The cataract situation in Latin America: barriers to cataract surgery

Mapping Human Resources to Guide Ophthalmology Capacity-Building Projects in Honduras: Sub-national Analyses of Physician Distribution and Surgical Practices

Objective

To map ophthalmologist locations and surgical practices as they vary sub-nationally within Honduras to maximize the impact of efforts to develop cataract surgical capacity.

Methods

An anonymous survey was sent to all Honduran ophthalmologists with questions on surgical volume, department-level location, type of facility in which they work, surgical methods, and age. Surgical volume, population, and poverty data sourced through the Oxford Poverty Human Development Initiative were mapped at the department level, and cataract surgical rates (CSR; surgeries per million population per year) were calculated and mapped.

Results

Sixty-one of the 102 Honduran ophthalmologists contacted responded. Of those, 85% perform cataract surgery, and 49% work at least part time in a non-profit or governmental facility. Honduras has fewer surgical ophthalmologists per million than the global average, and though national CSR appears to be increasing, it varies significantly between departments. The correlation between CSR and poverty is complex, and outliers provide valuable insights.

Conclusion

Mapping ophthalmological surgical practices as they relate to population and poverty at a sub-national level provides important insights into geographic trends in the need for and access to eye care. Such insights can be used to guide efficient and effective development of cataract surgical capacity.

Safety of intracameral application of moxifloxacin and dexamethasone (Vigadexa®) after phacoemulsification surgery

BACKGROUND

Intracameral antibiotics, such as moxifloxacin and cefuroxime, are safe to corneal endothelial cells and effective prophylaxis of endophthalmitis after cataract surgery. Corneal endothelial cells decrease in density after cataract surgery. Any substance used in the anterior chamber may affect corneal endothelial cells and lead to a greater decrease in density. This study wants to determine the percentage of endothelial cell loss after cataract extraction by phacoemulsification with off-label intracameral injection of moxifloxacin and dexamethasone (Vigadexa®).

METHODS

An observational retrospective study was performed. The clinical records of patients undergoing cataract surgery by phacoemulsification plus intracameral injection of Vigadexa® were analyzed. Endothelial cell loss (ECL) was calculated using preoperative and postoperative endothelial cell density. The relation of endothelial cell loss with cataract grade using LOCS III classification, total surgery time, total ultrasound time, total longitudinal power time, total torsional amplitude time, total aspiration time, estimated fluid usage, and cumulative dissipated energy (CDE) was studied using univariate linear regression analysis and logistic regression analysis.

RESULTS

The median loss of corneal endothelial cells was 4.6%, interquartile range 0 to 10.4%. Nuclear color and CDE were associated with increased ECL. ECL>10% was associated with age and total ultrasound time in seconds.

CONCLUSIONS

The endothelial cell loss after the intracameral use of Vigadexa® at the end of cataract surgery was similar to the reported in other studies of cataract surgery without the use of intracameral prophylaxis for postoperative endophthalmitis (POE). This study confirmed the association of CDE and nuclear opalescence grade with postoperative corneal endothelial cell loss.

Carbon Monoxide Releasing Molecule-3 Alleviates Oxidative Stress and Apoptosis in Selenite-Induced Cataract in Rats via Activating Nrf2/HO-1 Pathway

PURPOSE

This study investigated the protective effect of carbon monoxide releasing molecule-3 (CORM-3), the classical donor of carbon monoxide, on selenite-induced cataract in rats and explore its possible mechanism.

METHODS

Sprague-Dawley rat pups treated with sodium selenite (Na2SeO3) were chosen as the cataract model. Fifty rat pups were randomly divided into 5 groups: Control group, Na2SeO3 (3.46 mg/kg) group, low-dose CORM-3 (8 mg/kg/d) + Na2SeO3 group, high-dose CORM-3 (16 mg/kg/d) + Na2SeO3 group, and inactivated CORM-3 (iCORM-3) (8 mg/kg/d) + Na2SeO3 group. The protective effect of CORM-3 was tested by lens opacity scores, hematoxylin and eosin staining, TdT-mediated dUTP nick-end labeling assay, and enzyme-linked immunosorbent assay. Besides, quantitative real-time PCR and western blotting were used for mechanism validation.

RESULTS

Na2SeO3 induced nuclear cataract rapidly and stably, and the achievement ratio of Na2SeO3 group was 100%. CORM-3 alleviated lens opacity of selenite-induced cataract and attenuated the morphological changes of the rat lens. The levels of antioxidant enzymes GSH and SOD in rat lens were also increased by CORM-3 treatment. CORM-3 significantly reduced the ratio of apoptotic lens epithelial cells, besides, CORM-3 decreased the expression of Cleaved Caspase-3 and Bax induced by selenite and increased the expression of Bcl-2 in rat lens inhibited by selenite. Moreover, Nrf-2 and HO-1 were upregulated and Keap1 was downregulated after CORM-3 treatment. While iCORM-3 did not exert the same effect as CORM-3.

CONCLUSIONS

Exogenous CO released from CORM-3 alleviates oxidative stress and apoptosis in selenite-induced rat cataract via activating Nrf2/HO-1 pathway. CORM-3 may serve as a promising preventive and therapeutic strategy for cataract.

