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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 11
| Issue : 1 | Page : 21-25 |
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Proposed predictive score for visual outcome in cataracts with comorbidities following small-incision cataract surgery
Mehul Shah, Shreya Shah, Apeksha Kataria, Ashvini Korane
Drashti Netralaya, Dahod, Gujarat, India
| Date of Submission | 21-Mar-2022 |
| Date of Decision | 26-Oct-2022 |
| Date of Acceptance | 18-Dec-2022 |
| Date of Web Publication | 8-Feb-2023 |
Correspondence Address:
Mehul Shah
Drashti Netralaya, Nr. GIDC, Chakalia Road, Dahod - 389 151, Gujarat
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcor.jcor_48_22
Introduction: Cataract with comorbidity having poor prognosis, it is important to predict visual outcome in these eyes. Materials and Methods: This was a prospective cohort study to develop scoring system to predict visual outcome in case of cataracts with comorbidities. We enrolled all cataracts with comorbidities fulfilling inclusion criteria between August 2019 and 2020. For all enrolled cases, data were collected in pretested online format in electronic medical records. A specially designed form was used to calculate preoperative score which was categorized and compared with postoperative visual outcome. All data were exported and analyzed with SPSS 22 using descriptive, cross-tabulation, and one-sample test functions. Results: Our cohort consisted of 230 eyes of 230 patients with a mean age of 44 ± 21.22 years with 121/230 (52.6%) females and 109/230 (47.4%) males. Out of total 230 eyes Traumatic cataracts were in 64, cataract with corneal opacity in 45, postuveitic cataract in 43, neglected cataracts in 39 eyes. We found a significant difference in pre- and postoperative visual outcome. When we studied preoperative score, we found a significant difference between outcomes. Conclusion: Preoperative score for cataracts with comorbidities undergoing small-incision cataract surgery SICS is a very useful tool to predict visual outcome and universalize for comparison.
Keywords: Complicated cataract, predictive score, visual outcome
How to cite this article:
Shah M, Shah S, Kataria A, Korane A. Proposed predictive score for visual outcome in cataracts with comorbidities following small-incision cataract surgery. J Clin Ophthalmol Res 2023;11:21-5 |
How to cite this URL:
Shah M, Shah S, Kataria A, Korane A. Proposed predictive score for visual outcome in cataracts with comorbidities following small-incision cataract surgery. J Clin Ophthalmol Res [serial online] 2023 [cited 2023 Mar 23];11:21-5. Available from: https://www.jcor.in/text.asp?2023/11/1/21/369351 |
Cataracts are responsible for 47% of all cases of blindness worldwide. The epidemiological impacts of cataracts are not the same in different countries, and the rates are associated with the prevailing economic conditions. In developed countries with good health care, cataracts account for only 5% of the cases of blindness, whereas the issue is still responsible for 50% of such cases in developing countries. After a brief overview of the historical, clinical, and therapeutic aspects, this article presents an update on the global epidemiological cataract data. It also provides insights into the political, socioeconomic, and cultural factors that adversely affect the availability of health care in developing countries, making cataract a major public health concern and an impediment to development.[1]
The prevalence of cataracts increases with age. As the world's population ages, the incidence of cataract-induced visual dysfunction and blindness is rising, which represents a significant global problem. The challenges include preventing or delaying the formation of cataracts and treating those that occur.[1]
Cataracts can be cured by surgery; however, this option is not equally available everywhere and all surgical methods do not produce similar outcomes. Standard surgical services capable of providing good visual rehabilitation must be made accessible to all in need, regardless of their circumstances. The establishment and sustained delivery of these services requires comprehensive strategies that go beyond a narrow focus on surgical techniques. Changes in governmental priorities, population education, and an integrated approach to surgical and management training are warranted.[2] India is a signatory to the World Health Organization Resolution on Vision 2020. The concerted efforts of all the stakeholders have resulted in a hike in the number of manual small-incision cataract surgeries performed in the country. However, the actual impact of these measures on the elimination of avoidable blindness is unknown.[3]
Various risk factors impact the outcome of cataract surgery.
