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Impact of Cataract Surgery in ReducingVisualImpairment: A Review

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80 Middle East African Journal of Ophthalmology, Volume 22, Number 1, January - March 2015

Department of Research, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia

Corresponding Author: Dr. Rajiv Khandekar, Department of Research, King Khalid Eye Specialist Hospital, POB: 7191, Riyadh 11462,

Saudi Arabia. E-mail: [email protected]

Access this article online

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www.meajo.org

DOI:

10.4103/0974-9233.148354

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INTRODUCTION

Cataract is an ocular morbidity of aging. It is the leadingcause of blindness.1 Little progress has been noted in the

field of preventing senile cataract, however, surgery allowsrecovery of vision lost due to cataract. Cataract surgery isthe second most cost-effective health intervention after

vaccination.2 The global initiative for eliminating avoidableblindness called “VISION 2020 – The right to the sight”therefore prioritized cataract and recommended the member

countries of the World Health Organization (WHO) and thenon-governmental organizations focus on performing morecataract surgeries.3 For monitoring progress, the cataract

surgery rate (CSR) per million per year was accepted as an

indicator. Evidence-based data suggested that if the CSRrate was 3500 per million per year, the backlog of operablecataracts and incidence blindness due to cataract can beaddressed. However, the CSR varies widely among countries

It ranged from as low as 824 in Guatemala to as high as5100/million in Argentina 2011.4

ABSTRACT

Purpose: The aim was to assess the impact of cataract surgeries in reducing visual disabilities

and factors inuencing it at three institutes of India.

Materials and Methods: A retrospective chart review was performed in 2013. Data of 4 years

were collected on gender, age, residence, presenting a vision in each eye, eye that underwent

surgery, type of surgery and the amount the patient paid out of pocket for surgery. Visual

impairment was categorized as; absolute blindness (no perception of light); blind (<3/60);

severe visual impairment (SVI) (<6/60-3/60); moderate visual impairment (6/18-6/60) and;

normal vision (≥6/12). Statistically analysis was performed to evaluate the association

between visual disabilities and demographics or other possible barriers. The trend of visual

impairment over time was also evaluated. We compared the data of 2011 to data available

about cataract cases from institutions between 2002 and 2009.

Results: There were 108,238 cataract cases (50.6% were female) that underwent cataract

surgery at the three institutions. In 2011, 71,615 (66.2%) cases underwent surgery. There were

45,336 (41.9%) with presenting vision < 3/60 and 75,393 (69.7%) had SVI in the fellow eye.

Blindness at presentation for cataract surgery was associated to, male patients, Institution

3 (Dristi Netralaya, Dahod) surgeries after 2009, cataract surgeries without Intra ocular

lens implant implantation, and patients paying <25 US $ for surgery. Predictors of SVI at

time of cataract surgery were, male, Institution 3 (OM), phaco surgeries, those opting to pay

250 US $ for cataract surgeries.

Conclusion: Patients with cataract seek eye care in late stages of visual disability. The goalof improving vision related quality of life for cataract patients during the early stages of

visual impairment that is common in industrialized countries seems to be non-attainable in

the rural India.

Key words: Blind, Cataract, Severe Visual Impairment, Visual Acuity

Impact of Cataract Surgery in Reducing Visual

Impairment: A Review

Rajiv Khandekar, Anand Sudhan, B. K. Jain, Madan Deshpande, Kuldeep Dole, Mahul Shah, Shreya Shah

Original Article

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Khandekar, et al .: Cataract Blindness Reduction

Middle East African Journal of Ophthalmology, Volume 22, Number 1, January - March 2015 81

