|Year : 2017 | Volume
| Issue : 12 | Page : 1477-1482
Safety, efficacy and cost-effectiveness of consecutive bilateral cataract surgery on two successive days in tribes at base hospital through community outreach program: A prospective study of Aravali Mountain, North West India
Amit Mohan, Navjot Kaur, Vishal C Bhatanagar
Department of Community Ophthalmology, Global Hospital Institute of Ophthalmology, Abu Road, Sirohi, Rajasthan, India
|Date of Submission||03-Aug-2017|
|Date of Acceptance||19-Sep-2017|
|Date of Web Publication||5-Dec-2017|
Dr. Amit Mohan
Global Hospital Institute of Ophthalmology, Talehati, Abu Road, Sirohi, Rajasthan
Source of Support: None, Conflict of Interest: None
Purpose: The aim of the study was to evaluate the safety and efficacy of consecutive bilateral cataract surgery (CBCS) on two successive days in a single hospital visit. Methods: Prospective study was conducted on 565 patients of various tribes of hilly area of West Rajasthan who had come to our hospital through community outreach programmed (CORP) between January 2015 and March 2016. Patients with significant bilateral cataract without any other ocular morbidity were advised bilateral manual small incision cataract surgery on two consecutive days. Intraoperative and postoperative complications were evaluated, and follow-up was done at 1 week, 1 month, and 3 months. Results: Out of 565 patients, 519 underwent both eye surgeries. Second eye surgery was deferred for a later date in 46 cases. Because of intraoperative and postoperative complications in the first eye, 31 had delayed surgeries while 15 patients refused to undergo another eye surgery either because of postoperative day 1 poor vision in the operated eye due to retinal pathologies (n = 8) or unwillingness (n = 7). The second eye surgery was performed for 519 patients, out of whom six had intra or postoperative complications. At 1 month follow-up, four patients had unilateral cystoid macular edema and three had prolonged postoperative inflammation. At 3 months, all patients were satisfied and had no complications. None of the patients had sight-threatening complications such as endophthalmitis, corneal decompensation, or vitreoretinal complications. Conclusion: CBCS may be considered safe and cost-effective for patients living in remote locations, dependent on CORP.
Keywords: Bilateral cataract surgery, community outreach programmed, cost-effective cataract surgery, small incision cataract surgery
|How to cite this article:|
Mohan A, Kaur N, Bhatanagar VC. Safety, efficacy and cost-effectiveness of consecutive bilateral cataract surgery on two successive days in tribes at base hospital through community outreach program: A prospective study of Aravali Mountain, North West India. Indian J Ophthalmol 2017;65:1477-82
|How to cite this URL:|
Mohan A, Kaur N, Bhatanagar VC. Safety, efficacy and cost-effectiveness of consecutive bilateral cataract surgery on two successive days in tribes at base hospital through community outreach program: A prospective study of Aravali Mountain, North West India. Indian J Ophthalmol [serial online] 2017 [cited 2020 Feb 28];65:1477-82. Available from: http://www.ijo.in/text.asp?2017/65/12/1477/219852
The most recent estimates from the WHO reveals that 47.8% of global blindness is due to cataract and in the South Asia region, 51% of blindness is due to cataract. Vision 2020: Right to sight approach is targeted toward the bilaterally blind. For the immediate future, where a significant proportion of those over 50 will be blind, the first priority should be given to restoring vision to those already blind. Cataract has been documented to be the most significant cause of bilateral blindness in India where vision <20/200 in the better eye on presentation is defined as blindness.
Rajasthan is the largest state in India, located in the northwestern part of the country. The most striking feature of this region is the densely forested Aravali mountains. These are home to various tribes. The main tribes of the study area are Bhil, Meena, Garasia and Kathodi, which form 12% of the total population of the state. These tribes are of low socioeconomic status, and have limited access to formal healthcare. They depend on local vaidyas who treat them with herbs and shrubs. They have to travel on an average about 100 km to reach the closest hospital. Our hospital organizes eye checkup camps in these remote villages from time to time.