Each of these risk factors increases the possibility of an adverse outcome during cataract surgery. However, until recently, prediction of the likelihood of a complication during small-incision cataract surgery (SICS) surgery has been based on a subjective assessment of the patient by the surgeon. Various studies have identified individual risk factors that increase the risk of intraoperative complications.[1],[2],[3],[4],[5]
There are scoring systems to predict visual outcome following cataract surgeries cataract[4] which has been validated by multicentric trials in India.[6]
There are cataracts with comorbidities secondary to other ocular diseases that may not have a similar outcome as uncomplicated primary cataracts.
As there are many conditions which may have different visual outcome
The objective is to prognosticate cataracts with comorbidities because of different causes, so outcome may be variable We have tried to develop a mathematical model which may prognosticate Clinical features of different diseases labeled as numbers and resulted score is scaled from small to large and correlated with visual outcome. Visual outcome according to various categories of complicated cataracts studied.
Postuveitis cataracts, traumatic cataracts, cataracts in association with colobomas, cataracts following glaucoma surgeries, cataracts following glaucoma, vitreoretinal surgeries, cataracts with corneal opacities. Cataract with poor zonular support. Other type of complicated cataracts.
| Materials and Methods | |  |
This was a prospective, hospital-based study conducted in Drashti Netralaya after ethical clearance from the hospital ethical committee (DN/11/21). Patients who presented with complicated cataracts during August 2020 and August 2021 were enrolled.
Detailed history taking, visual acuity slit-lamp biomicroscopic examination following examination preoperative risk score was calculated in numerical values and visual outcome predicted according to number [Annexure 1].
Calculation of preoperative cataract with comorbidity score using preoperative score guidelines was done. Cycloplegic refraction was performed and fundus examination with binocular. Posterior segment examination was done using indirect ophthalmoscope. B-scan was performed in case of opaque media, optical coherence tomography done whenever possible according to media clarity.
Digital biometric reading was done according to clinical conditions and specific power calculation formulas were used postrefractive surgery or postvitrectomy and eyes with silicon oil. For eyes with corneal opacity, keratometry of other eyes was taken into account. Surgical management was done according to clinical conditions.
For uveitic cataract management control of inflammation using periocular or systemic steroids followed by surgery, clinical findings were considered for surgical techniques. Occlusion pupillae, where membrane was removed, synechiolysis using ocular viscoelastic devices micro forceps was used to grasp the pupil edge to initiate pupil edge membrane peeling. Stripping of the fibrotic tissue band around the pupil margin allowed immediate dilation of the pupil. Proper postoperative care to control uveal inflammation for traumatic cataract management: Traumatic cataracts mainly were classified according to their morphology and mechanism of injury.[7] All open globe injuries causing traumatic cataract were operated using a second sitting. Traumatic cataracts were removed either using SICS along with primary posterior capsulotomy or vitrectomy.[8] For all ectopia lentis cases After careful evaluation minimal subluxation for partial support capsular tension ring (CTR) ring, or rigid poly methyl meth acrylate (PMMA) lens during SICS.
Coloboma cataract management: Slit-lamp examination of grade of cataract, microcornea, nondilating pupils, and zonular loss/phacodonesis. Presence of nystagmus and strabismus, amblyopia, colobomas retinal pathologies were also documented CTR rings were used to support lower bag, posttrabeculectomy cataract management: After careful evaluation of glaucoma control temporal small-incision manual cataract surgery were performed. For postvitrectomy cataract silicon oil removal combined with small incision cataract surgery (SICS).
Postoperative management was done according to cause.
All patients were followed up according to the standard format and schedule.
All preoperative scores were divided into three categories 1–5, 6–10, and >10, which was studied by comparing visual outcome. The prognosis was worse from small to large.
