The Pyhäjärvi Cataract Study. I. Study design, baseline characteristics and the demand for cataract surgery

Cataract Surgery in One-Eyed Patients: A Cohort Study of 100 Patients

Purpose

To determine the course and outcomes of cataract surgery in one-eyed patients.

Methods

This retrospective cohort study was conducted at the University Hospital of Nice, France. All one-eyed patients who underwent cataract surgery in their functional eye between January 2014 and December 2018 were included. A one-eyed patient was defined as having a visual acuity (VA) ≤20/200 in the other eye. Data were collected from the medical records and included the sociodemographic factors, the past medical history, data from the preoperative and postoperative clinical examinations, the surgical course, and the visual outcomes.

Results

One hundred one-eyed patients with a mean age of 74.01 years were included (48 men/52 women). The mean preoperative VA was 20/100 (+0.74 logMAR). The VA ranged between 20/200 and 20/40 in 75 (75%) patients, was >20/40 in 8 (8%), and was <20/200 in 17 (17%) patients. Fifty-eight (58%) patients were operated on an outpatient basis. General or locoregional anesthesia was used in 29 (29%) and 9 (9%) patients, respectively. All cataract surgery procedures were performed by phacoemulsification. Five (5%) patients experienced intraoperative complications. Seventy-three (73%) one-eyed patients achieved a final VA ≥20/40. The mean final VA was 20/50 (+0.37 logMAR) (p < 0.001).

Conclusion

A low rate of intraoperative complications was observed in one-eyed patients during cataract surgery. In most cases, a good visual recovery was achieved after cataract surgery, even in patients who experienced a surgical complication.

Health-related quality of life and related factors among older adults with visual impairments

Aim was to explore the health-related quality of life (HRQoL) and related factors among older adults with visual impairment (VI). A total of 39 independently living subjects aged ⩾65 years (83 ± 6.5), referred to the Low Vision Center of the Oulu University Hospital, Finland during one year participated in the study. The participants had low vision or blindness as defined by the World Health Organization (WHO). The 15D, a generic HRQoL instrument, was used to assess the HRQoL, and an ophthalmic examination was performed to assess vision. A population-based control group ( n = 1074) was available for comparison. The mean 15D index scores for the participants and the control group were 0.768 ( SD = 0.089) and 0.827 ( SD = 0.044), respectively, ( p < .002). In the dimensions of move ( p < .05), see ( p < .001), breath ( p < .05), usual activities ( p < .001), depression ( p < .05), and distress ( p < .05), the study participants scored statistically significantly lower than the control group. However, the participants had better mental function scores (0.856 vs 0.773, p < .05). Among the participants, there was no difference in the 15D by gender (men 0.755, women 0.774, p > .05), habitation (alone 0.768, with someone 0.770, p > .05), or age ( r = –.084), nor did the extent of low vision appear to affect the 15D index in this material. The older adults with VI had poorer 15D index score than Finnish population of equal age, but they scored better in the dimension of mental function. Mental skills may indeed be crucial for independent living despite VI.

Health-related quality of life of Finnish patients with diabetes

AIMS

This study evaluated the influence of diabetes on the health-related quality of life (HRQoL) scores of adult patients with diabetes in northern Finland.

METHODS

A total of 3771 patients of the population of 10,264 patients aged ⩾15 years with the right for reimbursement of the cost of diabetes medication attended fundus photography screening for retinopathy in 2012. The 15D HRQoL scores and data on age, sex, type and duration of diabetes were gathered concurrently. The results were compared with the 15D scores reported in Finnish population studies.

RESULTS

The 15D score was obtained from 2461 patients aged 60±14 years; 20% had type 1 diabetes (T1D). The mean±SD 15D index was 0.930±0.079 in patients with T1D and their mean±SD age was 46±15 years. The mean±SD 15D index of the patients with type 2 diabetes (T2D) was 0.890±0.100 and their mean±SD age was 63±11 years. The 15D index was no lower than in the Finnish general population in either patient group or in any age group. However, the 15D score was negatively influenced by an increasing duration of diabetes in both patients with T1D and patients with T2D. No sex difference was found.

CONCLUSIONS

The mean HRQoL score of patients with diabetes in this study is comparable with that of the general population of equal age. Neither the type of diabetes nor sex independently affected the HRQoL score, but a longer duration of diabetes seemed to impair the HRQoL score. Current diabetes care appears to maintain a normal HRQoL score in this diabetic population in Finland.