Technologies to manage cataract have advanced dramatically inlast three decades, and this has resulted in increased cataractsurgeries as well as greater acceptance in the community.5,6 Currently, ophthalmologists perform cataract surgery to improvethe vision related quality of life rather than to address blindness.This propensity towards quality of life means very few cataractpatients present for surgery when they are blind (vision < 3/60

in a better eye) and incapacitated in terms of mobility, reading, writing, and communication. Limburg et al. had found that40% to 50% of cataract surgeries in India are performed onpatients with >6/60 vision in fellow eye and the surgery wasnot a sight-restoring exercise7 For appropriate public healthpolicies in developing countries where a large backlog of operablecataract exists, there is a need to review the visual status ofpatients presenting with cataract and assess the role of cataractsurgery in reducing visual disabilities.[8] In addition, findingthe underlying factors associated with the late presentation ofpatients with severe visual impairment (SVI) due to cataract isnecessary. Late presentation is more common in rural areas. Two

of our study centers are located and serve rural and tribal areasof India, and the third center has majority of cataract patientsrecruited from outreach camps held in rural Maharashtra.The perceived benefit to these patients and for the provider

will be better compared with patients with moderate visualimpairment (MVI) due to cataract.

In this study, we evaluate the role of cataract surgery inreducing visual disabilities and assess common barriersto patients presenting for cataract surgery. Based onthe findings, we recommend a public health approachfor reducing cataract related blindness.

MATERIALS AND METHODS

The ethical and research committees of all three institutionsgranted consent for this study. This study was conducted fromNovember 2012 to January 2013. The data of 2004 and 2005,as well as data of 2010 and 2011, was referred for this review.

One ophthalmologist and one administrator of eachinstitute liaised with an ophthalmic epidemiologistto undertake this study. Institute 1 (SNC) is located incentral India, and the majority of patients were from

the tribal population. The cataract cases were screenedat camps, clinic of vision centers and the base hospital.

All surgeries are performed at the hospital . Inst itute2 (H.V.D.) is located in an urban area of Maharashtrastate, India. Cataract patients for this institute presentfrom rural Maharashtra through screening camps andfrom city hospital clinics. Institute 3 (Dristi Netralaya,Dahod) is located in the Gujarat State of India andprovides cataract services through outreach initiativesin the Gujarat, Rajasthan and Madhya Pradesh States.

All three institutes maintain medical information of cataractpatients in computerized databases. Demographic informationis collected at the time of the initial assessment by health carestaff speaking local language. To confirm age, the date of birthin relation to important historical events e.g. independence ofIndia (1947), China war (1962), last war with Pakistan (1969)

etc. were queried.

An ophthalmic assistant performed measurement of visual acuity. Visual acuity in each eye was noted “as presented” with a Snellenilliterate “E” chart. The chart was placed at six meters from the

patient. If the top “E” could not be correctly identified, the test was repeated at three meters. If the vision could not be testedeven at three meters, the perception of light with and withoutprojection for each eye from four directions was evaluated. Theophthalmologist examined each patient for diagnosing cataract,other ocular comorbidities and plan for cataract surgery. Oneeye underwent surgery at a time. A few patients underwent

surgery of both eyes within 1-day of each other. Patients and

relatives were informed of the different types of lens implants.The basic lens was offered without any cost to the patient if he/she

was referred from an outreach camp. Other patients selectedphacoemulsification surgery and more expensive intraocularlenses that were implanted by a senior ophthalmologist at anominal price to cover the cost. The cost in rupees was converted

in dollars as per the exchange rate sin January 2005 and January2010 respectively.

Data of all three institutions were collated together, however,the year of surgery and the institution code was added later.

The Statistical Package for the Social Studies (SPSS 16;IBM Corp., New York, NY, USA) was used for data analysis.

We assumed that the eye scheduled for cataract surgery wouldhave worse vision than the fellow eye. Based on presenting

vision in the fellow eye, we grouped all persons into; WHOblind (<3/60), SVI (<6/60), MVI (≤6/18-6/60) and normal

sighted persons (>6/18). For determining the magnitude of visual disabilities in patients with cataract, we calculated thefrequencies, percentage proportion and their 95% confidenceintervals (CIs). Univariate analysis by the parametric method

was used to test the association of visual disability to different

risk factors such as age, sex, state of residence, eye operated,

type of surgery and payment for cataract surgery. The oddsratio, 95% CI, Chi-square value were calculated. A P < 0.05

was statistically significant. Based on the year of surgery, wegrouped participants into those underwent surgery between2005 and 2009 and those who underwent surger y in 2010 and2011. Subsequently, we compared the trend in visual disability

when the patient presented for cataract surgery.

