Do Patients with Age Related Maculopathy and Cataract Benefit
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Br J Ophthalmol 1998;82:611–616 611 Do patients with age related maculopathy and cataract benefit from cataract surgery? Br J Ophthalmol: first published as 10.1136/bjo.82.6.611 on 1 June 1998. Downloaded from G N Shuttleworth, E A Luhishi, R A Harrad Abstract surgery will be of benefit, a decision that is Aims—To assess the benefits of cataract often diYcult to make. Sometimes the patient extraction in patients with age related is listed for surgery on the grounds that there is maculopathy (ARM). little to lose. However, the constraints of tight Methods—1073 randomly selected cata- budgets and waiting lists, and the need to ract operations were reviewed and 99 target resources, means that medical practice cases of preoperatively recognised ARM must be evidence based and it is therefore nec- were identified for investigation. Data essary to have reliable data to support the deci- relating to visual function were retrieved sion of whether or not to operate. from case notes, and patient responses to Although previous investigators have identi- a questionnaire were analysed. fied factors associated with poor outcome Results—98% had dry or unspecified following cataract surgery, including the pa- ARM. Only 2% had exudative maculopa- tient age and ocular co-morbidity (especially thy. 81% of cases had an improvement in ARM),9–16 none has addressed specifically the best distance acuity; mean change 0.44 benefits of surgery in these high risk groups. logMAR (change of 6/36 to 6/12). 65% We have performed a retrospective analysis responded to the questionnaire; 67% felt of case notes and circulated a self completion that the operation had been worthwhile, questionnaire in order to determine whether 17% had mixed feelings, and 17% thought patients with ARM benefit from cataract it not worthwhile. surgery both in terms of visual function and Conclusion—This study, which is the first patient satisfaction. In addition, we attempted of its kind to be reported, shows a clear to identify predictors of benefit and to benefit from cataract surgery in the determine whether we are operating on appro- majority of patients with ARM. However, priate numbers of patients in order to pave the the prevalence of ARM in this study is way for a future investigation. To our knowl- lower than expected, suggesting that some edge this is the first study of its kind to be patients with both ARM and cataract were reported. not listed for surgery. The design of a pro- spective study to quantify the subjective http://bjo.bmj.com/ and objective benefits of cataract surgery Methods In all, 1073 case notes were randomly selected in these patients is outlined and predictors from computer records and reviewed by two of successful outcome identified. This will ophthalmologists (GNS, EAL) from the 2264 promote the development of guidelines for cataract operations performed during 1994 at the surgical management of this group of Bristol Eye Hospital. Details of all ocular diag- patients. (Br J Ophthalmol 1998;82:611–616) noses in operated eyes were recorded. All cases in which reference was made to ARM (dia- on October 1, 2021 by guest. Protected copyright. grammatically or in writing) before the cataract Age related maculopathy (ARM) aVects ap- extraction and who were more than 50 years of proximately 40% of those over the age of 75 age were selected for further investigation. years.12It is the most common maculopathy to Where both eyes had been operated upon dur- aVect individuals with cataract, the two condi- ing 1994, the first eye was selected for investi- tions occurring with increasing frequency with gation. age.34 ARM currently contributes to around Data were collected from case notes and 50% of all those registered as blind and from a simple, self completion questionnaire partially sighted in England and Wales5 and a sent to the patients’ most recent address. recent study has suggested that the condition 6 may be becoming more prevalent. DATA COLLECTED FROM CASE NOTES Approximately 1.2 million cataract extrac- Data collected from the case notes included tions are performed in the USA,7 and 105 0008 age, sex, type of procedure and complications, Bristol Eye Hospital, in the UK each year. Around 10% of all other ocular and systemic diagnoses. The type Lower Maudlin Street, patients who undergo first or second eye cata- of ARM and cataract was assessed from the last Bristol BS1 2LX ract extraction have some form of ARM.89 preoperative record. G N Shuttleworth E A Luhishi Although this proportion is rather lower than In addition, visual acuities at the time of list- R A Harrad would be expected from prevalence data, this ing and postoperatively (best recorded vision still constitutes around 100 000 operations in and last recorded vision) were collected. The Correspondence to: the USA and 10 000 operations in the UK best acuity (unaided, corrected, or with a Dr