What are the priorities for improving cataract surgical outcomes in Africa? Results of a Delphi exercise

Reducing the carbon footprint of cataract surgery: co-creating solutions with a departmental Delphi process

BACKGROUND

Climate change is arguably the greatest threat to global health of the 21st century. Although cataract surgery is a major contributor to global greenhouse gas emissions, recent literature review identified a paucity of evidence-based strategies for improving the environmental impact of cataract services. Our study aimed to assess the effectiveness of a departmental Delphi process for improving cataract services' environmental sustainability.

METHODS

All members of ophthalmology theatre teams in a UK teaching hospital were invited to participate in a three-stage Delphi process. Team members were surveyed for suggestions for reducing the department's environmental impact. Suggested interventions were refined during a plenary face-to-face discussion and ranked. The highest ranked interventions were combined into a mutually agreed action plan. Data on the economic and environmental cost of cataract services was collected prior to and six months after the Delphi process using the Eyefficiency mobile application.

RESULTS

Twenty-three interventions were suggested by a range of staff cadres. Interventions were ranked by 24 team members. The 2nd, 4th, 5th, 8th and 11th ranked interventions were combined into an "Eco-packs" project in collaboration with suppliers (Bausch + Lomb), saving 675 kg of waste and 350 kg of CO2 equivalent annually.

CONCLUSIONS

The Delphi process is an effective method for provoking departmental engagement with the sustainability agenda that we would encourage all ophthalmology departments to consider utilising. The baseline per case CO2 equivalent measured in our department was reproducible and could serve as a maximum benchmark to be improved upon.

Clinical diagnosis and management of Demodex blepharitis: the Demodex Expert Panel on Treatment and Eyelid Health (DEPTH)

BACKGROUND

Twelve ocular surface disease experts convened to achieve consensus about Demodex blepharitis (DB) using a modified Delphi panel process.

METHODS

Online surveys were administered using scaled, open-ended, true/false, and multiple-choice questions. Consensus for questions using a 1 to 9 Likert scale was predefined as median scores of 7-9 and 1-3. For other question types, consensus was achieved when 8 of 12 panellists agreed. Questions were randomized, and results of each survey informed the following survey.

RESULTS

Twelve practitioners comprised the Demodex Expert Panel on Treatment and Eyelid Health (DEPTH). Following 3 surveys, experts agreed that DB is chronic (n = 11) and recurrent (n = 12) and is often misdiagnosed. Consensus was achieved regarding inflammation driving symptoms (median = 7; range 7-9), collarettes as the most common sign (n = 10) and pathognomonic for DB (median = 9; range 8-9), and itching as the most common symptom (n = 12). Panellists agreed that DB may be diagnosed based on collarettes, mites, and/or patient symptoms (n = 10) and felt that patients unresponsive to typical therapies should be evaluated for DB (n = 12). Consensus about the most effective currently available OTC treatment was not reached.

CONCLUSIONS

The Delphi methodology proved effective in establishing consensus about DB, including signs, symptoms, and diagnosis. Consensus was not reached about the best treatment or how to grade severity. With increased awareness, eyecare practitioners can offer DB patients better clinical outcomes. A follow-up Delphi panel is planned to obtain further consensus surrounding DB treatment.

Deferring Postoperative Follow‑Up Visits up to 4 Weeks After Uneventful Cataract Surgery in a Tertiary Level Eye Hospital: Protocol for a Prospective, Quantitative, Experimental Control Study

BACKGROUND

Routine examination after cataract surgery, including a refraction test 4 to 6 weeks after surgery, is mandatory in most hospitals. In recent years, there has been growing interest in exploring alternative approaches to postoperative follow-up in cataract surgery patients due to the increasing number of cataract surgeries being performed, the limited availability of health care resources, and the need to optimize the use of health care services.

OBJECTIVE

We aim to compare postoperative visual outcomes after a day 0 examination in patients with 2 follow‑ups, one on day 7 and other on day 30, and patients with a single ophthalmic follow‑up between days 25 to 30.

METHODS

A prospective, quantitative, experimental control study will be carried out in Reiyukai Eiko Masunaga Eye Hospital, located in Banepa, Kavrepalanchok, Nepal. All patients undergoing cataract surgery meeting the inclusion and exclusion criteria irrespective of the type of surgery (small-incision cataract surgery or phacoemulsification) will be included in the study. The patients will be randomly assigned to 1 of 2 groups. Patients in group 1 will be examined on day 1, day 7, and day 30, whereas patients in group 2 will be examined on day 1 and once between days 25 to 30. The minimum clinically important difference (MCID) in our study will be set according to the improvement in the Snellen visual acuity chart.