The results of this study were shared with the administrators atall three institution and presented at ophthalmic conferences.








RESULTS

We reviewed a representative sample of 108,238 patients whounderwent cataract surgery at three eye institutions in India.Patient demographics and other characteristics are presentedin Table 1. Two third of cases underwent surgery in the year2011 at Institute 1.

The prevalence of bilateral blindness “as presented” was41.9% (95% CI: 41.6-42.2). The prevalence of severe visualdisabilities (VA < 6/60 in the better eye as presented) was69.7% (95% CI: 69.4-69.9). The magnitude and associationof visual disabilities (blind and SVI) to different variables ispresented in Table 2. Patients from Institute 2 (an urban center)had a lower incidence of blindness in the fellow eye. Patients

who paid for a higher cost implant had a lower incidence ofblindness at the time of cataract surgery. Approximately half ofthe cataract patients who underwent surgery after 2009 wereblind at presentation. Only 17% of patients who underwent

surgery before 2009 were blind at presentation. In contrast,the proportion of cataract cases with SVI was statisticallysignificantly higher in patients who underwent surgery after2009 ( P < 0.05).

We carried out regression analysis to identify the predictorsof SVI at the time of presentation for cataract surgery. The

variables that were significantly associated to SVI were includedin the model [Table 3]. Female gender, institutions of urbanarea, those selecting the option of phacoemulsification with anexpensive lens implant and paying a substantial cost out of pocketfor cataract surgery were independent predictors of lower visual

disabilities at the time of cataract surgery.

DISCUSSION

We studied a large number of cases to assess visual impairmentof patients presenting with cataracts. Only 42% of cataractcases were blind, and 70% had SVI at the time of cataractsurgery. Hence, by successfully operating on the cataract inthe eye, one can reduce the visual disabilities of these patients.The conventional thinking that patients with cataract seek eyecare in the early stages of their visual disability does not seemto be applicable to the patients we evaluated in this study. Patients

who were willing to share the cost of surgery and prepared toundergo phacoemulsification and lens implantation, presentedfor cataract surger y in the early stages of visual disability. Thesepatients underwent cataract surgery for improving their visionrelated quality of life rather than reducing their visual disability.

The gender distribution of cataract patients in our series wasnot statistically significantly different ( P > 0.05). This is incontrast to the findings of previous studies where femalegender was a barrier to access cataract surgery.9-11 Perhaps the

outreach camp approach was able to bridge the gender gapin our study.12 Male (but not female) gender was statisticallysignificantly associated to blindness ( P < 0.05). However, the

female had statistically significantly higher risk of SVI thanmales ( P < 0.05). In the older population, retired males mayhave lower visual needs than females. For example, older femalesremain responsible for looking after household chores in therural and tribal Indian communities.

Distance is a noted barrier for eye care and cataract surgery indeveloping countries.9,13,14 In Institute 2 (PMBA) which is inan urban location, with many of their patients presenting fromnearby urban areas, distance was not a barrier. This has resultedin less visual disabilities in institutions located in urban areascompared to patients from the two other institutions which

were in tribal areas, and access due to distances could be a majorbarrier. Hence, distance could result in late presentation and ahigh proportion of cases with blindness at the time of cataractsurgery. Sending outreach screening teams and transportingcataract cases to the base hospital at low cost could improvethe uptake and result in patients presenting in a timely mannerfor cataract assessment and surgery.

Direct and indirect costs of cataract surgery are known causes ofthe low uptake and late presentation for surgery in developing

Table 1: Demographics, geographic locale and other

characteristics of patients who underwent cataract eye surgery

at three ophthalmic institutes in India

Variable Number (%)

GenderMale 53,477 (49.4)Female 54,761 (50.6)

Institution*

SNC 79,309 (73.3)HVD 16,382 (15.1)Dristi 12,547 (11.6)

State of residenceMadhya Pradesh 31,987 (29.6)Uttar Pradesh 39,257 (36.3)Bihar 10,478 (9.7)Maharashtra 16,405 (15.2)Rajasthan 1635 (1.5)Gujarat 8342 (7.7)Other 134 (0.1)

Year of surgery2004–2005 36,622 (33.8)2010–2011 71,615 (66.2)

Payment modeFree of cost 43,234 (39.9)<20 US $ 26,527 (24.5)20–100 US $ 32,342 (29.9)>100 US $ 6135 (5.7)

AgeMean 62.9 yearsSD 10.3 years

Total 108,238 (100)

*SNC: Sadguru Netra Chikitsalaya Chitrakoot, HVD: H V Desai eye hospital, Pune,

District: Dristi Netralaya, Dahod, SD: Standard deviation








lenses were inserted in urban population through payment.