All data were included in pretested online format in EMR data exported in an Excel sheet and analyzed using statistical package for the social sciences (SPSS) (IBM, Chicago USA) with descriptive and cross-tabulation function. All numerical variables were tested by one-sample t-test.
| Results | | |
Our cohort consisted of 230 eyes of 230 patients with a mean age of 44 ± 21.22 years with 121/230 (52.6%) females and 109/230 (47.4%) males [Table 1].
Considering clinical conditions posttrauma 64/230 (27.8%) followed by corneal opacity 45/230 (19.6%) and postuveitis 43/230 (18.7%) were the most common conditions [Table 2]. When we studied the outcome and compared other categories, we found a significant difference only in neglected category [Table 3]. | Table 3: Comparative study of visual outcome in different clinical conditions
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On presentation, 9/230 (3.8%) eyes had no perception vision while 157/230 (68.3%) had vision <1/60. In postoperative, 5/230 (2.2%) had no perception and 74 (32.2%) had vision <1/60.
The mean preoperative score was 5.19 ± 2.7 (median: 6). When we studied a visual outcome with various clinical categories, we found a significant difference in neglected cataracts We studied different variables like pre- and postoperative vision, preoperative score with preoperative and postoperative vision [Table 4].
When we compared the final visual outcome with preoperative score, we found a significant difference, concluding that preoperative score can predict the final visual outcome [[Table 5], P = 0.037]. | Table 5: Comparative study of preoperative score categories with final visual outcome
Click here to view |
| Discussion | | |
Over the last 2–3 decades, it has been proven that cataract surgery has been of immense benefit in visual rehabilitation of patients with uveitis and cataract. Cataract surgery with lens implantation has been established as a safe modality of treating cataract in patients with uveitis.[9],[10]
Conventional cataract surgery for cataract with comorbidity secondary to chronic uveitis is confronted with many complications, such as recurrent inflammation, pupillary membrane, and glaucoma.[11] This could be due to existing cystoid macular edema as a part of the uveitic disease process, as has been reported by Diamond and Kaplan.[12] However, it is hard to determine preexisting findings before surgery in the presence of the cataract. Diamond et al.[12] are of the opinion that mechanical removal and debridement of the vitreous framework in association with the lens facilitates the elimination of the cellular material from the vitreous cavity, i.e., large number of inflammatory cells in the vitreous cavity, and the persistent immune complexes are mechanically reduced and contribute to the beneficial effect in such cases.
There are poor visual outcomes because of other ocular conditions such as corneal opacities, postvitrectomies, traumatic cataracts, and subluxated cataracts.[13],[14],[15],[16],[17],[18],[19]
It is important to predict visual outcome postoperatively for these conditions.[6] The current study has tried to develop and validate a mathematic model to predict postoperative visual outcomes in the presence of different comorbidities.
We are not aware of any model available currently which is comparable. Such models are prevailing for normal cataracts where cataracts are stratified and vision is predicted which were developed by Muhtaseb et al. and Osborne et al.[4],[20] A study concluded with useful finding helps in prognosticating, counseling, and selection of cases and surgeons.
This model has been validated by Agrawal et al. which has been validated by a Indian multicentric trial for stratification of cataracts preoperatively.[6]
The current study included all clinical conditions which can cause complicated cataracts and developed scoring accordingly. We could compare the categories of preoperative score which can predict visual outcome and found a significant difference (P = 0.037).
