Cataract and "Vision 2020-the right to sight" initiative

Gender disparities in myotonic dystrophy 1

Myotonic Dystrophy Type 1 (DM1) is a complex, inherited disorder characterized by significant clinical heterogeneity, affecting multiple organ systems with varying severity and age of onset. It is a multisystemic disorder with a wide range of clinical presentations that lead to symptoms and complications associated with various body systems. Predicting the overall phenotype and prognosis is challenging due to the lack of a single determining factor, complicating medical management and clinical trials. While extensive research has explored the genetic and molecular mechanisms of DM1, the influence of gender on disease manifestations, progression, and outcomes remains elusive. Emerging evidence suggests that male patients often experience greater morbidity and mortality with severe muscular, cardiac, central nervous system, and respiratory impairments, while females are more prone to ophthalmological, gastrointestinal, and endocrine complications. Potential gender-based differences in inheritance patterns also require further investigation. Despite these disparities, gender-specific considerations are largely absent in clinical management and research, limiting the development of targeted therapeutic strategies. This review provides a comprehensive analysis of gender-related differences in DM1, emphasizing their implications for disease prognosis, diagnosis, and treatment. Recognizing gender as a crucial factor in DM1 research and clinical practice could improve patient outcomes and more personalized therapeutic approaches.

Objective Quality Assessment of the Capsulorhexis - A Novel Augmented Reality Tool for Trainees and Experts

PURPOSE

To assess the usability of a smartphone-based augmented reality tool for capsulorhexis training.

METHODS

This is a single-center, prospective, clinical study conducted at the Department of Ophthalmology, University Hospital, LMU Munich, Munich, Germany. Surgery-naïve residents were included and divided into three subgroups: (1) augmented reality supported by the Custom Surgical MicroREC system during their capsulorhexis procedures; (2) Expert support supported by an experienced cataract surgeon; (3) No support without support. Capsulorhexis quality was graded by circularity, centration, and radius.

RESULTS

Twenty-one (ntotal = 21) participants were enrolled. The augmented reality group was statistically significantly better in terms of circularity than the Expert support (Mann-Whitney's U-test: p = .00175) and the No support group (Mann-Whitney's U-test: p = .00268). The procedure duration decreased statistically significantly for all three groups when try 1 and 10 were compared (augmented reality: p < .0001; Expert support: p = .0099; No support: p < .0001). The other parameters did not differ statistically significantly. The questionnaires handed to the augmented reality and No support group before and after the wet lab revealed a high importance of wet lab trainings to all polled participants. The provided wet lab setup was considered adequate by both groups.

CONCLUSION

Augmented reality can assist in cataract training. The Custom Surgical MicroREC system can have a positive influence on capsulorhexis quality in a training environment. Automated quality metrics measured by the augmented reality software provide an objective quality score of the performed surgical procedure. As the tested augmented reality system can be used in training as well as in a real-world setting, this will be a useful tool for trainees and expert surgeons alike.

Applications of generative adversarial networks in the diagnosis, prognosis, and treatment of ophthalmic diseases

PURPOSE

Generative adversarial networks (GANs) are key components of many artificial intelligence (AI) systems that are applied to image-informed bioengineering and medicine. GANs combat key limitations facing deep learning models: small, unbalanced datasets containing few images of severe disease. The predictive capacity of conditional GANs may also be extremely useful in managing disease on an individual basis. This narrative review focusses on the application of GANs in ophthalmology, in order to provide a critical account of the current state and ongoing challenges for healthcare professionals and allied scientists who are interested in this rapidly evolving field.

METHODS

We performed a search of studies that apply generative adversarial networks (GANs) in diagnosis, therapy and prognosis of eight eye diseases. These disparate tasks were selected to highlight developments in GAN techniques, differences and common features to aid practitioners and future adopters in the field of ophthalmology.

RESULTS

The studies we identified show that GANs have demonstrated capacity to: generate realistic and useful synthetic images, convert image modality, improve image quality, enhance extraction of relevant features, and provide prognostic predictions based on input images and other relevant data.

CONCLUSION

The broad range of architectures considered describe how GAN technology is evolving to meet different challenges (including segmentation and multi-modal imaging) that are of particular relevance to ophthalmology. The wide availability of datasets now facilitates the entry of new researchers to the field. However mainstream adoption of GAN technology for clinical use remains contingent on larger public datasets for widespread validation and necessary regulatory oversight.

Acute postoperative endophthalmitis after phacoemulsification in a private ophthalmic surgical group

PURPOSE

To analyze the incidence, causes, risk factors and treatment of acute postoperative endophthalmitis (POE) after phacoemulsification in a private ophthalmological group.

DESIGN

Uncontrolled retrospective observational study of all cases of POE over 22 years.

MATERIAL AND METHODS

369,476 eyes were included after phacoemulsification in 41 surgical centers of the Clínica Baviera-AIER EYE Group from 2002 to 2023. POE cases were reviewed.

RESULTS

The general group was divided into two: group A (2002-2007), with vancomycin in the intracameral irrigation flow (27,705 eyes); Group B (2008-2023), with intracameral cefuroxime (341,771 eyes). 31 cases of POE were found (incidence, 0.0084%); 5 in group A (0.018%) and 26 in group B (0.0076%) (P = .314), with a mean age of 67.3 years (14 men and 17 women). Cultures were positive in 14 cases in Groups A and B. Treatment was based on intravitreal antibiotics and vitrectomy. The mean time to symptom onset was 6.76 days and the mean time to resolution was 120.7 days. 12 eyes achieved corrected distance visual acuity ≥ 20/40.

CONCLUSIONS

The incidence of POEwas 0.0084% (0.0181% in group A and 0.0076% in group B). The probability of having POE in group A was 2.37 times greater than in group B (OR: 2.37; 95% CI: 0.71-6.2; P = .079). The only significant risk factor for POE was posterior capsular rupture.

Cataract surgery workload estimates in Theni district, India

BACKGROUND/AIMS

To estimate the annual cataract surgery workload in Theni district, Tamil Nadu, India based on current utilisation of cataract services, prevalence of blindness and vision impairment (VI), and cataract burden-reduction goals.

METHODS

We conducted a population-based longitudinal study between January 2016 and April 2018. We recruited 24 327 participants based on a random cluster sampling method; 7127 participants were ≥40 years. During the year following initial enrolment, we tracked utilisation of eye care services; and at the end of the 1-year period, we conducted a detailed eye examination of participants age ≥40.

RESULTS

In the sample age ≥40 years, 13.0% had a visually significant cataract, and 17.8% had prior cataract surgery in at least one eye. The prevalence of cataract blindness based on presenting visual acuity in the better eye (PVABE)<3/60 was 0.34% and VI (PVABE<6/12) was 9.92%. 3.10% of the study population had obtained cataract surgery during 1 year, resulting in a cataract surgical rate of 9085. We estimated the effective cataract surgical coverage (eCSC) to be 54.5% and the CSC to be 75.7%, implying a sizeable quality gap. Prevalence, utilisation and coverage varied by age and gender. We estimated that a goal of eliminating the backlog of VI (PVABE<6/12) in 5 years would increase the annual cataract surgery workload by 11.5% from the current level.

CONCLUSIONS

Our estimates of cataract surgery workloads under different scenarios can provide a useful input into planning of eye health services in Theni district.

Statistical analysis plan for the phaco TIp position during clear corneal Phacoemulsification Surgery (TIPS) randomized controlled trial

BACKGROUND

Cornea is the most important refractive media in the eye, and damage to the corneal endothelium is one of the most common causes of poor visual outcome following cataract surgery, particularly in those with predisposing factors. The role of phaco tip position during phacoemulsification on corneal endothelial damage is ambiguous, and there is no consensus regarding the most cornea-friendly phaco tip position (bevel-up or bevel-down). The objective of the trial is to compare the effect of phaco tip position (bevel-up vs. bevel-down) during phacoemulsification using direct chop technique on corneal endothelial cell count.

METHODS AND DESIGN

TIPS is a randomised, multicentre, parallel-group, triple-masked (participant, outcome assessor, and statistician) trial with 1:1 allocation ratio. A total of 480 eligible participants, aged > 18 years with immature cataract, will be randomly allocated into bevel-up and bevel-down groups at two centres. Randomisation will be stratified according to the cataract grade. The primary outcome is postoperative endothelial cell count at 1 month. Secondary outcomes are central corneal thickness on postoperative days 1, 15, and 30 and difference in intraoperative complications.

CONCLUSION

In this paper, we describe the detailed statistical analysis plan (SAP) for the TIPS trial, which was prepared prior to database lock. The SAP includes details of planned analyses and unpopulated tables, which will be reported in the publications. We plan to lock the database in July 2023 and publish the results later in the same year. SAP Version 0.1 (dated: 28 April 2023) Protocol version:2.0 TRIAL REGISTRATION: Clinical Trial Registry of India CTRI/2019/02/017464. Registered on 5 February 2019; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=29764&EncHid=&userName=2019/02/017464.

