|Year : 2016 | Volume
| Issue : 2 | Page : 75-81
Impact of cataract on the quality of life of rural patients in India
Seema Dutt Bandhu1, YG Vabale1, PP Sambarey1, Amol B Walke2, Swati Raje3
1 Department of Ophthalmology, Talegaon Dabhade, Pune, Maharashtra, India
2 Department of Community Medicine, Talegaon Dabhade, Pune, Maharashtra, India
3 Department of MIMER Medical College,Talegaon Dabhade, Pune, Maharashtra, India
|Date of Submission||22-Oct-2014|
|Date of Acceptance||27-Nov-2015|
|Date of Web Publication||9-Jun-2016|
Seema Dutt Bandhu
118, Parmar Garden Wanowrie, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: To evaluate the impact of cataract on the quality of life of rural patients in India. Materials and Methods: Cataract patients visiting a rural hospital in Maharashtra, India were surveyed preoperatively and 3 months after undergoing cataract surgery for their quality of life. Indian visual function (VF) questionnaire 33 was used for this purpose. Expectation and satisfaction from cataract surgery were evaluated separately using subjective questions. The outcomes were compared by gender, age-group and literacy and subjective visual gain (post- and pre-operative vision). Results: Of the 150 patients who participated in the study, the visual acuity of 108 (72%) was <20/200 before surgery. The data show that scores for the general, psychosocial, and VFs were 56.7 ± 18.79, 12.82 ± 4.7, and 20.24 ± 4.17, respectively, for all three before surgery. One hundred and thirty-five (90%) participants expected to be economically productive after cataract surgery. Literate patients and patients <60 years old had higher expectations for improvement of VF from surgery. Conclusions: It is concluded that though the quality of life was decreased across all the domains, the study population contributed economically toward their households before cataract surgery and expected to be able to do so after surgery. Illiterate and older patients had a lower expectation and higher satisfaction from surgery.
Keywords: Expectations, quality of life, visual function
|How to cite this article:|
Bandhu SD, Vabale Y G, Sambarey P P, Walke AB, Raje S. Impact of cataract on the quality of life of rural patients in India. J Clin Ophthalmol Res 2016;4:75-81
|How to cite this URL:|
Bandhu SD, Vabale Y G, Sambarey P P, Walke AB, Raje S. Impact of cataract on the quality of life of rural patients in India. J Clin Ophthalmol Res [serial online] 2016 [cited 2022 Jun 27];4:75-81. Available from: https://www.jcor.in/text.asp?2016/4/2/75/183658
A growing body of research indicates that visual acuity (VA) alone is an inadequate measure of visual impairment.  In any society, a patient's visual function (VF), which is a measurement of the important vision-dependent tasks that he or she can do, is a more important measure of the need for cataract surgery than VA alone.  The impact on VF is related to patient-perceived outcomes and has become a significant factor in the evaluation of the outcome of surgical interventions. Therefore, both VA and functional status after surgery need to be studied to know the outcome. However, although patients may benefit from an increase in VA and VF after cataract surgery, their satisfaction may be limited. Assessment of patient satisfaction gives additional information on the result of surgery and is, therefore, of further importance in evaluating the surgical outcome.  This study was carried out with the aim of finding out the effect of cataract on the quality of life of patients with reference to VA and VF and to assess the patient satisfaction with the surgical outcome in a rural area of India.
| Materials and Methods|| |
This was a cross-sectional hospital based survey carried out in a rural hospital in Maharashtra over a period of 6 months after taking permission from the Ethics Committee. The inclusion criteria adopted was patients who had a cataract in both the eyes but no other vision threatening ocular comorbidity and who were willing to be interviewed. The questionnaire used was the Indian VF questionnaire-33 (IVFQ-33) after taking permission from the authors [Appendix 1[SUPPORTING:3]].
The authors were the investigators in this study. The IVFQ-33 is in English, but the questions were read out in the local dialect to the participants. The relatives did not contribute in responses. The response of the patients was calibrated quantitatively by giving a score to each of the responses from 1 to 5 so that the VFs were graded from excellent to poor according to the score. Data collection pertained to indices of VF, expectation and satisfaction from surgical outcome and demography. The demographic data included age, sex, educational status, and occupation. Patients were considered illiterate if they had not attended school at all or attended school only up to Class 5. The expectation from surgery was asked subjectively as to what they should be able to do/perform after cataract surgery [Appendix 2 [Additional file 2]]. The expectation was considered to be low if the patient expressed the outcome of surgery to be a "will of God" or to gain just enough vision to be able to manage to go out for toilet unassisted. Satisfaction from cataract surgery was asked at about 1 month after the patient had received the final corrective glasses after surgery that is after about 3 months from the collection of the preoperative data. The patients' expectation from cataract surgery was referred to and the patients were asked if their expectations had been fulfilled or not. If all the expectations had been fulfilled, the patient was considered to be highly satisfied, if partly fulfilled, he/she was considered to be moderately satisfied and if not fulfilled at all then he/she was considered to be dissatisfied with the surgery. All the patients underwent manual small incision cataract surgery or phacoemulsification with intraocular lens implantation.
