cases. The main risk factors in both groups were: higher age, female gender, left side, complicated cataract, higher dioptric power of IOL and ECCE. Regular control opthalmologic examinations 30, 90 and 180 days after the cataract extraction did not reveal signs bullous keratopathy, wound dehiscence, cystoid macular edema and endophtalmitis in any of patients. Postoperative visual acuity 180 days after the operation in DCCS was 0.920 ± 0.154 and 0.928 ± 0.144 in ICS. Visual acuity less than 0.5 was noted in 4.5% due to posterior eye segment changes. Patients in DCCS group had 30 control examinations more and 95 days of hospitalization less than ICS with 16.5% cost reduction.

Conclusion:

The concept of day care cataract surgery is equally safe and more cost effective than inpatient cataract surgery.

The role of surgery in global health: analysis of United States inpatient procedure frequency by condition using the Global Burden of Disease 2010 framework

Background

The role of surgical care in promoting global health is the subject of much debate. The Global Burden of Disease 2010 study (GBD 2010) offers a new opportunity to consider where surgery fits amongst global health priorities. The GBD 2010 reinforces the DALY as the preferred methodology for determining the relative contribution of disease categories to overall global burden of disease without reference to the likelihood of each category requiring surgery. As such, we hypothesize that the GBD framework underestimates the role of surgery in addressing the global burden of disease.

Methods and Findings

We compiled International Classification of Diseases, Version 9, codes from the United States Nationwide Inpatient Sample from 2010. Using the primary diagnosis code for each hospital admission, we aggregated admissions into GBD 2010 disease sub-categories. We queried each hospitalization for a major operation to determine the frequency of admitted patients whose care required surgery. Major operation was defined according to the Agency for Healthcare Research and Quality (AHRQ). In 2010, 10 million major inpatient operations were performed in the United States, associated with 28.6% of all admissions. Major operations were performed in every GBD disease subcategory (range 0.2%–84.0%). The highest frequencies of operation were in the subcategories of Musculoskeletal (84.0%), Neoplasm (61.4%), and Transport Injuries (43.2%). There was no disease subcategory that always required an operation; nor was there any disease subcategory that never required an operation.

Conclusions

Surgical care cuts across the entire spectrum of GBD disease categories, challenging dichotomous traditional classifications of ‘surgical’ versus ‘nonsurgical’ diseases. Current methods of measuring global burden of disease do not reflect the fundamental role operative intervention plays in the delivery of healthcare services. Novel methodologies should be aimed at understanding the integration of surgical services into health systems to address the global burden of disease.

Outcomes and projected impact on vision restoration of the China Million Cataract Surgeries Program

PURPOSE

The recently completed Chinese "Million Cataract Surgeries Program" (MCSP) is among the largest such campaigns ever, providing 1.05 million operations. We report MCSP outcomes for the first time, in Jiangxi, the province with the greatest program output.

METHODS

Ten county hospitals participating in MCSP were selected in Jiangxi (range of gross domestic product per capita US$743-2998). Each hospital sought to enroll 75 consecutive MCSP patients aged ≥ 50 years. Data recorded included type of cataract procedure, bilateral uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA), and refractive error pre- and ≥ 50 days postoperatively.

RESULTS

Among 715 patients (mean age 72.3 ± 9.1 years, 55.5% female), preoperative UCVA was <3/60 (legally blind) bilaterally in 13.3% and unilaterally in the operated eye in 50.9%. No subjects had UCVA >6/18 preoperatively. Small incision cataract surgery was performed in 92.3% patients. Among 662 patients (92.6%) completing follow-up was ≥ 40 days after surgery, BCVA was ≥ 6/18 in 80.1%, UCVA was ≥ 6/18 in 57.1% and UCVA was <3/60 in 2.1%. Older age (p < 0.001), female sex (p = 0.04), worse refractive error (p = 0.02) and presence of intra- (p = 0.002) and postoperative surgical complications (p < 0.001), were independently associated with worse postoperative UCVA. Based on these results, the MCSP cured an estimated 124,950 cases (13.3% × [100-2.1%] × 1.05 million) of bilateral and 502,500 (50.9% × [100-2.1%] × 1.05 million) of unilateral blindness.

CONCLUSIONS

Due to relatively good outcomes and the large number of surgeries performed on blind persons, the sight-restoring impact of the MCSP was probably substantial.

Blindness and visual impairment due to age-related cataract in sub-Saharan Africa: a systematic review of recent population-based studies

AIM

We aimed to evaluate age-related cataract as a contributor to blindness and visual impairment (VI) in sub-Saharan Africa (SSA).

METHODS

A systematic review of population-based studies published between 2000 and October 2012. Prevalence and proportions of blindness and VI due to cataract, cataract surgical coverage (CSC), per cent intraocular lens (IOL) implantation and visual outcomes of surgery in accordance with WHO criteria were ascertained.

RESULTS

Data from 17 surveys (subjects mostly aged ≥ 50-years-old) from 15 different countries in SSA were included, comprising 96 402 people. Prevalence of blindness (presenting visual acuity <3/60 in better eye) ranged from 0.1% in Uganda to 9.0% in Eritrea, and the proportion of total blindness due to cataract ranged between 21% and 67%. Cataract was the principal cause of blindness and VI in 15 and 14 studies, respectively. There was a strong positive correlation between good visual outcomes and IOL use (R=0.69, p=0.027). Considerable inter-study heterogeneity was evident in CSC and visual outcomes following surgery, and between 40% and 100% of operations had used IOL.

CONCLUSIONS

Cataract represents the principal cause of blindness and VI and should remain a priority objective for eye care in SSA. However, the prevalence of blindness and VI due to cataract was variable and may reflect differences in the availability of cataract surgical programmes and cataract incidence.