Cataract surgery in developing countries

First in-human clinical performance of a new non-cavitating handheld lensectomy system in 665 consecutive cataract surgeries

PURPOSE

To investigate the intraoperative performance and lens fragmentation efficacy of a non-cavitating handheld lensectomy system in mild, moderate, and severe cataract.

SETTING

Ambulatory surgical centers.

DESIGN

Retrospective consecutive case series.

METHODS

665 consecutive eyes underwent cataract surgery by 12 surgeons using a new handheld non-cavitating lensectomy system for nuclear fragmentations and extraction. Intraoperative measurements included surgical time, miLOOP pretreatment, and irrigation fluid use.

RESULTS

Of the 665 eyes, 38 (6%), 468 (70%), 126 (19%), and 33 (5%) were of grade 1, 2, 3, and 4 nuclear densities, respectively, as graded by the surgeon intraoperatively. Successful nuclear fragmentation, lens extraction, and cortical removal were achieved in all eyes. Total nucleus fragmentation and extraction times were 70.1 seconds, 100.3 seconds, 132.6 seconds, and 287.9 seconds for grades 1, 2, 3, and 4, respectively ( P < .001). In addition, irrigation and aspiration cortical removal times were 64.1 seconds, 51.1 seconds, 48.5 seconds, and 59.0 seconds, respectively ( P = .14). There was a low rate of capsular tear (3 cases in 665 surgeries, 0.45%) and no other emergent adverse events.

CONCLUSIONS

The miCOR handheld non-cavitating lensectomy system demonstrated nuclear fragmentation and extraction in the absence of intraocular cavitation across all grades of nuclear densities.

Decline in unmet needs for cataract surgery among the ageing population in India: findings from LASI, wave-1

Introduction

Cataracts are the leading cause of blindness among older people, but they can be treated with corrective surgery. India boasts the oldest blindness control programme in the world. We aimed to assess the prevalence of cataract surgery, and we compared the determinants of undergoing cataract surgery and identified the unmet needs for cataract surgery among older adults in India.

Methods

We included 52,380 individuals aged ≥50 years from the Longitudinal Ageing Study in India, wave-1. The primary outcome measures of our study were the prevalence of cataract surgery and the unmet need for cataract surgery. Multivariate analysis was executed to investigate the association between socio-demographic variables and outcomes, expressing the results as adjusted odds ratios with 95% confidence intervals (CIs).

Results

The overall prevalence of cataracts was 14.85%. The coverage of cataract surgery was 76.95%, with 23% having unmet needs for cataract surgery. Notably, cataract surgery coverage was higher at 78.30% (95% CI: 76.88-79.48) among participants aged 66-80 years, while the percentage of those who did not undergo cataract surgery was higher at 24.62% (95% CI: 23.09-26.20) among participants aged 50-60 years. The most deprived group had a higher odds ratio [adjusted odds ratio: 1.20 (95% CI: 1.00-1.44)] (p < 0.05) of having unmet needs for cataract surgery.

Conclusions

There is a considerable burden of age-related cataracts in India. While the coverage of cataract surgery is high, the unmet need for cataract surgery cannot be overlooked. The existing blindness control programme has contributed significantly to increasing the coverage of cataract surgery, but it still needs to be strengthened, especially to reach the most deprived sections of society.

Imaging analysis of the biological parameters of the lens in patients with cortical age-related cataracts using ultrasound biomicroscopy

BACKGROUND

The spatial position of the lens in patients with cortical age-related cataract (CARC) is unclear. We investigated a basis for the assessment of visual quality after cataract surgery by analysing the ultrasound biomicroscopic characteristics of the biological parameters of the lens in patients with CARC.

METHODS

In this retrospective study, 119 patients (50 males and 69 females, totalling 238 eyes) with CARC who underwent simple cataract surgery were selected. The lens thickness (LT), axial length (AL), anterior chamber depth (ACD), lens vault (LV), trabecular-iris angle (TIA), iris-lens angle (ILA), iris-lens contact distance (ILCD) were measured by A-scan ultrasound and ultrasound biomicroscopy. The corresponding lens position (LP) and relative lens position (RLP) were calculated.

RESULTS

LP was greater in men than in women (P < 0.05), LV was smaller in men than in women (P = 0.002), ILA and ILCD were not statistically significant (P = 0.072 and P = 0.854, respectively). There were significant differences in TIA, ILA, and ILCD in the four quadrants (all P < 0.05), with a trend in the distribution of TIA: superior < inferior < nasal < temporal, ILA: nasal < inferior < temporal < superior, and ILCD: superior < temporal < inferior < nasal.

CONCLUSIONS

The lens protrudes more obviously in females than in males and the lens tilts to a certain extent with the increase of age and tends to be more upward and temporal in the supine position. Therefore, trends in lens-related parameters in patients with CARC should be taken seriously.

Cataract Surgery Visual Outcome and Associated Factors Among Adults Attended Jimma University Medical Center, Jimma, Southwest Ethiopia

Background

Cataract is the leading cause of blindness and the second leading cause of visual impairment worldwide, accounting for 51% and 33% of all cases, respectively, in low- and medium-income countries bearing a disproportionately high burden. Hence, this study aimed to assess the visual outcome of age-related cataract surgery and identify factors associated with patients' postoperative visual outcomes in Jimma University Medical Center, Southwest Ethiopia.

Methods

An institution-based cross-sectional study design was conducted among 386 cataract surgery patients from January 1, 2016, to December 30, 2017. The study participants were selected using a systematic random sampling technique. Data were collected by reviewing the selected patients' medical records using a pre-tested checklist, entered into EpiData version 3.1, and exported to SPSS 20 for analysis. Proportions, summary statistics, and tables were used for presentations of the findings. Binary logistic regression was carried out to identify independent predictors of visual outcome. Findings were presented with adjusted odds ratios and their 95% confidence interval. A p-value <0.05 was used to declare a statistically significant association.

Results

About 231 individuals (59.8%) had poor visual results following cataract surgery. Furthermore, age >70 (AOR = 3.64; 95% CI [1.35-9.82]), preoperative ocular co-morbidities (AOR = 2.34; [1.32-4.15]), incision-based cataract surgery (AOR = 7.11; [3.16-16.02]), compared phacoemulsification operated by resident surgeons (AOR = 2.19; [1.23-3.89]), presence of intraoperative complication (AOR = 3.41; [1.47-7.92]), lens remnant (AOR = 2.91; [1.11-4.92]), ocular inflammation (OR = 2.56; [1.34-4.92]), and striate keratopathy/corneal edema (AOR = 1.91; [1.07-3.44]) were significantly associated with poor visual outcome.

Conclusion

The visual outcome following cataract surgery fall below WHO recommendation. In this study, age, ocular co-morbidities, surgical method, surgeon status, intraoperative complication, SK, and ocular inflammation associated with post-operative Uveitis and anterior chamber reaction were associated with a poor visual outcome.

Impact of preoperative posterior segment evaluation on surgical intervention in camp patients: A retrospective analysis

Purpose

To retrospectively study impact of preoperative posterior segment evaluation on surgical intervention in camp patients recruited for cataract surgery in Gujarat India.

Methods

Retrospective analysis of six months data collected from hospital electronic medical record (EMR) system of 9820 admitted patients recruited from screening camp for cataract surgery from 1/10/2019 to 31/3/2020 in Tertiary Eye Hospital in Gujarat, India, has been done. Comprehensive clinical evaluation, of both anterior and posterior segment which included detailed history; best corrected visual acuity (BCVA); intraocular pressure measurement with non-contact tonometer (NCT) and when required with Goldman applanation tonometer; slit lamp examination; and fundus examination with + 90 diopter lens as well as indirect ophthalmoscope as and when indicated. In case there was no view of retina, a B-scan ultrasound was done to rule out any posterior segment pathology. Immediate surgical intervention done was assessed and results analyzed in percentage.