Cataracts

94 million people are blind or visually impaired globally, and cataract is the most common cause of blindness worldwide. However, most cases of blindness are avoidable. Cataract is associated with decreased quality of life and reduced life expectancy. Most cases of cataract occur after birth and share ageing and oxidative stress as primary causes, although several non-modifiable and modifiable risk factors can accelerate cataract formation. In most patients, phacoemulsification with intraocular lens implantation is the preferred treatment and is highly cost-effective. There has been an increase in the use of comprehensive cataract surgical services, including diagnoses, treatment referrals, and rehabilitation. However, global inequity in surgical service quality is still a limitation. Implementation of preoperative risk assessment, risk reduction strategies, and new surgical technologies have made cataract surgery possible at an earlier stage of cataract severity with the expectation of good refractive outcomes. The main challenge is making the service that is currently available to some patients accessible to all by use of universal health coverage.

Does the phaco TIp position during clear corneal Phacoemulsification Surgery adversely affect corneal endothelium? TIPS study protocol for a randomised, triple-masked, parallel-group trial of bevel-up versus bevel-down phacoemulsification

Introduction: Globally, at least 30 million cataract surgeries are required annually to prevent cataract-related blindness. Corneal endothelial decompensation is one of the most common causes of poor visual outcome following cataract surgery, particularly in those with predisposing factors. The increasing ageing population and reduced visual impairment threshold for cataract surgery have resulted in rising cataract surgical rates and hence, an increase in corneal endothelial decompensation is expected. The role of phaco tip position on corneal endothelial damage is ambiguous. Previous studies have reported contradictory results and were also underpowered to detect a significant difference due to small sample sizes. With no consensus regarding the most cornea-friendly phaco tip position (bevel-up versus bevel-down) during phacoemulsification, we propose a randomised clinical trial with a robust design using direct chop phaco-technique. Objective: To compare the effect of phaco tip position (bevel-up vs. bevel-down) on corneal endothelial cell count during phacoemulsification. Methods: A randomised, multicentre, parallel-group, triple-masked (participant, outcome assessor, and statistician) trial with 1:1 allocation ratio is proposed. By adopting stratified randomisation (according to cataract grade), we will randomly allocate 480 patients aged >18 years with immature cataract into bevel-up and bevel-down groups at two centres. History of significant ocular trauma, previous intraocular surgery, shallow anterior chamber, low endothelial cell count, pseudoexfoliation syndrome, intraocular inflammation, and corneal endothelial dystrophy are the key exclusion criteria. The primary outcome is postoperative endothelial cell count at one month. Secondary outcomes are central corneal thickness on postoperative days 1, 15, and 30, and intraoperative complications. Trial registration: Clinical Trial Registry of India CTRI/2019/02/017464 (05/02/2019).

WHO Vision 2020: Have We Done It?

BACKGROUND

Eye health has widespread implications across many aspects of life, ranging from the individual to the societal level. Vision 2020: The Right to Sight is an initiative that was conceptualised in 1997 and launched in 1999. It was led by the World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB) in response to the increasing prevalence of blindness. Approximately 80% of the causes of blindness were avoidable. Hence, the initiative set out to eliminate the major causes of avoidable blindness. These included cataract, uncorrected refractive error, trachoma, onchocerciasis, and childhood blindness.

METHODS

An electronic literature search was performed using PubMed, MEDLINE and Embase databases to assess the impacts of the Vision 2020 initiative.

RESULTS AND CONCLUSION

The Vision 2020 initiative was ambitious and was essential in catapulting the issue of avoidable blindness in the spotlight and putting it on the global health agenda. The causes of avoidable blindness remain and have not been eliminated. However, there have been noticeable changes in the distribution of the causes of avoidable blindness since the conception of Vision 2020, and this is mainly due to demographic shifts globally. We highlight some of the remaining challenges to acheiving avoidable blindness including, population size, gender disparities in access to eyecare services, and the professional workforce.

Gender effect on onset, prevalence and surgical treatment of cataract in patients with Myotonic Dystrophy type 1

Myotonic Dystrophy type 1 (DM1) is the most common muscular dystrophy in adults, affecting 1:8000 individuals. It is a multi-systemic disorder involving muscle, heart, endocrine and respiratory apparatus and eye. The eye symptoms can include ptosis, external ophthalmoplegia, epiphora, and early onset cataracts. Cataracts occur at a much earlier age (usually between 30 and 40) than the general population, where females are usually affected more than men. We studied gender differences in cataract prevalence and treatment age in 243 DM1 patients (134 M; 109 F), aged 18 to 70 years, who were subsequently screened at routine follow-up. For each patient, information was collected on age, sex, CTG expansion, age of cataract onset, and age at cataract surgery, when available. Seventy-three patients, 30 females and 43 males, had cataracts, at a mean age of onset of 41.14 ± 12.64 in females, and 40.36 ± 10.03 in males. Sixty-nine of them underwent cataract surgery, males at an earlier age than females (42.8 ± 9.8 years versus 47.3 ± 12.6 years) and in 52.5% of cases before the age of 40, compared to 17.2% of females. The difference was statistically significant. The assumption that females in general and those with DM1 in particular develop cataracts more frequently and earlier than males is not confirmed, at least in this study. A possible explanation for these results could be related to non-advanced age, the protective role of estrogen and the lower prevalence of smoking in the study population.

Prevalence of cataract and factors associated with cataract surgery uptake among older persons in Malaysia: A cross-sectional study from the National Eye Survey II

Nationally-representative evidence is limited on factors affecting uptake of cataract surgery in Malaysia. We found the prevalence of cataract among older persons to be 26.8%. The two most common barriers were ‘need not felt’ (43.5%) and ‘fear of surgery or poor result’ (16.2%). Reluctance for surgical intervention was greater outside the Central zone.

Sutured Scleral-Fixated Versus Anterior Chamber Intraocular Lens Implantation: A Meta-Analysis

BACKGROUND AND OBJECTIVE

No consensus exists on the comparative efficacy and safety of sutured scleral-fixated (SSF) and anterior chamber (AC) intraocular lens (IOL) implantation. We aim to compare outcomes of these two techniques.

PATIENTS AND METHODS

A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was conducted (2005 to 2020). Studies comparing SSFIOLs with ACIOLs were included. Outcomes included corrected distance visual acuity and complications. A meta-analysis was conducted with a random effects model. Weighted mean differences and risk ratios with 95% CIs were computed.

RESULTS

Seven hundred eighty-three eyes from nine studies were included. SSFIOLs had a significantly higher absolute postoperative spherical equivalent (weighted mean difference, 0.32; 95% CI, 0.03 to 0.60; P = .03; low certainty) and incidence of IOL decentration/subluxation (risk ratio, 2.69; 95% CI, 1.03 to 7.01; P = .04; moderate certainty) than ACIOLs. There was no difference in final corrected distance visual acuity (P = .26).

CONCLUSIONS

SSFIOLs have a higher absolute postoperative spherical equivalent and incidence of IOL decentration/subluxation than ACIOLs. Future prospective studies are needed to confirm these findings. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:12-21.].

Predicting Post-Cataract Surgery Visual Acuity in Vitrectomized Eyes: The Efficacy and Accuracy of "Lambda" Retinometry

BACKGROUND AND OBJECTIVE

Determine the ability of Lambda retinometry to predict post-cataract surgery visual acuity in vitrectomized eyes.

PATIENTS AND METHODS

Prospective study including 47 cataract surgery candidates with a history of pars plana vitrectomy (PPV). Lambda retinometry using a hand-held Lambda retinometer and best-corrected visual acuity (BCVA) were measured preoperatively, and BCVA was reassessed postoperatively.

RESULTS

Lambda predictions strongly correlated with postoperative BCVA (logarithm of the minimum angle of resolution [logMAR]) (P < .001, r² = 0.57), especially combined with preoperative BCVA (logMAR) (P < .001, r² = 0.65). In 89% of cases, postoperative BCVA was equal to or higher than the prediction. Neither cataract grades nor indications for PPV were associated with the accuracy of Lambda predictions (P = .882 and P = .790, respectively). Underestimation of visual outcome was more common than overestimation. A Lambda prediction of ≥ 20/40 (Snellen) had a positive predictive value of 85.7% and a negative predictive value of 73.6% for the postoperative outcome.

CONCLUSIONS

Lambda retinometry can reliably predict the postoperative BCVA in cataract patients who previously underwent PPV, with a tendency towards underestimation. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:535-542.].

Refractive Outcome of Cataract Surgery Done at University of Gondar Tertiary Eye Care and Training Center, North West Ethiopia

PURPOSE

According to World Health Organization (WHO), cataract is the leading cause of blindness and visual impairment throughout the world. Post-operative refractive error is one of the commonest reasons for poor visual outcome after cataract surgery especially in developing countries where the standard modern biometry equipments are not available. The objective of this study was to assess the refractive outcome of cataract surgery done at University of Gondar (UoG) Tertiary Eye Care and Training Center, North West Ethiopia.

METHODS

A descriptive cross-sectional study was done on 66 patients who had undergone manual small incision cataract surgery (MSICS) and fulfilled the inclusion criteria at UoG Tertiary Eye Care and Training Center from July 15 2019 to October 15 2019.