Since cataract is a major cause of avoidable blindness, the key to the success of Vision 2020: the right to sight initiative is a special effort to tackle cataract blindness. Hence, we decided to perform bilateral manual small incision cataract surgery (BMSICS) in those patients whose vision was <20/200 in the better eye and having significant cataract in both eyes. As with any controversial procedure, there are pros and cons to BMSICS, the main risks being endophthalmitis, simultaneous toxic anterior segment syndrome, postoperative cystoids macular edema as well as the inability to alter one's surgical plan for the second eye. However, there are economical and logistic benefits if a patient were to undergo bilateral cataract surgeries in a single hospital visit. Another reason for considering BMSICS is because the patients are delaying cataract surgery in the other eye after having undergone cataract surgery in one eye since their immediate visual needs are taken care of. Therefore, they present very late for other eye surgery as lens-induced glaucoma. There are numerous studies favoring immediate simultaneous bilateral cataract surgeries,, but few have reported vision-threatening complications such as endophthalmitis, corneal decompensation, retinal detachment, and refractive surprises., Considering all these factors, we decided that performing the second eye surgery on the consecutive day on the next day would be effective, and therefore we termed it consecutive bilateral cataract surgery (CBCS). The aim of the study was to assess the visual outcome and intraoperative and postoperative complications of CBCS in tribes of this region, who had visited the base hospital through community outreach programmes (CORP).
| Methods|| |
All patients who had bilateral significant cataract without any other detectable or known ocular comorbidities attended the outreach camp and came to the base hospital for surgery between January 2015, and March 2016 were included in the study. The Institutional Ethics Committee on Human Subjects Research, 2013–2014, granted approval, subsequent to which the study was initiated. Informed written consent in the local language was obtained from all participants before surgery, and guarded visual prognosis was explained in cases of mature and hypermature cataract. In mature and hypermature cataract, ultrasonography B scan was done to rule out any retinal pathology. Diagnosis of cataract was based on vision on snellen's chart, slit lamp examination, and direct ophthalmoscopy and cataract were graded using the Lens Opacities Classification System (LOCS) III. Only those patients were included in the study whose best-corrected visual acuity in the better eye was <20/200.
Thorough general examination was done on all patients, including blood pressure measurement, blood sugar, routine urine examination, and if required physician referral. Not all high-risk patients with uncontrolled diabetes, hypertension, and coronary artery diseases were enrolled for CBCS. The complete ophthalmic examination was done by the resident ophthalmologist as well as by the operating surgeon, which included slit lamp examination, intraocular pressure (IOP) measurement, dilated fundus examination, and screening for patency of nasolacrimal duct one day before the first eye surgery. Blocked nasolacrimal duct obstruction, High IOP, any adnexal infection, lid condition, and retinal pathology were not enrolled for CBCS. Contact biometry and intraocular lens (IOL) power were calculated one day before surgery for both eyes and patients with axial length between 21.00 and 26.00 mm were included because of fear of inaccurate biometry in other cases. Patients with difference between axial length in two eyes >2.5 mm or irregular corneal astigmatism were also excluded from the study.
Preoperative topical ciprofloxacin had been started 4–6 times a day 1 day before surgery.
MSICS was done through superior or superotemporal sclerocorneal tunnel in all patients in a routine functional eye operation theater (OT) under strict aseptic and sterilization precaution as per the National Programme for Control of Blindness guidelines set down by experienced surgeons under peribulbar block. All surgeries were performed by two surgeons (one had more than 25 years of experience, and the other had eight years of experience). A solution of 10% povidone iodine was used for surface painting/cleaning. About 5% povidone solution is used as eye drop for conjunctival sac cleaning. The operated eyes were evaluated for amount of inflammation, postoperative refractive error, and status of retina on the next day first by resident ophthalmologist and then by the operating surgeon. Visual acuity was recorded by a senior optometrist. Resident ophthalmologist and senior optometrist, who were involved in evaluation, were not aware of hypothesis. The other eye surgery was advised on the basis of visual improvement in the operated first eye. In the event of poor visual outcome (pinhole vision <6/18), posterior capsular rent or any other sight-threatening intra- or post-operative complications in the first eye, the second eye surgery was deferred to a later date.
The second eye surgery was done by the second surgeon in different OT room/table with an assistant. A different batch of irrigating solution, ocular viscoelastic device, dyes, and IOLs were used for the second eye surgery to avoid a smaller risk of any contamination on the very next day. Both eyes were evaluated the next morning for visual acuity and any complications.
Postoperative topical fluoroquinolone antibiotics 4–6 times/day for 7 days along with topical steroids in tapering doses for 6–8 weeks and cycloplegics if required were prescribed. Personal hygiene was emphasized and protective dark glasses provided. Follow-up was done on the first and second-postoperative day in the hospital by operating surgeon and discharged on the third day. Patients were sent to their native village by transport provided by the hospital. Postoperative follow-up examination was conducted at 1 week, 1 month, and 3 months at their places by our ophthalmic team including one resident ophthalmologist using our mobile eye clinic which had all the necessary portable ophthalmic instruments. Visual acuity, refraction, slit-lamp examination, and dilated fundus examination were done at 1 month follow-up and glasses were prescribed.
The uncorrected visual acuity (UCVA) and pin-hole visual acuity (PHVA) were tested and classified according to the WHO recommendations. This visual acuity was converted to log MAR values for statistical analysis. Pre- and post-operative visual outcome comparison was performed using paired t-test. P < 0.05 was taken as statistically significant.
