Simultaneous bilateral cataract surgery with IOL implantation in children in Kenya

The outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa: a systematic review

IMPORTANCE

Cataract is one of the leading causes of childhood blindness in Africa. The management of this condition requires timely surgical extraction of the cataractous lens with immediate optical correction and long-term follow-up to monitor visual improvement and manage complications that may arise. This review provides an opportunity to benchmark outcomes and to shed light on the reasons for those outcomes.

OBJECTIVES

To review the published literature and report on the outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa.

DATA SOURCE

The EMBASE, PubMed, Scopus, and Web of Science were searched for relevant articles.

STUDY SELECTION

We included all published primary studies from sub-Saharan Africa on cataract surgery outcomes in children aged 0-16 years with primary intraocular lens implantation conducted between 1990 and 2020. Eligible studies were those published in English or for which an English translation was available. In addition, reviewers screened the reference lists of all studies included in the full-text review for eligible studies. During the review, studies fitting the inclusion criteria above except for having been conducted in middle and high-income countries were tagged and placed in a comparison arm.

DATA EXTRACTION AND SYNTHESIS

Study eligibility was determined by two independent reviewers, and data extraction was conducted by one reviewer with entries checked for accuracy by another reviewer. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for data synthesis were followed. The Joanna Briggs Institute (JBI) critical appraisal checklist was used for quality appraisal of the studies. The statistical software R was used in the analysis, and data were pooled using a random-effects model. Forest plots were generated using the R package 'metafor'.

MAIN OUTCOMES AND MEASURES

The primary outcome was visual acuity (VA) after cataract surgery and the proportions of eyes that achieved good, borderline, or poor visual outcome according to the World Health Organisation (WHO) categorisation of post-operative visual acuity. The secondary outcome measures reported included lag time to surgery, rates of follow-up, and rate of complications.

RESULTS

Eight out of 4763 studies were eligible for inclusion in this review, and seven were included in the quantitative analysis. There was a male preponderance in the study population, and the mean age at the time of cataract surgery ranged from 3.4 to 8.4 years. Visual outcomes were available for short-term visual outcomes (1 to 6 months) as the studies had a significant loss to follow-up. The pooled proportion of eyes that achieved a good visual acuity (i.e. equal to or greater than 6/18) in the short-term period was 31% (CI, 20-42). The comparative studies from middle and high-income countries reported proportions ranging from 41 to 91%, with higher thresholds for good visual acuity of 6/12 and 6/15.

CONCLUSION AND RELEVANCE

This review reports that there is a lower proportion of eyes with good outcomes after undergoing paediatric cataract surgery in sub-Saharan Africa than in middle- and high-income countries. Furthermore, this review states that there is a high proportion of patients lost to follow-up and suboptimal refractive correction and amblyopia treatment after paediatric cataract surgery.

Management of childhood cataract: practice patterns among ophthalmologists in Nigeria

OBJECTIVE

To describe the practice patterns for the management of paediatric cataracts among ophthalmologists practising in Nigeria.

METHODS

A cross-sectional study of fully trained Nigerian ophthalmologists who perform cataract surgery in children aged 16 years and below. An online questionnaire was distributed via e-mail and social media platforms to respondents. Data on socio-demographic characteristics, type, location and years of practice, status and preferred approach to management of childhood cataracts were obtained and analysed.

RESULTS

A total of 41 ophthalmologists responded that they perform paediatric cataract surgery. Of these, 25 (61.0%) were paediatric ophthalmologists while 7 (17.0%) were general ophthalmologists. Most respondents (92.7%) practise in urban settings and 30 (73.2%) work in tertiary hospitals. Most respondents (90.2%) routinely insert intraocular lenses (IOLs) in children aged 2 years and above while 32 (78.0%) routinely under-correct the IOL power. Thirty-four (82.9%) have an anterior vitrectomy machine, 31 (75.6%) routinely perform posterior capsulotomy and anterior vitrectomy, and 17 (58.5%) routinely perform same-day sequential bilateral cataract surgery. Twenty-six (63.4%) respondents routinely give near correction in aphakic children, while 24 (58.5%) respondents routinely give bifocals in pseudophakic children. Compared to other sub-specialists, paediatric ophthalmologists were 24 times more likely to routinely under-correct IOL power (p = 0.001) and 4 times more likely to routinely correct near vision in aphakic children (0.036) as well as prescribe bifocals for pseudophakic children respectively (0.029).

CONCLUSION

The practice of paediatric cataract surgery in Nigeria is mainly in line with expected standards, but there is a need for the development of detailed practice guidelines.