Results

Cataract surgery was advised for 8390 patients (85.43%). Surgical intervention for management of glaucoma was done for 68 patients (0.692%). Retina intervention was done for 86 patients. Posterior segment evaluation changed immediate surgical plane of management for 154 (1.57%) patients.

Conclusion

Comprehensive clinical evaluation is economical and should be mandatory especially in community services as comorbid conditions like glaucoma, diabetic retinopathy, retinal vein occlusion, and other varied posterior segment diseases contribute significantly to visual disability in elderly age group. It is difficult to follow these patients later if manageable comorbidity is not informed about and if indicated dealt simultaneously for visual rehabilitation of patient.

Beyond vision:Cataract and health status in old age, a narrative review

Cataract is a leading cause of visual impairment in old age. Lens opacification is notoriously associated with several geriatric conditions, including frailty, fall risk, depression and cognitive impairment. The association is largely attributable to visual impairment, while other mechanisms, associated with extraocular comorbidity and lifestyle, might partly explain this correlation. Available literature suggests that cataract surgery may be effective in decreasing fall risk, improving depressive symptoms and limiting the risk of cognitive impairment and dementia incidence, although intervention studies on these outcomes are still limited. In this review we also emphasize the need to move from the concept of visual acuity to functional vision, especially in the context of the geriatric patient. Research is needed regarding the effect on the cited outcomes of different cataract treatment strategies, such as systematic bilateral versus monolateral surgery and use of different intraocular lenses.

Cost-Effectiveness of Preoperative Topical Antibiotic Prophylaxis for Endophthalmitis Following Cataract Surgery

PURPOSE

To determine the cost-effectiveness of preoperative topical antibiotic prophylaxis for the prevention of endophthalmitis following cataract surgery.

DESIGN

Cost-effectiveness analysis using a decision-analytic microsimulation model.

METHODS

Preoperative topical antibiotic prophylaxis vs no-prophylaxis costs and effects were projected over a life-time horizon for a simulated cohort of 500 000 adult patients (≥18 years old) requiring cataract surgery in theoretical surgical centers in the United States. Efficacy and cost (2021 US dollars) values were obtained from the literature and discounted at 3% per year.

RESULTS

Based on inputted parameters, the mean incidence of endophthalmitis following cataract surgery for preoperative topical antibiotic prophylaxis vs no-prophylaxis was 0.034% (95% CI 0%-0.2%) and 0.042% (95% CI 0%-0.3%), respectively-an absolute risk reduction of 0.008%. The mean life-time costs for cataract surgery with prophylaxis and no-prophylaxis were $2486.67 (95% CI $2193.61-$2802.44) and $2409.03 (95% CI $2129.94-$2706.69), respectively. The quality-adjusted life-years (QALYs) associated with prophylaxis and no-prophylaxis were 10.33495 (95% CI 7.81629-12.38158) and 10.33498 (95% CI 7.81284-12.38316), respectively. Assuming a cost-effectiveness criterion of ≤$50 000 per QALY gained, the threshold analyses indicated that prophylaxis would be cost-effective if the incidence of endophthalmitis after cataract surgery was greater than 5.5% or if the price of the preoperative topical antibiotic prophylaxis was less than $0.75.

CONCLUSIONS

General use of preoperative topical antibiotic prophylaxis is not cost-effective compared with no-prophylaxis for the prevention of endophthalmitis following cataract surgery. Preoperative topical antibiotic prophylaxis, however, would be cost-effective at a higher incidence of endophthalmitis and/or a substantially lower price for prophylaxis.

Lens nucleus dislocation in hypermature cataract: Case report and literature review

INTRODUCTION

Hypermature cataract is a form of late-stage cataract progression that can lead to a variety of complications. Spontaneous capsular rupture with lens nucleus displacement in hypermature cataracts has rarely been reported. We describe 2 cases of spontaneous dislocation of the lens nucleus in a hypermature cataract and perform a review of the literature on this complication.

PATIENT CONCERNS

We report 2 rural men aged 50 and 76 years with deteriorating vision.

DIAGNOSIS

The final diagnosis was senile hypermature cataract with dislocation of the lens nucleus in both patients and secondary glaucoma for the second patient.

INTERVENTIONS AND OUTCOMES

During admission, both patients complained of deteriorating vision. Slit-lamp examination showed lens nucleus dislocation into the anterior chamber. The 50-year-old patient exhibited a residual lens capsule and a turbid cortex, with a normal anterior chamber and intraocular pressure. The 76-year-old patient presented a shrunken and ruptured capsule and no cortex in the pupillary area, mild inflammation in the anterior chamber, and high intraocular pressure. Both patients underwent intracapsular cataract extraction combined with anterior vitrectomy and achieved good postoperative recovery.

CONCLUSION

Lens nucleus dislocation in hypermature cataracts can be seen in clinical practice, particularly in underdeveloped areas. Early recognition and surgery can improve vision.

[TeleOftalmo: strategy to expand the offer of ophthalmologic telediagnostics for primary healthcare in the Southern Brazil]

The use of teleophthalmology may be a viable strategy to track and to diagnose major eye diseases primary health care patients. This study aimed to describe the performance of 30,315 telediagnoses in ophthalmology in primary care patients and the case management of this service. This is a cross-sectional study to evaluate the telediagnosis performed in patients treated at the eight remote points of the TeleOftalmo project from January 2nd, 2018, to December 31st, 2020. The patients' demographic characteristics, the reasons for referral, the diagnoses made according to age group, and the case management of the telediagnosis were evaluated. Most patients were female (66.1%), adults (70.3%), and referred to telediagnosis mainly due to reduced visual acuity (60.5%). Refractive errors were the most prevalent diagnosis in all age groups. Presbyopia was the most prevalent eye disease in adults (65.4%) and older adults (64%), followed by cataracts (41.3%) and suspected glaucoma (10.6%) in older adults. In total, 30,315 patients underwent telediagnosis, 70.5% had their ocular complaints fully resolved, without the need for referral to an in-person ophthalmologist. Telemedicine can be resolutory for the most prevalent eye diseases in the population, increasing the supply of diagnoses, qualifying and assisting in reducing waiting lines for ophthalmologic care.

Effect of cryotherapy on pain scores and satisfaction levels of patients in cataract surgery under topical anesthesia: a prospective randomized double-blind trial

Objective

To evaluate the effects of cryotherapy on pain scores and satisfaction levels of patients during cataract surgery under topical anesthesia. Eighty patients aged between 55 and 75 years scheduled for cataract surgery were randomly allocated to two study groups to receive topical anesthesia with cryotherapy (TC) or topical anesthesia alone (T) groups. Visual analog pain scores, patient satisfaction level, hemodynamic parameters, and quality of operating conditions were recorded.

Results

Cryotherapy significantly reduced VAS pain scores during surgery (P = 0.014). Although no significant difference in postoperative pain scores, opioid consumption, heart rate, and mean arterial blood pressure was seen in the postoperative period. The surgeon reported better quality of operating conditions in the TC group (P = 0.018). Cryotherapy as a complementary method with topical anesthesia reduced pain scores of patients during surgery. It also produced a better quality of operating conditions for surgeons. There was no significant difference in either postoperative pain scores or opioid consumption.

Trial registration This trial was registered at Iranian clinical trial registering: IRCT registration number: IRCT2017052734091N2

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-06125-w.

Prevalence and correlates of vision impairment and its association with cognitive impairment among older adults in India: a cross-sectional study

OBJECTIVE

This study aimed to investigate the predictors of vision impairment in old age and how impaired vision is associated with cognitive impairment among the ageing population.

DESIGN

A cross-sectional study was conducted using a large country-representative survey data.

SETTING AND PARTICIPANTS

This study used data from the 'Building a Knowledge Base on Population Ageing in India' survey, conducted in 2011. Participants included 9541 older adults aged 60 years and above.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome variables were vision impairment and cognitive impairment. Descriptive statistics along with bivariate analysis were presented. Additionally, multivariable binary logistic regression analysis was performed to fulfil the objectives.