Recovery after cataract surgery

Cataract surgery is the most common ophthalmological surgical procedure, and it is predicted that the number of surgeries will increase significantly in the future. However, little is known about the recovery after surgery. The first aim of this study was to evaluate the prevalence, severity and duration of pain and other ocular discomfort symptoms experienced after cataract surgery. The other objectives were to identify the factors associated with lower postoperative patient satisfaction and to measure the effect of cataract surgery on patients' health-related quality of life (HRQoL) and visual function in everyday life. The study design was a prospective follow-up study. The course of the recovery and the presence of ocular symptoms were evaluated by interviewing the patients via a questionnaire at 1 day, 1 week, 6 weeks and one year after surgery The visual functioning in everyday life was measured with Visual Functioning Index VF-7 and Catquest-9SF-questionnaires and furthermore the HRQoL was measured with the 15D-instrument before surgery and at 12 months after surgery. The patients returned the questionnaires by mail and were interviewed in the hospital on the day of the surgery. The same patients filled-in all the questionnaires. The patient reports were used to collect the data on medical history. A total of 303 patients were approached at Kuopio University Hospital in 2010-2011 and of these 196 patients were eligible and willing to participate, with postoperative data being available from 186 (95%) patients. A systematic review article was included in the study procedure and it revealed the wide range in the reported incidence of postoperative ocular pain. Some of the identified randomized controlled studies reported no or only minor pain whereas in some studies significant pain or pain lasting for several weeks has been described in more than 50% of the study patients. In the present study setting, pain was reported by 34% during the first postoperative hours and by approximately 10% of patients during the first six weeks after surgery. During the early recovery in the hospital, only a minority of the patients reporting pain were provided with pain medication. The ocular discomfort symptoms such as itchiness, burning, foreign-body sensation and tearing were common both before (54%) and after surgery (38-52%). These symptoms can also be described as painful symptoms and are often difficult to distinguish from ocular pain. The symptoms are also typical of ocular surface disease, and some patients may benefit from the postoperative administration of tear substitutes. The patients reporting postoperative ocular symptoms were less satisfied with the treatment outcome at 12 months after surgery (p = 0.001) compared to the patients who experienced no symptoms. Those patients reporting less disability in visual functioning before surgery were more satisfied than patients with more reported disability. The HRQoL improved significantly after cataract surgery (p = 0.002). However, when compared to an age-and gender-standardized control population, in cataract subjects the HRQoL remained slightly worse both before and at 12 months after surgery.

Indication for cataract surgery. Do we have evidence of who will benefit from surgery? A systematic review and meta-analysis

The need for cataract surgery is expected to rise dramatically in the future due to the increasing proportion of elderly citizens and increasing demands for optimum visual function. The aim of this study was to provide an evidence-based recommendation for the indication of cataract surgery based on which group of patients are most likely to benefit from surgery. A systematic literature search was performed in the MEDLINE, CINAHL, EMBASE and COCHRANE LIBRARY databases. Studies evaluating the outcome after cataract surgery according to preoperative visual acuity and visual complaints were included in a meta-analysis. We identified eight observational studies comparing outcome after cataract surgery in patients with poor (<20/40) and fair (>20/40) preoperative visual acuity. We could not find any studies that compared outcome after cataract surgery in patients with few or many preoperative visual complaints. A meta-analysis showed that the outcome of cataract surgery, evaluated as objective and subjective visual improvement, was independent on preoperative visual acuity. There is a lack of scientific evidence to guide the clinician in deciding which patients are most likely to benefit from surgery. To overcome this shortage of evidence, many systems have been developed internationally to prioritize patients on waiting lists for cataract surgery, but the Swedish NIKE (Nationell Indikationsmodell för Katarakt Ekstraktion) is the only system where an association to the preoperative scoring of a patient has been related to outcome of cataract surgery. We advise that clinicians are inspired by the NIKE system when they decide which patients to operate to ensure that surgery is only offered to patients who are expected to benefit from cataract surgery.

Health-related quality of life after cataract surgery with the phacoemulsification technique and intraocular lens implantation

PURPOSE

Disease-specific instruments have shown significant gains in measuring health-related quality of life (HRQoL) in subjects having cataract surgery. However, the usage of generic instruments has resulted in conflicting evidence.

METHODS

In this prospective study, we have evaluated the impact of cataract surgery on subjects' HRQoL measured with a 15-dimension generic instrument, the 15D. The HRQoL of cataract subjects was compared with that of an age- and gender-standardized sample of the general population in Finland. A total of 152 subjects (mean age 74 years, 66% females) with a first-eye cataract surgery completed the 15D questionnaire both before and 12 months after cataract surgery.

RESULTS

When compared with the general population, cataract subjects had much lower HRQoL at baseline (mean difference 0.037 (95% CI: 0.020, 0.054), p < 0.001). At 12 months after cataract surgery, the overall utility index improved from the mean of 0.837 to 0.855 (mean difference 0.018 (95% CI: 0.007, 0.029), p = 0.002). Significant improvement was observed on the following five dimensions: seeing, moving, hearing, usual activities and discomfort/symptoms in the 15D questionnaire.