Descriptive statistical analysis was performed for other variables and presented in a number (%). The statistical software, statistical product, and service solutions (SPSS 15.0, SPSS for Windows, Version 16.0, Chicago, SPSS Inc.) were used for analysis of the data and Microsoft Word and Excel have been used to generate graphs, tables, and so on.
| Results|| |
A total of 6,998 cataract patients were operated on between January 2015 and March 2016 at our hospital, out of which 565 patients with age range from 44 to 86 years (mean age 63.77) were included in the study, 57.87% (n = 327) were female and 42.13% (n = 238) were male [Table 1]. Totally 519 patients underwent for CBCS while in 46 patients second eye surgery had been abandoned due to different cause [Table 2]. The mean axial length was 22.9 mm (range 21.5–25.5 mm). The entire 1084 eyes were evaluated (565 first eye + 519 s eye) for visual and refractive outcome and for complications analysis.
The mean preoperative best-corrected visual acuity (BCVA) was 1.207 logarithm of the minimum angle of resolution (logMAR) which improved to 0.335 logMAR at 1 week and 0.240 logMAR at 1 month follow-up (P< 0.05). As per the WHO classification, all 565 patients enrolled for CBCS had BCVA <6/60 in better eye and categorized as poor vision (100%). At 1 month postoperative follow-up UCVA in 941 (86.8%) eyes were >6/18, PHVA in 1041 eyes (96.03%) were >6/18. [Table 3a] and [Table 3b] summarizes the preoperative and postoperative visual acuity at 4 weeks follow-up. Visual outcome as per the WHO recommendations is good in 96.03%, borderline in 2.50%, and poor in 1.47%. Poor visual outcome was either due to fundus pathology or intraoperative or postoperative complications [Table 4].
|Table 3a: Preoperative and postoperative visual acuity in consecutive bilateral cataract surgery|
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|Table 3b: Visual outcome in consecutive bilateral cataract surgery as per the WHO classification|
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The mean corneal astigmatism by keratometry reading of preoperative patients was 1.054 D ranging from 0 to 4.25 D. At 4 week follow-up, the mean corneal astigmatism was 1.314 D ranging from 0.25–4.5 D [Table 5].
Intraoperative and postoperative complications
Out of 1084 eyes, 1.47% (n = 16) had intraoperative complication. Posterior capsular rent with or without vitreous loss was recorded in nine eyes (0.83%), zonular dialysis in two eyes (0.18%), and tunnel-related complication in five eyes (0.46%). Only 4 cases (0.37%) left aphakic. Postoperative complications include transient IOP elevation in 3 eyes (0.27%), corneal edema in seven eyes (0.64%), soft eye in 1 case (0.09%), lens decentration in two cases (0.18%), hyphema in two cases (0.18%), retained cortical matter in one case (0.09%), and signs of inflammation in 3 cases (0.27%). Resurgery on operated eye were done on next postoperative day in six cases (0.55%); Anterior chamber wash in three cases, intraocular lens centration in two cases and wound suturing in one case (four re-surgeries were done in first eye so other eye surgery deferred on next day). At 1 month follow-up, three eyes had optic capture of IOL, one had iris prolapse, and sent for iris abscission and suturing. Only three patients had prolonged inflammation. Two had uniocular cystoid macular edema (CME) which was detected on the basis of reduced visual acuity and loss of foveal depression on slit-lamp biomicroscopy. None of the patients developed any sight-threatening complication such as endophthalmitis, corneal decompensation, or bilateral CME. At three months in 98.53%, there was improvement in visual acuity at least two Snellen lines while other 1.47% patients had poor vision (<6/60).
| Discussion|| |
Cataracts are the major cause of blindness and visual impairment in developing countries and contribute to more than 90% of total disability-adjusted life years. A review done by Rao et al. shows that this continues to be a problem in India, especially for the female population, those residing in rural areas and those who are illiterate. In our study, most of the patients were female (57.87%). Most of the rural population living in this part of the country is widely scattered among hilly villages, which are accessible only by foot. These tribes reside in the interior parts of the forest, and there are poor transportation facilities and less accessibility of eye care services. CORP can be good alternative for elimination of avoidable blindness in this scenario. We are doing community-based outreach activities for these tribes and giving them the facility for transportation and affordability of eye care services at the base hospital.
High quality, high-volume cataract surgery has been popularized in community eye care centers to effectively manage the large backlog of cataract blindness. Manual small incision cataract surgery through sclera tunnel that does not need to be sutured may be the most appropriate technology for such settings., In this study, we have done MSICS in all cases because of hard and more mature cataracts. Most of our patients of this study have such cataracts because patients from these tribes tend to wait longer for operations due to lack of awareness.