Shuttleworth. each year. pinhole) was used for the analysis assuming Accepted for publication When treating a patient with ARM and cata- this to be most indicative of best visual poten- 9 January 1998 ract the clinician must decide whether cataract tial. 612 Shuttleworth, Luhishi, Harrad The Snellen acuities were ranked for non- Table 1 Ocular disease in operated eyes of reviewed parametric analysis or converted to the log of cataract patients 10 Br J Ophthalmol: first published as 10.1136/bjo.82.6.611 on 1 June 1998. Downloaded from the Snellen fraction (equivalent of logMAR) Those with for parametric analysis. The logMAR scale was preoperative Whole sample extended assuming counting fingers vision to Ocular disease ARM (n=99) (n=1073) be equivalent to 1.6 logMAR (Snellen 1.5/60), No other disease 70 (71%) 720 (67%) hand movement vision to be equivalent to 1.9 Cornea/external eye disease 0 (0%) 14 (1%) Retina/choroidal disease 14 (14%) 124 (12%) logMAR (Snellen 0.75/60), and perception of Glaucomas 19 (19%) 125 (12%) light vision to be equivalent to 2.2 logMAR Orbital disease 0 (0%) 3 (0.3%) units (Snellen 0.375/60) as used by Javitt et Strabismus 0 (0%) 10 (1%) 17 Amblyopia 1 (1%) 12 (1%) al. Neuro-ophthalmic disease 1 (1%) 13 (1%) Uveitis 1 (1%) 12 (1%) Ocular trauma 0 (0%) 10 (1%) DATA COLLECTED FROM THE QUESTIONNAIRE ARM 99 (100%) 99 (9%) The questionnaire (reproduced on BJO web- site: www.bjophthalmol.com) was designed for self completion and kept as short and simple as all those with ARM) were diagnosed postop- possible. To encourage response, simple ordi- eratively. These were not included in the analy- nal adjectival scales or categorical response sis. options were employed. All print was black, 18 or 20 point, Arial typeface on white paper. Two DESCRIPTIVE DATA versions of the questionnaire were used, one Of the 99 patients with ARM, 76 (77%) were each for operations on the left and right eyes. female and the mean age at operation was 83.4 Questions were designed to be as direct and years (range 70–100 years). Seventy four clear as possible and were based upon ques- (75%) operations were on first eyes and 32% of tions commonly used in the clinical setting. these were either awaiting or had had cataract They focused upon the main preoperative surgery on their second eye at the time of the complaints and the eVects of the operation review. Nineteen per cent (19/99) of operated upon these, and inquired into aspects of visual eyes had concurrent glaucoma and 14% function, including near and distance tasks, (14/99) retinal or choroidal disease, the most visual field, and the eVect of vision upon every- common of which was diabetic retinopathy day activities. For each aspect of visual (Table 1). Seventy one (71/99) per cent of function, the questionnaire assessed difficulties operations were extracapsular cataract extrac- preoperatively and determined whether any tions, 22% (22/99) were phacoemulsification improvement had occurred and whether this extractions, 5% (5/99) were combined proce- lasted. In addition, further questions assessed dures (cataract extraction and trabeculec- the patient’s current diYculties. The same tomy), and one was an accidental intracapsular method was used for scoring answers to preop- cataract extraction. Ninety nine per cent erative and current diYculties. A further ques- (98/99) of operations resulted in the placement of a posterior chamber intraocular lens. Sight tion asked whether the operation had been http://bjo.bmj.com/ worthwhile. aVecting peroperative or postoperative compli- The questionnaire was sent to all patients cations occurred in 3% (3/99) of cases still thought to be alive and included a stamped (vitreous loss, iris prolapse, cystoid macular addressed envelope for return. Three weeks oedema); in addition, one patient died postop- later, if no reply had been received, an attempt eratively. was made to contact the patient by telephone. Ninety eight per cent (97/99) of operated If patients had received the questionnaire they eyes had dry or unspecified ARM and 2% were encouraged to complete and return it as severe (active or inactive exudative disease). In on October 1, 2021 by guest. Protected copyright. soon as possible; if no questionnaire had been fellow eyes the proportions were 91% and 6% received then a second was sent. No question- respectively with 3% having no evidence of naires were completed over the telephone in an ARM. attempt to eliminate bias. Missing data or spoilt questionnaire responses were omitted DISTANCE ACUITY from analyses. At listing 9% (8/92) of operated eyes had a dis- Both parametric and non-parametric analy- tance visual acuity of 6/12 or better. This ses were performed. Student’s t tests were used proportion increased to 61% (60/98) for best to assess the diVerence between sample means, postoperative distance acuity and decreased a Mann–Whitney U tests and Wilcoxon’s little to 45% (44/97) for last recorded distance matched pairs test were used to compare acuity.