The Role of Demographic Characteristics in the Outcomes of Cataract Surgery and Gender Roles in the Uptake of Postoperative Eye Care: A Hospital-based Study

Migraine is a risk factor for pseudophakic positive dysphotopsia following monofocal lens implantation

OBJECTIVE

To identify neuroadaptation-related risk factors for persistent positive dysphotopsia (>6 months) following monofocal lens implantation.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients of an academic institution and a private practice in Saint Louis, Missouri. Inclusion criteria were adults with cataract extraction between January 2010 and April 2021 with monofocal intraocular lens implantation. Exclusion criteria included dementia, <20/40 acuity, visual pathway damage, visual field loss, and significant pathology causing photopsia.

METHODS

Participants were surveyed via telephone.

RESULTS

There were 385 participants (385 eyes), of whom 66 had persistent dysphotopsia (58 positive), 298 had none, and 21 had nonpersistent dysphotopsia. Among the 58 who had positive persistent dysphotopsia, mean Pseudophakic Dysphotopsia Questionnaire 6 (PDQ-6) score was 14.11 (SD, 8.46). There were no significant differences in sex or race. Migraine prevalence was greater among those with dysphotopsia (21.2%) than among those without (11.4%; p = 0.054). History of migraine was associated with an increase in PDQ-6 score of 2.76 points (p = 0.006). Six people in each group had Visual Aura Rating Scale (VARS) scores greater than zero. Mean VARS score was 0.48 for those with dysphotopsia and 0.14 for those without (p = 0.03). History of migraine or increased VARS score, younger age, and female sex were associated with lower satisfaction.

CONCLUSION

History of migraine was associated with increased dysphotopsia severity and decreased patient satisfaction. Although further study with a larger sample size is warranted, these preliminary results highlight the potential of simple questions to individualize lens choice, reduce the risk of dysphotopsia, and improve patient satisfaction.

Impact of the value driven outcomes program among cataract surgery patients in Singapore: an interrupted time series analysis

BACKGROUND

Healthcare cost is increasing rapidly in Singapore. Moving towards a value-based healthcare framework enables a sustainable health system. The National University Hospital (NUH) implemented the Value Driven Outcome (VDO) Program for cataract surgery due to its high volume and cost variability. We aimed to evaluate the association between VDO program implementation and costs and quality outcomes for cataract surgery in NUH.

METHODS

We conducted an interrupted time-series analysis for cataract surgery episodes between January 2015 and December 2018. Using segmented linear regression models, we estimate the changes in levels and trends of cost and quality outcomes post-program implementation. We adjusted for autoregression and various confounders.

RESULTS

Following VDO program implementation, the total cost of cataract surgery had a significantly decreased by $327.23 (95% CI: -$421.04 to -$233.43; p < 0.01) and the trend significantly decreased by $13.75 per month (95% CI: -$23.19 to -$4.30 per month; p < 0.01). There was a small improvement in the combined quality outcome score (0.028, 95% CI: 0.016 to 0.040; p < 0.01), but the trend remained unchanged.

CONCLUSION

The VDO program was associated with a reduction in cost without compromising on quality outcomes. The program provides a structured methodology to measure performances, and through these data, initiatives were implemented to improve value. There are benefits to providing a data reporting system to physicians to understand actual care costs and quality outcomes achieved by individual patients with defined clinical conditions.

Healthcare disparities contribute to missed follow-up visits after cataract surgery in the USA: results from the perioperative care for intraocular lens study

OBJECTIVE

To identify factors that contribute to missed cataract surgery follow-up visits, with an emphasis on socioeconomic and demographic factors.

METHODS

In this retrospective cohort study, patients who underwent cataract extraction by phacoemulsification at Massachusetts Eye and Ear between 1 January and 31 December 2014 were reviewed. Second eye cases, remote and international patients, patients with foreign insurance and combined cataract cases were excluded.

RESULTS

A total of 1931 cases were reviewed and 1089 cases, corresponding to 3267 scheduled postoperative visits, were included. Of these visits, 157 (4.8%) were missed. Three (0.3%) postoperative day 1, 40 (3.7%) postoperative week 1 and 114 (10.5%) postoperative month 1 visits were missed. Age<30 years (adjusted OR (aOR)=8.2, 95% CI 1.9 to 35.2) and ≥90 years (aOR=5.7, 95% CI 2.0 to 15.6) compared with patients aged 70-79 years, estimated travel time of >2 hours (aOR=3.2, 95% CI 1.4 to 7.4), smokers (aOR=2.7, 95% CI 1.6 to 4.8) and complications identified up to the postoperative visit (aOR=1.4, 95% CI 1.0 to 2.1) predicted a higher rate of missed visits. Ocular comorbidities (aOR=0.7, 95% CI 0.5 to 1.0) and previous visit best-corrected visual acuity (BCVA) of 20/50-20/80 (aOR=0.4, 95% CI 0.3 to 0.7) and 20/90-20/200 (aOR=0.4, 95% CI 0.2 to 0.9), compared with BCVA at the previous visit of 20/40 or better, predicted a lower rate of missed visits. Gender, race/ethnicity, language, education, income, insurance, alcohol use and season of the year were not associated with missed visits.