RESULTS

From 90 post-operatively refracted eyes, 58 (64.4%) eyes achieved a target refraction of ±1.00 Diopter (D). The right and left eyes achieved mean post-operative refraction SE of -0.073±1.45D and -0.93±1.70 D, respectively. But only 54 (60%) eyes were implanted with the calculated IOL power and for the remaining 40% the calculated IOL was not available at the store. And the target (Good) post-operative uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA) was achieved in 66.7% and 82.2% eyes, respectively.

CONCLUSION

The post-operative refractive outcome after cataract surgery at the center is low. For over one-third of operated eyes, the calculated IOL was not implanted due to the absence of the required IOL power at the store and, therefore, a wide range of IOL power should be available at the center.

Pharmacologic interventions for mydriasis in cataract surgery

BACKGROUND

Cataract surgery is one of the most common surgical procedures performed worldwide. Achieving appropriate intraoperative mydriasis is one of the critical factors associated with the safety and performance of the surgery. Inadequate pupillary dilation or constriction of the pupil during cataract surgery can impair the surgeon's field of view and make it difficult to maneuver instruments.

OBJECTIVES

To evaluate the relative effectiveness of achieving pupillary dilation during phacoemulsification for cataract extraction using three methods of pupillary dilation: topical mydriatics, intracameral mydriatics, or depot delivery systems. We also planned to document and compare the risk of intraoperative and postoperative complications following phacoemulsification for cataract extraction, as well as the cost-effectiveness of these methods for pupillary dilation.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register) (2021, Issue 1); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 22 January 2021.

SELECTION CRITERIA

We included only randomized controlled trial (RCTs) in which participants underwent phacoemulsification for cataract extraction.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology.

MAIN RESULTS

We included a total of 14 RCTs (1670 eyes of 1652 participants) in this review. Of the 14 trials, 7 compared topical versus intracameral mydriatics, 6 compared topical mydriatics versus depot delivery systems, and 1 compared all three methods. We were unable to calculate overall estimates of comparative effectiveness for most outcomes due to statistical heterogeneity among the estimates from individual studies or because outcome data were available from only a single study. Furthermore, the certainty of evidence for most outcomes was low or very low, due primarily to imprecision and risk of bias. Comparison 1: topical mydriatics versus intracameral mydriatics Four RCTs (739 participants, 757 eyes) of the 8 RCTs that had compared these two methods reported mean pupillary diameters at the time surgeons had performed capsulorhexis; all favored topical mydriatics, but heterogeneity was high (I2 = 95%). After omitting 1 RCT that used a paired-eyes design, evidence from three RCTs (721 participants and eyes) suggests that mean pupil diameter at the time of capsulorhexis may be greater with topical mydriatics than with intracameral mydriatics, but the evidence is of low certainty (mean difference 1.06 mm, 95% confidence interval (CI) 0.81 mm to 1.31 mm; I2 = 49%). Four RCTs (224 participants, 242 eyes) reported mean pupillary diameter at the beginning of cataract surgery; the effect estimates from all trials favored topical mydriatics, with very low-certainty evidence. Five RCTs (799 participants, 817 eyes) reported mean pupillary diameter at the end of cataract surgery. Data for this outcome from the largest RCT (549 participants and eyes) provided evidence of a small difference in favor of intracameral mydriasis. On the other hand, 2 small RCTs (78 participants, 96 eyes) favored topical mydriatics, and the remaining 2 RCTs (172 participants) found no meaningful difference between the two methods, with very low-certainty evidence. Five RCTs (799 participants, 817 eyes) reported total intraoperative surgical time. The largest RCT (549 participants and eyes) reported decreased total intraoperative time with intracameral mydriatics, whereas 1 RCT (18 participants, 36 eyes) favored topical mydriatics, and the remaining 3 RCTs (232 participants) found no difference between the two methods, with very low-certainty evidence. Comparison 2: topical mydriatics versus depot delivery systems Of the 7 RCTs that compared these two methods, none reported mean pupillary diameter at the time surgeons performed capsulorhexis. Six RCTs (434 participants) reported mean pupillary diameter at the beginning of cataract surgery. After omitting 1 RCT suspected to be responsible for high heterogeneity (I2 = 80%), meta-analysis of the other 5 RCTs (324 participants and eyes) found no evidence of a meaningful difference between the two methods, with very low-certainty evidence. Three RCTs (210 participants) reported mean pupillary diameter at the end of cataract surgery, with high heterogeneity among effect estimates for this outcome. Estimates of mean differences and confidence intervals from these three RCTs were consistent with no difference between the two methods. A fourth RCT reported only means for this outcome, with low-certainty evidence. Two small RCTs (118 participants) reported total intraoperative time. Surgical times were lower when depot delivery was used, but the confidence interval estimated from one trial was consistent with no difference, and only mean times were reported from the other trial, with very low-certainty evidence. Comparison 3: Intracameral mydriatics versus depot delivery systems Only one RCT (60 participants) compared intracameral mydriatics versus depot delivery system. Mean pupillary diameter at the time the surgeon performed capsulorhexis, phacoemulsification time, and cost outcomes were not reported. Mean pupil diameter at the beginning and end of cataract surgery favored the depot delivery system, with very low-certainty evidence. Adverse events Evidence from one RCT (555 participants and eyes) comparing topical mydriatics versus intracameral mydriatics suggests that ocular discomfort may be greater with topical mydriatics than with intracameral mydriatics at one week (risk ratio (RR) 10.57, 95% CI 1.37 to 81.34) and one month (RR 2.51, 95% CI 1.36 to 4.65) after cataract surgery, with moderate-certainty evidence at both time points. Another RCT (30 participants) reported iris-related complications in 11 participants in the intracameral mydriatics group versus no complications in the depot delivery system group, with very low-certainty evidence. Cardiovascular related adverse events were rarely mentioned.

AUTHORS' CONCLUSIONS

Data from 14 completed RCTs were inadequate to establish the superiority of any of three methods to achieve mydriasis for cataract surgery, based on pupillary dilation at different times during the surgery or on time required for surgery. Only one trial had a sample size adequate to yield a robust effect estimate. Larger, well-designed trials are needed to provide robust estimates for the comparison of mydriasis approaches for beneficial and adverse effects.

Improving productivity, costs and environmental impact in International Eye Health Services: using the 'Eyefficiency' cataract surgical services auditing tool to assess the value of cataract surgical services

Objective

Though one of the most common surgeries, there is limited information on variability of practices in cataract surgeries. ‘Eyefficiency’ is a cataract surgical services auditing tool to help global units improve their surgical productivity and reduce their costs, waste generation and carbon footprint. The aim of the present research is to identify variability and efficiency opportunities in cataract surgical practices globally.

Methods and Analysis

9 global cataract surgical facilities used the Eyefficiency tool to collect facility-level data (staffing, pathway steps, costs of supplies and energy use), and live time-and-motion data. A point person from each site gathered and reported data on 1 week or 30 consecutive cataract surgeries. Environmental life cycle assessment and descriptive statistics were used to quantify productivity, costs and carbon footprint. The main outcomes were estimates of productivity, costs, greenhouse gas emissions, and solid waste generation per-case at each site.

Results

Nine participating sites recorded 475 cataract extractions (a mix of phacoemulsification and manual small incision). Cases per hour ranged from 1.7 to 4.48 at single-bed sites and 1.47 to 4.25 at dual-bed sites. Average per-case expenditures ranged between £31.55 and £399.34, with a majority of costs attributable to medical equipment and supplies. Average solid waste ranged between 0.19 kg and 4.27 kg per phacoemulsification, and greenhouse gases ranged from 41 kg carbon dioxide equivalents (CO2e) to 130 kg CO2e per phacoemulsification.

Conclusion

Results demonstrate the global diversity of cataract surgical services and non-clinical metrics. Eyefficiency supports local decision-making for resource efficiency and could help identify regional or global best practices for optimising productivity, costs and environmental impact of cataract surgery.

Development of Diabetic retinopathy screening guidelines in South-East Asia region using the context, challenges, and future technology

Objective: To formulate guidelines for screening of diabetic retinopathy (DR) for the World Health Organization (WHO) South-East Asia Region (SEAR) aligned with the current infrastructure and human resources for health (HRH).Design: A consultative group discussion of technical experts of the International Agency for the Prevention of Blindness (IAPB) from SEAR.Participants: IAPB country chairs and DR technical experts from SEAR countries.Methods: Data related to DR in SEAR was collected from published literature on available DM and DR guidelines and the participating experts. The 10 SEAR countries (the Democratic Republic of Korea was not included for lack of sufficient data) were divided into 3 resource levels (low, medium, and high) based on gross national income/per capita, cataract service indicators (cataract surgical rate and cataract surgical service), current infrastructure and available HRH. Two countries each were assigned to low (Myanmar, Timor-Leste) and high resource (India, Thailand) levels, and the remaining 6 countries (Bangladesh, Bhutan, Indonesia, Maldives, Nepal, Sri Lanka) were assigned the medium resource level. The DR care system was divided into 3 levels of care (essential, recommended, and desirable) and 3 levels of service delivery (primary, secondary, and tertiary).Main outcome measures: Primary, secondary, and tertiary level guidelines for screening of DRResults: Nine WHO SEAR countries participated in the formulation of the new country-specific DR screening guidelines. The DR screening recommendations were: advocacy at the community level, visual acuity measurement, and non-mydriatic fundus photography at the primary level, comprehensive eye examination and retinal laser at the secondary level, and intravitreal therapy and vitrectomy at the tertiary level. The systemic care of DM and hypertension are recommended at all levels commiserating with their care capabilities.Conclusions: The DR guidelines for the SEAR region are the first region-specific and resource-aligned recommendations for comprehensive DR care in each country of the region. In the future, the new technological advances in retinal camera technology, teleophthalmology, and artificial intelligence should be included within the structure of the public DR care system.