RESULTS

The study is expected to be completed within 6 to 8 months from the start of the project. Data analysis and report writing will be carried out in a 2-month period. Best-corrected visual acuity will be compared between the 2 groups to determine if the MCID is achieved. The cost-effectiveness of the new approach will also be analyzed.

CONCLUSIONS

We aim to conclude that we can safely defer the 1-week postoperative follow-up visit in patients undergoing uncomplicated cataract surgery and that, moreover, we can reduce the patient load at the hospital and decrease patient expenses by decreasing the frequency of hospital visits.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/48616.

Delphi Panel Consensus Regarding Current Clinical Practice Management Options for Demodex blepharitis

Purpose

To obtain consensus on Demodex blepharitis (DB) treatment using a modified Delphi panel process.

Methods

Literature search identified gaps in knowledge surrounding treatment of DB. Twelve ocular surface disease experts comprised the Demodex Expert Panel on Treatment and Eyelid Health (DEPTH). They completed a live roundtable discussion in addition to 3 surveys consisting of scaled, open-ended, true/false, and multiple-choice questions pertaining to the treatment of DB. Consensus for scaled questions using a 1 to 9 Likert scale was predefined as median scores of 7-9 and 1-3. For other question types, consensus was achieved when 8 of 12 panelists agreed.

Results

The experts agreed that an effective therapeutic agent for treatment of DB would likely decrease the necessity of mechanical intervention, such as lid scrubs or blepharoexfoliation (Median = 8.5; Range 2-9). When treating DB, panelists believed that collarettes serve as a surrogate for mites, and that eliminating or reducing collarettes should be the main clinical goal of treatment (Median = 8; Range 7-9). The panelists would treat patients with at least 10 collarettes, regardless of other signs or symptoms and agreed that DB can be cured, but there is always the possibility for a reinfestation (n = 12). There was also consensus that collarettes, and therefore mites, are the primary treatment target and the way by which clinicians can monitor patient response to therapy (Median = 8; Range 7-9).

Conclusion

Expert panelists achieved consensus on key facets of DB treatment. Specifically, there was consensus that collarettes are pathognomonic for DB, that DB patients with >10 collarettes should be treated even in the absence of symptoms, and that treatment efficacy can be tracked by collarette resolution. By increasing awareness about DB, understanding the goals of and monitoring treatment efficacy, patients will receive better care and, ultimately, better clinical outcomes.

Knowledge, Attitudes and Practices of Eye Health among Public Sector Eye Health Workers in South Africa

In South Africa, primary eye care is largely challenged in its organisational structure, availability of human and other resources, and clinical competency. These do meet the standard required by the National Department of Health. This study seeks to assess the levels of knowledge, attitudes, and practices on eye health amongst Human Resources for eye health (HReH) and their managers, as no study has assessed this previously. A cross-sectional study was conducted in 11 districts of a South African province. A total of 101 participants completed self-administered, close-ended, Likert-scaled questionnaires anonymously. Binary logistic regression analysis was conducted, and values of p < 0.05 were considered statistically significant. Most participants had adequate knowledge (81.6%), positive attitudes (69%), and satisfactory practices (73%) in eye health. HReH showed better knowledge than their managers (p < 0.01). Participants with a university degree, those aged 30-44 years, and those employed for <5 years showed a good attitude (p < 0.05) towards their work. Managers, who supervise and plan for eye health, were 99% less likely to practice adequately in eye health when compared with HReH (aOR = 0.012; p < 0.01). Practices in eye health were best amongst participants with an undergraduate degree, those aged 30-44 years (aOR = 2.603; p < 0.05), and participants with <5 years of employment (aOR = 26.600; p < 0.01). Knowledge, attitudes, and practices were found to be significantly moderately correlated with each other (p < 0.05). Eye health managers have poorer knowledge and practices of eye health than the HReH. A lack of direction is presented by the lack of adequately trained directorates for eye health. It is therefore recommended that policymakers review appointment requirements to ensure that adequately trained and qualified directorates be appointed to manage eye health in each district.

Efficacy, safety and visual outcomes of cataract surgeries performed during blindness prevention programs in different locations in Kenya

PURPOSE

To determine the visual outcomes achieved in terms of efficacy and safety during high-volume cataract surgery programs in different locations in Kenya.

METHODS

Eight hundred eighty-one eyes of 849 patients underwent extracapsular cataract extraction with intraocular lens implantation in a retrospective, observational, consecutive cohort study on patients who underwent cataract surgery in five programs that a Spanish non-governmental organization conducted between 2013 and 2019 for the prevention of blindness in different geographical areas of Kenya: Thika, Athi River, Kissi, Bagavathi, and Nakuru. The programs were carried out by Spanish and Kenyan surgeons working together.