Alcohol use patterns and risk of incident cataract surgery: a large scale case-control study in Japan

To examine the risk of incident cataract surgery associated with alcohol use patterns among Japanese adults. This was a case-control study evaluating 14,861 patients with incident cataract surgery and 14,861 matched controls. Subjects admitted to any of the 34 hospitals in Japan and aged between 40 and 69 years were included. Drinking patterns (drinking frequency, daily average drinks, and total amount of lifetime drinking), smoking history, lifestyle-related comorbidities, and occupational factors were surveyed by trained interviewers. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression models. For drinking frequency, ORs in the 1-3 days/week and 4-7 days/week groups were 1.10 (95% CI 1.03-1.17) and 1.30 (1.21-1.40), respectively. For average drinks, ORs in > 0-2 drinks/day, > 2-4 drinks/day, and > 4 drinks/day were 1.13 (1.06-1.20), 1.23 (1.12-1.35), and 1.16 (1.03-1.31), respectively. Both men and women had an increased risk of incident cataract surgery with increased total lifetime drinking, with a significant increase in risk occurring at > 90 drink-years for men and > 40 drink-years for women. A positive dose-response relationship was observed between alcohol consumption and cataract. Restricted drinking may help to reduce the progression of cataracts.

Biliverdin/Bilirubin Redox Pair Protects Lens Epithelial Cells against Oxidative Stress in Age-Related Cataract by Regulating NF-κB/iNOS and Nrf2/HO-1 Pathways

Age-related cataract (ARC) is the leading cause of vision impairment globally. It has been widely accepted that excessive reactive oxygen species (ROS) accumulation in lens epithelial cells (LECs) is a critical risk factor for ARC formation. Biliverdin (BV)/bilirubin (BR) redox pair is the active by-product of heme degradation with robust antioxidative stress and antiapoptotic effects. Thus, we purpose that BV and BR may have a therapeutic effect on ARC. In the present study, we determine the expression levels of enzymes regulating BV and BR generation in human lens anterior capsule samples. The therapeutic effect of BV/BR redox pair on ARC was assessed in hydrogen peroxide (H₂O₂)-damaged mouse LECs in vitro. The NF-κB/inducible nitric oxide synthase (iNOS) and nuclear factor erythroid 2-related factor 2 (Nrf2)/heme oxygenase-1 (HO-1) signaling pathways were evaluated to illustrate the molecular mechanism. The results revealed that the mRNA expressions of Nrf2, HO-1, and biliverdin reductase A (BVRA) were all decreased in human samples of age-related nuclear cataract. BV/BR redox pair pretreatment protected LECs against H₂O₂ damage by prohibiting NF-κB p65 nuclear trafficking, ameliorating iNOS expression, reducing intracellular and mitochondrial ROS levels, and restoring glutathione (GSH) and superoxide dismutase (SOD) levels. BV and BR pretreatment also regulated the expression of apoptotic molecules (Bax, Bcl-2, and cleaved caspase-3), thus decreasing the apoptosis of LECs. In addition, BV/BR pair promoted Nrf2 nuclear accumulation and HO-1 induction, whereas the knockdown of BVRA counteracted the effect of BV on activating Nrf2/HO-1 pathway and antiapoptosis. These findings implicated that BV/BR redox pair protects LECs against H₂O₂-induced apoptosis by regulating NF-κB/iNOS and Nrf2/HO-1 pathways. Moreover, BVRA is responsible for BV-mediated cytoprotection by reductive conversion of BV to BR. This trial is registered with ChiCTR2000036059.

The association between cataract and sleep apnea: a nationwide population-based cohort study

STUDY OBJECTIVES

The association between sleep apnea (SA) and cataract was confirmed in a comprehensive large-scale study. This study aimed to investigate whether SA was associated with increased risk of cataract.

METHODS

The 18-year nationwide retrospective population-based cohort study used data retrieved from the Taiwan National Health Insurance Database. We selected adult patients with a diagnosis of SA, based on diagnostic codes (suspected SA cohort) or on presence of diagnosis after polysomnography (SA cohort), and matched each of them to 5 randomly selected, and age- and sex-matched control participants. The incidence rate of cataract was compared between patients with SA and the controls. The effect of SA on incident cataract was assessed using multivariable Poisson regression and Cox regression analyses.

RESULTS

A total of 6,438 patients in the suspected SA cohort were matched with 32,190 controls (control A cohort), including 3,616 patients in the SA cohort matched with 18,080 controls (control B cohort). After adjusting for age, sex, residency, income level, and comorbidities, the incidence rates of cataract were significantly higher in the SA cohorts than in the corresponding control cohorts. SA was an independent risk factor for incident cataract (adjusted hazard ratio [95% confidence interval]: 1.4 [1.2-1.6]). In patients with SA, elder age, heart disease, chronic pulmonary disease, and diabetes mellitus were independent risk factors for incident cataract.

CONCLUSIONS

Our study revealed a significantly higher risk for developing cataract in patients with SA. Physicians caring for patients with SA should be aware of this ophthalmic complication.