RESULTS

A proportion of 59.1% of the respondents had vision impairment. Nearly 60% of the participants had cognitive impairment. Those who had vision impairment were 11% more likely to have cognitive impairment compared to their counterparts (OR: 1.11, 95% CI: 1.01 to 1.23). low psychological health (OR: 1.55; 95% CI: 1.36 to 1.77), low activities of daily living (OR: 1.80; 95% CI: 1.43 to 2.27), low instrumental activities of daily living (OR: 1.26; 95% CI: 1.14 to 1.40), poor self-rated health (OR: 1.28; 95% CI: 1.15 to 1.41) and chronic morbidity (OR: 1.27; 95% CI: 1.14 to 1.41) were found to be risk factors for cognitive impairment among older adults.

CONCLUSIONS

Additional efforts in terms of advocacy, availability, affordability and accessibility especially in a country with big illiteracy issue are mandatory to increase the reach of eye-care services and reduce the prevalence of avoidable visual impairment and vision losses that lead to cognitive deficits among the older population.

Incidence of Pseudophakic Cystoid Macular Oedema Post-Cataract Surgery in Illawarra Shoalhaven Local Health District, Australia

BACKGROUND

Post-operatively, cataract surgery is associated with pseudophakic cystoid macular oedema (PCMO) causing vision disturbances. The presence of comorbidities may increase the incidence of PCMO post-cataract surgery.

OBJECTIVE

This observational study aimed to assess the incidence of PCMO in Australia (Illawarra region) and identify risk factors for developing PCMO.

METHODS

Retrospective analysis was performed on data from patients who underwent uncomplicated phacoemulsification and intraocular lens implantation between 1st March and June 30, 2016. Demographics, comorbidities, central subfield thickness (CST), visual acuity, and intraocular pressure (IOP) were collected preoperatively, day 1, and weeks 2, 4, and 6 post-operatively. Statistical analysis was performed using SPSS v.27.0 and GraphPad Prism v.9.0. The median and 95% confidence intervals were used to describe data. Logistic regression and χ2 tests were used to describe the associations. We followed the Declaration of Helsinki guidelines.

RESULTS

Fifty right and 35 left cataract eyes were operated on (58.8% were females; average age 72.8 ± 8.146 years). Total PCMO incidence was 10.6%, and true PCMO incidence (removing PCMO risk factors) was 4.2% at week 6 post-operatively. CST was slightly increased between pre- and post-cataract surgery at week 4 (p = 0.002) and week 6 (p < 0.0001; median = 259 μm, 264 μm, and 263 μm, respectively). IOP was found to be decreased (p < 0.0001) compared to day 1 (median = 17 mm Hg) and week 6 (median = 13 mm Hg). The probability of developing PCMO (odds ratio [OR] = 3) and vitreomacular traction (OR = 2.9) was higher in diabetic patients compared to non-diabetic patients and in patients >65 years old (OR = 1.5).

CONCLUSION

The true incidence of PCMO was found to be the greatest at 2-4 weeks post-operatively. Patients with diabetes or advanced age (>65 years) are at an elevated risk of developing PCMO after cataract surgery. The treatment regimens for the comorbid populations, especially diabetic patients, remain limited, and future efforts should target pharmaceutical management for these groups.

Intraocular lens optic edge design for the prevention of posterior capsule opacification after cataract surgery

BACKGROUND

Posterior capsule opacification (PCO) is a clouding of the posterior part of the lens capsule, a skin-like transparent structure, which surrounds the crystalline lens in the human eye. PCO is the most common postoperative complication following modern cataract surgery with implantation of a posterior chamber intraocular lens (IOL). The main symptoms of PCO are a decrease in visual acuity, 'cloudy', blurred vision and reduced contrast sensitivity. PCO is treated with a neodymium:YAG (Nd:YAG) laser to create a small opening in the opaque capsule and regain a clear central visual axis. This capsulotomy might cause further ocular complications, such as raised intraocular pressure or swelling of the central retina (macular oedema). This procedure is also a significant financial burden for health care systems worldwide. In recent decades, there have been advances in the selection of IOL materials and optimisation of IOL designs to help prevent PCO formation after cataract surgery. These include changes to the side structures holding the lens in the centre of the lens capsule bag, called IOL haptics, and IOL optic edge designs.

OBJECTIVES

To compare the effects of different IOL optic edge designs on PCO after cataract surgery.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, Ovid Embase, Latin American and Caribbean Health Sciences Literature Database (LILACS), the ISRCTN registry, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) up to 17 November 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared different types of IOL optic edge design. Our prespecified primary outcome was the proportion of eyes with Nd:YAG capsulotomy one year after surgery. Secondary outcomes included PCO score, best-corrected distance visual acuity (BCDVA) and quality of life score at one year. Due to availability of important long-term data, we also presented data at longer-term follow-up which is a post hoc change to our protocol.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane and the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 10 studies (1065 people, 1834 eyes) that compared sharp- and round-edged IOLs. Eight of these studies were within-person studies whereby one eye received a sharp-edged IOL and the fellow eye a round-edged IOL. The IOL materials were acrylic (2 studies), silicone (4 studies), polymethyl methacrylate (PMMA, 3 studies) and different materials (1 study). The studies were conducted in Austria, Germany, India, Japan, Sweden and the UK. Five studies were at high risk of bias in at least one domain. We judged two studies to be at low risk of bias in all domains. There were few cases of Nd:YAG capsulotomy at one year (primary outcome): 1/371 in sharp-edged and 4/371 in round-edged groups. The effect estimate was in favour of sharp-edged IOLs but the confidence intervals were very wide and compatible with higher or lower chance of Nd:YAG capsulotomy in sharp-edged compared with round-edged lenses (Peto odds ratio (OR) 0.30, 95% CI 0.05 to 1.74; I² = 0%; 6 studies, 742 eyes). This corresponds to seven fewer cases of Nd:YAG capsulotomy per 1000 sharp-edged IOLs inserted compared with round-edged IOLs (95% CI 9 fewer to 7 more). We judged this as low-certainty evidence, downgrading for imprecision and risk of bias. A similar reduced risk of Nd:YAG capsulotomy in sharp-edge compared with round-edge IOLs was seen at two, three and five years but as the number of Nd:YAG capsulotomy events increased with longer follow-up this effect was more precisely measured at longer follow-up: two years, risk ratio (RR) 0.35 (0.16 to 0.80); 703 eyes (6 studies); 89 fewer cases per 1000; three years, RR 0.21 (0.11 to 0.41); 538 eyes (6 studies); 170 fewer cases per 1000; five years, RR 0.21 (0.10 to 0.45); 306 eyes (4 studies); 331 fewer cases per 1000. Data at 9 years and 12 years were only available from one study. All studies reported a PCO score. Four studies reported the AQUA (Automated Quantification of After-Cataract) score, four studies reported the EPCO (Evaluation of PCO) score and two studies reported another method of quantifying PCO. It was not possible to pool these data due to the way they were reported, but all studies consistently reported a statistically significant lower average PCO score (of the order of 0.5 to 3 units) with sharp-edged IOLs compared with round-edged IOLs. We judged this to be moderate-certainty evidence downgrading for risk of bias. The logMAR visual acuity score was lower (better) in eyes that received a sharp-edged IOL but the difference was small and likely to be clinically unimportant at one year (mean difference (MD) -0.06 logMAR, 95% CI -0.12 to 0; 2 studies, 153 eyes; low-certainty evidence). Similar effects were seen at longer follow-up periods but non-statistically significant data were less fully reported: two years MD -0.01 logMAR (-0.05 to 0.02); 2 studies, 311 eyes; three years MD -0.09 logMAR (-0.22 to 0.03); 2 studies, 117 eyes; data at five years only available from one study. None of the studies reported quality of life. Very low-certainty evidence on adverse events did not suggest any important differences between the groups.

AUTHORS' CONCLUSIONS

This review provides evidence that sharp-edged IOLs are likely to be associated with less PCO formation than round-edged IOLs, with less Nd:YAG capsulotomy. The effects on visual acuity were less certain. The impact of these lenses on quality of life has not been assessed and there are only very low-certainty comparative data on adverse events.