Willingness to pay for cataract surgery and associated factors among cataract patients in Outreach Site, North West Ethiopia

Introduction

In Ethiopia, cataract surgery is mainly provided by donors free of charge through outreach programs. Assessing willingness to pay for patients for cataract surgery will help explain how the service is valued by the beneficiaries and design a domestic source of finance to sustain a program. Although knowledge concerning willingness to pay for cataract surgery is substantive for developing a cost-recovery model, the existed knowledge is limited and not well-addressed. Therefore, the study aimed to assess willingness to pay for cataract surgery and associated factors among cataract patients in Outreach Site, North West Ethiopia.

Methods

A cross-sectional outreach-based study was conducted on 827 cataract patients selected through a simple random sampling method in Tebebe Gion Specialized Hospital, North West Ethiopia, from 10/11/2018 to 14/11/2018. The data were collected using a contingent valuation elicitation approach to elicit the participants’ maximum willingness to pay through face to face questionnaire interviews. The descriptive data were organized and presented using summary statistics, frequency distribution tables, and figures accordingly. Factors assumed to be associate with a willingness to pay were identified using a Tobit regression model with a p-value of <0.05 and confidence interval (CI ≠ 0).

Results

The study involved 827 cataract patients, and their median age was 65years. About 55% of the participants were willing to pay for the surgery. The average amount of money willing to pay was 17.5USD (95% CI; 10.5, 35.00) and It was significantly associated with being still worker (β = 26.66, 95% CI: 13.03, 40.29), being educated (β = 29.16, 95% CI: 2.35, 55.97), free from ocular morbidity (β = 28.48, 95% CI: 1.08, 55.90), duration with the condition, (β = -1.69, 95% CI: -3.32, -0.07), admission laterality (β = 21.21, 95% CI: 3.65, 38.77) and remained visual ability (β = -0.29, 95% CI (-0.55, -0.04).

Conclusions

Participants’ willingness to pay for cataract surgery in outreach Sites is much lower than the surgery’s actual cost. Early intervention and developing a cost-recovery model with multi-tiered packages attributed to the neediest people as in retired, less educated, severely disabled is strategic to increase the demand for service uptake and service accessibility.

Common variants in SOX-2 and congenital cataract genes contribute to age-related nuclear cataract

Nuclear cataract is the most common type of age-related cataract and a leading cause of blindness worldwide. Age-related nuclear cataract is heritable (h² = 0.48), but little is known about specific genetic factors underlying this condition. Here we report findings from the largest to date multi-ethnic meta-analysis of genome-wide association studies (discovery cohort N = 14,151 and replication N = 5299) of the International Cataract Genetics Consortium. We confirmed the known genetic association of CRYAA (rs7278468, P = 2.8 × 10⁻¹⁶) with nuclear cataract and identified five new loci associated with this disease: SOX2-OT (rs9842371, P = 1.7 × 10⁻¹⁹), TMPRSS5 (rs4936279, P = 2.5 × 10⁻¹⁰), LINC01412 (rs16823886, P = 1.3 × 10⁻⁹), GLTSCR1 (rs1005911, P = 9.8 × 10⁻⁹), and COMMD1 (rs62149908, P = 1.2 × 10⁻⁸). The results suggest a strong link of age-related nuclear cataract with congenital cataract and eye development genes, and the importance of common genetic variants in maintaining crystalline lens integrity in the aging eye.

Here, the authors report a multi-ethnic genome wide association meta-analysis of 12 studies from the International Cataract Genetics Consortium. They find six new loci associated with age-related nuclear cataract, in addition to replicating the association at CRYAA, and suggest a strong genetic link between age-related nuclear and congenital cataracts.

Impact of cataract screening integrated into establishment of resident health record on surgical output in a rural area of south China

Background

Strategy establishment for improving the efficiency and sustainability of cataract surgical output is important for eye health program. The aim of this study is to assess the three-year output of a novel cataract screening model integrated into establishment of resident health record in a rural area of south China.

Methods

A novel cataract screening model which combined private hospital screening and annual health examinations for establishing resident health record from January 2015 to December 2017 was implemented in an eye hospital in Zhaoqing, Guangdong, China. Demographic information and cataract surgery rate were recorded. A subgroup of patients who underwent cataract surgery were surveyed by customized questionnaire to determine the accessibility to eye-care services and barriers to cataract surgery.

Results

A total of 172,814 people aged ≥50 years in Zhaoqing were screened and 56,292 (32.57%) people were diagnosed with age-related cataract, among whom 18,422 (10.66%) with a best corrected visual acuity (BCVA) less than 20/63 were recommended for cataract surgery. Surgery was performed on 11,105 (60.28%) recommended patients. After the introduction of this screening model, the cataract surgical rate (CSR) in this area dramatically increased to 2,739/million/y (by 1.8 folds) in 2015 and 3,678/million/y (by 2.4 folds) in 2017, compared with that in 2014 (1,520/million/y). Accessibility to eye-care service was improved, and the main reason for not receiving cataract surgery changed from misconception of cataract to having good vision in the fellow eye after 3 years of screening.

Conclusions

This study documented the benefit of a novel cataract screening model integrated into establishment of resident health record in rural China, which may serve as a cost-effective, practicable, and sustainable strategy to disseminate cataract knowledge and eliminate cataract blindness.

Does the phaco TIp position during clear corneal Phacoemulsification Surgery adversely affect corneal endothelium? TIPS study protocol for a randomised, triple-masked, parallel-group trial of bevel-up versus bevel-down phacoemulsification

Introduction: Globally, at least 30 million cataract surgeries are required annually to prevent cataract-related blindness. Corneal endothelial decompensation is one of the most common causes of poor visual outcome following cataract surgery, particularly in those with predisposing factors. The increasing ageing population and reduced visual impairment threshold for cataract surgery have resulted in rising cataract surgical rates and hence, an increase in corneal endothelial decompensation is expected. The role of phaco tip position on corneal endothelial damage is ambiguous. Previous studies have reported contradictory results and were also underpowered to detect a significant difference due to small sample sizes. With no consensus regarding the most cornea-friendly phaco tip position (bevel-up versus bevel-down) during phacoemulsification, we propose a randomised clinical trial with a robust design using direct chop phaco-technique. Objective: To compare the effect of phaco tip position (bevel-up vs. bevel-down) on corneal endothelial cell count during phacoemulsification. Methods: A randomised, multicentre, parallel-group, triple-masked (participant, outcome assessor, and statistician) trial with 1:1 allocation ratio is proposed. By adopting stratified randomisation (according to cataract grade), we will randomly allocate 480 patients aged >18 years with immature cataract into bevel-up and bevel-down groups at two centres. History of significant ocular trauma, previous intraocular surgery, shallow anterior chamber, low endothelial cell count, pseudoexfoliation syndrome, intraocular inflammation, and corneal endothelial dystrophy are the key exclusion criteria. The primary outcome is postoperative endothelial cell count at one month. Secondary outcomes are central corneal thickness on postoperative days 1, 15, and 30, and intraoperative complications. Trial registration: Clinical Trial Registry of India CTRI/2019/02/017464 (05/02/2019).

Are we advancing universal health coverage through cataract services? Protocol for a scoping review

INTRODUCTION

Universal health coverage (UHC) includes the dimensions of equity in access, quality services that improve health and protection against financial hardship. Cataract continues to be the leading cause of blindness globally, despite cataract surgery being an efficacious intervention. The aim of this scoping review is to map the nature, extent and global distribution of data on cataract services for UHC in terms of equity, access, quality and financial protection.

METHODS AND ANALYSIS

The search will be constructed by an Information Specialist and undertaken in MEDLINE, Embase and Global Health databases. We will include all published non-interventional primary research studies and systematic reviews that report a quantitative assessment of access, equity, quality or financial protection of cataract surgical services for adults at the subnational, national, regional or global level from population-based surveys or routinely collected health service data since 1 January 2000 and published through to February 2020.Screening and data charting will be undertaken using Covidence systematic review software. Titles and abstracts of identified studies will be screened by two authors independently. Full-text articles of potentially relevant studies will be obtained and reviewed independently by two authors against the inclusion criteria. Any discrepancies between the authors will be resolved by discussion, and with a third author as necessary. A data charting form will be developed and piloted on three studies by three authors and amendments made as necessary. Data will be extracted by two reviewers independently and summarised narratively and using maps.

