A study of high-volume, high-quality, and low-cost cataract surgeries in a rural setup in an emerging and developing country

Shipra Singh; Neelima Mehrotra

doi:10.4103/jcor.jcor_191_20

ORIGINAL ARTICLE

Year : 2021 | Volume : 9 | Issue : 3 | Page : 103-107

A study of high-volume, high-quality, and low-cost cataract surgeries in a rural setup in an emerging and developing country

Shipra Singh, Neelima Mehrotra
Department of Ophthalmology, SRMS IMS, Bareilly, Uttar Pradesh, India

Date of Submission	10-Sep-2020
Date of Decision	26-Apr-2021
Date of Acceptance	17-May-2021
Date of Web Publication	27-Sep-2021

Correspondence Address:
Neelima Mehrotra
Department of Ophthalmology, SRMS IMS, Bhojipura, Bareilly - 243 202, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jcor.jcor_191_20

Abstract

Aim: Evaluation of visual outcome following high volume, high quality and low cost cataract surgeries in a rural setup in North India. Methods: A retrospective study was done on all patients who underwent MSICS from March 2018 to March 2020 in a tertiary care hospital. Postoperative best-corrected visual acuity (BCVA) was assessed at day 1, between 1 and 3 weeks, and after 1–2 months of surgery. Results: A total of 6514 patients were included, out of which 1952 patients had ocular comorbidities; BCVA for each patient was categorized according to the World Health Organization criteria of visual impairment. It was seen that a statistically significant number of patients had good visual outcome following surgery at 1–2 months (3017 patients) 57.6%. Among the complications following surgery, posterior capsular rent was the most common and statistically significant. Conclusion: Good visual outcome in high volume of patients can be achieved with compliance to treatment and follow-up and proper management of complications.

Keywords: Cataract, small incision cataract surgery, visual outcome

How to cite this article:
Singh S, Mehrotra N. A study of high-volume, high-quality, and low-cost cataract surgeries in a rural setup in an emerging and developing country. J Clin Ophthalmol Res 2021;9:103-7

How to cite this URL:
Singh S, Mehrotra N. A study of high-volume, high-quality, and low-cost cataract surgeries in a rural setup in an emerging and developing country. J Clin Ophthalmol Res [serial online] 2021 [cited 2023 Jun 8];9:103-7. Available from: https://www.jcor.in/text.asp?2021/9/3/103/326789

The number of blind people in India was estimated to be 18.7 million, of which 9.5 million were cataract related in 2001, and it was projected to reach 36.1 million by 2020 if there was no change in the current trend of blindness.^[1] According to the National Blindness and Visual Impairment Survey 2019, the prevalence of blindness in India is 1.99% and Uttar Pradesh (U.P.) has the highest population suffering from blindness.

In India, a large sector of population resides in rural communities where there is a relative scarcity of health services, specialized health care workers, and newer advancements.^[2] Due to increasing backlog of unoperated patients and poor uptake of surgical services, there is an increasing burden of cataract in rural areas of developing countries.^[3] The prevalence of cataract studied in India was 44.6% in the rural and 43.6% in the urban population in the year 2019.^[4] Among the rural population, cataract accounts for 83.3% of visual impairment and 74.3% of blindness.^[5]

Cataract leads to gradual painless loss of vision, and blindness if left untreated. To eliminate preventable blindness, the World Health Organization (WHO) promotes high-volume, high-quality, and low-cost cataract surgeries.^[6] Small incision cataract surgery (SICS) is termed as “cataract surgery for the 21^st century.”^[7] Manual SICS (MSICS) has proven to be equally effective and a highly cost-effective alternative to instrumental phacoemulsification with a lower complication rate.^[8],[9]

Due to the increasing load of cataract patients and high cost, phacoemulsification has still a limited role in many developing countries. Our institute serves the rural people of Western U.P. providing camp services inclusive of free cataract surgery under the District Blindness Control Society. The National Program for Control of Blindness (NPCB) was launched in 1976 with the goal of reducing the prevalence of blindness to 0.3% by 2020. Visual outcome and quality of life are the most suitable measures available to the routine cataract surgeon to assess the visual outcome.^[10] This study assessed the outcomes of cataract surgeries done with a high-volume intake of patients at a tertiary level eye care center of Western U.P.

Methods

This retrospective study was approved by the Ethics Committee of the Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, U.P., and it was conducted in accordance with the tenets of the Declaration of Helsinki. The medical identity of every patient was kept anonymous. The study included 6514 patients with senile cataract which underwent cataract extraction with intraocular lens implantation in Shri Ram Murti Smarak Institute of Medical Sciences over a 2-year period from March 2018 to March 2020.