Visual outcomes after cataract surgery among the elderly residents in the 'homes for the aged' in South India: the Hyderabad Ocular Morbidity in Elderly Study

BACKGROUND/AIM

To report visual outcomes and factors associated with good visual outcomes after cataract surgery among the elderly residents in 'homes for the aged' in Hyderabad, India.

METHODS

Individuals aged ≥60 years were recruited from 41 'homes for the aged'. All participants had a detailed eye examinations including visual acuity (VA) assessment , refraction, slit-lamp examination and fundus imaging by trained professionals. A detailed history of cataract surgery was recorded. Multivariate logistic regression was used to determine the factors associated with good visual outcomes after cataract surgery which was defined as presenting VA of 6/18 or better in the operated eye. Visual impairment (VI) is defined as presenting VA worse than 6/18 in the operated eye.

RESULTS

1215 eyes of 703 individuals had cataract surgery. The mean age of these participants was 77.5 years (SD: 8.2 years; range: 60-108 years), 66.8% were women, 29.9% reported diabetes and 61% reported hypertension. 406/1215 (33.4%; 95% CI 30.8 to 36.1) eyes had VI after cataract surgery. Posterior capsular opacification (31.8%; n=129) was the leading cause of VI followed by uncorrected refractive error (24.1%; n=98). The prevalence of good outcomes was 66.6% (95% CI 63.8 to 69.2). On applying multivariable analysis, younger age, self-reported hypertension, independent mobility, surgery in a non-government (as opposed to private) hospital and undergoing paid surgery were associated with good outcomes.

CONCLUSIONS

One-third of the eyes of elderly individuals living in homes for the aged that had previously undergone cataract surgery had VI. Regular eye examinations with the provision of laser capsulotomy and appropriate refractive correction can substantially improve their vision.

A decision aid to facilitate informed choices among cataract patients: A randomized controlled trial

OBJECTIVE

To assess the effect of a patient decision aid on the quality of decision-making for patients with age-related cataracts.

METHODS

773 patients with cataracts aged 50-80 years were randomly assigned to receive either the intervention decision aid (including standard information, quantitative information on the possible outcomes of cataract surgery and a value clarification exercise) or the control booklet (including standard information). The primary outcome was informed choice (defined as adequate knowledge and congruency between attitudes and surgical intentions), which was assessed at 2 weeks after intervention via a telephone interview.

RESULTS

The decision aid increased the proportion of participants making an informed choice, from 5.68 % in the control group to 27.7 % in the intervention group (P < 0.001). Compared with controls, more participants in the intervention group had adequate overall knowledge about cataract surgery (36.8 % vs. 8.79 % in controls; P < 0.001), and fewer participants intended to undergo surgery (22.5 % vs. 34.1 % in controls; P < 0.001).

CONCLUSION

Use of the patient decision aid may increase the proportion of patients making informed choices. Importantly, it might also reduce the acceptance of operations.

PRACTICE IMPLICATIONS

Patient decision aids represent a simple and low-cost tool to facilitate informed choice among patients with cataracts.

Prevalence, care-seeking practices and impact of self-reported vision impairment in Southwest Cameroon: a community-based study

OBJECTIVES

To establish the prevalence of self-reported vision impairment (VI) in Southwest Cameroon and describe associated care-seeking practices, functional limitations and economic hardships.

DESIGN

A three-stage clustered sampling household community-based survey.

SETTING

The Southwest region of Cameroon.

PARTICIPANTS

8046 individuals of all ages residing in the Southwest region of Cameroon.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of self-reported VI, onset of vision loss, care-seeking practices, diagnosis and treatment, functional limitations, economic hardships on household, beliefs about surgical treatability of blindness and barriers to surgical care.

RESULTS

The estimated prevalence of self-reported VI in Southwest Cameroon was 0.87% (95% CI 0.62 to 1.21). Among participants aged ≥40 years, the prevalence increased to 2.61% (95% CI 1.74 to 3.90). Less than a quarter of affected participants reported difficulty working (20.5%) or trouble going to school (12.0%) as a result of their VI. Yet, over half (52%, n=43) of affected households experienced significant economic hardships due to the VI. Residing in an urban setting (aOR 1.16, 95% CI 1.04 to 1.30) and belonging to a higher socioeconomic status (aOR 1.13, 95% CI 1.02 to 1.26) were factors associated with the belief that certain types of blindness were surgically reversible. Formal care was not sought by 16.3% (n=8) of affected participants. Cataracts was the leading diagnosis among participants who did seek formal care (43.2%, n=16), although 93.8% of these cases were not surgically treated, primarily due to a lack of perceived need.

CONCLUSION

The prevalence of individuals who report vision impairment in Southwest Cameroon is considerably lower than prior published estimates based on visual physical examinations. Routine community-level screening and cost financing schemes could improve detection of pre-clinical eye disease and the utilisation of surgical care. It could also pre-empt disability and economic hardships associated with advanced VI in the region.

Factors associated with the uptake of cataract surgery and interventions to improve uptake in low- and middle-income countries: A systematic review

Despite significant evidence around barriers hindering timely access to cataract surgery in low- and middle-income countries (LMICs), little is known about the strategies necessary to overcome them and the factors associated with improved access. Despite significant evidence that certain groups, women for example, experience disproportionate difficulties in access, little is known about how to improve the situation for them. Two reviews were conducted recently: Ramke et al., 2018 reported experimental and quasi-experimental evaluations of interventions to improve access of cataract surgical services, and Mercer et al., 2019 investigated interventions to improve gender equity. The aim of this systematic review was to collate, appraise and synthesise evidence from studies on factors associated with uptake of cataract surgery and strategies to improve the uptake in LMICs. We performed a literature search of five electronic databases, google scholar and a detailed reference review. The review identified several strategies that have been suggested to improve uptake of cataract surgery including surgical awareness campaigns; use of successfully operated persons as champions; removal of patient direct and indirect costs; regular community outreach; and ensuring high quality surgeries. Our findings provide the basis for the development of a targeted combination of interventions to improve access and ensure interventions which address barriers are included in planning cataract surgical services. Future research should seek to examine the effectiveness of these strategies and identify other relevant factors associated with intervention effects.

MicroRNA-182-5p protects human lens epithelial cells against oxidative stress-induced apoptosis by inhibiting NOX4 and p38 MAPK signalling

Background

MicroRNAs (miRNAs) are abnormally expressed in various ocular diseases, including age-related cataract. However, the role of miR-182-5p in the progression of age-related cataract remains unclear.

Methods

The expression of miR-182-5p in HLE-B3 cells was detected by qRT-PCR. HLE-B3 cells were transfected with miR-182-5p mimics. CCK-8, EdU, flow cytometry, 2′,7′-dichlorodihydrofluorescein diacetate, JC-1 kit, and western blot were used to assess the cell viability, proliferation, apoptosis, reactive oxygen species (ROS) level, mitochondrial membrane potential (MMP), and protein expression, respectively, in vitro. The relationship between miR-182-5p and NOX4 was confirmed using the dual-luciferase reporter gene analysis.

Results

We found that miR-182-5p expression was significantly decreased by the H₂O₂ exposure. Overexpression of miR-182-5p promoted cell proliferation and inhibited ROS production and apoptosis in H₂O₂-induced HLE-B3 cells. Moreover, p-p-38, p-ERK, and p-JNK were up-regulated in H₂O₂-treated HLE-B3 cells, and overexpression of miR-182-5p reversed the effects of H₂O₂ on HLE-B3 cells. In addition, dual-luciferase reporter assay substantiated that NOX4 was a direct target and downregulated by miR-182-5p.

Conclusions

We concluded that miR-182-5p inhibited lens epithelial cells apoptosis through regulating NOX4 and p38 MAPK signaling, providing a novel biomarker for treatment of age-related cataract.

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.

[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.

