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Visual Outcome of Cataract Surgery Complications Repair at a Cataract Training Centre of Western Central India
Mehul A. Shah1*, Shreya M. Shah1 and Ashit Desai1
1Drashti Netralaya, Dahod, Gujarat, India.
Authors’ contributions
This work was carried out in collaboration among all authors. Author MAS designed the study, performed the statistical analysis, wrote the protocol and wrote the first draft of the manuscript.
Authors SMS and AD data managed the analyses of the study. Author AD data acquisition managed the literature searches. All authors read and approved the final manuscript.
Article Information
DOI: 10.9734/OR/2020/v12i330148 Editor(s):
(1)Tatsuya Mimura, Tokyo Women's Medical University, Japan.
Reviewers:
(1)Gabor Nemeth, Borsod-Abaúj-Zemplén County Hospital and University Teaching Hospital, Hungary.
(2)Asaad Ahmed Ghanem, Mansoura University, Egypt.
Complete Peer review History:http://www.sdiarticle4.com/review-history/56874
Received 08 March 2020 Accepted 12 May 2020 Published 27 May 2020
ABSTRACT
Introduction: Cataract is a major cause of blindness, but it can be eliminated by surgical management. The visual outcome depends upon the competency of the surgeon, and quality training can contribute to the creation of such skilled surgeons.
Methods: This is a retrospective study in which we enrolled all the cataract cases operated between 2004 and 2018, any complication and its repair reported in pretested online form, and all documented post-operative data. All these data were exported to excel sheet from EMR and analysed using SPSS22.
Results: Our cohort involved 2998(2.49%) cases out of 120,000 total cataract operated cases. Out of complications documented for45.5% did not require surgical intervention, 30% eyes required secondary implant and remaining cases required other surgeries. Intervention medical and surgical has made significant difference in visual outcome. (p=0.002) 43.9% complications reported during stage of cortical clean up.
Primary surgery and trainee categories did not cause significant differences in the visual outcome.
Original Research Article
Conclusion: Cataract surgeries done by trainee surgeons caused complications at various stages.
However, interventions by vitreo-retinal surgeons led to a significant difference in the final visual outcome.
Keywords: Complications; trainee surgeons; visual outcome; stages of complications.
1. INTRODUCTION
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 healthcare, cataracts account for only 5% of the cases of blindness, whereas the issue is still responsible for 50% of such cases in the 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 healthcare 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 cataract surgeries performed in the country. However, the actual impact of these measures on the elimination of avoidable blindness is unknown [3].
Training the personnel to perform cataract surgery is an important action plan adopted by the National Program for Control of Blindness and Vision 2020 [4]. Various postgraduate training programs in cataract surgery are currently available in India (MS, DO, DNB, etc.).
Postdoctoral fellowship programs also exist in different government and private institutions with a range of facilities.
There are challenges in conducting the training programs because of the differences in infrastructure, patient load, and faculty skill at the training facilities. These factors lead to differing skill levels as well as surgical results. If facilities are unavailable or the trainee does not have the required skill to deal effectively with the complications that may occur, it can further reduce the performance of a given medical centre.
2. MATERIALS AND METHODS
This was a retrospective study conducted in a surgical training centre. During 2004 to 2018, 384 trainees performed cataract surgeries, out of which the resident doctors and short- and long- term trainees did either Phaco or SICS. Our cohort included all cataract cases without comorbidity that were treated surgically by the trainees/consultants of the facility between Jan 2003 and Dec 2017 as well as any type of per operative complications documented by the trainee surgeon in the online logbook. Corrective surgery performed either on the same day or after a week by a senior vitreo-retinal surgeon was also documented in the online log book.
Different variables were studied, and all data retrieved from the electronic medical record were exported to excel sheet and analysed using SPSS 22. Descriptive analysis and cross tabulations were used, and P value <0.05 was considered significant.
3. RESULTS AND DISCUSSION
We operated 120,000 cataract surgeries without comorbidities during this period. Our cohort of complications included2998 eyes, with a mean
87(Table1). Our cohort comprised 1402(46.8%) female and 1596(53.2%) male patients (Table 1).
The overall surgical complications amounted to 2.49 (%),out of which 43.9% occurred during the stage of cortical clean up (Table 2).
Moreover, 45.5% of the eyes did not require any corrective surgery, they were managed with medical treatment, and vitrectomy +sec iol was performed for 30.2% of the cases.
Medical and surgical treatment made a significant difference in the visual outcome (p=0.002).Besides, 55.5% of the eyes regained
>20/60, while 24 (0.8%) remained <1/60. (Table 3) At the end of the treatment, 215 (7.2%) patients remained aphakic and pseudophakia made a significant difference in the visual outcome (p=0.000).
Besides, the stage of complication made a significant difference in the visual outcome (p=0.000).
Complications that occurred during the early stages resulted in poor visual outcome (Table 4).
Surgeon category had a significant impact on the visual outcome (p=0.000).The resident doctors
contributed to 1665 (55%) complications. (Table 5) Furthermore, 481(16%) lost follow up after the corrective surgery. Primary surgery did not make a significant difference in the visual outcome (p=0.27).
Bullous keratopathy (26.8%) and secondary glaucoma (10.3%) contributed for causes of non- improvement in vision When compared between sulcus fixated and scleral fixated lens no significant difference in visual outcome (p=0.335) Comparative study of visual outcome between management of nucleus drop and other complications had significant difference.
(p=0.000).