CITATION

Liu P-K, Chang Y-C, Wang N-K, et al. The association between cataract and sleep apnea: a nationwide population-based cohort study. J Clin Sleep Med. 2022;18(3):769-777.

Trends in cataract surgical treatment within the Brazilian national public health system over a 20-year period: Implications for Universal Eye Health as a global public health goal

Cataract is a highly prevalent, treatable, and sight threatening condition considered one of the main focuses of public health policies addressing visual impairment and blindness towards Universal Eye Health. We aimed to investigate the trends on number of cataract surgical procedures performed through the Brazilian national health system (SUS) from 2000 to 2019 while also evaluating costs associated with it. The Brazilian Public Health System Information Database (DATASUS) was used as the primary data source for procedures including extracapsular cataract extraction (ECCE) and phacoemulsification. Trends along the years were evaluated through generalized linear models. A total of 8,424,521 cataract procedures were performed from 2000 to 2019, with a significant increase along the years from 228,145 in 2000 to 663,186 in 2019 (p<0.001), a cataract surgical procedure rate change from 13.15 to 32.28 procedures per 10,000 people. It was observed a significant increase on the number of phacoemulsification (p<0.001) and a significant decrease on the number of ECCE (p<0.001). A shift on the predominant technique has occurred between 2007 and 2008 with phacoemulsification increasing its percentual representativity from 34.3% to 69.7% of all procedures, reaching 96.1% in 2019. Phacoemulsification costs per procedure increased 30.5% from from USD$119.00 to USD$155.33 (p = 0.007) and the ECCE costs per procedure increased 29.1% from USD$78.57 to USD$101.43 (p = 0.001). There is an increasing trend of procedures related to cataract treatment performed through SUS along the 20-years period and a switch on the technique predominance from ECCE to phacoemulsification was observed after 2007. The costs associated with both techniques have increased but have not followed the country's overall inflation. Data derived from DATASUS is important to understand the overall panorama of ocular health offered by the national health system and to provide information to guide healthcare leaders on management and planning of public health policies within the system.

Ocular Complications of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), the most common form of sleep-disordered breathing, is characterized by repetitive episodes of paused breathing during sleep, which in turn induces transient nocturnal hypoxia and hypercapnia. The high prevalence of OSA and its associated health consequences place a heavy burden on the healthcare system. In particular, the consequent episodic oxygenic desaturation/reoxygenation series and arousals from sleep in patients with OSA have the potential to trigger oxidative stress, elevated systemic inflammatory responses, and autonomic dysfunction with sympathetic activation. Given these adverse side-effects, OSA is highly correlated to many eye diseases that are common in everyday ophthalmic practices. Some of these ocular consequences are reversible, but they may permanently threaten a patient’s vision if not treated appropriately. Here, this article seeks to review the ocular consequences and potential pathophysiologic associations in patients with OSA. Understanding these OSA-related eye diseases may help clinicians provide comprehensive care to their patients.

How can we improve the quality of cataract services for all? A global scoping review

BACKGROUND

Cataract is a leading cause of blindness and vision impairment globally. Cataract surgery is one of the most frequently performed operations worldwide, but good quality services are not universally available. This scoping review aims to summarise the nature and extent of published literature on interventions to improve the quality of services for age-related cataract globally.

METHODS

We used the dimensions of quality adopted by WHO-effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency-to which we added planetary health. On 17 November 2019, we searched MEDLINE, Embase and Global Health for manuscripts published since 1990, without language or geographic restrictions. We included studies that reported quality-relevant interventions and excluded studies focused on technical aspects of surgery or that only involved children (younger than 18 years). Screening of titles/abstracts, full-text review and data extraction were performed by two reviewers independently. Studies were grouped thematically and results synthesised narratively.

RESULTS

Most of the 143 included studies were undertaken in high-income countries (n = 93, 65%); 29 intervention groups were identified, most commonly preoperative education (n = 17, 12%) and pain/anxiety management (n = 16, 11%). Efficiency was the quality element most often assessed (n = 58, 41%) followed by people-centredness (n = 40, 28%), while integration (n = 4) and timeliness (n = 3) were infrequently reported, and no study reported outcomes related to planetary health.

CONCLUSION

Evidence on interventions to improve quality of cataract services shows unequal regional distribution. There is an urgent need for more evidence relevant to low- and middle-income countries as well as across all quality elements, including planetary health.

Assessment of Knowledge and Attitude of Cataract and Their Associated Factors Among Adults in Arba Minch Zuria Woreda, Southern Ethiopia

Background

Cataract is the major cause of reversible blindness and visual impairment in developing countries. It has been assumed that there is poor access to information related to the cause, prevention, and treatment of cataract in developing countries. There is also a paucity of data on knowledge and attitude towards cataract in Ethiopia.

Purpose

This study aimed to assess the knowledge and attitude of cataract and their associated factors among adults in Arba Minch Zuria Woreda, Southern Ethiopia.

Patients and Methods

A community-based cross-sectional study was conducted among 623 adults from February 6 to April 16, 2020. The study participants were selected by the multi-stage sampling technique. Data were collected with a pre-tested structured questionnaire by using face-to-face interviews. The data were entered into Epi info version 7.2 and exported to SPSS version 23 for analysis. The level of statistical significance was set at a p-value less than 0.05 in multivariable logistic regression.

