|COMMUNITY EYE CARE
|Year : 1998 | Volume
| Issue : 1 | Page : 47-50
Cataract surgery in India: Results of a 1995 survey of ophthalmologists
AK Gupta, HK Tewari, LB Ellwein
Amar Eye Center, Delhi, India
A K Gupta
Amar Eye Center, Delhi
Source of Support: None, Conflict of Interest: None
The aim of this study was to investigate cataract surgery procedures and caseloads among Indian ophthalmologists in private and government practices. Members of the All India Ophthalmological Society and state ophthalmic societies were surveyed by mail questionnaire in December 1995. Out of 6,800 surveyed, 2,098 responses (31%) were received. Over 61% of the 990,249 reported cataract surgeries were carried out in private facilities with 24% of private patients receiving extracapsular cataract extraction (ECCE) and 41% ECCE with intraocular lens (IOL). Intracapsular cataract extraction remains more common in government facilities with 62% of cases. Over 85% of all surgeons reported some experience with ECCE/IOL. Surgeons operating in both private and government facilities carry an average annual caseload of 861 cataract surgeries, which is twice that of their colleagues operating exclusively in either private or government settings. Although the questionnaire response rate was low, the findings suggest that ECCE is more common in India than is generally recognized, and with the recent availability of low-cost IOLs, its popularity is rapidly expanding.
Keywords: Cataract surgery, ophthalmologist, survey, India
|How to cite this article:|
Gupta A K, Tewari H K, Ellwein L B. Cataract surgery in India: Results of a 1995 survey of ophthalmologists. Indian J Ophthalmol 1998;46:47-50
|How to cite this URL:|
Gupta A K, Tewari H K, Ellwein L B. Cataract surgery in India: Results of a 1995 survey of ophthalmologists. Indian J Ophthalmol [serial online] 1998 [cited 2020 May 31];46:47-50. Available from: http://www.ijo.in/text.asp?1998/46/1/47/14977
A survey of cataract surgery in India was carried out in 1992. This first survey was targeted to the 4,356 members of the All India Ophthalmological Society (AIOS). Responses were received from 49%, reporting on 1,023,070 cataract cases. It was found that 26% of private patients received extracapsular cataract extraction (ECCE) with intraocular lens (IOL) implantation and another 21% received ECCE without IOL. Among patients operated in government facilities (1/3 of the annual national total), the corresponding ECCE/IOL and ECCE percentages were 9% and 22%, respectively.
The current survey represents a repeat study aimed again at AIOS members, plus members of the various state societies who are not AIOS members. The extension to state society memberships was motivated by an attempt to reach the half of the 8,000 Indian ophthalmologist population who are not AIOS members. The purpose of the survey was to investigate cataract surgery patterns during 1995 and to investigate the extent to which these patterns and surgeon caseloads vary by practice setting, time since graduation, and affiliation with teaching institutions.
| Methods|| |
The survey questionnaire requested information on the number and type of cataract procedures carried out within the past 12 months and whether the cases were operated in private or government facilities. Although anonymity was encouraged, respondents were asked to identify their state and district of residence, the year of their post-graduate degree or diploma, and whether they held any affiliation with a teaching institution. These latter two questions were not part of the earlier 1992 survey. For reporting purposes, graduation in 1981 or later was used (somewhat arbitrarily) as a cut-off to divide surgeons into two groups.
The initial query, sent out in December 1995, was followed by a second one in April 1996. The query list was compiled from names of the AIOS roster supplemented by additional names from state ophthalmologic society membership lists. A total of 6,800 ophthalmologists were queried and 2,098 (30.9%) responded before November 1996, the time at which data analysis began.
| Results|| |
Of the 2,098 ophthalmologists responding to the survey, 1,959 were active cataract surgeons [Table - 1]. All but 18.8% of active surgeons operate in private facilities, either exclusively (58.6%), or in addition to their government practice (22.6%). Across all practice categories, 57.7% of active surgeons reported graduating in 1981 or later, versus 34.6% for those graduating earlier. Private surgeons were least likely to be recent graduates (60.5%) and government surgeons most likely (70.8%). The median year of the post-graduate degree or diploma was 1983.
Over 61% of the reported cataract surgeries were carried out in private patients [Table - 2]. Only 15.6% of all patients were operated by surgeons operating exclusively in government facilities. The majority of government patients (59.8%) were operated by surgeons who practice in both private and government settings (composite surgeons). Indeed, the workload of composite surgeons involved more government patients than private patients by a 3 to 2 ratio.
Private practice surgeons averaged 396 cataract cases per year, while government practice surgeons averaged 419 cases; composite practice surgeons carry an average case load of private patients (342) almost equal to that of private surgeons and a case load of government patients (518) that exceeds that of the government surgeon. In effect, the composite practice ophthalmologist is engaged in two "full-time" equivalent practices. Nearly 8% of both private and government practice surgeons report operating on <25 cataract cases in the one-year period, whereas only 1.4% of composite practice surgeons (2) had such low volume [Table - 3].
Upon categorization by year of graduation, the major difference in volume distribution occurs in the frequencies of the two extremes [Table - 3]. Younger surgeons are more likely to operate on <100 cases annually and less likely to have volumes >l,000 cases. This same degree of asymmetry holds when surgeons are divided on the basis of affiliation with a teaching institution. Here the non-affiliated (79%) are less likely to have high volumes and more likely to experience relatively low volumes.