Only cataract surgery records of patients aged >40 years were included in the study. Surgery records involving traumatic cataract, congenital cataract, combined procedures, and secondary intraocular lens implantation were excluded. All consecutive patients were included in the analysis after the exclusion criteria. All the patients are enrolled in our study through outreach camps or outpatient department (OPD) camps. The outreach camps were conducted every alternate day in every week, and almost on every day of camp, 80–90 patients were allotted dates for surgery and free transport facilities were available for these patients. The OPD camps were conducted on every first 3 days of every month, and these patients were allotted dates on every day of the month and a maximum of seven patients were allotted dates for 1 day. A maximum of 30 surgeries were conducted in 1 day, but still, the backlog of cataract patients was very high. These patients were admitted 1 day prior to the surgery to ensure preoperative instillation of topical antibiotics. The average cost of NPCB for every patient was justified on the basis of consumables used and not on the workforce, machines, or infrastructure, and maximum benefit to every patient was given in a cheaper way. Proper sterility was maintained during surgery to decrease the risk of cluster endophthalmitis. Polymethylmethacrylate rigid lens was used in every patient.

All patients who were examined for cataract surgery received a comprehensive ophthalmic examination. The standard preoperative examination included detailed history, measurement of presenting visual acuity, and best-corrected visual acuity (BCVA) with Snellen's charts, intraocular pressure measurement with applanation or Schiotz tonometry, detailed slit-lamp examination including a dilated slit lamp and retinal examination under mydriasis to assess the lens status as well as ocular comorbidities likely to affect the outcome, and biometry (keratometry and amplitude scan) were conducted.

Before surgery, visual acuity was recorded and categorization was done using the WHO categories of visual impairment.^[11] Surgery was performed under local anesthesia by peribulbar anesthesia and patients who underwent MSICS. Postoperatively, patients were discharged on postoperative day 1, at which time the vision was recorded. A follow-up was conducted after 1 week of surgery when vision was recorded with best possible correction. The operated eye was examined, and the cause of poor visual outcome (<20/200 best corrected) was recorded, if any.

Ocular comorbidities were grouped as corneal and ocular surface lesions, uveal involvement, retinal diseases, glaucoma, and others (amblyopia, high myopia, lid abnormality, and tear film abnormality). The procedure performed was MSICS. Intraocular lenses used were either posterior chamber (PCIOL) or anterior chamber (ACIOL) polymethylmethacrylate lenses. Details of date of operation, type of surgery, intraocular lens implanted, and intraoperative complications were recorded from the case files. Follow-up visits were on the 1^st day, between 1 and 3 weeks, and at 4–11 weeks.

In order to assess outcome, visual acuities were categorized according to the WHO guidelines on the outcome of cataract surgery: mild ≥20/60, moderate <20/60–20/200, severe <20/200–20/400, and blind <20/400.^[11] For ease of statistical analysis, age was categorized into four categories: 40–49 years, 50–59 years, 60–69 years, and 70 years of age and above. All comorbidities and intraoperative complications were categorized as present or absent.

All the data analysis is performed by the Statistical Package for the Social Sciences (SPSS) version 20 software. Chi-square test was used to compare the distribution of categorical data. P <0.05 was considered as statistically significant.

Results

A total of 6514 patients underwent cataract surgery, out of which 6009 (92.2%) underwent PCIOL implantation and 505 (7.7%) underwent ACIOL implantation. Gender-wise distribution showed that 3387 (51.9%) were females and 3127 (48%) were males [Table 1].

Table 1: Distribution of patients according to different parameters

Click here to view

Maximum surgeries were performed in the age group of 50–59 years (32.7%), followed by 27.2% in 60–69 years, 26.4% in ≥70 years, and only 13.5% in 40–49 years. Preoperative BCVA of operated eye was categorized according to the WHO criteria of visual impairment, in which 667 (10.2%) had visual acuity ≥20/60, 1992 (30.5%) had visual acuity of <20/60–20/200, 2897 (44.4%) patients were having <20/200–20/400, and 958 (14.7%) had visual acuity of <20/400.

There were no preoperative comorbidities in 70.3% of patients. Preoperative comorbidities were seen in 29.7%, out of which 711 (10.9%) patients had corneal and ocular surface lesions, 652 (10%) had glaucoma, 372 (5.7%) patients had retinal conditions, 147 (2.2%) patients had uveal involvement, 37 (0.56%) patients had optic nerve conditions, whereas amblyopia, high myopia, lid, and tear film abnormalities were seen in 33 (0.50%).

BCVA was compared at postoperative day 1, 1–3 weeks, and 1–2 months. A total of 573 patients (91.2%) missed the follow-up at 1–3 weeks and 1284 (80.2%) patients missed the follow-up at 1–2 months [Table 2].