Results

Among 623 total participants, 54.9% of them had good knowledge about cataract, while 37.9% of them had favorable attitude about cataract. Inability to read and write (AOR=0.104, 95% CI: 0.042–0.258), primary school educational level (AOR=0.208, 95% CI: 0.091–0.478), secondary school educational level (AOR=0.199, 95% CI: 0.088–0.451), earning average monthly income 350–820 Ethiopian birr (AOR=2.364, 95% CI: 1.277–4.373), not having previous eye examination (AOR=0.605, 95% CI: 0.425–0.861) and unavailability of eye clinic (AOR=0.65, 95% CI: 0.446–0.945) were significantly associated with knowledge of cataract. No history of cataract (AOR=0.257, 95% CI: 0.157–0.418) was significantly associated with attitude towards cataract.

Conclusion

Significant portion of participants had poor knowledge and an unfavorable attitude towards a cataract. So, it is recommended that stakeholders in different hierarchies need to exert efforts on creating awareness about cataract by considering the education level of the community. Moreover, attention should be given to the availability and accessibility of the primary eye care unit.

Cataract as a Cause of Blindness and Vision Impairment in Latin America: Progress Made and Challenges Beyond 2020

PURPOSE

To provide an update of cataract as a cause of vision loss in Latin America and to analyze sex inequalities in cataract surgical coverage (CSC) and effective CSC (eCSC) in the region.

DESIGN

Population-based systematic review with longitudinal comparisons.

METHODS

The Latin American and Caribbean Health Sciences Literature (LILACS) and PubMed databased were searched for population-based studies reporting cataract blindness, surgical coverage, and outcomes published between January 2014 and December 2019. Information on the number of surgeries performed from the 2014-2016 period was obtained from ministries of health and was used for calculation of the cataract surgical rate (CSR). Sources such as Rapid Assessment of Avoidable Blindness (RAAB) and Rapid Assessment of Cataract Surgical Services data were reanalyzed to calculate sex inequality in CSC and eCSC by subtracting the rate in women from the rate in men.

RESULTS

Cataract was the cause of 29.8%-77.6% of cases of blindness in the included studies; the CSR improved in 10 countries. The CSC pinhole visual acuity of 3/60 varied from 24.1% in Peru to 97.1% in Argentina, and the median absolute gender inequality CSC pinhole visual acuity 3/60 was -0.7%. The eCSC pinhole visual acuity 3/60 varied from 14.8% in Guatemala to 92.1% in Argentina, and the median absolute gender inequality eCSC pinhole visual acuity 3/60 was -0.8%.

CONCLUSIONS

Cataract remains a leading cause of blindness in Latin America. Coverage is suboptimal, and surgical results are also below target levels in many countries. Incentives for a better distribution of human resources, adequate training of ophthalmologists, and the inclusion of vision services in universal health care coverage could reduce the burden of cataract in Latin America.

A Perspective on Biophysical Studies of Crystallin Aggregation and Implications for Cataract Formation

Lens crystallins are subject to various types of damage during their lifetime which triggers protein misfolding and aggregation, ultimately causing cataracts. There are several models for crystallin aggregation, but a comprehensive picture of the mechanism of cataract is still underway. The complex biomolecular interactions underlying crystallin aggregation have motivated major efforts to resolve the structural details and mechanism of aggregation using multiple biophysical techniques at different resolutions. Together, experimental and computational approaches identify and characterize both amyloidogenic and amorphous aggregates leading to an improved understanding of crystallin aggregation. A rigorous characterization of the aggregation-prone intermediates is crucial in cataract-mediated drug discovery. This Perspective summarizes recent biophysical studies on lens crystallin aggregation. We evaluate the outstanding challenges, future outlook, and rewards in this fertile field of research. With lessons learned from protein folding and multiple pathways of aggregation, we highlight the differences in the overall mechanisms of age-related and congenital cataracts. We expect that a correlation between the existing and developing biophysical techniques would provide a platform to study amyloid architecture in the eye lens and reduce the existing gaps in our understanding of crystallin biophysics.

Intraocular pressure variation after conventional extracapsular cataract extraction, manual small incision cataract surgery and phacoemulsification in an indigenous black population

Introduction

intraocular pressure changes have been reported following the various cataract surgical technique. This study aims to compare the intra-ocular pressure (IOP) variation following conventional extra-capsular cataract extraction (ECCE), manual small incision cataract surgery (MSICS) and phacoemulsification in an indigenous black population.

Methods

a comparative cross-sectional study of adult patients aged 40 years and above who had pressure was measured with Goldman’s applanation tonometer pre-operatively and 1^st day, 1^st week, 1^st month as well as 3^rd month post-operative periods and recorded. Data was analyzed using SPSS version 21. Mean IOP changes between study groups were compared using ANOVA. P-value of < 0.05 was taken as statistically significant.