In investigating experience with specific cataract extraction procedures, we find that at some time within the one-year survey period, the overwhelming majority of surgeons had performed both ECCE and intracapsular cataract extraction (ICCE) procedures [Table - 4]. Experience with cataract extraction by phacoemulsification is approaching 10% for cataract surgeons as a whole. As expected, surgeons with teaching institution affiliation report the highest degree of experience with this new technology and government surgeons the lowest. ICCE with implantation of an anterior chamber IOL was practiced by 23% of all surgeons. It should be recognized that the data in [Table - 4] reflect surgical procedures performed only in 1995, and thus should not be interpreted as reflecting lifetime experience. For example, surgeons without ICCE experience in 1995 would include those who have abandoned the technique in favor of ECCE with or without IOL.
In terms of procedure frequency, we see that ECCE is reported as the most popular method of cataract extraction (53.7%) in India [Table - 5]. However, in more than a third of ECCE cases an IOL is not inserted. For government patients, ICCE (without IOL) remains the most commonly reported procedure, particularly for patients operated by surgeons who also offer cataract surgery in a private setting, where they are least likely to perform an ICCE procedure.
| Discussion|| |
It is of interest to note that a substantial fraction of ECCE cases are still not receiving an IOL. It is reasonable to assume that the majority of these cases were planned as ECCE, and not cases where the lens capsule ruptured during intracapsular delivery of the lens leading to an unplanned ECCE. Unavailability of (high quality) low-cost IOLs may be one reason for not implanting an IOL. Another explanation may, in part, lie with the 5.2% of the surgeon population who report ECCE experience but no ECCE/IOL surgeries (data not shown). It is also of interest that 22.8% of surgeons reported ECCE or ECCE/IOL experience, but no ICCE procedures.
The National Programme for the Control of Blindness (NPCB) in India reports that 2,164,000 cataract operations were performed between April 1994 and March 1995, and 2,469,000 in 95-96 (unpublished data). It is probable that this increase was stimulated by implementation of the World Bank-assisted cataract blindness control project. It is unlikely that underreporting among respondents could account for the more than two-fold difference between NPCB reported cases and those obtained in this survey. Accordingly, a substantial amount of cataract surgery must have been carried out by ophthalmologists not responding to the survey. Indeed, the low response rate (31%) is the most serious weakness of the survey. In 1992 when only AIOS members were surveyed, the response rate was 49%. An estimated 1,200 ophthalmologists not members of AIOS or a state society were not on the survey mailing list, and it is possible that they, too, are carrying out a substantial number of cataract surgeries.
The important question is not what the magnitude of unreported surgeries is, but whether the responses obtained are representative of both cataract patients and the surgeon population at large. In this regard it is difficult to assess the possible nature and direction of biases introduced because of respondent self-selection. Those who responded are likely to be the most progressive practitioners and prepared to report on their experience. The responses appear to be unrepresentative in at least one important way: ophthalmologists operating on patients in government facilities appear to be underrepresented based on the relatively low percentage of patients reported as receiving surgery in these facilities (39%). Perhaps these surgeons are less likely to be members of the AIOS or of their state ophthalmology society, and thus, did not receive the survey questionnaire. In this regard, the percentage of the overall cataract patient population receiving ECCE/ IOL may not be as widespread as this survey suggests. The discrepancy between the number of cases reported in the survey and the number from NPCB data is of the order of 1,400,000 cases. If it is conservatively assumed that these unreported cases are predominately government patients and with ECCE/IOL experience comparable to that reported here for government cases (20.6% received ECCE/IOL), the total number of IOL implantations would have exceeded 600,000 cases in 1995 (the 329,235 reported in the survey plus another unreported 288,400 IOL cases). This is about 25% of the total NPCB cataract cases.
Because of the low response rate, one must exercise caution in extrapolating survey findings to the cataract population at large. Accordingly, calculation of confidence intervals or other statistical analyses were not considered appropriate.
Comparing results with those from the 1992 survey must also proceed with caution because there is no way of knowing the extent to which the responding surgeon sample was comparable for the two surveys. Nevertheless, a trend toward ECCE/IOL for both private and government patients appears clear. Among private patients, the percentage receiving ECCE/IOL increased from 26% to 41% while ICCE decreased from 51% to 31%. Among government patients, the percentages increased from 9% to 21% for ECCE/IOL and decreased from 65% to 63% for ICCE. ECCE without IOL increased from 21% to 24% among privately operated patients but decreased from 22% to 16% in government patients. Although less conclusive, changes may also be taking place within practice settings. Surgeons in composite practices may be managing an increasing percentage of both government and private cataract patients. Composite practice surgeons operated on 60% of government patients, up from 46% in the 1992 survey. Although the overwhelming majority of private patients continue to be operated on by surgeons devoted to private practice, the percentage operated by composite surgeons increased from 20% to 25%. Interestingly, composite practice surgeons appear to be using ICCE in those patients operated in government facilities and ECCE in those operated in private facilities, even if an IOL is not available for the private patient [Table - 5].
The data reported here on cataract surgery procedure utilization and surgeon caseloads are complementary to other indicators of cataract intervention efforts such as resource availability and cataract blindness prevalence. What is not receiving sufficient attention, however, is the extent to which cataract surgery is satisfactorily restoring sight and visual function in the operated patient, whatever the procedure or the setting in which it is performed. Ultimately, the primary indicator of accomplishment is not the number of operations performed, but the number of cases with patient reported improvement in vision.
| Acknowledgement|| |
This work was supported in part by a grant from Allergen, Inc. to the All India Ophthalmological Society.
| References|| |
Gupta AK, Ellwein LB. The pattern of cataract surgery in India:1992. Indian J Ophthalmol
Jose R, Bachani D. World Bank-assisted cataract blindness control project. Indian J Ophthalmol
Limburg H, Kumar R, Bachani D. Monitoring and evaluating cataract intervention in India. Br J Ophthalmol
Ellwein LB, Kupfer C. Strategic issues in preventing cataract blindness in developing countries. Bull WHO
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]