After having reviewed many studies for comparison, we have not come across a similar study anywhere in literature. Chan et al. [5]
reported that capsular rupture is one of the most common complications of cataract surgery and that surgical complications have an impact on the final visual outcome. Chen, X. Set al. documented that the incidence of intraoperative complications is 9.7% as compared to 5.6% by the staff surgeons [6]. The overall incidence was 2.49 in the current study and 2.33% by trainee and 0.17% by staff surgeons.
Table 1. Age and sex distribution
Age Sex Total
Female Male
0 TO 10 1 0 1
11 TO 20 1 0 1
21 TO 30 2 3 5
31 TO 40 18 19 37
41 TO 50 113 113 226
51 TO 60 610 637 1247
61 TO 70 543 642 1185
71 TO 80 106 151 257
>80 10 29 39
Total 1404 1594 2998
Table 2. Stages of complication
Stage Number(N) Percent (%)
Capsulotomy 47 1.6
Cortical clean up 1315 43.9
Descment detachment 334 11.1
IOL management 44 1.5
Nucleus Management 673 22.4
Wound Construction 584 19.5
Total 2998 100.0
Table 3. Comparative study of visual acuity pre and post intervention
Final vision category PRE operative vision
<1/60 1/60 TO 3/60 20/200 TO 20/120 20/80 TO 20/60 20/40 TO 20/30
<1/60 12 5 2 4 1
1/60 TO 3/60 21 14 6 1 1
20/200 TO 20/120 182 61 60 11 5
20/80 TO 20/60 549 158 164 60 8
20/40 TO 20/30 513 183 216 103 26
20/20 TO 6/5 70 34 25 15 4
Lost follow up 265 85 86 40 5
Total 1612 540 559 234 50
Shah et al. [7] reported significant improvement in visual outcome with intervention and surgeon category made significant difference in visual outcome. Our study has similar findings.
Haripriya et al. [8] observed that the PCR rate in residentswas 1.37% while it was 2, 49% in the current study. Das M, et al. found that 22.4%
experienced Descemet’s detachment during surgeries performed by trainee surgeons [9].
Nderitu P and P. Ursell noted that the surgical time was an important variable that determined the visual outcome [10]. Sen et al. uncovered that the incidence of complications during phacoemulsification training was within the inacceptable range [11].
In our study, a significant effect on visual outcome after corrective procedures was observed for surgeons in the category of
“undertrained”. Buchan and Cassels - Brown [12]
also came up with similar findings. Surgical complications weremore common among undertrained doctors, as indicated in earlier reports [12-14]. Similar findings have been reported from centres that have trainees with different skill levels [12-14].
However, Chen, X. et al. noted no significant difference between the trainee and staff surgeons [15]. Low et al. identified that the overall complication rate was 1.7%, andthe PCR rate was 0.9%. In the current study, the corresponding rates were 2.49% and 1.1% [16].
Thevi et al. reported that the overall complication rate was 6.1% [6] Kim, B. Z. Documented the overall intraoperative complication rate to be 2.2%, and no significant difference was seen between the trainee and staff surgeons [17].
Suryawanshi et al. found that the PCR rate by the trainee surgeons was 6.2% in phacoemulsification [18]. Nevertheless, Haripriya et al. reported that there is a variation in the incidence of complications among ECCE, manual SICS and phacoemulsification, but there wasno significant difference in the visual outcome[8].
Visual rehabilitation is difficult in case of aphakia.
Long term contact lens use may be attempted, but this is not a practical solution as it is associated with numerous problems. Several groups have reported difficulties in the rehabilitation of aphakia either with spectacles or with contact lenses [19-23]. We attempted such rehabilitation with a corrective surgical procedure. David et al. [24] recorded that the long-term results of anterior chamber implants were also not very positive. There have been many reports on the pathological effects associated with the use of various types of anterior chamber implants[14]. However, Bekibele reported that anterior chamber implant was safe and effective [25]. We also investigated the use of vitrectomy and the implantation of a posterior chamber lens in the remaining part of the capsular support, which was also reported by Dick and Augustin, [26] Hayward et al. [27] and Slade[28]. The secondary implant outcomes reported by Hayward et al. [27] and Slade [28]
were encouraging, with both studies showing similar results for these implants.
Alhassan et al. reported that extracapsular cataract extraction with posterior chamber intraocularlens implantation offers good visual rehabilitation even under training conditions[14].
The current study also achieved comparable results. As previously reported by Woodhams and Lester, [29] we found that secondary glaucoma is a common complication.
18
Table 4. Comparative study of visual acuity according to stage of complication
Final vision category Stage of complications Total
Capsulotomy Cortical clean up
Descmets detachment
INF IOL
management
Nucleus management
wound management
<1/60 0 11 2 0 0 9 2 24
1/60 TO 3/60 0 14 3 0 1 20 5 43
20/200 TO 20/120 3 138 41 0 9 68 60 319
20/80 TO 20/60 12 421 84 0 13 218 192 940
20/40 TO 20/30 21 414 147 1 15 204 241 1043
20/20 TO 6/5 5 48 27 0 2 21 45 148
LF 6 269 30 0 4 133 39 481
Total 47 1315 334 1 44 673 584 2998
4. CONCLUSION
During cataract more incidence of complications more in cortical clean up stage, Visual outcome improves significantly following intervention primary surgery and trainee surgeon category did not make significant difference.
CONSENT
As per international standard informed and written participant consent has been collected and preserved by the authors.
ETHICAL APPROVAL
As per international standard written ethical permission has been collected and preserved by the author(s).
COMPETING INTERESTS
Authors have declared that no competing interests exist.
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