Results

total of 82 patients consisting of 20(24.4%) ECCE, 32(39%) MSICS and 30(36.6%) phacoemulsification with mean preoperative 13.4mmHg, 13.5mmHg and 14.1 mmHg (p = 0.657) respectively was studied. Mean IOP increased from baseline at 1st day post-operative period in the ECCE and MSICS groups (13.4 ± 3.0mmHg to 13.7 ± 4.5mmHg (p = 0.84) and 13.5 ± 3.1mmHg to 15.3 ± 5.1mmHg (P = 0.48) respectively), and decrease in the phacoemulsification group (14.1 ± 2.6mmHg to 13.9 ± 3.5mmHg (p = 0.378). There was a decline in IOP in all the 3 study groups by one week post-operative period; the difference was significant only in the ECCE group (p = 0.032). By 3^rd month postoperatively, there was a reduction in mean IOP when compared with pre-operative IOP the difference being greatest in the ECCE group.

Conclusion

ECCE, MSICS, and Phacoemulsification cause a decline in IOP below preoperative levels at 3^rd month postoperatively in the MSICS group.

Difluprednate 0.05% versus Prednisolone Acetate Post-Phacoemulsification for Inflammation and Pain: An Efficacy and Safety Clinical Trial

Background

The purpose of this study was to compare the efficacy and safety of difluprednate 0.05% (PRO-145) versus prednisolone acetate 1% (Prednefrin^® SF), for management of postoperative inflammation and pain, after cataract surgery.

Methods

This was a Phase III, multicenter, prospective, double-blind, clinical trial. Intent-to-treat population included 178 post-phacoemulsification patients that were assigned to receive either PRO-145, or prednisolone. One day after unilateral eye surgery, patients instilled a drop 4 times a day for 14 days (then tapering the dose downward for 14 days). The primary efficacy endpoints were anterior chamber (AC) cell grade and flare. Other parameters measured included: retinal central thickness (measured via OCT), conjunctival hyperemia, edema, pain and photophobia. Tolerability and safety were assessed through burning, itching, foreign body sensation, visual acuity (VA), intraocular pressure (IOP) and incidence of adverse events (AE).

Results

A total of 171 subjects were randomized (1:1) and completed the study. Compared to day 1, there was a significant improvement in the AC cell count and flare in both groups by the final visit (80.2% vs 88.4%, p=1.000). Conjunctival hyperemia improved in a similar fashion (81.2% vs 79%, p=0.234) in both PRO-145 and prednisolone groups, without differences between them. This was also observed for edema (82.4% vs 82.5%, p=0.246), pain (15.3% vs 7%, p=0.497) and photophobia (16.4% vs 15.1%, p=0.246), respectively. There was no significant difference between treatments for any tolerability parameter studied. Finally, at the 4-week postoperative visit, there were no significant differences between treatments for VA, IOP and AE results (p-values; 0.095, 0.053 and 0.099, respectively).

Conclusion

The results of this study suggest that PRO-145 is as effective and safe as prednisolone acetate in treating postoperative inflammation and pain in patients undergoing phacoemulsification. The study was registered at ClinicalTrials.gov as NCT03693989.

A Preliminary Comparative Study of Visual Performance Between Two Newly Commercially Available Monofocal Intraocular Lenses Implanted During Cataract Surgery

Purpose

To compare visual outcomes of two newly developed monofocal intraocular lenses (IOLs) (I-Stream H and CT Lucia 211P) implanted in patients undergoing surgery for senile cataract.

Methods

This prospective, comparative, single-center, randomized study included 94 eyes of 94 patients undergoing cataract surgery. Patients were randomized to receive the implantation of I-Stream H IOL (Group 1) or CT Lucia 211P IOL (Group 2). Each patient underwent a complete ocular examination before (V0), 1 month (V1), 3 months (V2) and 6 months (V3) after surgery, including visual acuity testing, objective refraction, slit-lamp biomicroscopy, contrast sensitivity testing and visual function index questionnaire (VF-14).

Results

After surgery, a significant increase of best-corrected visual acuity (BCVA), CS and VF-14 and a significant decrease of SE were detected in both groups at each time point compared to baseline (always p<0.01). No significant differences in the postoperative increase of BCVA (p=0.12), CS (p=0.21) and VF-14 (p=0.31) and decrease of SE (p=0.08) were detected comparing patients from Group 1 and Group 2 at V3. Mean and median prediction error, as well as absolute prediction error values, did not significantly differ between the two groups (p>0.05). Eyes with an actual refraction within 0.25, 0.50 and 1 D were 53.1%, 85.1% and 100% for Group 1 and 55.3%, 87.2% and 100% for Group 2 (p>0.05).

Conclusion

I-Stream H and CT Lucia 211P allowed a satisfied recovery of visual function after senile cataract surgery; both IOLs were shown to have similar outcomes of visual performance.

Population-Based Cataract Surgery Complications and Their Impact on Visual Status in the Brazilian Amazon Region

PURPOSE

To investigate cataract surgery prevalence, complications, visual outcomes, and coverage in a population of older adults from the Brazilian Amazon region.

DESIGN

Population-based cross-sectional study.

METHODS

Individuals ≥45 years of age from urban and rural areas of Parintins City, Brazil, were identified by cluster random sampling. Participants underwent ophthalmic examination, including uncorrected visual acuity, acuity with presenting correction (APC), and best-corrected visual acuity (BCVA) from each eye. In those with previous cataract surgery, surgical technique and complications including its contribution to vision impairment were noted. The association of surgical complications and surgical coverage with sociodemographic variables was assessed by multiple logistic regression.