ETHICS AND DISSEMINATION

Ethical approval was not sought as the scoping review will only use published and publicly accessible data. The review will be published in an open access peer-reviewed journal. A summary of the results will be developed for website posting, stakeholder meetings and inclusion in the ongoing Lancet Global Health Commission on Global Eye Health.

Global and regional prevalence of age-related cataract: a comprehensive systematic review and meta-analysis

The aim of our study was to estimate regional and global cataract prevalence, its prevalence in different age groups, and the determinants of heterogeneity and its prevalence. For that, we used international databases such as PubMed, Web of Science, Scopus, Embase, and other sources of information to conduct a systematic search for all articles concerning the prevalence of age-related cataract and its types in different age groups. Of the 9922 identified articles, 45 studies with a sample size of 161,947 were included in the analysis, and most of them were from the Office for the Western Pacific Region (19 studies). Age- standardized pooled prevalence estimate (ASPPE) and 95% confidence interval (95% CI) of any cataract, cortical cataract, nuclear cataract, and posterior subcapsular (PSC) cataract were 17.20% (13.39-21.01), 8.05% (4.79-11.31), 8.22% (4.93-11.52), and 2.24% (1.41-3.07), respectively. Significant effects on heterogeneity were observed for the WHO region in the prevalence of any cataract (b: 6.30; p: 0.005) and study year in the prevalence of nuclear cataract (b: -0.66, p: 0.042). In general, the prevalence of cataract not only varies by region but also by age group, and most cases are over the age of 60 years. We examined the sources of variance in the prevalence of cataract and its different types, and identified age as a responsible factor in the prevalence of any cataract, cortical cataract, nuclear cataract, and PSC of cataract, WHO region in the prevalence of any cataract, and study year in the prevalence of nuclear cataract.

Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility

PURPOSE

To measure the waste generation and lifecycle environmental emissions from cataract surgery via phacoemulsification in a recognized resource-efficient setting.

SETTING

Two tertiary care centers of the Aravind Eye Care System in southern India.

DESIGN

Observational case series.

METHODS

Manual waste audits, purchasing data, and interviews with Aravind staff were used in a hybrid environmental lifecycle assessment framework to quantify the environmental emissions associated with cataract surgery. Kilograms of solid waste generated and midpoint emissions in a variety of impact categories (eg, kilograms of carbon dioxide equivalents).

RESULTS

Aravind generates 250 grams of waste per phacoemulsification and nearly 6 kilograms of carbon dioxide-equivalents in greenhouse gases. This is approximately 5% of the United Kingdom's phaco carbon footprint with comparable outcomes. A majority of Aravind's lifecycle environmental emissions occur in the sterilization process of reusable instruments because their surgical system uses largely reusable instruments and materials. Electricity use in the operating room and the Central Sterile Services Department (CSSD) accounts for 10% to 25% of most environmental emissions.

CONCLUSIONS

Surgical systems in most developed countries and, in particular their use of materials, are unsustainable. Results show that ophthalmologists and other medical specialists can reduce material use and emissions in medical procedures using the system described here.

International experiences during United States ophthalmology residency training: Current structure of international experiences and perspectives of faculty mentors at United States training institutions

Background

There is a high level of interest in international experiences during United States (U.S.) ophthalmology residency training among both program directors and trainees.

Methods

An electronic invitation to a 26-question survey was sent to all 114 U.S. ophthalmology residency program directors. The invitation requested that the survey be completed by the one faculty member who was most involved in overseeing the international experiences for the residents. The survey consisted of multiple choice and Likert-type scale questions. The Mann-Whitney U test was used for analysis of demographic data and Friedman’s test and Wilcoxon-Signed Rank test were used to analyze ranked responses.

Results

Responses were obtained from 70 faculty mentors representing unique programs, yielding a response rate of 61.4%. The majority of programs that responded (88.6%, n = 62) either offered international ophthalmology experiences for residents or supported residents finding their own experiences to go abroad. International experience participation rate among residents correlated with the number of years the experiences had been offered by the programs (p = 0.001). More than half of the respondents (55.0%, n = 33) felt that the residents benefited more than the hosts during these international experiences. Approximately half of the respondents (51.6%, n = 32) believed that additional training beyond what is covered in the standard curriculum to practice ophthalmology in the U.S. is necessary for practicing ophthalmology in an international setting.

Conclusions

There is high interest and participation in international experiences within U.S. ophthalmology residency programs. This high participation warrants further investigation into the long-term impact of these international experiences and how U.S. residency programs can structure these experiences to maximize the benefits to both the residents and the international host communities.

Preoperative visual acuity of cataract patients at a tertiary hospital in sub-Saharan Africa: a 10-year review

Purpose:

To determine the preoperative visual acuity of cataract patients over a 10-year period in a tertiary facility as a means of auditing the cataract surgical services.

Methods:

A retrospective study of patients with age-related cataracts who had cataract surgery performed between January 2007 and December 2016 at the University College Hospital, Ibadan. Systematic random sampling and probability proportionate to size were used to recruit a representative sample. Information on sociodemographic characteristics, preoperative visual acuity, ocular and systemic comorbidities were retrieved and analysed.

Results:

Of the 499 patients studied, males were 268 (53.7%) and their mean age was 67.69 (±9.51) years. The predominant visual acuity was hand motion 184 (36.9%) and yearly mean preoperative visual acuity was in the range of 0.0037–0.04 decimal.

Conclusion:

The mean preoperative visual acuity of patients in this facility did not change over the 10-year study period. Mean value of preoperative visual acuity remained within the range of blindness and did not improve over the decade. This could either be a reflection of visual impairment at which our patients seek care or an indication of the range of visual acuities at which surgeons are willing to offer cataract surgery in our environment. This trend has negative implications on the burden of cataract blindness as it reflects poor coverage of surgery for other levels of visual impairment due to cataract.

Incidence of Visually Impairing Cataracts Among Older Adults in Kenya

Importance

Half of all the cases of blindness worldwide are associated with cataract. Cataract disproportionately affects people living in low- and middle-income countries and persons of African descent.

Objective

To estimate the 6-year cumulative incidence of visually impairing cataract in adult participants in the Nakuru Eye Disease Cohort Study in Kenya.

Design, Setting, and Participants

This secondary analysis of the Nakuru Eye Disease Cohort Study was conducted from February 2016 to April 2016. This cohort comprised citizens of Nakuru, Kenya, aged 50 years or older who consented to participate in the initial or baseline survey from January 2007 to November 2008, as well as the follow-up conducted from January 2013 to March 2014. All participants at baseline (n = 4364) and follow-up (n = 2159) underwent ophthalmic examination.

Main Outcomes and Measures

Six-year cumulative incidence of visually impairing cataract, risk factors of incidence, population estimates, and required cataract surgical rates to manage incident visually impairing cataract.

Results

In total, 4364 individuals (with a mean [SD] age of 63.4 [10.5] years and with 2275 women [52.1%]) had complete eye examinations at baseline, and 2159 participants (with a mean [SD] age of 62.5 [9.3] years and with 1140 men [52.8%]) were followed up 6 years later. The 6-year cumulative incidence of visually significant cataract in either eye was 251.9 per 1000 (95% CI, 228.5-276.8), with an increase with age from 128.9 (95% CI, 107.9-153.2) per 1000 for the group aged 50 to 59 years to 624.5 (95% CI, 493.1-739.9) per 1000 for the group aged 80 years or older. This equated to an annual incidence of visually significant cataract of 45.0 per 1000 people aged 50 years or older. Multivariable analysis showed alcohol consumption (risk ratio [RR], 1.4; 95% CI, 1.1-1.8), diabetes (RR, 1.7; 95% CI, 1.3-2.3), educational level, and increasing age (RR, 3.8; 95% CI, 2.6-5.5 for those aged ≥80 years) were associated with incident visually impairing cataract. Extrapolations to all people aged 50 years or older in Kenya indicated that 148 280 (95% CI, 134 510-162 950) individuals might develop new visually impairing cataract in either eye (visual acuity <6/18 in the worse-seeing eye) and that 9540 (95% CI, 6610-13 750) might become cataract blind in both eyes (visual acuity <3/60 in better-seeing eye).

Conclusions and Relevance

Adults in Kenya appeared to have a high incidence of visually impairing cataract, making cataract a priority for blindness prevention programs in the region; surgical interventions and awareness of these services are also required.

Changing trends of blindness, visual impairment and cataract surgery in Bhutan: 2009-2018

Purpose

To obtain new rapid assessment of avoidable blindness (RAAB) data on the prevalence, causes and trends of blindness, visual impairment and cataract surgery; and compare the new 2018 data with the older RAAB 2009 data.

Methodology

The second nationwide RAAB used android based mRAAB technique and technology for data collection. Using the compact segment sampling probability proportionate to size, 5,050 participants from 101 clusters of 50 people aged 50 years and older were enrolled through house-to-house visits. Eligible participants received ophthalmic examination and interview by the ophthalmologist-led emuneration team as per the RAAB protocol.