Phototoxicity of environmental radiations in human lens: revisiting the pathogenesis of UV-induced cataract

The magnitude of cataract pathology is indeed significant as it is the principal cause of blindness worldwide. Also, the prominence of this concept escalates with the current aging population. The burden of the disease is more tangible in developing countries than developed ones. Regarding this concern, there is a gap in classifying the pathogenesis of the ultraviolet (UV) radiation-induced cataracts and explaining the possible cellular and subcellular pathways. In this review, we aim to revisit the effect of UV radiation on cataracts categorizing the cellular pathways involved. This may help for better pharmaceutical treatment alternatives and their wide-reaching availability. Also, in the last section, we provide an overview of the protecting agents utilized as UV shields. Further studies are required to enlighten new treatment modalities for UV radiation-induced pathologies in human lens.

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.

Cataract management in Ebola virus disease survivors: clinical and scientific implications

"The EVICT study was the first study to demonstrate a step-wise approach on how to safely screen EVD survivors for cataract surgery, providing evidence that vision restoration though surgical management was safe and feasible in this cohort of EVD survivors".

Prevalence and causes of vision loss in North Africa and Middle East in 2015: magnitude, temporal trends and projections

BACKGROUND

To assess the prevalence and causes of vision impairment in North Africa and the Middle East (NAME) from 1990 to 2015 and to forecast projections for 2020.

METHODS

Based on a systematic review of medical literature, the prevalence of blindness (presenting visual acuity (PVA) <3/60 in the better eye), moderate and severe vision impairment (MSVI; PVA <6/18 but ≥3/60) and mild vision impairment (PVA <6/12 but ≥6/18) was estimated for 2015 and 2020.

RESULTS

The age-standardised prevalence of blindness and MSVI for all ages and genders decreased from 1990 to 2015, from 1.72 (0.53-3.13) to 0.95% (0.32%-1.71%), and from 6.66 (3.09-10.69) to 4.62% (2.21%-7.33%), respectively, with slightly higher figures for women than men. Cataract was the most common cause of blindness in 1990 and 2015, followed by uncorrected refractive error. Uncorrected refractive error was the leading cause of MSVI in the NAME region in 1990 and 2015, followed by cataract. A reduction in the proportions of blindness and MSVI due to cataract, corneal opacity and trachoma is predicted by 2020. Conversely, an increase in the proportion of blindness attributable to uncorrected refractive error, glaucoma, age-related macular degeneration and diabetic retinopathy is expected.

CONCLUSIONS

In 2015 cataract and uncorrected refractive error were the major causes of vision loss in the NAME region. Proportions of vision impairment from cataract, corneal opacity and trachoma are expected to decrease by 2020, and those from uncorrected refractive error, glaucoma, diabetic retinopathy and age-related macular degeneration are predicted to increase by 2020.

The national and subnational prevalence of cataract and cataract blindness in China: a systematic review and meta-analysis

Background

Cataract is the second leading cause of visual impairment and the first of blindness globally. However, for the most populous country, China, much remains to be understood about the scale of cataract and cataract blindness. We aimed to investigate the prevalence of cataract and cataract blindness in China at both the national and subnational levels, with projections till 2050.

Methods

In this systematic review and meta-analysis, China National Knowledge Infrastructure (CNKI), Wanfang, Chinese Biomedicine Literature Database (CBM-SinoMed), PubMed, Embase, and Medline were searched using a comprehensive search strategy to identify all relevant articles on the prevalence of cataract or cataract blindness in Chinese population published from January 1990 onwards. We fitted a multilevel mixed-effects meta-regression model to estimate the prevalence of cataract, and a random-effects meta-analysis model to pool the overall prevalence of cataract blindness. The United Nations Population Division (UNPD) data were used to estimate and project the number of people with cataract and cataract blindness from 1990 to 2050. According to different demographic and geographic features in the six geographic regions in China, the national numbers of people with cataract in the years 2000 and 2010 were distributed to each region.

Results

In males, the prevalence of any cataract (including post-surgical cases) ranged from 6.71% (95% CI = 5.06-8.83) in people aged 45-49 years to 73.01% (95% CI = 65.78-79.2) in elderly aged 85-89 years. In females, the prevalence of any cataract increased from 8.39% (95% CI = 6.36-10.98) in individuals aged 45-49 years to 77.51% (95% CI = 71.00-82.90) in those aged 85-89 years. For age-related cataract (ARC, including post-surgical cases), in males, the prevalence rates ranged from 3.23% (95% CI = 1.51-6.80) in adults aged 45-49 years to 65.78% (95% CI = 46.72-80.82) in those aged 85-89 years. The prevalence of ARC in females was 4.72% (95% CI = 2.22-9.76) in the 45-49 years age group and 74.03% (95% CI = 56.53-86.21) in the 85–89 years age group. The pooled prevalence rate of cataract blindness (including post-surgical cases) by best corrected visual acuity (BCVA)<0.05 among middle-aged and older Chinese was 2.30% (95% CI = 1.72-3.07), and those of cataract blindness by BCVA<0.10 and cataract blindness by presenting visual acuity (PVA)<0.10 were 2.56% (95% CI = 1.94-3.38) and 4.51% (95% CI = 3.53-5.75) respectively. In people aged 45-89 years, the number of any cataract cases was 50.75 million (95% CI = 42.17-60.37) in 1990 and 111.74 million (95% CI = 92.94-132.84) in 2015, and that of ARC rose from 35.77 million (95% CI = 19.81-59.55) in 1990 to 79.04 million (95% CI = 44.14-130.85) in 2015. By 2050, it is projected that the number of people (45-89 years of age) affected by any cataract will be 240.83 million (95% CI = 206.07-277.35), and that of those with ARC will be 187.26 million (95% CI = 113.17-281.23). During 2000 and 2010, South Central China consistently owed the most cases of any cataract, whereas Northwest China the least.

Conclusions

The prevalence of cataract and cataract blindness in China was unmasked. In the coming decades, cataract and cataract blindness will continue to be a leading public-health issue in China due to the ageing population. Future work should be prioritized to the promotion of high-quality epidemiological studies on cataract.

The national and subnational prevalence of cataract and cataract blindness in China: a systematic review and meta-analysis

Background

Cataract is the second leading cause of visual impairment and the first of blindness globally. However, for the most populous country, China, much remains to be understood about the scale of cataract and cataract blindness. We aimed to investigate the prevalence of cataract and cataract blindness in China at both the national and subnational levels, with projections till 2050.

Methods

In this systematic review and meta-analysis, China National Knowledge Infrastructure (CNKI), Wanfang, Chinese Biomedicine Literature Database (CBM-SinoMed), PubMed, Embase, and Medline were searched using a comprehensive search strategy to identify all relevant articles on the prevalence of cataract or cataract blindness in Chinese population published from January 1990 onwards. We fitted a multilevel mixed-effects meta-regression model to estimate the prevalence of cataract, and a random-effects meta-analysis model to pool the overall prevalence of cataract blindness. The United Nations Population Division (UNPD) data were used to estimate and project the number of people with cataract and cataract blindness from 1990 to 2050. According to different demographic and geographic features in the six geographic regions in China, the national numbers of people with cataract in the years 2000 and 2010 were distributed to each region.