Table 2: Best-corrected visual acuity at follow-up visits

Click here to view

The results of our study showed that at 1–2 month follow-up visit, based on BCVA, 57.6% of patients had a good outcome which was statistically significant (P < 0.05). Patients with BCVA <20/200 were only 9.8%. [Table 2] describes the distribution of patients at different follow-up visits. Complications following surgery were assessed at 1–2 month follow-up visit [Table 3]. Overall, the most common complication following cataract surgery was posterior capsular rent (PCR) which was statistically significant. The most common postoperative complication following cataract surgery is striate keratopathy in patients with PCIOL implantation followed by PCR in patients with ACIOL implantation.

Table 3: Complications following surgery at 1-2 months

Click here to view

Discussion

Compared to phacoemulsification, MSICS offers similar advantages, is more frequently performed, and has wider acceptability; it is less time-consuming, has lower cost, and therefore is more popular in developing and underdeveloped countries, where high-volume surgery is common.^[12],[13] MSICS has a lesser complication rate in comparison to phacoemulsification even for trainee surgeons.^[14]

In a study done in Nigeria, cataract was found to be the most important cause of reversible blindness in people above 40 years of age in Nigeria and the most common cause of severe visual impairment in this group;^[15] similarly, in our study, we have taken patients above 40 years of age. In our study, the female population was higher in comparison to the male. This was similar to Gurung et al.^[16] who had a higher incidence of female patients. In contrast to our study, a study conducted in rural Punjab depicts a higher incidence of male patients in comparison to females. Patients with preoperative comorbidities were explained guarded visual prognosis before surgery to decrease a nominal burden of patient's dissatisfaction after surgery as these patients were more prone to develop intraoperative and postoperative complications and poorer visual outcomes following surgery. Preexisting ocular comorbid conditions were seen in 29.7% of patients in our study which was higher in comparison to Ugalahi et al. who had 22% of ocular comorbidities.^[17] In contrast to our study, a study conducted in Malaysia depicts glaucoma to be the highest preoperative comorbidity followed by proliferative diabetic retinopathy.^[18] Visual outcome is strongly affected by postoperative complications and ocular comorbidities.^[19]

PCIOL was the preferred choice in every patient; ACIOL was put as a result of intraoperative complication that is PCR. On subsequent follow-up visits, there was loss to follow-up at 1–3 weeks with further more decrease in compliance at 1–2 months which is a major issue of concern in developing countries. The determination of efficacy of cataract surgery in terms of postoperative vision is not new. In the era of intracapsular cataract surgeries in Nepal^[20] and China,^[21] 69% and 56.6% of operated persons had improved vision to >6/60 by aphakic correction. In our study, the visual acuity tends to show an increasing trend at 1–2-month follow-up visit.

The overall most common complication was PCR in 11.17% of total patients. Thevi et al. also reported that PCR was the most common intraoperative complication for all cataract surgeries.^[22],[23] PCR is the most common potentially sight-threatening intraoperative complication during cataract surgery, and it can occur both by experienced surgeons and junior surgeons, although with a higher frequency in the latter group.^[24] In contrast to our study, another study conducted in Malaysia demonstrated that there was a higher rate of combined complications rather than single complication.^[18] The overall rate of striate keratopathy in our study was 6.2%. In comparison to our study, higher rates of striate keratopathy were seen by Gupta and Nanda.^[25] However, factors such as time of presentation with cataract, surgical technique, comorbidities, and skill of surgeons affect the visual outcome.^[26] Haripriya et al.^[14] and Venkatesh et al.^[27] have shown that safety limits are significantly high with MSICS in comparison to phacoemulsification among trainees and complicated cataract cases.

Limitations

One of the major limitations of this study could be the patients who were lost to follow-up. Surgically induced astigmatism was not taken into account which could further affect the visual outcome.