RESULTS

A total of 2,384 persons were determined to be eligible, and 2,041 (85.6%) were examined. Overall, prevalence of cataract surgery was 8.6%, with 11.3% urban and 5.0% rural. Surgical complications were associated with males, older age, and urban residency and were found in 60.4%, with posterior capsule opacification in 29.6% and posterior capsule rupture in 16.3%. Among the 270 eyes having cataract surgery, APC ≥20/32 was found in 44.4%, APC 20/40 to 20/63 in 20.8%, APC <20/63 to 20/200 in 14.4%, APC <20/200 to 20/400 in 2.6%, and APC <20/400 in 17.8%. Low surgical coverage was found with 57.9% of those with visual impairment due to cataract not being treated surgically.

CONCLUSIONS

Although a reasonable prevalence of cataract surgery was found, a high complication rate, poor visual outcomes, and low cataract surgery coverage indicated that actions to improve quality and appropriate postsurgical management should be planned and implemented by public health authorities.

Association Between a Centrally Reimbursed Fee Schedule Policy and Access to Cataract Surgery in the Universal Coverage Scheme in Thailand

Importance

Uptake of cataract surgery in developing countries is much lower than that in developed countries. Cataract unawareness and financial barriers have been cited as the main causes. Under the Universal Coverage Scheme (UCS), Thailand introduced a central reimbursement (CR) system for cataract surgery. It is unknown if this financial arrangement could incentivize service provision (private or public) in areas that are hard to reach.

Objective

To examine the association between the CR policy and access to cataract surgery in Thailand.

Design, Setting, and Participants

Using time series analysis, hospitalization data during 2005 to 2015 for UCS members were analyzed for time trends and subnational variations in the cataract surgery rate (CSR) before and after the CR implementation.

Main Outcomes and Measures

The annual growth in access was estimated using segmented regression. The CSR gap across regions was determined by the slope index of inequality (SII). Unequal access across districts was represented by the gap between the top and bottom quintiles.

Results

During 2005 to 2015, a total of 0.98 million UCS members (mean [SD] age, 67.4 [11.2] years; 58.7% female) received cataract surgery. The number of cases increased from 77 897 in 2005 to 192 290 in 2015. At the national level, the CSR per 100 000 population increased from 352.0 to 378.7 cases in 2005 to 2008, to 716.3 cases in 2013, and then to 765.3 cases in 2015. With the use of mobile services through an exclusive CR, 3 private hospitals took the lead in service growth, sharing 79.2% of cases in the private sector in 2009. From 2010, the number of cases in public hospitals grew yearly by 12.6% to 13.6% until 2012, rose 21.7% in 2013, and then the rate of increase declined to that of 8.2% to 8.3% in 2014-2015. During the periods of an increase in overall access, the CSR gap across regions widened as indicated by the SII of 755.4 cases per 100 000 population in 2010 because of rapid uptake in areas with mobile services. When the national CSR became adequately large and mobile services were discouraged in 2013, the gap in 2014-2015 narrowed.

Conclusions and Relevance

This study found that the appropriate payment and service designs helped reduce the cataract surgery backlog. With an adequately high CSR, Thailand is on track to reach the VISION 2020 goal, aiming for blindness elimination by the year 2020, which has been achieved by most developed countries.

Prevalence and causes of vision loss in Latin America and the Caribbean in 2015: magnitude, temporal trends and projections

OBJECTIVE

To estimate the prevalence and causes of blindness and vision impairment for distance and near in Latin America and the Caribbean (LAC) in 2015 and to forecast trends to 2020.

METHODS

A meta-analysis from a global systematic review of 283 cross-sectional, population-representative studies from published and unpublished sources from 1980 to 2014 in the Global Vision Database included 17 published and 6 unpublished studies from LAC.

RESULTS

In 2015, across LAC, age-standardised prevalence was 0.38% in all ages and 1.56% in those over age 50 for blindness; 2.06% in all ages and 7.86% in those over age 50 for moderate and severe vision impairment (MSVI); 1.89% in all ages and 6.93% in those over age 50 for mild vision impairment and 39.59% in all ages and 45.27% in those over 50 for near vision impairment (NVI). In 2015, 117.86 million persons were vision impaired; of those 2.34 million blind, 12.46 million with MSVI, 11.34 million mildly impaired and 91.72 million had NVI. Cataract is the most common cause of blindness. Undercorrected refractive-error is the most common cause of vision impairment.

CONCLUSIONS

These prevalence estimates indicate that one in five persons across LAC had some degree of vision loss in 2015. We predict that from 2015 to 2020, the absolute numbers of persons with vision loss will increase by 12% to 132.33 million, while the all-age age-standardised prevalence will decrease for blindness by 15% and for other distance vision impairment by 8%. All countries need epidemiologic research to establish accurate national estimates and trends. Universal eye health services must be included in universal health coverage reforms to address disparities, fragmentation and segmentation of healthcare.