CONCLUSIONS

Medical factors and demographic characteristics, including patient age and distance from the hospital, are associated with missed follow-up visits in cataract surgery. Additional studies are needed to identify disparities in cataract postoperative care that are population-specific. This information can contribute to the implementation of policies and interventions for addressing them.

Prevalence and Major Causes of Visual Impairment in Iranian Adults: A Systematic Review

PURPOSE:

The purpose of this study is to provide a pooled estimate of moderate-to-severe visual impairment (MSVI) and blindness in Iran for people 50 years and over and to identify the major causes through systematic review.

MATERIALS AND METHODS:

International (PubMed, ISI Web of Science, and Scopus) and national databases (Scientific Information Database, Barakat Knowledge Network System, Iran Databank of Ophthalmology Research, and Magiran) databases were searched. Following relevance assessment and critical appraisal, eight studies were included. A funnel plot was drawn to explore the stability for estimation. Single-variable meta-regression analysis was applied for heterogeneity assessment, and a random effect model was used (but no significant source for the observed heterogeneity was found).

RESULTS:

Age-standardized pooled estimate of MSVI was 4.24% (95% confidence interval [CI]: 2.92–5.56); 3.98% (95% CI: 2.37–5.59) for men, and 4.08% (95% CI: 2.95–5.21) for women. Blindness (visual acuity <3/60) prevalence was 1.31% (95% CI: 1.23–1.39); 0.96% (95% CI: 0.89–1.03) for men, and 1.13% (95% CI: 1.06–1.20) for women. Causes of visual impairment (VI) were cataract (40.23%), amblyopia (12.03%), corneal opacity (9.63%), age-related macular degeneration (9.31%), diabetic retinopathy (4.94%), and glaucoma (3.67%).

CONCLUSION:

VI prevalence in the 50 years and older population in Iran seems significantly better than the corresponding global estimates. A rough 60% rate of treatable VI was estimated, mostly attributable to unoperated cataract.

Multiple deprivation, vision loss, and ophthalmic disease in adults: global perspectives

The association between socioeconomic position and morbidity and mortality has long been recognized. We evaluate the evidence for an association between multiple aspects of deprivation and ocular health in a global context. This is a systematic review of studies that evaluated deprivation in the adult population in the context of the major acquired causes of visual loss such as cataract, diabetic eye disease, glaucoma, age-related macular degeneration, and ocular trauma. The search strategy identified relevant studies reported between 1946 and August 2016, with randomized control trials, case-control, cohort, and cross-sectional study designs being selected for inclusion. The studies identified in this review from across the world demonstrate the extent to which the common themes such as low educational attainment and low income may be associated with increased incidence of various sight-threatening conditions and may adversely affect access to specialist assessment and delivery of treatment. Health inequality may always persist, but an increased recognition of the importance of the various impacts of deprivation may empower policy makers to target limited resources to the most vulnerable groups in order to deliver the greatest benefit.

Cataract Surgery Visual Outcomes and Associated Risk Factors in Secondary Level Eye Care Centers of L V Prasad Eye Institute, India

PURPOSE

To evaluate cataract surgery visual outcomes and associated risk factors in rural secondary level eye care centers of L V Prasad Eye Institute (LVPEI), India.

METHODS

The Eye Health pyramid of LVPEI has a network of rural secondary care centres (SCs) and attached vision centres (VCs) that provide high quality comprehensive eye care with permanent infrastructure to the most disadvantaged sections of society. The most common procedure performed at SCs is cataract surgery. We audited the outcome of a random sample of 2,049 cataract surgeries done from October 2009-March 2010 at eight rural SCs. All patients received a comprehensive ophthalmic examination, both before and after surgery. The World Health Organization recommended cataract surgical record was used for data entry. Visual outcomes were measured at discharge, 1-3 weeks and 4-11 weeks follow up visits. Poor outcome was defined as best corrected visual acuity <6/18.