Conclusion

Retrospective study and high percentage of dropouts in the follow-up are major drawbacks of this study. Good visual outcome in high volume of patients can be achieved with compliance to treatment and follow-up and proper management of complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Dandona L, Dandona R, John RK. Estimation of blindness in India from 2000 through 2020: Implications for the blindness control policy. Natl Med J India 2001;14:327-34.
2.	Flaxman SR, Bourne RR, Resnikoff S, Ackland P, Braithwaite T, Cicinelli MV, et al. Global causes of blindness and distance vision impairment 1990-2020: A systematic review and meta-analysis. Lancet Glob Health 2017;5:e1221-34.
3.	Rabiu MM. Cataract blindness and barriers to uptake of cataract surgery in a rural community of northern Nigeria. Br J Ophthalmol 2001;85:776-80.
4.	Singh S, Pardhan S, Kulothungan V, Swaminathan G, Ravichandran JS, Ganesan S, et al. The prevalence and risk factors for cataract in rural and urban India. Indian J Ophthalmol 2019;67:477-83. [PUBMED] [Full text]
5.	Thevi T, Basri M, Reddy S. Prevalence of eye diseases and visual impairment among the rural population – A case study of temerloh hospital. Malays Fam Physician 2012;7:6-10.
6.	Brian G, Taylor H. Cataract blindness – Challenges for the 21^st century. Bull World Health Organ 2001;79:249-56.
7.	Gogate PM, Deshpande M, Wormald RP, Deshpande R, Kulkarni SR. Extracapsular cataract surgery compared with manual small incision cataract surgery in community eye care setting in western India: A randomised controlled trial. Br J Ophthalmol 2003;87:667-72.
8.	Natchiar G. Manual Small Incision Cataract Surgery: An Alternative Technique to Instrumental Phacoemulsification. 2^nd ed. Madurai: Aravind Eye Hospitals; 2004. p. 8-56.
9.	Malik KS, Goel R. Manual of Small Incision Cataract Surgery. 1^st ed. CBC Publishers; 2003. p. 71-95.
10.	Limburg H, Foster A, Vaidyanathan K, Murthy GV. Monitoring visual outcome of cataract surgery in India. Bull World Health Organ 1999;77:455-60.
11.	International Statistical Classification of Diseases and Related Health Problems 10^th Revision (ICD-10) – WHO Version for 2016.
12.	Singh K, Misbah A, Saluja P, Singh AK. Review of manual small-incision cataract surgery. Indian J Ophthalmol 2017;65:1281-8. [PUBMED] [Full text]
13.	El-Shafy E, El-Sayed S, El-Sobky H, Badawy N. Phacoemulsification versus manual small incision cataract surgery for treatment of cataract. Menoufia Med J 2015;28:191-6. [Full text]
14.	Haripriya A, Chang DF, Reena M, Shekhar M. Complication rates of phacoemulsification and manual small-incision cataract surgery at Aravind Eye Hospital. J Cataract Refract Surg 2012;38:1360-9.
15.	Dineen B, Gilbert CE, Rabiu M, Kyari F, Mahdi AM, Abubakar T, et al. The Nigerian national blindness and visual impairment survey: Rationale, objectives and detailed methodology. BMC Ophthalmol 2008;8:17.
16.	Gurung A, Karki DB, Shrestha S, Rijal AP. Visual outcome of conventional extracapsular cataract extraction with posterior chamber intraocular lens implantation versus manual small-incision cataract surgery. Nepal J Ophthalmol 2009;1:13-9.
17.	Ugalahi MO, Uchendu OC, Ugalahi LO. Preoperative visual acuity of cataract patients at a tertiary hospital in sub-Saharan Africa: A 10-year review. Ther Adv Ophthalmol 2019;11:2515841419886451.
18.	Thanigasalam T, Reddy SC, Zaki RA. Factors associated with complications and postoperative visual outcomes of cataract surgery; a study of 1,632 Cases. J Ophthalmic Vis Res 2015;10:375-84. [PUBMED] [Full text]
19.	Lundström M, Barry P, Henry Y, Rosen P, Stenevi U. Visual outcome of cataract surgery; study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery. J Cataract Refract Surg 2013;39:673-9.
20.	Hennig A, Shrestha SP, Foster A. Results and evaluation of high volume intracapsular cataract surgery in Nepal. Acta Ophthalmol (Copenh) 1992;70:402-6.
21.	Lau J, Michon JJ, Chan WS, Ellwein LB. Visual acuity and quality of life outcomes in cataract surgery patients in Hong Kong. Br J Ophthalmol 2002;86:12-7.
22.	Thevi T, Abas AL. Intraoperative and postoperative complications of cataract surgery in eyes with pseudoexfoliation – An 8-year analysis. Oman J Ophthalmol 2019;12:160-5. [PUBMED] [Full text]
23.	Thevi T, Maizura Z, Abas AL. The Melaka Hospital cataract complications study analysis of 12,992 eyes. Indian J Ophthalmol 2017;65:24-9. [PUBMED] [Full text]
24.	Chakrabarti A, Nazm N. Posterior capsular rent: Prevention and management. Indian J Ophthalmol 2017;65:1359-69. [PUBMED] [Full text]
25.	Gupta V, Nanda R. Corneal complications after manual small-incision cataract surgery – A clinical study in a tertiary-based hospital. Int J Sci Stud 2019;6:111-4.
26.	Quillen DA, Phipps SJ. Visual outcomes and incidence of vitreous loss for residents performing phacoemulsification without prior planned extracapsular cataract extraction experience. Am J Ophthalmol 2003;135:732-3.
27.	Venkatesh R, Tan CS, Sengupta S, Ravindran RD, Krishnan KT, Chang DF. Phacoemulsification versus manual small-incision cataract surgery for white cataract. J Cataract Refract Surg 2010;36:1849-54.