The strength of the study is prospective design and inclusion of all types of comorbidities. Weakness is less number of cases.
| Conclusion | | |
Preoperative score for SICS is a relevant tool to predict outcome in cataracts with comorbidities which will help individualized counseling on the chances of operative complications, meaningful comparisons between national complication rates, and those of individual units or surgeons.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Lawani R, Pommier S, Roux L, Chazalon E, Meyer F. Magnitude and strategies of cataract management in the world. Med Trop (Mars) 2007;67:644-50.  |
| 2. | Brian G, Taylor H. Cataract blindness – Challenges for the 21 st century. Bull World Health Organ 2001;79:249-56. |
| 3. | Murthy G, Gupta SK, John N, Vashist P. Current status of cataract blindness and Vision 2020: The right to sight initiative in India. Indian J Ophthalmol 2008;56:489-94. [ PUBMED] [Full text] |
| 4. | Muhtaseb M, Kalhoro A, Ionides A. A system for preoperative stratification of cataract patients according to risk of intraoperative complications: A prospective analysis of 1441 cases. Br J Ophthalmol 2004;88:1242-6. |
| 5. | Chan E, Mahroo OA, Spalton DJ. Complications of cataract surgery. Clin Exp Optom 2010;93:379-89. |
| 6. | Agrawal V, Upadhyay J, Indian Cataract Risk Stratification Study group. Validation of scoring system for preoperative stratification of intra-operative risks of complications during cataract surgery: Indian multi-centric study. Indian J Ophthalmol 2009;57:213-5. [ PUBMED] [Full text] |
| 7. | Shah MA, Shah SM, Shah SB, Patel CG, Patel UA. Morphology of traumatic cataract: Does it play a role in final visual outcome? BMJ Open 2011;1:e000060. |
| 8. | Shah MA, Shah SM, Patel KD, Shah AH, Pandya JS. Maximizing the visual outcome in traumatic cataract cases: The value of a primary posterior capsulotomy and anterior vitrectomy. Indian J Ophthalmol 2014;62:1077-81. [ PUBMED] [Full text] |
| 9. | Desai S, Rao V. Visual Outcome after cataract surgery in complicated cataract. J Evol Med Dent Sci 2014;34:9142-56. |
| 10. | Agrawal R, Murthy S, Ganesh SK, Phaik CS, Sangwan V, Biswas J. Cataract surgery in uveitis. Int J Inflam 2012;2012:548453. |
| 11. | Namperumalsamy P, Das T. Surgical treatment of cataract with co morbidity following chronic uveitis. Indian J Ophthalmol [serial online] 1982;30:87-9. |
| 12. | Diamond JG, Kaplan HJ. Lensectomy and vitrectomy for complicated cataract secondary to uveitis. Arch Ophthalmol 1978;96:1798-804. |
| 13. | Ho YJ, Sun CC, Chen HC. Cataract surgery in patients with corneal opacities. BMC Ophthalmol 2018;18:106. |
| 14. | Sinha R, Sharma N, Vajpayee RB. Visual outcome of cataract surgery with pupillary sphincterotomy in eyes with coexisting corneal opacity. BMC Med 2004;2:10. |
| 15. | Azhany Y, Hemalatha C, Nani D, Rosediani M, Liza-Sharmini AT Sequelae of neglected senile cataract. Malays Fam Phys 2013;8:33-7. |
| 16. | Völcker HE, Naumann G. Clinical findings in phakolytic glaucoma (author's transl). Klin Monbl Augenheilkd 1975;166:613-8. |
| 17. | Joshi RS. Primary posterior capsular opacification in Indian rural population undergoing cataract surgery for hypermature senile cataract. Clin Ophthalmol 2013;7:1605-8. |
| 18. | Agarkar S, Mailankody S, Settu S, Srinivasan R, Raman R. Visual outcomes following cataract surgery with intraocular lens implantation in vitrectomized eyes among children. Indian J Ophthalmol 2021;69:2078-81. [ PUBMED] [Full text] |
| 19. | Lingam G, Sen AC, Lingam V, Bhende M, Padhi TR, Xinyi S. Ocular coloboma-a comprehensive review for the clinician. Eye (Lond) 2021;35:2086-109. |
| 20. | Osborne SA, Severn P, Bunce CV, Fraser SG. The use of a pre-operative scoring system for the prediction of phacoemulsification case difficulty and the selection of appropriate cases to be performed by trainees. BMC Ophthalmol 2006;6:38. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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