CONCLUSION

Our data indicate that at 12 months after first-eye cataract surgery, patients' HRQoL is slightly better than that before surgery. However, patients' postoperative HRQoL may remain lower than that of an age-and gender-standardized control population.

Comparison of resource utilization in the treatment of open-angle glaucoma between two cities in Finland: is more better?

INTRODUCTION

Glaucoma is a progressive optic neuropathy associated with neural rim loss of the optic disc and the retinal nerve fibre layer typically causing visual field (VF) deterioration. Generally, glaucomatous lesions in the eye and in the visual field progress slowly over the years. In population-based cross-sectional studies, the percentage of unilateral or bilateral visual impairment varied between 3-12%. In screening studies, 0.03-2.4% of patients have been found to suffer visual impairment. Glaucoma has previously been associated with substantial healthcare costs and resource consumption attributable to the treatment of the disease. The disease also causes reduction in health-related quality of life (HRQoL) in patients with glaucoma.

OBJECTIVE AND METHODS

This study compares patients with diagnosed open-angle glaucoma from two geographically different regions in Finland. A total of 168 patients were examined, 85 subjects from an area with higher per patient treatment costs (Oulu) and 83 patients from a region with lower per patient treatment costs (Turku). All patients had a history of continuous glaucoma medication use for a period of 11 years. For each patient, the total direct costs from glaucoma treatment were calculated and the total amount of resource consumption was determined from registries and patient records. Each patient underwent a clinical examination with visual field assessment and fundus photography. These data were used to determine the current stage of disease for each patient. Health-related quality of life questionnaire (15D) was used in determining each patient's subjective HRQoL score.

RESULTS

When applying the current diagnostic criteria for open-angle glaucoma, a total of 40% of patients did not to display any structural or functional damage suggesting glaucoma after 11 years of continuous medical treatment and follow-up. Patients with higher glaucoma stage (worse disease) were found to have statistically higher treatment costs compared with those at lower disease stages. Resource consumption was also greater in the patients in higher glaucoma stage. Patients in the Oulu district consumed more resources, and glaucoma treatment was more expensive than in the Turku area. The total treatment cost in Oulu and Turku was 6010 € and 4452 €, respectively, for the whole 11-year period. There was no statistically significant difference in quality-of-life scores between the two areas. No difference was noted between the higher-spending and lower-spending areas in this respect. However, when the population was analysed as a whole, patients with higher glaucoma stage were found to have lower vision-based 15D scores compared with those at lower disease stages. This observation was made also at both districts independently.

CONCLUSIONS

Major cost source in open-angle glaucoma treatment is medication, up to 74% of annual costs. In addition, it seems that higher resource consumption and higher treatment costs do not increase the patients' HRQoL as assessed by the 15D instrument.

The Pyhäjärvi Cataract Study II. Criteria for cataract surgery

PURPOSE

It is necessary to develop tools for patient selection to target cataract surgery to patients with the best expected outcomes. We used visual acuity, visual functioning 14 (VF-14) test, the 15-dimension health-related quality-of-life questionnaire (15D) and the New Zealand priority criteria to evaluate the criteria for cataract surgery in a post hoc setting.

MATERIAL AND METHODS

Ninety-three consecutive patients living in a defined rural area in Finland had cataract surgery as a part of the Pyhäjärvi Cataract Study in 2003. Success of cataract surgery was defined as improvement of visual acuity by at least 2 lines and/or improvement of visual function measured by questionnaires.

RESULTS

The patients with a visual acuity of 0.30 logMAR (0.5 Snellen decimal) or worse in the better eye and/or 0.52 logMAR (0.3 Snellen decimal) in the worse eye had successful surgery in 59-83% of cases depending on the definition of success. When subjective judgement was added, the success rates varied between 63% and 91%.

CONCLUSION

Setting indication criteria, it seems sufficient to use two global questions in addition to visual acuity: one on the subjective view on disability, and one on a more neutral view on visual function, such as the 15D item on vision. The VF-14 did not perform any better than the single item counterparts.

Use of the patient acceptable symptom state and the minimal clinically important difference to evaluate the outcomes of cataract extraction

PURPOSE

To determine the minimal clinically important difference and the patient acceptable symptom state for visual acuity and visual function, 2 key visual outcomes for patients undergoing cataract extraction, as an aid for evaluating the outcome of cataract extraction.

DESIGN

Prospective cohort study.

METHODS

SETTING

Multicenter study of 17 hospitals.

PATIENTS

A total of 4335 consecutive patients advised to undergo cataract extraction.

MAIN OUTCOME MEASURES

Sociodemographic and clinical data, including visual acuity (VA), patient satisfaction, and responses to the Visual Function Index 14 (VF-14) and transitional questions were collected before and after cataract extraction. The patient acceptable symptom state and minimal clinically important difference were estimated for the entire sample and for subgroups by preintervention status and presence of ocular comorbidities.