Results

In males, the prevalence of any cataract (including post-surgical cases) ranged from 6.71% (95% CI = 5.06-8.83) in people aged 45-49 years to 73.01% (95% CI = 65.78-79.2) in elderly aged 85-89 years. In females, the prevalence of any cataract increased from 8.39% (95% CI = 6.36-10.98) in individuals aged 45-49 years to 77.51% (95% CI = 71.00-82.90) in those aged 85-89 years. For age-related cataract (ARC, including post-surgical cases), in males, the prevalence rates ranged from 3.23% (95% CI = 1.51-6.80) in adults aged 45-49 years to 65.78% (95% CI = 46.72-80.82) in those aged 85-89 years. The prevalence of ARC in females was 4.72% (95% CI = 2.22-9.76) in the 45-49 years age group and 74.03% (95% CI = 56.53-86.21) in the 85-89 years age group. The pooled prevalence rate of cataract blindness (including post-surgical cases) by best corrected visual acuity (BCVA)<0.05 among middle-aged and older Chinese was 2.30% (95% CI = 1.72-3.07), and those of cataract blindness by BCVA<0.10 and cataract blindness by presenting visual acuity (PVA)<0.10 were 2.56% (95% CI = 1.94-3.38) and 4.51% (95% CI = 3.53-5.75) respectively. In people aged 45-89 years, the number of any cataract cases was 50.75 million (95% CI = 42.17-60.37) in 1990 and 111.74 million (95% CI = 92.94-132.84) in 2015, and that of ARC rose from 35.77 million (95% CI = 19.81-59.55) in 1990 to 79.04 million (95% CI = 44.14-130.85) in 2015. By 2050, it is projected that the number of people (45-89 years of age) affected by any cataract will be 240.83 million (95% CI = 206.07-277.35), and that of those with ARC will be 187.26 million (95% CI = 113.17-281.23). During 2000 and 2010, South Central China consistently owed the most cases of any cataract, whereas Northwest China the least.

Conclusions

The prevalence of cataract and cataract blindness in China was unmasked. In the coming decades, cataract and cataract blindness will continue to be a leading public-health issue in China due to the ageing population. Future work should be prioritized to the promotion of high-quality epidemiological studies on cataract.

Macular assessment of preoperative optical coherence tomography in ageing Chinese undergoing routine cataract surgery

This retrospective consecutive case series aimed to evaluate spectral-domain optical coherence tomography (SD-OCT) for occult macular disease recognition preoperatively in patients scheduled for routine cataract surgery. All patients scheduled for cataract surgery underwent macular SD-OCT. Scans were reviewed for retinal, retinal pigment epithelium and vitreomacular interface abnormalities. For the subgroup analysis, the following information was collected: age; sex; and diabetes, hypertension, myopia, glaucoma, post intra-ocular surgery, endophotocoagulation, retinal vasculopathy and uveitis statuses. One-thousand-one-hundred-seventy-six consecutive scans were acquired from 1,176 patients. Macular pathology was found in 294 eyes. The most common macular disorders were an epiretinal membrane (n = 130), myopia atrophy (n = 61) and a dome-shaped macular with pathologic myopia (n = 32). One-hundred-thirty eyes (11.05%) presented macular epiretinal membranes not detected by dilated fundus examination, accounting for 44.22% of the abnormalities in diseased eyes and was higher than in previous Chinese studies. Some had multiple macular disorders. The most common ocular history was myopia, including high myopia. The pooled prevalence rate of macular diseases detected by OCT was 0.24 (95% CI 0.14-0.34) using meta-analysis. SD-OCT should be performed for routine cataract surgery patients to evaluate visual outcomes, especially in myopic patients and those considering advanced-technology intraocular lenses.

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.

Combined 30-degree bevel up and down technique against 0-degree phaco tip for phacoemulsification surgery of hard cataracts

Purpose

To evaluate the effective phaco time (EPT), cumulative dissipated energy (CDE) and nucleus emulsification time (NET) as phaco parameters with 0- and 30-degree phaco tip.

Patients and methods

This prospective, interventional and observational case series included 294 patients scheduled for cataract removal by phacoemulsification technique. Patients with nuclear cataracts of grade 4 and 5 nuclear opalescence of Lens Opacities Classification System III were included in the study. Patients were consecutively allocated to phaco chop technique with 0-degree (0-degree group, n=147) and combined bevel up and down position using 30-degree phaco tip (combined bevel up/down group, n=147). The 0-degree group had phacoemulsification with 0-degree phaco tip, while the 30-degree group had chopping of the nucleus with bevel down phaco tip and emulsification of nuclear fragments was accomplished with bevel up tip. EPT, CDE, NET and intraoperative complications were noted and compared between the groups using analysis of variance.

Results

Average EPT, CDE and NET were lower in the 30-degree group than in the 0-degree group. However, no statistically significant difference was found in EPT (P=0.0733), CDE (P=0.0663) and NET (P=0.0633) between the two groups. No serious intraoperative complications were noted. The anterior chamber was maintained throughout the procedure in both groups. No patients had wound burn and miosis during the procedure. None of the patients developed bullous keratopathy, uveitis and cystoid macular edema during the follow-up period.

Conclusion

Combined bevel up and down 30-degree tip can yield effective hard nucleus phacoemulsification. Bevel down tip of 30-degree helps in effective chopping and bevel up tip assists in emulsification of the nuclear fragments. Although combined bevel up and down 30-degree tip can yield effective hard nucleus phacoemulsification, no statistically significant difference was found in EPT, CDE and NET between the two groups.

Effects of phacoemulsification with versus without viscoelastic devices on surgical outcomes

PURPOSE

The aim of this study is to report surgical outcomes in patients undergoing phacoemulsification surgery (PE) with versus without ophthalmic viscosurgical devices (OVDs).

METHODS

This is a comparative case series study. In total, 145 patients who performed PE with OVDs in 68 eyes (Group 1) and without OVD in 77 eyes (Group 2) were enrolled. A comprehensive ophthalmological examination was performed including slit-lamp, fundus examination. Best-corrected visual acuity (BCVA), intraocular pressure (IOP) specular endothelial microscopy (SM), and ultrasound pachymetry (UP) were also measured before surgery and at four-time points postoperatively. The differences in baseline characteristics as well as in outcomes were compared between the two groups.

RESULTS

The mean BCVA was 0.41 ± 0.26 logMAR in Group 1 and 0.54 ± 0.34 in Group 2 at postoperative first day, with a significant difference (p < 0.01). The mean BCVA, IOP, and UP at 6 months did not differ between the groups. The mean baseline and postoperative SMs were 2063 and 1910 cells/mm², respectively, and the endothelial cell loss (ECL) was 153.89 ± 189 in Group 1. The mean baseline and postoperative SMs were 2153 and 1948 cells/mm², respectively, and the ECL was 205 ± 200 in Group 2. The difference between the groups was not statistically significant (p = 0.105).

CONCLUSIONS

The ECL seemed to be higher in the Group 2, but the difference was not significant. The final clinical outcomes were similar between the groups. In selected cases, PE without OVD may be preferable to reduce the cost of surgery in places with low economic status and to prevent side-effects of these devices.

Safety and Efficacy of the Transition from Extracapsular Cataract Extraction to Manual Small Incision Cataract Surgery in Prevention of Blindness Campaigns

PURPOSE

To compare the safety and the visual outcomes of two experienced cataract surgeons who converted from extracapsular cataract extraction (ECCE) to manual small incision cataract surgery (MSICS) during a campaign for the prevention of blindness.

METHODS

Two surgeons used the ECCE technique (ECCE group) during a campaign in Burkina Faso on 93 consecutive cataract patients with a corrected distance visual acuity (CDVA) <20/80 in the best eye. Both surgeons used MSICS for the first time on 98 consecutive cases in another campaign in Kenya after theoretical instructional courses.

RESULTS

There were no significant differences in CDVA at 3 months postoperatively. There were 69% of eyes with uncorrected distance visual acuity ≥20/60 in the MSICS group and 49% eyes in the ECCE group. Spherical equivalents ranged between -1D and +1D in 55% of the MSICS group versus 43% in the ECCE group. There were significant differences in the changes in the vertical component of astigmatism (J45) but not the horizontal (J0) component. There were no significant differences in the intraoperative complications. The most common postoperative complication was corneal edema on the first day in 40.86% and 19.38% of the ECCE and MSICS groups, respectively.

CONCLUSION

Transitioning from ECCE to MSICS for experienced cataract surgeons in surgical campaigns is safe. The rate of complications is similar for both techniques. Slightly better visual and refractive outcomes can be achieved due to the decreased induction of corneal astigmatism.