| Results|| |
For this study, 180 patients were recruited but the final data of only 150 was collected because of drop out. Since all the patients were considered, sampling was not done. Of the 150 patients included in the study, 30 (20%) were literate. The average age of the study population was 62.46 years. Forty (26.6%) patients were <60 years, the youngest being 45 years old. Out of the total of 150, 62 (41.33%) were female patients. In our study group 73 (48.66%) patients were farm laborers by occupation who are required to pull out weeds from among the crop, 50 (33.3%) were employed in professions other than farming such as shopkeepers, helpers in shops and hotels, technicians and drivers, etc. Rest of the patients (18%) lead sedentary lifestyles [Table 1].
Forty-two (28%) patients presented with VA more than 20/200, 60% patients presented with VA <20/200 in both eyes whereas 15 patients (10%) presented with vision <20/400 in both eyes. Three patients (2.0%) presented with VA of the only perception of light in both eyes. Postoperatively, 60 (40%) patients achieved 20/20 best corrected VA (BCVA), 63 (42%) patients attained 20/30 BCVA, 26 (17.3%) patients attained 20/40 to 20/60 BCVA. One patient (0.6%) achieved BCVA of 20/80 only due to operative complications.
The data show that the general, psychosocial, and VFs were decreased in all the patients of cataract before surgery and there was a significant improvement after undergoing the surgery and receiving the final refractive correction irrespective of gender, literacy, age group and their preoperative visual disability [Table 2],[Table 3],[Table 4],[Table 5] and [Table 6].
The patients expressed multiple expectations about resuming activities after cataract surgery. Most (90%) of the patients expected to be able to continue or resume their economically productive activity after cataract surgery and a majority (85%) expected to be able to perform their activity as before [Appendix 2].
None of the literate persons had low expectations while 20% of the illiterates had so. Of the illiterates who had high expectations, 72.9% had high satisfaction level whereas 27.08% had moderate satisfaction from their surgery. As against that out of the literates who had high expectations (100%), only 60% had high satisfaction level, whereas 40% had moderate satisfaction from the surgical outcome [Table 7].
Expectation levels were high in the age group up to 60 years. Eight percentage from the people above 60 years of age had low expectations. While 70% from the younger population (<60 years) were highly satisfied, 30% were moderately satisfied with their surgery. Of the older population (>60 years), 77% were highly satisfied whereas 23% were moderately satisfied with the surgical outcome. None of the patients was dissatisfied from the outcome [Table 7].
| Discussion|| |
India is a developing economy that has a largely agrarian population where every member of the household contributes for the sustenance of the family. This has been proven in this study that shows that despite growing age and low vision, the study population was gainfully employed and expected to be able to do so after cataract surgery. The study also shows that though the quality of life of the patients was compromised yet, reasonable VF permitted them to continue working because of the nature of their job that does not require fine acuity of vision.
The results of our study show that even though majority (74.4%) of the study population was more than 60 years old, most of them (88%) were gainfully employed. Other studies conducted in developing countries have reported similar observations. 
In our study, the mean age of the patients was 62.46 years which is comparable to another study conducted in India which has reported the mean age at presentation for the cataract to be 63.13 ± 9.82 years.  An African study had reported a similar age at a presentation at 66.5 years  whereas Conner-Spady et al. had reported the mean age of patients in Canada to be 73.4 years. 
Our data show that 70% of the study population had VA <20/200 at the time of presentation, 10% presented with vision <20/400 whereas 2% of patients presented with VA of perception of light only in both eyes. Another study from India had shown that 100% of the study population had presented with VA <20/200.  A study from Nepal had shown that (11.5%) patients operated for cataract were blind at presentation (PPVA <20/400 in the better eye). 
The fact that the study population had severe visual impairment and yet they were going out to work brings out the fact that despite low vision, they were not only independent in their daily activities but also contributed economically toward their households. The observation reinforces the findings of another study that concluded that clinically objective measures of a patient's visual status may not reflect the degree of visual impairment the patient experiences in his or her daily activities.  It also indicates that the profession in which the study population was engaged does not require fine acuity of vision. Farm laborers pull out weeds from among the crop that is done with bare hands and does not require the use of sharp instruments.
The results of the study show that cataract caused a decrease across all domains of quality of life. A study from south India had also suggested that vision impairment is associated with a decrease across all domains of quality of life.  However, only the 2% of patients who presented with VA of the only perception of light accepted that they had low vision and that they had to depend on their family members for their daily activities like going out for toilet. The rest of the study population, despite their poor vision, was independent in their daily activities. The attitude of the study population toward their visual incapacity reinforces the observations of a study conducted in Egypt that had concluded that stigmatizing attitudes that the blind are completely dependent and unable to fulfill their social roles encourage those with decreased vision to deny the extent of their visual loss. 