RESULTS

Among patients with simple cataract, postintervention patient acceptable symptom state values for VA ranged from 0.67 to 0.80, depending on preintervention VA, while VF-14 scores ranged from 88 to 90. For patients with any additional ocular comorbidity, VA ranged from 0.63 to 0.75, depending on preintervention VA, while VF-14 scores ranged from 86 to 92. For the entire sample, postintervention patient acceptable symptom state values were 0.75 for VA and 86.1 for VF-14 scores. Minimal clinically important difference for patients who reported being a little better ranged from 0.17 to 0.5 in VA and 0.41 to 37.46 in VF-14 scores, depending on preintervention status and presence of ocular comorbidities.

CONCLUSION

The minimal clinically important difference and patient acceptable symptom state values are complementary parameters that may help in the clinical decision-making process by providing more meaningful estimates of the impact of cataract extraction on 2 important outcomes, visual acuity and visual function.

Visual acuity level, ocular morbidity, and the better seeing eye affect sensitivity and responsiveness of the visual function index

PURPOSE

To examine the relation between Visual Function Index-14 (VF-14) scores and VA by accounting for concurrent ocular comorbidities, effect of the better seeing eye (BSE), and VA before and after cataract surgery.

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 4335 patients with cataract who completed the VF-14 before and after cataract surgery.

METHODS

Collaborating clinicians provided demographic and clinical data before and after cataract surgery. Lowess curves, general linear models, and Spearman correlation coefficients were used to study the relation between the VF-14 and the VA.

MAIN OUTCOME MEASURES

Scores in the VF-14 preintervention, change in VF-14 after surgery, VA before surgery, and VA change after surgery.

RESULTS

General linear models and Spearman correlation coefficients showed a significant (P < 0.0001) association between VF-14 score and VA (measured in decimal fraction) when the preoperative VA was ≤0.5 (20/40) and no association (P > 0.4020) when the VA was >0.5 (20/40). Small VA gains (≤0.5) after surgery only led to significant gains (P < 0.0001) in functionality in patients with other ocular pathologies and whose BSE was the surgical eye. Gains in VA >0.5 had a significant (P < 0.02) effect on VF-14 change scores in most patients.

CONCLUSIONS

The VF-14 seems to be more sensitive when the preoperative VA is <0.5 (20/40), especially in patients whose BSE is the surgical eye. The VF-14 seems responsive to increases in VA if the gains exceed 0.5. For gains <0.5, the VF-14 seems unresponsive, except for patients with other ocular pathologies in whom the BSE before and after surgery is the surgical eye.

The need and total cost of Finnish eyecare services: a simulation model for 2005-2040

PURPOSE

The aims of this study were: (i) to create a structural simulation model capable of predicting the future need and cost of eyecare services in Finland; and (ii) to test and rank different policy alternatives for access to care and the required physician workforce.

METHODS

Using the system dynamics approach, the number and cost of patients with cataract, glaucoma, diabetic retinopathy and age-related macular degeneration (AMD) were described with causal-loop diagrams and were then translated into a set of mathematical equations to build a computer simulation model. Mathematically, the problem was formulated as a set of differential equations that were solved numerically with specialized software. The validity of the model was tested against prevalence and administrative historical data. The costs covered by the public sector in Finland were obtained from 2003 from the Finnish Hospital Discharge Register (including outpatient care), the Finnish Social Insurance Institution and a survey of hospital price lists. Different levels of access to public care were then simulated in four eye diseases, for which the model estimated the need for services and resources and their costs in the years 2005-2040.

RESULTS

The model forecasted that the adoption of the 2005 national 'access to care' criteria for cataract surgery would shorten waiting lists. If the workload of Finnish ophthalmologists were kept at the 2003 level, the graduation rate of new ophthalmologists would have to increase by 75% from the current level. If all glaucoma patients were followed in the public sector in future, even this increase in training would not meet the demand for physician workforce. The current model indicated that the screening frequency of diabetes can be increased without large sacrifices in terms of costs. AMD therapy has a significant role in the allocation of future resources in eyecare. The modelling study predicted that ageing alone will increase the costs of eyecare during the next four decades in Finland by about 1% per year in real terms (undiscounted and without inflation of unit costs). The increases in total yearly costs were on average 8.6% between 2001 and 2003.

CONCLUSIONS

The results of this modelling study indicate that policy initiatives, such as defining criteria for access to care, can have substantial implications on the demand for care and waiting times whereas the effect of ageing alone was relatively small. Measures to control several other factors - such as the adoption and price level of new technologies, treatments and practice patterns - will be at least equally important in order to restrain healthcare costs effectively.