Endophthalmitis Reduction with Intracameral Moxifloxacin Prophylaxis: Analysis of 600 000 Surgeries

PURPOSE

To compare the postoperative endophthalmitis rate before and after initiation of intracameral (IC) moxifloxacin prophylaxis for both phacoemulsification and sutureless, manual small-incision cataract surgery (M-SICS), as well as in patients with posterior capsular rupture (PCR).

DESIGN

Retrospective, clinical registry.

PARTICIPANTS

All cataract surgeries (617 453) performed during the 29-month period from January 2014 to May 2016 at the 10 regional Aravind eye hospitals were included.

METHODS

The electronic health record data for all study eyes were analyzed. Endophthalmitis rates before and after moxifloxaxin were statistically compared for all eyes and separately for both phacoemulsification and M-SICS, and for the eyes complicated by PCR.

MAIN OUTCOME MEASURES

The postoperative endophthalmitis rates before and after initiation of IC moxifloxacin prophylaxis.

RESULTS

Overall, 302 815 eyes did not receive IC moxifloxacin and 314 638 eyes did, and there was a significant decline in the endophthalmitis rate, from 0.07% (214/302 815) to 0.02% (64/314 638) (P < 0.001), with moxifloxacin. For the 194 252 phacoemulsification eyes, the endophthalmitis rate was 0.07% (75/104 894) without IC moxifloxacin prophylaxis, compared with 0.01% (11/89 358) with moxifloxacin (P < 0.001). For the 414 657 M-SICS eyes, the endophthalmitis rate was 0.07% (135/192 149) without IC moxifloxacin prophylaxis, compared with 0.02% (52/222 508) with moxifloxacin (P < 0.001). Approximately half of the 8479 eyes that had PCR received IC moxifloxacin, and half did not. Without IC moxifloxacin, PCR increased the endophthalmitis rate nearly 7-fold to 0.48% (20/4186); IC moxifloxacin reduced the endophthalmitis rate with PCR to 0.21% (9/4293) (P = 0.034). No adverse events were due to IC moxifloxacin.

CONCLUSIONS

Routine IC moxifloxacin prophylaxis reduced the overall endophthalmitis rate by 3.5-fold (3-fold for M-SICS and nearly 6-fold for phacoemulsification). There was also a statistical benefit for eyes complicated by PCR, and IC antibiotic prophylaxis should be strongly considered for this high-risk population. These conclusions are strengthened by the high volume of cases analyzed at a single hospital network over a comparatively short time frame. Considering the association of hemorrhagic occlusive retinal vasculitis with vancomycin and the commercial unavailability of IC cefuroxime in many countries, moxifloxacin appears to be an effective option for surgeons electing IC antibiotic prophylaxis.

Prevalence and Visual Outcomes of Cataract Surgery in Rural South India: A Cross-Sectional Study

PURPOSE

To determine the prevalence of cataract surgery and postoperative vision-related outcomes, especially with respect to sex, socioeconomic status (SES) and site of first contact with eye care, in a rural area of South India.

METHODS

In a population-based cross-sectional survey of 5530 individuals aged 50 years or older from 10 villages selected by cluster sampling, individuals who had undergone cataract surgery in one or both eyes were identified. Consenting participants were administered a questionnaire, underwent vision assessment and ophthalmic examination. Outcomes were classified as good if visual acuity of the operated eye was 6/18 or better, fair if worse than 6/18 but better than or equal to 6/60, and poor if worse than 6/60.

RESULTS

Prevalence of cataract surgery in this age group (771 persons) was 13.9% (95% confidence interval, CI, 13.0-14.9%). In the 1112 eyes of 749 persons studied, at presentation, 53.1% (95% CI 50.1-56.1%) of operated eyes had good, 38.1% (95% CI 35.2-41.0%) had fair, and 8.8% (95% CI 7.1-10.5%) had poor outcomes. With pinhole, 75.2% (95% CI 72.6-77.8%) had good, 17.2% (95% CI 14.9-19.5%) had fair, and 7.4% (95% CI 5.8-9.0%) had poor outcomes. In 76.3% of eyes with fair and poor presenting outcomes we detected an avoidable cause for the suboptimal visual acuity. Place of surgery and duration since surgery of 3 years or more were risk factors for blindness, while SES, sex and site of first eye care contact were not.

CONCLUSION

The high prevalence of avoidable causes of visual impairment in this rural setting indicates the scope for preventive strategies.

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.

Efficacy of Intracameral Moxifloxacin Endophthalmitis Prophylaxis at Aravind Eye Hospital

PURPOSE

To compare the rate of postoperative endophthalmitis before and after initiation of intracameral (IC) moxifloxacin for endophthalmitis prophylaxis in patients undergoing cataract surgery.

DESIGN

Retrospective, clinical registry.

PARTICIPANTS

All charity and private patients (116 714 eyes) who underwent cataract surgery between February 15, 2014, and April 15, 2015, at the Madurai Aravind Eye Hospital were included. Group 1 consisted of 37 777 eyes of charity patients who did not receive IC moxifloxacin, group 2 consisted of 38 160 eyes of charity patients who received IC moxifloxacin prophylaxis, and group 3 consisted of 40 777 eyes of private patients who did not receive IC moxifloxacin.

METHODS

The electronic health record data for each of the 3 groups were analyzed, and the postoperative endophthalmitis rates were statistically compared. The cost of endophthalmitis treatment (groups 1 and 2) and the cost of IC moxifloxacin prophylaxis (group 2) were calculated.

MAIN OUTCOME MEASURES

Postoperative endophthalmitis rate before and after initiation of IC moxifloxacin endophthalmitis treatment cost.

RESULTS

Manual, sutureless, small incision cataract surgery (M-SICS) accounted for approximately all of the 75 937 cataract surgeries in the charity population (97%), but only a minority of the 40 777 private surgeries (21% M-SICS; 79% phacoemulsification). Thirty eyes in group 1 (0.08%) and 6 eyes in group 2 (0.02%) were diagnosed with postoperative endophthalmitis (P < 0.0001). The group 3 endophthalmitis rate was 0.07% (29 eyes), which was also higher than the second group's rate (P < 0.0001). There were no adverse events attributed to IC moxifloxacin in group 2. The total cost of treating the 30 patients with endophthalmitis in group 1 was virtually identical to the total combined cost in group 2 of routine IC moxifloxacin prophylaxis and treatment of the 6 endophthalmitis cases.

CONCLUSIONS

Routine IC moxifloxacin prophylaxis achieved a highly significant, 4-fold reduction in postoperative endophthalmitis in patients undergoing M-SICS. Compared with previous studies, having such a high volume of patients undergoing surgery during a relatively short 14-month time period strengthens the conclusion. This study provides further evidence that moxifloxacin is an effective IC prophylactic antibiotic and suggests that IC antibiotics should be considered for M-SICS and phacoemulsification.

The Barrie Jones Lecture-Eye care for the neglected population: challenges and solutions

Globally, pockets of 'neglected populations' do not have access to basic health-care services and carry a much greater risk of blindness and visual impairment. While large-scale public health approaches to control blindness due to vitamin A deficiency, onchocerciasis, and trachoma are successful, other causes of blindness still take a heavy toll in the population. High-quality comprehensive eye care that is equitable is the approach that needs wide-scale application to alleviate this inequity. L V Prasad Eye Institute of India developed a multi-tier pyramidal model of eye care delivery that encompasses all levels from primary to advanced tertiary (quaternary). This has demonstrated the feasibility of 'Universal Eye Health Coverage' covering promotive, preventive, corrective, and rehabilitative aspects of eye care. Using human resources with competency-based training, effective and cost-effective care could be provided to many disadvantaged people.

Gendered Disparities in Quality of Cataract Surgery in a Marginalised Population in Pakistan: The Karachi Marine Fishing Communities Eye and General Health Survey

Background

Marine fishing communities are among the most marginalised and hard-to-reach groups and have been largely neglected in health research. We examined the quality of cataract surgery and its determinants, with an emphasis on gender, in marine fishing communities in Karachi, Pakistan, using multiple indicators of performance.