Results

The age-sex adjusted magnitude of bilateral blindness in Bhutan was 1.0% (95% Confidence Interval, CI 0.5–1.4) with relatively higher prevalence in rural population (Odds Ratio, OR 1.5, p = 0.13) and women (OR 1.6, p = 0.06). Untreated cataract accounted for the most of blindness (53.8%), severe vision impairment (57.1%), and moderate visual impairment (65.3%); uncorrected refractive error was the main cause of early visual impairment (46.7%). Cataract Surgical Coverage was 86.1% with relatively better coverage in men (76.7% men; 73.1% female) and urban population (79.2% urban; 70.2% rural). Good cataract surgical outcome was achieved in 67.3% and leading cause of poor outcome was ocular comorbidity (43.6%). Accessibility was a significant barrier to the uptake of cataract surgical services.

Conclusion

There is a 33% reduction in blindness from 1.5% to 1.0%, since the first RAAB survey in 2009. In order to further reduce blindness and visual impairment, Bhutan should continue to implement long-term strategic action plan for eye health focused on strengthening primary eye care and comprehensive eye care service.

Dysfunctional Lens Index Serves as a Novel Surgery Decision-Maker for Age-Related Nuclear Cataracts

Purpose: To study the correlations between subjective and objective cataract metrics with dysfunctional lens index. To investigate the potential of the DLI as a novel surgery decision-maker. Methods: In this prospective, cross-sectional study, we measured the dysfunctional lens index (DLI), Lens Opacities Classification System III nuclear opalescence (LOCS III NO) grading, preoperative corrected distance visual acuity (CDVA), objective scatter index (OSI) and Scheimpflug-based average lens density (ALD) in eyes with nuclear cataract. Eyes were classified as Surgical and Non-Surgical groups. Correlations among the DLI, OSI, ALD, LOCS III NO grading, and preoperative CDVA were analyzed. The receiver operating characteristic (ROC) curve analysis was performed for DLI, OSI, and CDVA to determine optimal cut-off values to separate between surgical and non-surgical cataracts. Results: The DLI showed the strongest correlation with the OSI (r= -0.712, P< .001), followed by LOCS III NO score (r= -0.661, P< .001), ALD (r= -0.596, P< .001) and preoperative CDVA (r= 0.563, P< .001). The area under ROC curves (AUCs) of the DLI, OSI and preoperative CDVA curve were 0.972, 0.912 and 0.844 (All P< .001), respectively. The DLI cut-off value of 5.7 implied higher levels of sensitivity (91.67%) and specificity (91.84%) than the OSI cut-off value of 2.9 and the CDVA cut-off value of 0.55 (sensitivity of 89.58% and 71.92%; specificity of 81.63% and 85.71%, respectively). Conclusion: The surgery criterion of DLI ≤ 5.7 behaved better than the surgery criterions of OSI ≥ 2.9 and preoperative CDVA ≤ 0.55 in discrimination between surgical and non-surgical nuclear cataracts.

Barriers between community screening for visual problems and treatments in a tertiary center

OBJECTIVE

To evaluate the effectiveness of mobile ophthalmic unit screenings and to investigate barriers between community care and resolution of the problem at a tertiary center.

METHODS

This prospective study evaluated a convenience sample from 10 municipalities in São Paulo State, Brazil. Patients were assessed in the municipality by a mobile ophthalmic unit and underwent a complete ophthalmic consultation. Patients were referred as warranted to a tertiary hospital.

RESULTS

The mobile ophthalmic unit screened 1,928 individuals and 714 (37%) were referred. The mean age of the referred patients was 57.12 (SD = 19.5) years with best corrected visual acuity of 0.37 (SD = 0.36) logMAR. Forty-seven (6.6%) patients were blind and 185 (26.5%) were visually impaired. Cataracts (44.7%) and pterygium (14.7%) accounted for most referrals. Of those referred, 67.1% presented to the tertiary center. The diagnosis by the mobile ophthalmic unit corresponded to the one by the tertiary center in 88.5% of the cases. There were a significantly higher number of blind and visually impaired persons among those who presented to the hospital. There was a significantly greater attendance among patients living in more distant municipalities from the reference center with a higher number of inhabitants and a greater number of ophthalmologists in the cities of origin (p < 0.05, all comparisons). Complete treatment was performed in 65.6% of patients, and loss to follow-up was the main cause of incomplete treatment in 50.7% of patients. A total of 313 cataract surgeries were performed, which reduced the number of blind patients from 20 to 2 and of visually impaired individuals from 87 to 2 (p < 0.001).

CONCLUSIONS

Only 37% of the patients assessed by a mobile ophthalmic unit required referral to a tertiary hospital. Among the referred patients, 67.1% presented to the hospital, and complete resolution after treatment was approximately 65.5%. There was a significant improvement in visual acuity and a reduction in the prevalence of blindness and visual impairment postoperatively.

Comparative analysis of the safety and efficacy of intracameral cefuroxime, moxifloxacin and vancomycin at the end of cataract surgery: a meta-analysis

BACKGROUND

Current practice methods are unclear as to the most safe and effective prophylactic pharmacotherapy and method of delivery to reduce postoperative endophthalmitis occurrence.

METHODS

A systematic review and meta-analysis using Meta-analysis of Observational Studies in Epidemiology guidelines was performed to compare the efficacy of intracameral cefuroxime, moxifloxacin and vancomycin in preventing postphacoemulsification cataract surgery endophthalmitis. A safety analysis of intracameral antibiotics was concurrently performed.

DATA SOURCES

BIOSIS Previews, CINAHL, ClinicalTrials.gov, Cochrane Library, Dissertations & Theses, EMBASE, PubMed, ScienceDirect and Scopus were searched from inception to January 2017. Data were pooled using a random effects model. All articles were individually reviewed and data were extracted by two independent reviewers. Funnel plot, risk of bias and quality of evidence analyses were performed.

RESULTS

Seventeen studies with over 900 000 eyes were included, which favoured the use of intracameral antibiotics at the end of cataract surgery (OR 0.20; 95% CI 0.13 to 0.32; P<0.00001). The average weighted postoperative endophthalmitis incidence rates with intracameral cefuroxime, moxifloxacin and vancomycin were 0.0332%, 0.0153% and 0.0106%, respectively. Secondary analyses showed no difference in efficacy between intracameral plus topical antibiotics versus intracameral alone (P>0.3). Most studies had low to moderate risk of bias. The safety analysis showed minimal toxicity for moxifloxacin. Dosing errors led to the majority of toxicities with cefuroxime. Although rare, vancomycin was associated with toxic retinal events.

CONCLUSION

Intracameral cefuroxime and moxifloxacin reduced endophthalmitis rates compared with controls with minimal or no toxicity events at standard doses. Additionally, intracameral antibiotics alone may be as effective as intracameral plus topical antibiotics.

Estimation of intraocular lens position from full crystalline lens geometry: towards a new generation of intraocular lens power calculation formulas

In a cataract surgery, the opacified crystalline lens is replaced by an artificial intraocular lens (IOL). To optimize the visual quality after surgery, the intraocular lens to be implanted must be selected preoperatively for every individual patient. Different generations of formulas have been proposed for selecting the intraocular lens dioptric power as a function of its estimated postoperative position. However, very few formulas include crystalline lens information, in most cases only one-dimensional. The present study proposes a new formula to preoperatively estimate the postoperative IOL position (ELP) based on information of the 3-dimensional full shape of the crystalline lens, obtained from quantitative eye anterior segment optical coherence tomography imaging. Real patients were measured before and after cataract surgery (IOL implantation). The IOL position and the postoperative refraction estimation errors were calculated by subtracting the preoperative estimations from the actual values measured after surgery. The proposed ELP formula produced lower estimation errors for both parameters -ELP and refraction- than the predictions obtained with standard state-of-the-art methods, and opens new avenues to the development of new generation IOL power calculation formulas that improve refractive and visual outcomes.

Genomics-Based Identification of Microorganisms in Human Ocular Body Fluid

Advances in genomics have the potential to revolutionize clinical diagnostics. Here, we examine the microbiome of vitreous (intraocular body fluid) from patients who developed endophthalmitis following cataract surgery or intravitreal injection. Endophthalmitis is an inflammation of the intraocular cavity and can lead to a permanent loss of vision. As controls, we included vitreous from endophthalmitis-negative patients, balanced salt solution used during vitrectomy and DNA extraction blanks. We compared two DNA isolation procedures and found that an ultraclean production of reagents appeared to reduce background DNA in these low microbial biomass samples. We created a curated microbial genome database (>5700 genomes) and designed a metagenomics workflow with filtering steps to reduce DNA sequences originating from: (i) human hosts, (ii) ambiguousness/contaminants in public microbial reference genomes and (iii) the environment. Our metagenomic read classification revealed in nearly all cases the same microorganism that was determined in cultivation- and mass spectrometry-based analyses. For some patients, we identified the sequence type of the microorganism and antibiotic resistance genes through analyses of whole genome sequence (WGS) assemblies of isolates and metagenomic assemblies. Together, we conclude that genomics-based analyses of human ocular body fluid specimens can provide actionable information relevant to infectious disease management.