Patients undergoing phacoemulsification and directly paying

a higher cost for special lenses had less visual disabilities thanother patients at presentation. The earlier intervention for an

urban population could be due to the visual needs for better

visual function in the urban setting. In addition, is it likely

that surgeons could have motivated urban patients to undergo

phacoemulsification in the early stages of cataract progression

as phacoemulsification is difficult in mature or hyper-mature

cataracts compared to operating upon immature cataract.17

The quantitative indicator of cataract surgery to monitor the

progress of various countries efforts to eliminate blindness

due to cataract is judiciously applied by the prevention of

blindness program managers.18

However, Gujarat state had a very high CSR (5000-6000/M/Y) and had a substantial number

of individuals with blindness due to cataract.19 The impact of

cataract surgery in reducing blindness will vary with visual

status of the eye undergoing surgery and the status of the fellow

eye.20 Researchers have proposed both CSR and cataract surgery

coverage (CSC) as indicators to monitor progress of cataract

blindness reduction.21 However, CSC is difficult to generate

more frequently as it requires community-based assessment

of lens status among the elderly population in the community.

Table 2: Visual disability and determinants in study participants schedule for cataract surgery

Variable Patients operated

for cataract

Vision in fellow eye <3/60 (WHO blind) SVI in fellow eye

Number (%) Validation Number (%) Validation

GenderMale 53,477 22,618 (42.3) OR=1.03 (95% CI 1.01-1.06) 37,037 (69.3) OR=0.97 (95% CI 0.94-0.99)Female 54,761 22,718 (41.5) 38,356 (70.0)

InstitutionSNC 79,309 35,309 (44.5) χ2=157, df=3, P =<0.001 79,309 (74.9) χ2=1600, df=3, P =<0.001PMBA 16,382 1289 (7.9) 16,382 (44.4)OM 12,547 8738 (69.6) 12,547 (69.7)

Year of surgery<2009 30,688 5149 (16.8) OR=0.19 (95% CI 0.18-0.19) 19,469 (63.4) OR=0.67 (95% CI 0.65-0.69)≥2009 77,550 40,187 (51.8) 55,924 (72.1)

StateMadhya Pradesh 31,987 13,700 (42.8) χ2=88, df=7, P =<0.001 23,832 (74.5) χ2=2141, df=7, P =<0.001Uttar Pradesh 39,257 18,521 (47.2) 29,305 (74.6)Bihar 10,478 4738 (45.2) 7855 (75.0)Other 134 53 (39.6) 81 (60.4)Maharashtra 16,405 1298 (7.9) 7293 (44.5)Rajasthan 1635 1077 (65.9) 1077 (65.9)Gujarat 8342 5949 (71.3) 5950 (71.3)

Type of surgeryNo IOL 386 288 (74.6) χ2=28,184, df=3, P =<0.001 303 (78.5) χ2=2650, df=3, P =<0.001

SICS+IOL 83,248 36,917 (44.3) 61,229 (73.6)Phaco 24,604 8131 (33.3) 13,861 (56.3)

Cost shared by patientNo cost 43,234 13,887 (32.1) 28,208 (65.2) χ2=6437, df=3, P =<0.001<20 US $ 26,527 13,691 (51.6) 20,234 (76.3)20-100 $ 32,342 15,921 (49.2) 23,476 (72.6)>100 US $ 6137 1837 (29.9) 3475 (56.6)

Total 108,238 45,336 (41.9) 41.6-42.2 75,393 (69.7) 69.4-69.9

P <0.05 was statistically significant. IOL: Intraocular lens, Phaco: Phacoemulsification, SICS: Small Incision Cataract Surgery, df: Degrees of freedom, WHO: World Health