RESULTS

Mean age was 66.81 ± 14.47 years. Fifty-one percent of the operated eyes (447 eyes) were women. 94% of patients belonged to six ethnic groups. The mean uncorrected distance visual acuity (UDVA) before surgery was 1.98 ± 0.98 logMAR (20/2000), which changed to 0.82 ± 0.68 logMAR (20/150) 3 months after surgeries. The corrected distance visual acuity (CDVA) was 0.4 ± 0.53 logMAR (20/50) 3 months after surgery, 77.5% of the patients had good visual outcomes, and 6.3% had poor outcomes. Preoperative UDVAs were significantly different with respect to the different geographical areas (Kruskal-Wallis; p < 0.001). The most common intraoperative complication was posterior capsule rupture (incidence, 4.2%, 37 of 881), and the most serious complication was expulsive hemorrhage (incidence, 0.1%, 1 of 881).

CONCLUSIONS

Cataract programs performed in a middle-income country with the proper technique and standardized protocols of action improved the visual outcome of the patients. Dissimilar baseline status was found in different areas regarding preoperative visual acuities. Training programs of local surgeons should be reinforced.

Ophthalmology training in sub-Saharan Africa: a scoping review

Sub-Saharan Africa is home to 12% of the global population, and 4.3 million are blind and over 15 million are visually impaired. There are only 2.5 ophthalmologists per million people in SSA. Training of ophthalmologists is critical. We designed a systematic literature review protocol, searched MEDLINE Ovid and Embase OVID on 1 August 2019 and limited these searches to the year 2000 onwards. We also searched Google Scholar and websites of ophthalmic institutions for additional information. We include a total of 49 references in this review and used a narrative approach to synthesise the results. There are 56 training institutions for ophthalmologists in eleven Anglophone, eleven Francophone, and two Lusophone SSA countries. The median duration of ophthalmology training programmes was 4 years. Most curricula have been regionally standardised. National, regional and international collaborations are a key feature to ophthalmology training in more than half of ophthalmology training programmes. There is a drive, although perhaps not always evidence-based, for sub-specialisation in the region. Available published scientific data on ophthalmic medical and surgical training in SSA is sparse, especially for Francophone and Lusophone countries. However, through a broad scoping review strategy it has been possible to obtain a valuable and detailed view of ophthalmology training in SSA. Training of ophthalmologists is a complex and multi-faceted task. There are challenges in appropriate selection, capacity, and funding of available training institutions. Numerous learning outcomes demand curriculum, time, faculty, support, and appropriate assessment. There are opportunities provided by modern training approaches. Partnership is key.

Cataract surgery in surgical camps: outcomes in a rural area of Cameroon

AIM

To assess the complications and visual outcomes of cataract surgery during an outreach eye camp in Cameroon in which two foreign ophthalmologists operate alongside a local one.

MATERIALS AND METHODS

This is a retrospective and comparative cohort study. The patients were consecutively assigned to three groups depending on the ophthalmologist who performed the cataract surgeries. All eyes underwent manual sutureless incision cataract surgery with posterior chamber intraocular lens (PCIOL) implantation under peribulbar anesthesia. Postoperative visits were scheduled for the first day, first week and second month after the procedures. Intra- and postoperative complications, best-corrected visual acuity and also refractive errors were assessed.

RESULTS

A total of 263 eyes underwent cataract extraction with PCIOL implantation. The percentage of eyes in which two or more lines of corrected distance visual acuity decreased were 2.4%, 2.7% and 0% for groups A, B and C, respectively. The percentage of eyes with good visual outcome (uncorrected distance visual acuity UDVA > 20/60) were, respectively, 82.09%, 81.43% and 80.82% for the three groups. Similar results were found between the three groups regarding complications. Ocular hypertension, transient corneal edema and hyphema were the incidences registered at the first postoperative control performed 24 h after surgery. The most common complication observed 2 months after surgery was posterior capsular opacity (2.6%).

CONCLUSION

High-volume cataract surgery in low- and middle-income countries may have good visual outcomes and a low rate of complications when the procedures are performed by either foreign or local ophthalmologists.

SYNOPSIS

A program of high-volume cataract surgery carried out in a rural environment with few resources can give good visual outcomes in the hands of both foreign and local experienced ophthalmologists.

