|Year : 2003 | Volume
| Issue : 3 | Page : 209-210
The Cataract Scene
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Thomas R. The Cataract Scene. Indian J Ophthalmol 2003;51:209-10
Into the 21st century, hype around the cataract backlog continues to mesmerise and drive Indian ophthalmology. Cataract blindness figures don't need repetition: anyone remotely involved in blindness control probably lives and dreams "backlogs" and "targets". It is however important to remember that the prevalence and incidence of blindness were estimated using the technique of distant direct ophthalmoscopy. This is not the most appropriate technique for the detection of cataracts. If we adjust for the sensitivity and specificity of the distant direct ophthalmoscopy in cataract detection, we realise the incidence of cataract blindness has probably been overestimated. This seems to be borne out by more recent data; and by the fact that we are increasingly operating on second eyes.
If the magnitude of the problem has been overestimated, and the incidence is not really as high as it is made out to be, perhaps we can afford to improve our quality. The question is, is there a need to? The assessment of outcome of cataract surgery in several states, was published relatively recently by the National Society for Prevention of Blindness (NSPB). Most states were found to have success rates above 70%. Reasonably impressive for a poor developing country, until we realise that success was defined as vision better than 3/60; that the inclusion criterion was vision equal to or less than 6/60 makes it even less palatable. The WHO guideline for reasonable quality is that following cataract surgery, less than 5% of patients should have a visual acuity <6/60; including preexisting causes. In most states this proportion was around 30%. The need to improve the quality was (partly) what the World Bank programme was about. How are we faring there?
The NPCB also published the results of the evaluation of training for ophthalmic surgeons in extracapsular cataract extraction (ECCE) and intraocular lens implantation (IOL). I hope things have changed since, but those truth tables showed that 14 of 66 training sites did not have operating microscopes. How was training carried out? (I presume that those that did have microscopes also had the beam splitters and observers' scopes required for the teaching). Twenty sites did not have a slitlamp; 14 of the sites did not have an A Scan; 28 did not have a Keratometer.
So then, was training without slitlamp examinations and IOL power calculations? Forty-two of the 66 sites did not have a vitrectomy machine; how were they trained to manage vitreous loss? I presume that at the sites where vitrectomy machines were available, they were functional and had a supply of functioning cutters. Fourteen sites did not have a tonometer. Did the pre- and post-op assessment not include an IOP? In view of all this, should we really be surprised that our outcomes are what they are? And is this what we would like them to be in our country?
As students, Prof LP Agarwal (Rajendra Prasad Centre, All India Institute of Medical Sciences, New Delhi) kept reminding us that there was more to ophthalmology than cataract surgery. He didn't say there was more to ophthalmology than cataract -there's lots and lots to cataract. He said cataract surgery . Sure enough, over the years we have managed to reduce ophthalmology to cataract, and worse still to numbers of cataract operations done. There is no question that the backlog needs to be addressed. But we tend to use the backlog as an excuse for everything: as an excuse not to perform routine pre and postoperative slitlamp examination. As an excuse not to perform routine tonometry, or examination of the fundus, thus missing a whole lot of treatable pathology in the process. As an excuse not to procure instrumentation to manage vitreous loss, the most common complication of cataract surgery. Knowing that if properly managed by a trained person, the outcomes of cataract surgery in an eye with vitreous loss can be similar to uncomplicated cases.
The objective of cataract surgery is restoration of eyesight and the outcome measure should be visual rehabilitation. WHO has reasonable guidelines we should follow. Regrettably in our target oriented mega IOL camps usually designed to meet arbitrary deadlines, this outcome seems to have been substituted by the act of inserting an IOL. In the quest for numbers, it does not seem to matter if the patient can or cannot see, as long as an IOL has been inserted. No matter if the IOL is inserted into the vitreous or the cornea in front of it has melted, or indeed the eye has had to be removed. As long as the IOL had been inserted, the case is a success to be reported and collected on. Surely we cannot continue using the excuse of a large backlog in a poor developing country to maintain the status quo forever. Sooner or later we have to catch up with what ophthalmology is really about. And, by the way, ophthalmology may not about using the latest technique (or smallest possible incision) in vogue for dismantling cataracts either. The latest (untested) technology is not necessarily the best or safest for the patient: the objective is restoration of sight, not the technique used to achieve it. There is cause for hope. The publication of outcomes means we are willing to confront the issue, a welcome change from our usual complacent attitude. The resultant sentinel surveillance units are a step in the right direction. If they function effectively (and they can be made to), I am sure they will play a crucial role in improving outcomes. Isn't it also time to lay down the minimum acceptable in outcomes? Aren't the WHO guidelines a good place to start? Of course we must realise too that all current strategies are short term. Sustained quality care in the long term, can only be achieved by dramatically improving the quality of training in our residency programs.
This issue's lead article is a tribute to the father of the intraocular lens, Sir Harold Ridley. To quote the authors, "Sir Harold Ridley has changed the world so that our patients may better see it." Let us strive to ensure that.
| References|| |
Thomas R, Muliyil J. The incidence of cataract in India is an overestimate. The National Medical Journal of India
Dandona L, Dandona R, Naduvilath TJ, McCarthy CA, Nanda A, Srinivas M, Mandal P, Rao GN. Is current eye-care policy focus almost exclusively on cataract adequate to deal with blindness in India? The Lancet
Assessment of outcome of cataract surgery: Results of the survey between April 1998 to March 1999. A publication of the National Programme for Control of Blindness, Ministry of Health & Family Welfare, Government of India.
NPCB. Evaluation of training of ophthalmic surgeons in ECCE/IOL cataract surgery: Results of study done between July to October 1999. New Delhi: National Programme for Control of Blindness, Ministry of Health & Family Welfare, Government of India.
Trivedi RH, Apple DJ, Pandey SK, Werner L, Izak AM, Vasavada AR, Ram J. Sir Nicholas Harold Ridley. He changed the world, so that we might better see it. Indian J Ophthalmol
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