The economics of vision impairment and its leading causes: A systematic review

Vision impairment (VI) can have wide ranging economic impact on individuals, households, and health systems. The aim of this systematic review was to describe and summarise the costs associated with VI and its major causes. We searched MEDLINE (16 November 2019), National Health Service Economic Evaluation Database, the Database of Abstracts of Reviews of Effects and the Health Technology Assessment database (12 December 2019) for partial or full economic evaluation studies, published between 1 January 2000 and the search dates, reporting cost data for participants with VI due to an unspecified cause or one of the seven leading causes globally: cataract, uncorrected refractive error, diabetic retinopathy, glaucoma, age-related macular degeneration, corneal opacity, trachoma. The search was repeated on 20 January 2022 to identify studies published since our initial search. Included studies were quality appraised using the British Medical Journal Checklist for economic submissions adapted for cost of illness studies. Results were synthesized in a structured narrative. Of the 138 included studies, 38 reported cost estimates for VI due to an unspecified cause and 100 reported costs for one of the leading causes. These 138 studies provided 155 regional cost estimates. Fourteen studies reported global data; 103/155 (66%) regional estimates were from high-income countries. Costs were most commonly reported using a societal (n = 48) or healthcare system perspective (n = 25). Most studies included only a limited number of cost components. Large variations in methodology and reporting across studies meant cost estimates varied considerably. The average quality assessment score was 78% (range 35-100%); the most common weaknesses were the lack of sensitivity analysis and insufficient disaggregation of costs. There was substantial variation across studies in average treatment costs per patient for most conditions, including refractive error correction (range $12-$201 ppp), cataract surgery (range $54-$3654 ppp), glaucoma (range $351-$1354 ppp) and AMD (range $2209-$7524 ppp). Future cost estimates of the economic burden of VI and its major causes will be improved by the development and adoption of a reference case for eye health. This could then be used in regular studies, particularly in countries with data gaps, including low- and middle-income countries in Asia, Eastern Europe, Oceania, Latin America and sub-Saharan Africa.

Immediately sequential bilateral cataract surgery: pros and cons

This review presents the main pros and cons of immediately sequential bilateral cataract surgery versus delayed sequential bilateral cataract surgery. The main arguments against immediately sequential bilateral cataract surgery are the likelihood of postoperative bilateral endophthalmitis and refractive errors. At the same time, a careful selection of patients, implementation of safety recommendations and the use of intracameral antibiotics, combined with the improvement of formulas for calculating intraocular lenses, provide the advantages of immediately sequential bilateral cataract surgery associated with the rapid rehabilitation of patients after surgery and economic reasons.

Evolution of and developments in simultaneous bilateral cataract surgery. Update 2020

The debate on role of 'simultaneous bilateral cataract surgery' (SBCS) continues. The world population has exponentially increased during last fifty years and average human lifespan has increased by a decade during the last century. This translates to ever increasing geriatric population with its inherent problem of preventable blindness because of cataract formation in the elderly. We are adding to the backlog of cataract surgeries not only in the 'developing world' but also in the 'developed world.' Times demand that we reconsider our old fashioned approach of staggering bilateral cataract surgeries. Serious, but a potential, risk of simultaneous bilateral infection/endophthalmitis has been the biggest deterrent in acceptance of SBCS as a routine procedure. The opponents of SBCS strongly believe in this argument that has not been documented when strictly followed the recommendations regarding separate procedures of each eye. The advantages of reducing the ever-increasing backlog of preventable/treatable blindness, faster visual recovery, economic benefits to patients as well as health care providers, lesser risk of amblyopia in pediatric population, and decreased risk of as serious a complication as death by exposure to general anesthesia in pediatric and adult population, etc. outweigh the disadvantages of SBCS when compared with 'delayed bilateral cataract surgery' (DBCS). SBCS is favored over DBCS in pediatric population and in uncooperative, mentally retarded and physically disabled adults needing general anesthesia to reduce the risks and complications of general anesthesia. Considering such factors and review of available literature strongly support that SBCS has a definite role where indicated, under certain circumstances, and in certain select group of patients in both developing as well as developed countries.

Economic Analysis of Children's Surgical Care in Low- and Middle-Income Countries: A Systematic Review and Analysis

Background

Understanding the economic value of health interventions is essential for policy makers to make informed resource allocation decisions. The objective of this systematic review was to summarize available information on the economic impact of children’s surgical care in low- and middle-income countries (LMICs).

Methods

We searched MEDLINE (Pubmed), Embase, and Web of Science for relevant articles published between Jan. 1996 and Jan. 2015. We summarized reported cost information for individual interventions by country, including all costs, disability weights, health outcome measurements (most commonly disability-adjusted life years [DALYs] averted) and cost-effectiveness ratios (CERs). We calculated median CER as well as societal economic benefits (using a human capital approach) by procedure group across all studies. The methodological quality of each article was assessed using the Drummond checklist and the overall quality of evidence was summarized using a scale adapted from the Agency for Healthcare Research and Quality.