Organization, SVI: Severe visual impairment, OR: Odds ratio, CI: Confidence interval, SNC: Sadguru Netra Chikitsalaya Chitrakoot

Table 3: Predictors of SVI in the better eye at presentation for

cataract surgery

Variable AOR 95% CI of OR P

GenderMale 1.06 1.03-1.09 8.6×10−6

Female 1Institution

SNC 0.5 0.45-0.51 1.0×10−114

PMBA 2.84 2.71-2.99OM 1

Type of surgeryNo IOL 0.5 0.38-0.63 1.5×10−8

SICS 0.7 0.67-0.51 1.0×10−1102

Phaco 1Cost paid by patient (US $)

No cost 0.19 0.16-0.23 1.28×10−59

<20 0.34 28-0.41 2.1×10−27

20-100 0.41 0.34-0.50 6.6×10−9

>100 1.00

AOR: Adjusted odd’s ratio, CI: Confidence interval, OR: Odds ratio, SVI: Severe

visual impairment, IOL: Intraocular lens, SICS: Small Incision Cataract Surgery,

Phaco: Phacoemulsification, SNC: Sadguru Netra Chikitsalaya Chitrakoot

countries.15,16 Information on lens implantation seems tobe a proxy indicator for the cost of the cataract surgery inour study. Most of the surgeries were performed with lensimplantations except in a few cases with other morbidities or

with advanced stages of cataract. However, advanced types of








Our study also found that cataract surgery had the potentialof reducing visual disabilities by nearly a half as the rest didnot have blinding visual impairment in fellow eyes. Thus, CSRalone seems to be of limited value in assessing the impact ofthe VISION 2020 initiative. Further categorization of CSR inrelation to barriers (in male and females, in urban and ruralareas and for those sharing cost versus no cost to the patient)

will allow program managers direct their efforts more effectivelytowards reducing visual disabilities.

There are some limitations in our study. In this retrospectivereview, information of fellow eyes after cataract surgery of thefirst eye, was not available. Hence, we cannot judge if visualimpairment in the fellow eye was due to unoperated cataract,co-morbidities or poor outcomes of previous surgery in thefellow eye. All three institutes in our study are ISO 9001certified.22-24 Hence, poor surgical outcomes are less likely tocause visual disabilities in the fellow eyes as periodic auditshelps improve surgical outcomes.25 The data in our study does

not cover all patients underwent cataract surgery in the threeinstitutions before 2009. Thus, changes in the outcome inrelation to the time and institutions should be interpreted withcaution. The cost of cataract was converted in US $ at twodifferent years. Comparison of cost should be done with cautionas fluctuation of exchange rate could have influenced the costingexercise. This being retrospective data; some important factorsinfluencing the association of cataract and visual status were notincluded in the present study.

In our study, if we assume that surgery reduced visually disabilityand restored vision in all patients, the providers would be able

to reduce blindness in only 42% of blindness due to cataractand 70% of cataract responsible for SVI. Due to increase in theaged demographic of the population, the incidence of cataractis increasing in many developing countries. Thus, the backlog ofoperable cataract is also increasing. Alternately, more and morenon-sight threatening lens opacities are being treated whileblinding cataract still exists in the underprivileged areas. 26,27 Considerable progress has been made in reducing cataractblindness in India in the first half of VISION 2020.28 However,a significant effort has to be made if more cataract surgeries,especially for the underserviced population are to be performedin the coming years. The goal of improving vision related to

quality of life among patients with cataract in their early stagesof visual impairment that is common in industrialized countriesseems to be currently unattainable for the rural population ofIndia.29

ACKNOWLEDGMENTS

We thank the staff of all three institutions to assist us in the collectionof cataract related data. Mr. Rich Bern assisted in English editing themanuscript. Dr. Deepak Edward provided important tips to improvethe manuscript.

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Cite this article as: Khandekar R, Sudhan A, Jain BK, Deshpande M, Dole

K, Shah M, Shah S. Impact of cataract surgery in reducing visual impairment:

A review. Middle East Afr J Ophthalmol 2015;22:80-5.

Source of Support: Nil, Conict of Interest: None declared.




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