Interventions to improve the quality of cataract services: protocol for a global scoping review

INTRODUCTION

Cataract is the leading cause of blindness globally and a major cause of vision impairment. Cataract surgery is an efficacious intervention that usually restores vision. Although it is one of the most commonly conducted surgical interventions worldwide, good quality services (from being detected with operable cataract to undergoing surgery and receiving postoperative care) are not universally accessible. Poor quality understandably reduces the willingness of people with operable cataract to undergo surgery. Therefore, it is critical to improve the quality of care to subsequently reduce vision loss from cataract. This scoping review aims to summarise the nature and extent of the published literature on interventions to improve the quality of services for primary age-related cataract globally.

METHODS AND ANALYSIS

We will search MEDLINE, Embase and Global Health for peer-reviewed manuscripts published since 1990, with no language, geographic or study design restrictions. To define quality, we have used the elements adopted by the WHO-effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency-to which we have added the element of planetary health. We will exclude studies focused on the technical aspects of the surgical procedure and studies that only involve children (<18 years). Two reviewers will screen all titles/abstracts independently, followed by a full-text review of potentially relevant articles. For included articles, data regarding publication characteristics, study details and quality-related outcomes will be extracted by two reviewers independently. Results will be synthesised narratively and presented visually using a spider chart.

ETHICS AND DISSEMINATION

Ethical approval was not sought, as our review will only include published and publicly accessible information. We will publish our findings in an open-access peer-reviewed journal and develop an accessible summary of the results for website posting. A summary of the results will be included in the ongoing Lancet Global Health Commission on Global Eye Health.

REGISTRATION DETAILS

Open Science Framework (https://osf.io/8gktz).

Factors associated with visual outcomes after cataract surgery: A cross-sectional or retrospective study in Liberia

Objective

To report the initial outcomes and associated risk factors for poor outcome of cataract surgery performed in Liberia

Methods and analysis

LV Prasad Eye Institute (LVPEI), Hyderabad, started providing eye care in Liberia since July 2017. Electronic Medical Records of 573 patients operated for age-related cataract from July 2017 to January 2019 were reviewed. One eye per patient was included for analysis. All patients underwent either phacoemulsification or manual small incision cataract surgery (MSICS). Pre and postoperative uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA) were recorded at one day, 1–3 weeks and 4–11 weeks. Main outcome measure was BCVA at 4–11 weeks; Intraoperative complications and preoperative ocular comorbidities (POC) were noted. BCVA less than 6/12 was classified as visual impairment (VI). Risk factor for VI was analysed using the logistic regression model.

Results

Of the 573 patients, 288 were males and 285 were females (49.7%). Mean age was 65.9±10.9 years; 14.3% had POC. The surgical technique was mainly MSICS (94.59%, n = 542). At 4–11 weeks, good outcome of 6/12 or better was noted in 38.55% (UCVA) and 82.54% (BCVA). Visual acuity (VA) of 6/18 or better as UCVA and BCVA was noted in 63.5% and 88% eyes respectively. Poor outcome of less than 6/60 was noted as UCVA (11.11%) and BCVA (5.22%). Multivariable analysis showed poor visual outcomes significantly higher in patients with POC (odds ratio 3.28; 95% CI: 1.70, 6.34).

Conclusion

The cataract surgical outcomes in Liberia were good; with ocular comorbidities as the only risk factor.

Blindness above and below the Poverty Line: Reflections form Sofala, Mozambique

Although the correlation between visual impairment and poverty has been established, economic assessment is not a standard component of blindness surveys. The purpose of this study was to determine the prevalence of avoidable blindness and its association with poverty in Sofala province of Mozambique. As part of a Rapid Assessment of Avoidable Blindness, 94% of a random sample of 3600 people >50 years responded to questions regarding daily per capita expenditure. The WHO definition of blindness (presenting visual acuity <3/60) was used to determine the visual status of participants, and the World Bank's threshold of living on <$1.25 International Dollar a day demarcated the poverty line. The prevalence of blindness was 3.2% [95% Confidence Interval (CI): 2.6, 3.8]. People living below the poverty line had significantly greater odds of being blind [Odds Ratio (OR): 2.6 (CI: 1.6 to 4.5)]. Age above 60 [OR: 7.0 [CI: 4.6 to 10.80] predicted blindness but the association with illiteracy, gender or rural residence was not significant. Blindness disproportionately affects people living below the poverty line. Development initiatives could augment the impact of blindness prevention programs. Measuring poverty should become a standard component of visual impairment surveys.

Prevalence and causes of vision loss in sub-Saharan Africa in 2015: magnitude, temporal trends and projections

Background

This study aimed to assess the prevalence and causes of vision loss in sub-Saharan Africa (SSA) in 2015, compared with prior years, and to estimate expected values for 2020.