Most surgeons routinely perform delayed sequential cataract surgery separating bilateral surgeries by one to 4 weeks, which is considered the standard of care for cataract surgeries. Alternatively, surgeons and patients may elect immediate sequential bilateral cataract surgery which was popularized in 1996 by Steve Arshinoff in Canada. It has also been accepted in situ ations involving some of our highest risk patients such as small children, the mentally challenged and the demented elderly who require general anesthesia. Here, we have done CBCS in two successive days for the benefit of the population who do not have access to eye care facilities and are only dependent on community outreach activities. No literature is available on CBCS.
Patient selection and proven track record of OT are crucial for CBCS. We have excluded all complicated cases of pseudoexfoliation, posterior polar cataract, and nondilating pupil from our study. In the last 5 years, there was not even a single case of endophthalmitis in 23,099 operated intraocular surgeries at our center as per clinical record of complication register, so we have decided on CBCS. If a complication was encountered in the first eye, then the second eye surgery was deferred and not undertaken for the next day, which occurred in 31 eyes (5.48%) in our study. The second eye surgery was undertaken only after patient's desire to proceed was obtained, and if patient was not willing than other eye surgery was postponed. In our study, 15 (2.65%) patients were not willing to undertake the other eye surgery.
This prospective study result showed good visual outcome at 1 and 4 weeks. The visual outcome of the study was comparable with a similar study done on MSICS patients in India, Nepal, and Pakistan.,,, The presenting visual acuity was <6/60 in 100% of the eyes. At 4 weeks follow-up, 96.03% achieved a visual acuity of 6/18 or better. Our finding in the difference in the mean preoperative (1.054 D) and postoperative astigmatism (1.314D) was not significant and is lower than the study published by Hennig et al. and similar to the study done by Gogate., Intraoperative and postoperative complications were very low and comparable with different simultaneous bilateral cataract surgery done by phacoemulsification on same day., Only four (0.37%) patients were left aphakic and needed secondary IOL implantation at a later date in our study. There was no incidence of button holing or premature entry in any case; however, 5 cases required suturing at tunnel which is similar to the study done by Schroeder, who reported tunnel complications in 1.5% of his cases. Most of the MSICS report a transient corneal edema, which clears off by the 1st week. In our series, only seven eyes had corneal edema and none of them developed corneal decompensation. A series from Ghana had a single case of bullous keratopathy. A clinical audit of more than 8000 cataract surgeries done in Pune had found 12 cases of corneal decompensation.
In our study, only three cases had prolonged inflammation which healed in 3 months. The series from south India had mild iritis in 6% and moderate iritis in 3% cases in the first postoperative week  in white cataract.
Posterior capsular rent with or without vitreous loss was recorded in 9 cases (0.83%) in our study. A series of MSICS had 2/168 posterior capsular rent  while in another series of 100 cases of white cataract did not have a single rent.
In our series of MSICS, none of the patients developed endophthalmitis which may be due to all aseptic precautions were taken preoperative and intraoperatively. We have also excluded the cases with high risk. Arshinoff and Bastianelli suggested that bilateral endophthalmitis is ten times rarer than unilateral endophthalmitis. There is no bilateral CME or retinal detachment developed in our patients. However, three patients developed unilateral CME which resolved with topical nonsteroidal anti-inflammatory drugs in 3 months.
CBCS had also impact on cutting down the cost of cataract surgery to almost half by reducing the cost of double transportation, single hospital stay, single preoperative pathology test, preoperative medication cost reduction, follow-up cost, dark goggles, and spectacles cost. Hence, it had economic benefit for community.
Most previous studies have taken stands against simultaneous surgery in camp conditions and are conducting the same only for high-profile patients. However, the rural tribal community-based in remote locations, who are bilaterally blind, need the bilateral surgery simultaneously. If we are maintaining high standard of asepsis and same operative setup as for our routine outdoor patients, and different batch of consumables for two eyes we can do at least CBCS in two successive days for these underprivileged community.
The strength of our study is that we have studied prospectively all patients of CBCS and taken a large sample size and enabled 100% follow-up. We have ensured follow-up of all patients by involving the community outreach workers and local camp organizers from the same community. The main limitation of our study was that it was a single-center study and only an expert surgeon performed the surgery with all extra precautions, such as changing the batch of consumables.
| Conclusion|| |
CBCS can be performed on two consecutive days in patients with significant bilateral cataract living in remote location and having less access to healthcare and transport facilities through community outreach programs at a base hospital by experienced surgeons under strict aseptic precaution.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3a], [Table 3b], [Table 4], [Table 5]