Outcomes of and barriers to cataract surgery in Sao Paulo State, Brazil

Background

Cataract is the leading cause of blindness in developing countries and identification of the barriers to accessing treatment is essential for developing appropriate public healthcare interventions. To evaluate the barriers to cataract surgery after diagnosis and assess the postoperative outcomes in Sao Paolo State, Brazil.

Methods

This prospective study evaluated cataract patients from 13 counties in São Paulo State in 2014. Cataract was diagnosed in the community by a mobile ophthalmic unit and patients were referred to a hospital for management. Gender, age, distance to the hospital and local municipal health structure were evaluated as possible barriers. Data were analyzed for postoperative outcomes and the impact on blindness and visual impairment.

Results

Six hundred patients were diagnosed with cataract with a mean age of 68.8±10.3 years and 374 (62.3%) were females. Two hundred and fifty-four (42.3%) patients presented to the referral hospital. One hundred forty-four (56.7%) underwent surgery, 56 (22.0%) decided not to undergo surgery, 40 (15.7%) required only YAG-Laser and 14 (5.5%) required a spectacle prescription only. Visual acuity increased statistically significantly from 1.07±0.73 logMAR at presentation to 0.25±0.41 logMAR at the final visit after intraocular lens implantation (p=0.000). There was a statistically significantly decrease from 17 (11.8%) blind patients and 55 (38.2%) visually impaired patients at presentation to 2 (1.4%) and 5 (3.5%) patients respectively after treatment (p=0.000).

Conclusion

Less than half of the individuals with cataract presented to the hospital for surgery. Among the patients who underwent treatment, there was an overall decrease in the number of blind individuals and visually impaired individuals. The barriers to cataract surgery were older age, greater distance to the hospital, municipalities with fewer inhabitants and less ophthalmic services.

Field Testing Project to Pilot World Health Organization Eye Health Indicators in Latin America

PURPOSE

To develop and implement mechanisms to collect, report, and assess the World Health Organization (WHO) core eye health indicators in Chile, Honduras, Mexico, Peru, and Uruguay.

METHODS

Simple templates for a situational analysis (of data collection and reporting processes), a national data collection strategy, and a national work plan to implement the core eye health indicators were developed. Public and private sector representatives from the ministries of health (MOHs), national vision committees, and national societies of ophthalmology of each country used these tools with 2013 baseline data to improve their data collection processes and collected 2015 data. Final analysis and cross-validation were performed using intraocular lens sales data and last observation carried forward imputation.

RESULTS

Study tools were effectively implemented in all five countries and resulted in improved intersectoral stakeholder collaboration and communications, which improved the data collection and reporting processes. More complete and accurate data were reported by 2015 compared to the 2013 baseline.

CONCLUSIONS

Multisectoral stakeholders, including national professional societies and national vision committees, should collaborate with MOHs to improve the quality of data that are reported to WHO. This study involved these stakeholders in the data collection processes to better understand the realities of indicator implementation, better manage their expectations, and improve data quality. WHO Member States across the globe can feasibly adapt the study tools and methodologies to strengthen their data collection processes. Overall, the reliability and validity of the indicators is hampered with limitations that prevent fully accurate data from being collected.

Cataracts

An estimated 95 million people worldwide are affected by cataract. Cataract still remains the leading cause of blindness in middle-income and low-income countries. With the advancement of surgical technology and techniques, cataract surgery has evolved to small-incisional surgery with rapid visual recovery, good visual outcomes, and minimal complications in most patients. With the development of advanced technology in intraocular lenses, the combined treatment of cataract and astigmatism or presbyopia, or both, is possible. Paediatric cataracts have a different pathogenesis, surgical concerns, and postoperative clinical course from those of age-related cataracts, and the visual outcome is multifactorial and dependent on postoperative visual rehabilitation. New developments in cataract surgery will continue to improve the visual, anatomical, and patient-reported outcomes. Future work should focus on promoting the accessibility and quality of cataract surgery in developing countries.

The Challenge of Universal Eye Health in Latin America: distributive inequality of ophthalmologists in 14 countries

BACKGROUND

No comprehensive study currently exists on the supply of ophthalmologists across Latin America. We explored sociogeographic inequalities in the availability and distribution of ophthalmologists across 14 Latin American countries.

METHODS

The National Ophthalmologic Societies of Argentina, Bolivia, Brazil, Colombia, Costa Rica, Chile, the Dominican Republic, Ecuador, Guatemala, Mexico, Paraguay, Peru, Uruguay and Venezuela provided data on affiliated ophthalmologists by first-order subnational divisions in 2013. Human Development Index (HDI) estimates at the corresponding subnational division were used as equity stratifiers. Distributional inequality of ophthalmologists within each country was assessed by the health concentration index (HCI) and the index of dissimilarity (ID), along with the mean level of ophthalmologists per population.

RESULTS

Across all countries studied, there were 5.2 ophthalmologists per 100 000 population on average (95% CI 5.0 to 5.4) in 2013, with a mean HCI of 0.26 (0.16 to 0.37) and a mean relative ID of 22.7% (20.9% to 24.7%). There was wide inequality in ophthalmologist availability between countries, ranging from 1.2 (1.1 to 1.4) in Ecuador to 8.6 (8.5 to 8.8) in Brazil. All countries had positive (ie, pro-rich) HCI values ranging from 0.68 (0.66 to 0.71) in Guatemala to 0.02 (-0.11 to 0.14) in Venezuela. Correspondingly, redistributive potential to achieve equity was closest in Venezuela (ID: 1.5%) and farthest in Guatemala (ID: 60.3%). Benchmarked against regional averages, most countries had a lower availability of ophthalmologists and higher relative inequality.