Methods and Findings

The Karachi Marine Fishing Communities Eye and General Health Survey was a door-to-door, cross-sectional study conducted between March 2009 and April 2010 in fishing communities living on 7 islands and in coastal areas in Keamari, Karachi, located on the Arabian Sea. A population-based sample of 638 adults, aged ≥ 50 years, was studied. A total of 145 eyes (of 97 persons) had undergone cataract surgery in this sample. Cataract surgical outcomes assessed included vision (presenting and best-corrected with a reduced logMAR chart), satisfaction with surgery, astigmatism, and pupil shape. Overall, 65.5% of the operated eyes had some form of visual loss (presenting visual acuity [PVA] < 6/12). 55.2%, 29.0%, and 15.9% of these had good, borderline, and poor visual outcomes based on presenting vision; with best correction, these values were: 68.3 %, 18.6%, and 13.1%, respectively. Of 7 covariates evaluated in the multivariable generalized estimating equations (GEE) analyses, gender was the only significant independent predictor of visual outcome. Women’s eyes were nearly 4.38 times more likely to have suboptimal visual outcome (PVA<6/18) compared with men’s eyes (adjusted odds ratio 4.38, 95% CI 1.96-9.79; P<0.001) after adjusting for the effect of household financial status. A higher proportion of women’s than men’s eyes had an irregular pupil (26.5% vs. 14.8%) or severe/very severe astigmatism (27.5% vs. 18.2%). However, these differences did not reach statistical significance. Overall, more than one fourth (44/144) of cataract surgeries resulted in dissatisfaction. The only significant predictor of satisfaction was visual outcome (P <0.001).

Conclusions

The quality of cataract surgery in this marginalised population, especially among women, falls well below the WHO recommended standards. Gender disparities, in particular, deserve proactive attention in policy, service delivery, research and evaluation.

Comparison of surgically induced astigmatism in various incisions in manual small incision cataract surgery

AIM

To determine the surgically induced astigmatism (SIA) in Straight, Frown and Inverted V shape (Chevron) incisions in manual small incision cataract surgery (SICS).

METHODS

A prospective cross sectional study was done on a total of 75 patients aged 40y and above with senile cataract. The patients were randomly divided into three groups (25 each). Each group received a particular type of incision (Straight, Frown or Inverted V shape incisions). Manual SICS with intraocular lens (IOL) implantation was performed. The patients were compared 4wk post operatively for uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA) and SIA. All calculations were performed using the SIA calculator version 2.1, a free software program. The study was analyzed using SPSS version 15.0 statistical analysis software.

RESULTS

The study found that 89.5% of patients in Straight incision group, 94.2% in Frown incision group and 95.7% in Inverted V group attained BCVA post-operatively in the range of 6/6 to 6/18. Mean SIA was minimum (-0.88±0.61D×90 degrees) with Inverted V incision which was statistically significant.

CONCLUSION

Inverted V (Chevron) incision gives minimal SIA.

Comparison of occlusion break responses and vacuum rise times of phacoemulsification systems

Background

Occlusion break surge during phacoemulsification cataract surgery can lead to potential surgical complications. The purpose of this study was to quantify occlusion break surge and vacuum rise time of current phacoemulsification systems used in cataract surgery.

Methods

Occlusion break surge at vacuum pressures between 200 and 600 mmHg was assessed with the Infiniti® Vision System, the WhiteStar Signature® Phacoemulsification System, and the Centurion® Vision System using gravity-fed fluidics. Centurion Active Fluidics^TM were also tested at multiple intraoperative pressure target settings. Vacuum rise time was evaluated for Infiniti, WhiteStar Signature, Centurion, and Stellaris® Vision Enhancement systems. Rise time to vacuum limits of 400 and 600 mmHg was assessed at flow rates of 30 and 60 cc/minute. Occlusion break surge was analyzed by 2-way analysis of variance.

Results

The Centurion system exhibited substantially less occlusion break surge than the other systems tested. Surge area with Centurion Active Fluidics was similar to gravity fluidics at an equivalent bottle height. At all Centurion Active Fluidics intraoperative pressure target settings tested, surge was smaller than with Infiniti and WhiteStar Signature. Infiniti had the fastest vacuum rise time and Stellaris had the slowest. No system tested reached the 600-mmHg vacuum limit.

Conclusions

In this laboratory study, Centurion had the least occlusion break surge and similar vacuum rise times compared with the other systems tested. Reducing occlusion break surge may increase safety of phacoemulsification cataract surgery.

The safety and efficacy of day care cataract surgery

Purpose:

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

Patients and Methods:

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

Results:

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

Conclusion:

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

Evaluation of complications of extracapsular cataract extraction performed by trainees

Background:

Cataract extraction is the most common intraocular surgery taught to residents.

Aim:

This study aims to review the complications of trainee-performed extracapsular cataract extraction (ECCE) so as to identify the steps in which the trainee can benefit from closer supervision and practice.

Subjects and Methods:

This was a descriptive retrospective study of complications in the initial 150 ECCE with intraocular lens implant performed by two Ophthalmologists, from the University of Nigeria Teaching Hospital, Enugu, who visited a high volume training center. Both the intraoperative and early post-operative complications were studied. Data entry and analysis were performed descriptively using the Statiscal Package for the Social Sciences, SPSS version 15.0 (Chicago, IL, USA).

Results:

The age range of the patients was 40-95 years. The intraoperative complications included capsular flaps 12/161 (7.5%), posterior capsule rent, 10/161 (6.2%) and vitreous loss, 8/161 (5.0%). Corneal complications (striate keratopathy, superior corneal edema, generalized corneal edema and corneal folds) ranked highest in post-operative complications accounting for 34% (56/164).

Conclusions:

Performance of adequate and proper anterior capsulotomy, minimal handling of the cornea and avoidance of posterior capsular rent are some of the challenges of the trainee in mastering ECCE. Stepwise supervised training can help a trainee master these steps while keeping the complications at acceptably low levels.

Primary posterior capsular opacification in Indian rural population undergoing cataract surgery for hypermature senile cataract

AIM

To find out the incidence of primary posterior capsular opacification (PCO) in rural patients with a hypermature senile cataract undergoing cataract surgery.

SETTINGS

Tertiary eye care center in central India.

DESIGN

Prospective, observational, noncomparative study.

MATERIALS AND METHODS

Two-hundred eyes of 200 patients presenting with a hypermature cataract underwent manual small incision cataract surgery. A single surgeon performed all surgeries under peribulbar anesthesia. After cortical clean-up, the capsular bag was inflated with viscoelastic. The presence or absence of opacity on the posterior lens capsule and location was noted. Postoperative follow-up was done for visual acuity and need for neodymium-doped yttrium aluminum garnet (ND:YAG) laser capsulotomy.

RESULTS

Primary PCO occurred in 76 eyes (incidence of 38%). It was peripheral in 58 eyes (76.3%) and central in 18 eyes (23.7%). At 6 weeks postoperatively, best corrected visual acuity for eyes with central primary PCO (n = 18) was 0.2-0.3 logMAR and 0-0.2 logMAR for eyes with peripheral primary PCO (n = 58). Best corrected visual acuity at the 6- and 12-month follow-up was 0-0.2 logMAR in both groups. Fibrotic primary PCO was seen in four patients. No predilection for the development of primary PCO to a particular quadrant of posterior capsule was observed. At 1 year postoperatively, eleven (14.5%) patients required ND:YAG laser capsulotomy, six (7.90%) of whom underwent ND:YAG laser capsulotomy at the 6-month follow-up. Seven patients with central primary PCO and four patients with peripheral primary PCO required ND:YAG laser capsulotomy.

CONCLUSION

A high incidence of primary PCO was noted in rural patients with a hypermature senile cataract undergoing cataract surgery. No serious intraoperative complications were noted. Visual outcome at 1-year follow-up was satisfactory. Need for early ND:YAG laser posterior capsulotomy should be explained to these patients before cataract surgery. No post ND:YAG capsulotomy complications were noted in any patient.