Findings

We identified 86 articles that met inclusion criteria, spanning 36 groups of surgical interventions. The procedure group with the lowest median CER was inguinal hernia repair ($15/DALY). The procedure group with the highest median societal economic benefit was neurosurgical procedures ($58,977). We found a wide range of study quality, with only 35% of studies having a Drummond score ≥ 7.

Interpretation

Our findings show that many areas of children’s surgical care are extremely cost-effective in LMICs, provide substantial societal benefits, and are an appropriate target for enhanced investment. Several areas, including inguinal hernia repair, trichiasis surgery, cleft lip and palate repair, circumcision, congenital heart surgery and orthopedic procedures, should be considered “Essential Pediatric Surgical Procedures” as they offer considerable economic value. However, there are major gaps in existing research quality and methodology which limit our current understanding of the economic value of surgical care.

Safety of Simultaneous Bilateral Intraocular Surgery Under General Anesthesia in Pediatric Patients

Objective:

To evaluate the risks and benefits of simultaneous bilateral intraocular surgery (SBIS) in pediatric patients at a university hospital in the Kingdom of Saudi Arabia, who are placed under general anesthesia for the procedure.

Methods:

This retrospective, noncomparative case study comprised 15 children, who underwent bilateral cataract surgery and/or primary or secondary intraocular lens (IOL) implantation in one sitting between November 2008 and July 2014. Seven patients had bilateral lensectomy primary posterior capsulotomy and anterior vitrectomy, and the remaining eight patients had bilateral IOL implantation at the capsular bag either primarily IOL implantation (two cases) at the time of cataract extraction or secondary IOL implantation at the capsular bag (six cases). Bilateral surgeries were performed sequentially by the same surgeon, with strict aseptic separation of the two surgeries, while the patient was under general anesthesia.

Results:

The age of the patients at the time of the surgery ranged from 7 months to 9 years (mean age 2.13 years). The patients were followed up approximately for 4 months postsurgery. There were no catastrophic complications from the anesthesia (death, asphyxia, cardiac or respiratory arrest, or seizures) nor were there any intraoperative complications that necessitated cancelation of surgery in the second eye. Postoperatively, one patient was noted to have reproliferation of lens material in one eye. However, no serious postoperative complications such as endophthalmitis, aphakic glaucoma, and hyphema were noted.

Conclusion:

SBIS conducted during the same operative procedure is an alternative to sequential surgery in selected pediatric patients if operative guidelines and surgical asepsis are strictly followed.

Complications of pediatric cataract surgery

PURPOSE

Cataract surgery in young children poses different challenges and potential complications compared to those encountered in adult populations. We performed a literature review of the complications of pediatric cataract surgery.

METHODS

Literature review of complications of pediatric cataract surgery.

RESULTS

Complications in children vary based on the age of the patient at surgery and the cause of the cataract. Common events discussed include increased inflammatory response, opacification of the posterior capsule, lens reproliferation, pupillary membrane, and amblyopia; less common events include infections, significant bleeding, and retinal detachment.

CONCLUSION

Complications after cataract surgery in children are often associated with a robust inflammatory reaction or secondary opacity and, in infants, glaucoma. Late complications can occur decades later, so that long-term follow-up is required. Though surgery carries significant risks, the consequences of no surgery and irreversible deprivation amblyopia in very young children should be considered.

Quality assessment of economic evaluation studies in pediatric surgery: a systematic review

PURPOSE

To assess economic evaluation studies (EES) in pediatric surgery and to identify potential factors associated with high-quality studies.

METHODS

A systematic review of the literature using PubMed and Cochrane databases was conducted to identify EES in pediatric surgery published between 1 June 1993 and 30 June 2013. Assessment criteria are derived from the Drummond checklist. A high quality study was defined as a Drummond score ≥7. Logistic regression analysis was used to determine factors associated with high quality studies.

RESULTS

119 studies were included. 43.7% (n=52) of studies were full EES. Cost-effectiveness analysis was the most frequent (61.5%) type of full EES. Only 31.6% of studies had a Drummond score ≥7 and 73% of these were full EES. The factors associated with high quality were identification of costs (OR: 14.08; 95% CI: 3.38-100; p<0.001), estimation of utility value (OR: 8.13; 95% CI: 2.02-43.47; p=0.005) and study funding (OR: 3.50; 95% CI: 1.27-10.10; p=0.02).

CONCLUSION

This review shows that the number and the quality of EES are low despite the increasing number of studies published in recent years. In the current context of budget constraints, our results should encourage pediatric surgeons to focus more on EES.