The results show that 99.4% of the study population achieved good vision (>20/60) after surgery. Another study from India had reported that 79.9% of patients achieved >20/60 vision.  A study from Nigeria reported 74.6% of patients achieving vision >20/60 after cataract surgery. 
The results show that 20% of the illiterate among the study population had low expectation from surgery. The low expectation was also voiced by 8% of the study population above 60 years of age. Similar low expectations have been reported in other studies such as that of Brazil in which 6.9% respondents had low expectation from cataract surgery. 
The results show that though 99.4% of the patients had achieved good vision (>6/18) after surgery, all were not highly satisfied with the surgical outcome. Thus, even though their VA and VFs had increased, they were not necessarily highly satisfied with the results. The results also show that the group of patients with the relatively higher expectation from surgery was comparatively less satisfied from the surgical results than those who had a lower expectation. This underlines the importance of counseling the patients to have realistic expectations from a surgical procedure. A study has shown that controlling patient expectations may be more effective than improving patients' postoperative outcome in terms of maximizing patient satisfaction. 
Limitations of the study were that quantitative scores for expectations and satisfaction from surgery could not be worked out.
It is concluded that good quality cataract surgery improves the quality of life and should be available for the rural population. A similar study can be carried out on the urban population. The implication of this study is important as the good visual outcome is of vital importance for the sustenance of the dependent family. This demands good quality cataract surgery for all our patients irrespective of age, gender, or literacy.
The authors are thankful to the authors of the Indian VF Questionnare-33 for their permission to use the questionnaire for this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mozaffarieh M, Heinzl H, Sacu S, Wedrich A. Clinical outcomes of phacoemulsification cataract surgery in diabetes patients: Visual function (VF-14), visual acuity and patient satisfaction. Acta Ophthalmol Scand 2005;83:176-83.
Lewallen S, Courtright P. Recognising and reducing barriers to cataract surgery. Community Eye Health 2000;13:20-1.
Harvey AS, Taylor ME, Grosh M, Glewwe P. Designing Household Survey Questionnaires for Developing Countries. Lessons From 15 Years of the Living Standards Measurement Study. Washington: The World Bank; 2000. p. 249-75.
Domple VK, Gaikwad AV, Khadilkar HA, Doibale MK, Kulkarni AP. A study on visual outcomes after cataract surgery with intraocular lens implants at the rural health training center, Paithan, Maharashtra. Indian J Public Health 2011;55:22-4.
Conner-Spady BL, Sanmugasunderam S, Courtright P, McGurran JJ, Noseworthy TW; Steering Committee of the Western Canada Waiting List Project. Determinants of patient satisfaction with cataract surgery and length of time on the waiting list. Br J Ophthalmol 2004;88:1305-9.
Gurung R, Shrestha MK, Müller A, Ruit S. Preoperative visual acuity of people undergoing cataract surgery in rural and urban Nepal. Clin Experiment Ophthalmol 2011;39:501-5.
Margolis MK, Coyne K, Kennedy-Martin T, Baker T, Schein O, Revicki DA. Vision-specific instruments for the assessment of health-related quality of life and visual functioning: A literature review. Pharmacoeconomics 2002;20:791-812.
Nirmalan PK, Tielsch JM, Katz J, Thulasiraj RD, Krishnadas R, Ramakrishnan R, et al.
Relationship between vision impairment and eye disease to vision-specific quality of life and function in rural India: The Aravind Comprehensive Eye Survey. Invest Ophthalmol Vis Sci 2005;46:2308-12.
Lane SD, Mikhail BI, Reizian A, Courtright P, Marx R, Dawson CR. Sociocultural aspects of blindness in an Egyptian delta hamlet: Visual impairment vs. visual disability. Med Anthropol 1993;15:245-60.
Kapoor H, Chatterjee A, Daniel R, Foster A. Evaluation of visual outcome of cataract surgery in an Indian eye camp. Br J Ophthalmol 1999;83:343-6.
Olawoye OO, Ashaye AO, Bekibele CO, Ajayi BG. Visual outcome after cataract surgery at the university college hospital, Ibadan. Ann Ib Postgrad Med 2011;9:8-13.
Kara-Júnior N, Temporini ER, Kara-José N. Cataract surgery: Expectations of patients assisted during a community project in São Paulo, state of São Paulo, Brazil. Rev Hosp Clin Fac Med Sao Paulo 2001;56:163-8.
Pager CK. Expectations and outcomes in cataract surgery: A prospective test of 2 models of satisfaction. Arch Ophthalmol 2004;122:1788-92.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]