CONCLUSIONS

There is high inequality in the level and distribution of ophthalmologists between and within countries in Latin America, with a disproportionate number concentrated in more developed, socially advantaged areas. More equitable access to ophthalmologists could be achieved by implementing incentivised human resources redistribution programmes and by improving the social determinants of health in underserved areas.

The cataract situation in Suriname: an effective intervention programme to increase the cataract surgical rate in a developing country

AIMS

To provide an overview of cataract data in Suriname and to describe and evaluate a programme to control cataract blindness in a developing country.

DESIGN

Evaluation of hospital data and findings from a population-based cross-sectional survey.

METHODS

The implementation of a new cataract surgical intervention programme was described and retrospectively evaluated by analysing the number of cataract operations and other related indicators at the Suriname Eye Centre (SEC) in the period 2006-2014. Findings of the recent Rapid Assessment of Avoidable Blindness (2013-2014) survey were used to evaluate the national cataract situation in Suriname in people aged ≥50 years (n=2998), including prevalence of cataract blindness, outcome and cataract surgical rate (CSR).

RESULTS

Since the implementation of a new cataract intervention programme, the number of cataract operations at the SEC has increased from 1150 in 2006 to 4538 in 2014, leading to an estimated national CSR of 9103 per one million inhabitants. The prevalence of bilateral cataract blindness in Suriname was 0.8% (95% CI 0.2% to 1.3%) in individuals aged ≥50 years. The proportion of eyes with a postoperative visual acuity <6/60 (poor outcome) was lowest in eyes operated at the SEC (8.5%) and highest in surgeries performed by foreign humanitarian ophthalmic missions.

CONCLUSIONS

The cataract situation in Suriname is well under control since the implementation of the new intervention programme. Important factors contributing to this success were the introduction of phacoemulsification, intensive training, and improvement in the affordability and accessibility of cataract surgery. The proportion of poor outcomes was still >5%.

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.

The Global Issue of Vision Loss and What We Can Do About It: José Rizal Medal 2015

The prevalence of blindness increases rapidly with increasing age. Globally, there are some 32 million people who are blind and 191 million with poor vision. The leading cause of blindness worldwide is cataract, whereas uncorrected refractive error causes most poor vision. The rates of blindness from diabetes and macular degeneration are rapidly increasing, and age-related macular degeneration is the leading cause of blindness in developed countries. Three quarters of this blindness can be prevented or treated, and although the absolute number of blind people increased slightly between 1990 and 2010, very importantly, the prevalence of blindness has been halved as eye care programs and particularly cataract services have developed. We know how to deliver better eye care, and it works! However, with only 205,000 ophthalmologists worldwide, there is much work to do. The International Council of Ophthalmology has a major focus on education and team building to improve the quality and availability of eye care around the world. Its programs include curricula for all levels, examinations, fellowships, teaching of teachers, continuing professional development, and of course, the World Ophthalmology Congresses. We must work together in partnership to eliminate avoidable blindness worldwide.

Biophysical chemistry of the ageing eye lens

This review examines both recent and historical literature related to the biophysical chemistry of the proteins in the ageing eye, with a particular focus on cataract development. The lens is a vital component of the eye, acting as an optical focusing device to form clear images on the retina. The lens maintains the necessary high transparency and refractive index by expressing crystallin proteins in high concentration and eliminating all large cellular structures that may cause light scattering. This has the consequence of eliminating lens fibre cell metabolism and results in mature lens fibre cells having no mechanism for protein expression and a complete absence of protein recycling or turnover. As a result, the crystallins are some of the oldest proteins in the human body. Lack of protein repair or recycling means the lens tends to accumulate damage with age in the form of protein post-translational modifications. The crystallins can be subject to a wide range of age-related changes, including isomerisation, deamidation and racemisation. Many of these modification are highly correlated with cataract formation and represent a biochemical mechanism for age-related blindness.

Benefits and risks of immediately sequential bilateral cataract surgery: a literature review

Immediately sequential bilateral cataract surgery (ISBCS) is a highly contended issue in ophthalmology, mainly due to the risk of bilateral endophthalmitis and financial penalties that many ophthalmologists face when performing simultaneous cataract surgeries. The purpose of this review is to understand the current status of the knowledge of ISBCS, mainly its benefits and risks and how they compare with the standard of care, delayed sequential bilateral cataract surgery. Evidence, although limited, increasingly supports ISBCS for providing faster rehabilitation, improved visual outcomes, and cost and time savings. Evidence does not support the fear of bilateral endophthalmitis resulting from the simultaneous procedure. However, stronger and greater evidence is needed before ISBCSs can be considered the standard of care. Where ISBCS can potentially create the most beneficial impact is in public eye health programmes in developing countries, but this has not yet been explored.

[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.