Population-based assessment of visual acuity outcomes following cataract surgery in Australia: the National Eye Health Survey

AIM

To assess the visual outcomes of cataract surgery among a national sample of non-Indigenous and Indigenous Australians.

METHODS

This was a population-based study of 3098 non-Indigenous Australians (50-98 years) and 1738 Indigenous Australians (40-92 years), stratified by remoteness. A poor postoperative outcome in an eye that had undergone cataract surgery was defined as presenting distance visual acuity (PVA) <6/12-6/60, and a very poor outcome was defined as PVA <6/60. Effective cataract surgery coverage (eCSC; operated cataract and a good outcome (PVA ≥6/12) as a proportion of operable plus operated cataract) was calculated.

RESULTS

The sampling weight adjusted cataract surgery prevalence was 19.8% (95% CI 17.9 to 22.0) in non-Indigenous Australians and 8.2% (95% CI 6.0 to 9.6) in Indigenous Australians. Among the non-Indigenous population, poor and very poor PVA outcomes were present in 18.1% and 1.9% of eyes, respectively. For Indigenous Australians, these values were 27.8% and 6.3%, respectively. The main causes of poor vision were refractive error (non-Indigenous=41.8%; Indigenous=41.9%) and coincident disease (non-Indigenous=43.3%; Indigenous=40.3%). The eCSC rates in the non-Indigenous and Indigenous populations were 88.5% (95% CI 85.2 to 91.2) and 51.6% (95% CI 42.4 to 60.7), respectively.

CONCLUSION

Approximately half of eyes with a poor visual outcome postcataract surgery could be readily avoided through the appropriate refractive correction. The finding of a lower eCSC rate among Indigenous Australians suggests that improvements in access and quality of cataract services may be warranted in order to reduce cataract-related vision loss in the Indigenous population.

Safety, efficacy and cost-effectiveness of consecutive bilateral cataract surgery on two successive days in tribes at base hospital through community outreach program: A prospective study of Aravali Mountain, North West India

Purpose:

The aim of the study was to evaluate the safety and efficacy of consecutive bilateral cataract surgery (CBCS) on two successive days in a single hospital visit.

Methods:

Prospective study was conducted on 565 patients of various tribes of hilly area of West Rajasthan who had come to our hospital through community outreach programmed (CORP) between January 2015 and March 2016. Patients with significant bilateral cataract without any other ocular morbidity were advised bilateral manual small incision cataract surgery on two consecutive days. Intraoperative and postoperative complications were evaluated, and follow-up was done at 1 week, 1 month, and 3 months.

Results:

Out of 565 patients, 519 underwent both eye surgeries. Second eye surgery was deferred for a later date in 46 cases. Because of intraoperative and postoperative complications in the first eye, 31 had delayed surgeries while 15 patients refused to undergo another eye surgery either because of postoperative day 1 poor vision in the operated eye due to retinal pathologies (n = 8) or unwillingness (n = 7). The second eye surgery was performed for 519 patients, out of whom six had intra or postoperative complications. At 1 month follow-up, four patients had unilateral cystoid macular edema and three had prolonged postoperative inflammation. At 3 months, all patients were satisfied and had no complications. None of the patients had sight-threatening complications such as endophthalmitis, corneal decompensation, or vitreoretinal complications.

Conclusion:

CBCS may be considered safe and cost-effective for patients living in remote locations, dependent on CORP.

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

Background

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

Methods

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

Results

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

Conclusion

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

Assessing visual function behind cataract: preoperative predictive value of the Heine Lambda 100 retinometer

PURPOSE

To analyze the accuracy of the Lambda 100 (Heine) potential visual acuity (VA) measurements in subjects undergoing cataract surgery.

METHODS

The medical records of all consecutive patients who underwent clear corneal incision phacoemulsification cataract surgery by a single surgeon between 2010 and 2012 at the Department of Ophthalmology, Hadassah Medical Center, a tertiary care hospital in Jerusalem, Israel, were reviewed. Subjects age 18 or older with a follow-up time of at least 30 days were included. Subjects with previous ocular comorbidities other than glaucoma were excluded. In addition, patients with intraoperative or perioperative complications that could affect final VA were excluded. Analyses were performed to analyze the accuracy of preoperative retinometer potential VA as a predictor of postoperative best-corrected VA.

RESULTS

A total of 374 operated eyes were included. There was a moderate positive correlation between Lambda estimated VA potential and postoperative achieved best-corrected VA (BCVA) (β coefficient 0.35, p<0.0001). Overall Lambda accurately (within 2 Snellen lines) estimated postoperative BCVA results in 60% of cases. The accuracy of prediction was significantly better in moderate cataracts when compared with advanced cataracts (p<0.01) with a twofold tendency towards underestimation in advanced cataracts. A Lambda ≥0.5 decimal has a calculated positive predictive value of 82% and a negative predictive value of 40% for predicting postoperative BCVA outcome ≥0.5 decimal.

CONCLUSIONS

Lambda may be used to relatively accurately predict postoperative BCVA in cataract patients, specifically in those with moderate cataracts.

Prevention and reversal of selenite-induced cataracts by N-acetylcysteine amide in Wistar rats

BACKGROUND

The present study sought to evaluate the efficacy of N-acetylcysteine amide (NACA) eye drops in reversing the cataract formation induced by sodium selenite in male Wistar rat pups.

METHODS

Forty male Wistar rat pups were randomly divided into a control group, an N-acetylcysteine amide-only group, a sodium selenite-induced cataract group, and a NACA-treated sodium selenite-induced cataract group. Sodium selenite was injected intraperitoneally on postpartum day 10, whereas N-acetylcysteine amide was injected intraperitoneally on postpartum days 9, 11, and 13 in the respective groups. Cataracts were evaluated at the end of week 2 (postpartum day 14) when the rat pups opened their eyes. N-acetylcysteine amide eye drops were administered beginning on week 3 until the end of week 4 (postpartum days 15 to 30), and the rats were sacrificed at the end of week 4. Lenses were isolated and examined for oxidative stress parameters such as glutathione, lipid peroxidation, and calcium levels along with the glutathione reductase and thioltransferase enzyme activities. Casein zymography and Western blot of m-calpain were performed using the water soluble fraction of lens proteins.

RESULTS

Morphological examination of the lenses in the NACA-treated group indicated that NACA was able to reverse the cataract grade. In addition, glutathione level, thioltransferase activity, m-calpain activity, and m-calpain level (as assessed by Western blot) were all significantly higher in the NACA-treated group than in the sodium selenite-induced cataract group. Furthermore, sodium selenite- injected rat pups had significantly higher levels of malondialdehyde, glutathione reductase enzyme activity, and calcium levels, which were reduced to control levels upon treatment with NACA.

CONCLUSIONS

The data suggest that NACA has the potential to significantly improve vision and decrease the burden of cataract-related loss of function. Prevention and reversal of cataract formation could have a global impact. Development of pharmacological agents like NACA may eventually prevent cataract formation in high-risk populations and may prevent progression of early-stage cataracts. This brings a paradigm shift from expensive surgical treatment of cataracts to relatively inexpensive prevention of vision loss.

Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery

BACKGROUND

Endophthalmitis is a severe inflammation of the anterior or posterior (or both) chambers of the eye that may be sterile or associated with infection. It is a potentially vision-threatening complication of cataract surgery. Prophylactic measures for endophthalmitis are targeted against various sources of infection.

OBJECTIVES

To evaluate the effects of perioperative antibiotic prophylaxis for endophthalmitis following cataract surgery compared with no prophylaxis or other form of prophylaxis.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), Ovid MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to December 2016), Embase (January 1980 to December 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to December 2016),the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We used no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 6 December 2016. We also searched for additional studies that cited any included trials using the Science Citation Index.

SELECTION CRITERIA

We included randomized controlled trials that enrolled adults undergoing cataract surgery (any method and incision type) for lens opacities due to any origin. We included trials that evaluated preoperative antibiotics, intraoperative (intracameral, subconjunctival or systemic), or postoperative antibiotic prophylaxis for acute endophthalmitis. We excluded studies that evaluated antiseptic preoperative preparations using agents such as povidone iodine or antibiotics for treating acute endophthalmitis after cataract surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full-text articles for eligibility, assessed the risk of bias for each included study, and abstracted data.