RESULTS

Mean age was 61.8 years (SD: 8.9 years) and 1,133 (55.3%) surgeries were performed on female patients. Pre-existing ocular co-morbidity was present in 165 patients (8.1%). The most common procedure was small incision cataract surgery (SICS) with intraocular lens (IOL) implantation (91.8%). Intraoperative complications were seen in 29 eyes (1.4%). At the 4-11 weeks follow-up visit, based on presenting visual acuity (PVA), 61.8% had a good outcome and based on best-corrected visual acuity (BCVA), 91.7% had a good outcome. Based on PVA and BCVA, those with less than 6/60 were only 2.9% and 1.6% respectively. Using multivariable analysis, poor visual outcomes were significantly higher in patients aged ≥70 (OR 4.63; 95% CI 1.61, 13.30), in females (OR 1.58; 95% CI 1.04, 2.41), those with preoperative comorbidities (odds ratio 4.68; 95% CI 2.90, 7.57), with intraoperative complications (OR 8.01; 95% CI 2.91, 22.04), eyes that underwent no IOL or anterior chamber-IOL (OR 12.63; 95% CI 2.65, 60.25) and those undergoing extracapsular cataract extraction (OR 9.39; 95% CI 1.18, 74.78).

CONCLUSIONS

This study demonstrates that quality cataract surgeries can be achieved at rural SCs. The concept of the LVPEI SCs can be applied to other developing countries, allowing rural patients to attain better vision through cataract surgery. Despite improvements in quality of cataract surgery, gender discrimination in terms of outcome continues to be an issue and needs further investigation.

Outcomes of Cataract Surgery at a Referral Center

Purpose:

To report the outcomes of cataract surgery at a large referral eye hospital and to identify factors associated with less than excellent visual outcomes.

Methods:

Hospital records of patients, who had undergone age-related cataract extraction (1,285 procedures) within a two-year period were sampled randomly for 353 patients (405 eyes) and baseline characteristics were recorded. Up to three causes of visual loss (contributory reasons) were considered and the principal cause of “less than excellent outcome,” i.e., best spectacle corrected visual acuity (BSCVA) <20/25 was defined as the primary reason.

Results:

Mean age of the participants was 68.6 years, and 50.7% of enrolled subjects were female. Phacoemulsification had been performed in 92.1% of cases. Out of 405 eyes, 54%, 78%, and 97% achieved BSCVA of ≥20/25, ≥20/40, and ≥20/200, respectively. Poor visual outcomes were significantly associated with older age (OR: 4.55 for age >70 years), female gender (OR: 4.64), ocular comorbidities (OR: 7.68), surgically challenging eyes (OR: 7.33), long and short eyes (versus eyes with normal axial length, OR: 3.24), and being operated on by a novice surgeon (OR: 2.41). The leading contributory reasons for unfavorable outcome, in descending order were maculopathy (17%), posterior capsule opacification (PCO, 11.8%), corneal opacity (5.7%), and degenerative myopia (5.4%).

Conclusion:

Maculopathy, PCO, corneal opacity, degenerative myopia and ARMD may contribute to unfavorable outcomes in cataract surgery.

Uptake, Barriers and Outcomes in the Follow-up of Patients Referred for Free-of-Cost Cataract Surgery in the Sao Paulo Eye Study

PURPOSE

To determine uptake, barriers and outcomes in the follow-up of patients referred for free-of-charge, expedited cataract surgery in the Sao Paulo Eye Study (SPES).

METHODS

SPES was a population-based study of urban, low-middle income residents aged ≥50 years. Presenting visual acuity (PVA), best-corrected visual acuity, refraction, and slit-lamp examination were performed in 3677 participants. For subjects with cataract as a principal cause of best-corrected visual acuity ≤20/40, surgery was offered free of charge. Two years after the baseline study, surgery uptake, barriers to surgery, and visual outcomes were analyzed.

RESULTS

Among 210 (5.71%) participants who had a cataract surgery indication at baseline, 164 (78.1%) were successfully contacted and 55 (33.5%) reported being operated on for cataract, with 51 agreeing to be re-examined. In a multiple logistic regression model, age, sex, schooling, previous cataract surgery, and PVA at baseline were not significantly associated with surgery uptake. Co-existing health conditions (20.4%), fear of surgery (12.2%) and fear of losing eyesight (11.6%) were the most frequent barriers to cataract surgery adherence. Among the 69 eyes operated on in the interval between baseline and follow-up, PVA ≥20/63 was observed in 50 (72.6%, 95% confidence interval, CI, 62.2-82.3%), PVA <20/63-20/200 in 11 (15.8%, 95% CI 8.9-22.9%) and PVA <20/200 in 8 (11.6%, 95% CI 5.3-17.9%).

CONCLUSIONS

Quality of surgery is an increasing determinant of uptake rates. Although free-of-charge and expedited cataract surgery was offered, surgical outcomes might have influenced the low uptake. Aside from cataract surgery campaigns, improvement of surgeon skills, accurate biometry, treatment of ocular comorbidities, postoperative follow-up and eye-care education are needed.