Methods

A systematic review and meta-analysis assessed the prevalence of blindness (presenting distance visual acuity <3/60 in the better eye), moderate and severe vision impairment (MSVI; presenting distance visual acuity <6/18 but ≥3/60) and mild vision impairment (MVI; presenting distance visual acuity <6/12 and ≥6/18), and also near vision impairment (<N6 or N8 in the presence of ≥6/12 best-corrected distance visual acuity) in SSA for 1990, 2010, 2015 and 2020.

In SSA, age-standardised prevalence of blindness, MSVI and MVI in 2015 were 1.03% (80% uncertainty interval (UI) 0.39–1.81), 3.64% (80% UI 1.71–5.94) and 2.94% (80% UI 1.05–5.34), respectively, for male and 1.08% (80% UI 0.40–1.93), 3.84% (80% UI 1.72–6.37) and 3.06% (80% UI 1.07–5.61) for females, constituting a significant decrease since 2010 for both genders. There were an estimated 4.28 million blind individuals and 17.36 million individuals with MSVI; 101.08 million individuals were estimated to have near vision loss due to presbyopia. Cataract was the most common cause of blindness (40.1%), whereas undercorrected refractive error (URE) (48.5%) was the most common cause of MSVI. Sub-Saharan West Africa had the highest proportion of blindness compared with the other SSA subregions.

Conclusions

Cataract and URE, two of the major causes of blindness and vision impairment, are reversible with treatment and thus promising targets to alleviate vision impairment in SSA.

[Sumbawanga eye camp follow-up study 2019]

BACKGROUND

In 2019 the German Commission for the Prevention of Blindness (DKVB) held an eye camp in the Tanzanian town of Sumbawanga. For patients with mature cataracts and the ability to see light cateracts were treated by manual small incision cataract surgery (MSICS). For the first time in this camp the quality of the results of the cataract operations was measured.

OBJECTIVE

The quality of the cataract operations is presented and the results were assessed in the context of the guidelines of the World Health Organization (WHO).

METHODS

Those patients who had a cataract operation in the first week were examined during the second week with respect to the parameters vision, refraction, split lamp microscopic findings, results and complications after surgery. The results were retrospectively evaluated and compared with the guidelines of the WHO.

RESULTS

A total of 42 postoperative patients from the eye camp could be examined within 5-9 days after cataract sugery. The following parameters were found: median postoperative visual acuity 0.26, spherical equivalent -2.82 dpt, astigmatism -2.2 dpt, axis 113°. Visual acuity >0.3 in 14.2% (WHO 80%), vision 0.1-0.3 in 62% (WHO 15%), vision <0.1 in 23.8% (WHO 5%). Prolonged healing time and intraocular irritation in 29% of the cases.

CONCLUSION

Although the vision improved, the results are sobering when taken in the context of the WHO guidelines. The postoperative refraction showed a myopic shift and an high level of astigmatism. The reasons are manifold: ocular comorbidities, limited diagnostic and therapeutic possibilities in a nonclinical setting. Other factors are the kind of training of the staff in the camp, the difficult circumstances and advanced findings. Consideration of the results of this study is imperative to be able to measure the quality of the work and to create the potential to make future improvements.

Predictors of patient compliance with follow-up visits after cataract surgery

PURPOSE

To identify patient characteristics associated with follow-up compliance and to draw implications for better cataract treatment services.

SETTING

Aravind Eye Hospital, Madurai, India.

DESIGN

Retrospective case study.

METHODS

The data of all cataract surgeries performed in 2015 were analyzed. After each surgery, patients were asked to return for follow-up after 1 month. The follow-up rates were compared between patients with different demographic characteristics, surgical factors, and preoperative and discharge visual acuities. The behaviors of patients who complied with the follow-up advice were analyzed, including the number of days from surgery to follow-up and number of follow-up visits. Multivariate regression models were used to identify predictors associated with these behaviors.

RESULTS

The overall follow-up rate for the 86 776 surgeries analyzed was 85.6%. Patients more likely to follow-up were women, younger than 70 years, and paying (versus subsidized or free) and had phacoemulsification rather than manual small-incision cataract surgery (all P < .001). Patients who had complications, reoperations, or poorer visual acuity at discharge were less likely to comply with the follow-up advice (P < .001).

CONCLUSIONS

Targeted interventions to boost follow-up rates should be directed to patients with the characteristics found in this study. Furthermore, average measures of visual outcomes at 4 weeks are likely to be overstated relative to the truth.