MAIN RESULTS

Five studies met the inclusion criteria for this review, including 101,005 adults and 132 endophthalmitis cases. While the sample size was very large, the heterogeneity of the study designs and modes of antibiotic delivery made it impossible to conduct a formal meta-analysis. Interventions investigated included the utility of adding vancomycin and gentamycin to the irrigating solution compared with standard balanced saline solution irrigation alone, use of intracameral cefuroxime with or without topical levofloxacin perioperatively, periocular penicillin injections and topical chloramphenicol-sulfadimidine drops compared with topical antibiotics alone, and mode of antibiotic delivery (subconjunctival versus retrobulbar injections; fixed versus separate instillation of gatifloxacin and prednisolone). The risk of bias among studies was low to unclear due to information not being reported. We identified one ongoing study.Two studies compared any antibiotic with no antibiotic. One study, which compared irrigation with antibiotics in balanced salt solution (BSS) versus BSS alone, was not sufficiently powered to detect differences in endophthalmitis between groups (very low-certainty evidence). One study found reduced risk of endophthalmitis when combining intracameral cefuroxime and topical levofloxacin (risk ratio (RR) 0.14, 95% confidence interval (CI) 0.03 to 0.63; 8106 participants; high-certainty evidence) or using intracameral cefuroxime alone (RR 0.21, CI 0.06 to 0.74; 8110 participants; high-certainty evidence) compared with placebo, and an uncertain effect when using topical levofloxacin alone compared with placebo (RR 0.72, CI 0.32 to 1.61; 8103 participants; moderate-certainty evidence).Two studies found reduced risk of endophthalmitis when combining antibiotic injections during surgery and topical antibiotics compared with topical antibiotics alone (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.12 to 0.92 (periocular penicillin and topical chloramphenicol-sulfadimidine; 6618 participants; moderate-certainty evidence); and RR 0.20, 95% CI 0.04 to 0.91 (intracameral cefuroxime and topical levofloxacin; 8101 participants; high-certainty evidence)).One study, which compared fixed versus separate instillation of gatifloxacin and prednisolone, was not sufficiently powered to detect differences in endophthalmitis between groups (very low-certainty evidence). Another study found no evidence of a difference in endophthalmitis when comparing subconjunctival versus retrobulbar antibiotic injections (RR 0.85, 95% CI 0.55 to 1.32; 77,015 participants; moderate-certainty evidence).Two studies reported any visual acuity outcome; one study, which compared fixed versus separate instillation of gatifloxacin and prednisolone, reported only that mean visual acuity was the same for both groups at 20 days postoperation. In the other study, the difference in the proportion of eyes with final visual acuity greater than 20/40 following endophthalmitis between groups receiving intracameral cefuroxime with or without topical levofloxacin compared with no intracameral cefuroxime was uncertain (RR 0.69, 95% CI 0.22 to 2.11; 29 participants; moderate-certainty evidence).Only one study reported adverse events (1 of 129 eyes had pupillary membrane in front of the intraocular lens and 8 eyes showed posterior capsule opacity). No study reported outcomes related to quality of life or economic outcomes.

AUTHORS' CONCLUSIONS

Multiple measures for preventing endophthalmitis following cataract surgery have been studied. High-certainty evidence shows that injection with cefuroxime with or without topical levofloxacin lowers the chance of endophthalmitis after surgery, and there is moderate-certainty evidence to suggest that using antibiotic eye drops in addition to antibiotic injection probably lowers the chance of endophthalmitis compared with using injections or eye drops alone. Clinical trials with rare outcomes require very large sample sizes and are quite costly to conduct; thus, it is unlikely that many additional clinical trials will be conducted to evaluate currently available prophylaxis. Practitioners should rely on current evidence to make informed decisions regarding prophylaxis choices.

[Risk of senile cataract among nuclear industry workers]

AIM

to assess the relative risk (RR) of senile cataract in a cohort of workers occupationally exposed to external gamma-rays over a long time period.

MATERIAL AND METHODS

The RR of cataract development was studied in a cohort of nuclear workers that were first employed in 1948-1982 and followed up till the end of 2008 (n=22,377; females, 25.4%). The mean age at initial employment was 24.9 years. The mean cumulative gamma-ray dose was 0.54 Sv in males and 0.44 Sv in females. The analysis performed with EPICURE software provided RR estimates for cataract incidence in relation to a number of non-radiation and radiation factors.

RESULTS

The RR of senile cataract increased with the attained age of the workers. The RR was significantly higher in males during the 2006-2008 period as compared to the 1996-2005 period. The RR was significantly higher in workers that were diagnosed with glaucoma and high myopia as compared to those that were not. The risk of senile cataract increased with the external gamma-ray dose and was the highest in workers who had formerly been exposed to doses above 2.00 Sv. The RR of senile cataract showed no dependency on sex, age at initial employment, smoking status, alcohol consumption, or diabetes mellitus.

CONCLUSION

The incidence of senile cataract in the cohort under study was found to depend on both non-radiation and radiation factors.

Statin use and risk of cataract: A nested case-control study within a healthcare database

BACKGROUND AND AIMS

We aimed to assess the association between exposure to statins and hospitalization for cataract.

METHODS

A population-based, nested case-control study was performed on a cohort of 134,441 patients from Lombardy (Italy), newly treated with statins between 2005 and 2007. Cases were patients hospitalized for cataract or lens extraction surgery after initial statin prescription until December 31, 2012. For each case patient, up to 5 controls were randomly selected from the cohort and matched by gender, age at cohort entry, and date of index prescription. Logistic regression was used to model the outcome risk associated with low (proportion of days covered, PDC 25-49%), intermediate (PDC 50-74%), and high (PDC ≥ 75%) adherence compared with very-low adherence (PDC < 25%).

RESULTS

1334 case patients were matched to 6601 controls. Mean age (SD) of cases and controls was about 70 years (9 years) and 51% of them were men. There was a slight but continuous trend toward an increased risk of cataract as adherence to statin therapy increased in the adjusted risk models, with a significant odds ratio of 1.19 (95% CI 1.01-1.40%) for PDC 50-74% and 1.20 (95% CI 1.02-1.40) for PDC ≥ 75% vs. PDC < 25%, respectively. There was no statistical evidence that the effect of statins on cataract risk differed according to statin potency at starting therapy.

CONCLUSIONS

Statin therapy was associated with a modestly increased risk of cataract surgery. Nevertheless, in view of the overwhelming benefit of statins for reduction of CV events, clinical practice for statins therapy does not need to change.

A Cross-Sectional Retrospective Analysis of the Racial and Geographic Variations in Cataract Surgery

BACKGROUND

Cataract surgery is the most common surgery performed on beneficiaries of Medicare, accounting for more than $3.4 billion in annual expenditures. The purpose of this study is to examine racial and geographic variations in cataract surgery rates and determine the association between the racial composition of the community population and the racial disparity in the likelihood of receiving necessary cataract surgery.

METHODS

Using the national prevalence rates from the National Institute of Eye Health and the 2010 Healthcare Cost and Utilization Project-Florida State Ambulatory Surgery Database, we determined the estimated cases of cataract and the actual number of cataract procedures performed, on four race/gender determined groups aged 65 and over in the state of Florida in 2010. The utilization rates and disparity ratios were also calculated for each Florida county. The counties were segmented into groups based on their racial composition. The association between racial composition and disparity ratios in receiving necessary cataract surgery was examined. The Geographic Information System was used to display county-level geospatial relationships.

RESULTS

African-Americans have a lower gender-specific cataract prevalence (African-American male = 0.246, African-American female = 0.392, white male = 0.368, and white female = 0.457), but they are also less likely than whites to receive necessary cataract surgery (utilization rate: African-American male = 7.92%, African-American female = 6.17%, white male = 12.08%, and white female = 10.54%). The statistical results show no overall differences between the disparity ratios and the racial composition of the communities. However, our geospatial analyses revealed a concentration of high racial disparity/high white population counties largely along the West Coast and South Central portion of the state.

CONCLUSIONS

There are racial differences in the likelihood of receiving necessary cataract surgery. However, there is no significant statewide association between the racial composition of the community population and the racial disparity in the likelihood of receiving necessary cataract surgery. Geospatial techniques did, however, identify subpopulations of interest which were not otherwise identifiable with typical statistical approaches, nor consistent with their conclusions.

Six-year incidence of visually significant age-related cataract: the Chennai eye disease incidence study

BACKGROUND

The aim of this study is to report the 6-year incidence of age-related cataract in a population-based study.

DESIGN

The design used is a population-based cohort study.

PARTICIPANTS

A cohort of 2484 phakic subjects, aged 40 years and above at baseline, from a south Indian population was included in the study.

METHODS

Bilateral phakics with visual acuity of 6/12 or better and cataract less than N2, C2 and P2 on the Lens Opacities Classification System II at baseline were included. Subjects with glaucoma and corneal or retinal diseases were excluded. Incident visually significant cataract was defined as visual acuity of less than 6/18 with a corresponding one grade or greater change in Lens Opacities Classification System II or history of having undergone cataract surgery with evidence of pseudophakia or aphakia at the 6-year follow-up.

MAIN OUTCOME MEASURES

Six-year incidence of visually significant cataract and associated risk factors data were collected.

RESULTS

Incident visually significant cataract at 6 years was seen in 158 subjects (6.36%, 95% CI: 5.40-7.32, phakics:pseudophakics/aphakics 70:88). Incidence was higher in the rural cohort as compared with the urban cohort (P < 0.001). Incidence increased with age and was highest in the ≥70 years age group (odds ratio (OR):31.23, 95% CI: 15.20-64.16, P < 0.001). Other associated risk factors included illiteracy (OR 1.75, 95% CI: 1.17-2.61, P = 0.007) and smoking (OR 1.77, 95% CI: 1.08-2.88, P = 0.02).

CONCLUSIONS

A significant proportion of the population developed visually significant age-related cataract at 6 years. Incident visually significant cataract was significantly greater for the rural cohort between 50 and 69 years old.