Intra-operative and acute post- operative complications of surgery at Ruharo Eye Centre

KAREN REVERE, MS IV UNIVERSITY OF PENNSYLVANIA SCHOOL OF MEDICINE, PHILADELPHIA, PA, USA

RUHARO EYE CENTRE, MBARARA , MENTOR: DR. KENNETH KAGAME Blindness is a problem worldwide

 WHO estimates

 45 million people = blind

 135 million people = visually impaired  90% live in the developing world

 Majority of cases are due to avoidable causes

are #1 cause

(Chlamydia trachomatis infection)

 Xerophthalmia ( deficiency)

Johnson GI. Eye (2004) 18, 1235-50 Sandford-Smith J. (2003) 4th Ed https://apps.who.int/inf-fs/en/fact213.html Vision 20/20

 1999 – WHO and IAPB, 20 year initiative

 Everyone has the right to sight

 Nobody should lose their vision to an avoidable cause

 30 countries are involved, including Uganda  Reducing the worldwide cataract burden is a priority

www.who.org, National Eye Institute, Bethesda, MD, USA What is a cataract?

: organ within the eye  Normally clear  With opacification, a cataract develops Cataracts

 Causes:

 Old age

 Prolonged sun exposure, , chronic dehydration

 Systemic: DM, chronic renal failure, steroid use

 Ocular: trauma, , glaucoma, , radiation  Treatment:

 Surgical extraction Lessons from EACO, 2011

 Cataract burden in Uganda is large

 16,500 new cases of cataract blindness/year  32 ophthalmologists in Uganda

 Assuming they work ≅40 wks/yr

 Vision 20/20 goal: 0.5 million cataract surgeries/yr  The reality:

 2006-10, 17,733 cataract surgeries

 4,433 cataract surgeries/year

 Likely an underestimation, but still not enough

East African College of (EACO) Conference, April 2011, , UG

Cataracts in SW Uganda

• In SW Uganda

– Cataracts are the #1 cause of avoidable blindness

– Main barriers to seeking care by patients:

• Cost

• Agricultural responsibilities limiting free time

• Fear

Mbulaiteye SM et al. Br J Ophthalmol (2003) 87, 829-33. Whitworth J et al. Health Policy and Planning (1999) 14, 77-1 Ruharo Eye Centre

 Mission:

 Improve the social status of the society through the prevention and treatment of visual impairments Ruharo Eye Centre

 Private, not-for-profit (Anglican Church)

 Major referral hospital for East Africa

 Nominal fees for all procedures and medications

 Cataract extraction ≅ 120,000 Ush

 Main funding from NGO sources

 Christian Blind Mission, Light for the World, Lyons Club Germany, East Diocese

 10% from Health Office

Personal Communication with Ruharo staff and the Mbarara District Health Officer Ruharo Eye Centre

 Inpatient/outpatient facilities

 5 specialists, 4 ophthalmic clinical officers, 1 refractionist

 Growing residency program: 2 second year, 3 first year, 5 intended for next year

Personal Communication with Ruharo staff Research Questions

1. What are the most common complications of cataract surgery at Ruharo?

 Intra-operative, POD 1, POD 14

2. Do intra-operative complications predict post-operative complications?

3. Is there a relationship between surgical technique and rates?

4. Is there a relationship between intra-operative complications and visual acuity outcome? Rationale

 No published data from SW Uganda

 Complications may differ from those occurring in other parts of the world

 Vision 20/20 goals

 Future operative/post-op approaches can be tailored to reduce complications Method

 Prospective, observational study x 1 month  Inclusion criteria:

 All patients referred for cataract extraction (senile, medical, traumatic)

 With intra-ocular lens (IOL) placement at time of surgery  Analysis (completed by Dr. Dan, EPI Centre)

 Data collected in Excel 10.0

 Stata 10.0, SE

 Descriptive analysis using cross tabulations Clinically relevant complications

Ocular Pt. Pt. VA, Case # Date Dx Age Sex co- HIV DM Smoke HTN # Name pre-op

morbidity Background

op Incomplete - Capsule Vitreous Case # Nurse Res. Attg. Eye Tech. Cortical Other rupture loss prolapse

cleanup Intra

Corneal Raised Case # VA, POD#1 Iris prolapse/damage Anterior uveitis Other

Edema IOP POD #1 POD

Iris Posterior Case # POD # VA Infection IOL displacement Other

capture synechiae POD #14 POD Results Gender and cataract type

p<0.05 Cataract Type Sex Total Traumatic Mature Hypermature PSC 0 9 5 1 15 Female 0% 42.9% 83.3% 16.7% 41.7% 3 12 1 5 21 Male 100% 57.1% 16.7% 83.3 58.3% % 3 21 6 6 36 Total 100% 100% 100% 100% 100% Age and cataract type

p<0.05 Cataract Type Age Total Traumatic Mature Hypermature PSC 3 5 1 3 12 < 60 100% 23.8% 16.7% 50.0 33.3% % 0 16 5 3 24 > 60 0% 76.2% 83.3% 50.0 66.7% % 3 21 6 6 36 Total 100% 100% 100% 100% 100% Visual acuity

Pre-op POD 1 POD 14 VA Frequency, % Frequency, % Frequency, % 6/6-6/18 2 4 1 5.6% 15.2% 14.3% 6/24-6/36 4 6 5 11.1% 18.2% 71.4% ≤6/60 30 23 1 83.3% 67.0% 14.3% Total 36 33 7 Follow-up rate

Patient Number Intra-Op POD 1 POD 14 Frequency 36 33 7 % 100 91.6 19.4

* POD 14, did not include in statistical analysis due to small sample size

Intra-operative complications

Complications Frequency Percentage Intra-operative Capsule 7 19.4 tear/rupture Incomplete 5 13.9 cortical cleanup Vitreous loss 4 11.1 Other: accidental 3 8.6 iridectomy (x2),

Iris prolapse 1 2.8 Total 20 55.6 Post-operative complications

Complications Frequency Percentage POD 1 Corneal edema 17 51.5 Iris 4 12.1 damage/prolapse

Other: , 3 9.1 fibrin in AC, IOL displacement

Raised IOP 1 3.0 Uveitis 0 0.0 Total 25 69.4

Intra-operative and POD 1 complications

 What proportion of patients develop complications at POD 1, following an intra-operative complication?

 Comparison of all intra-operative complications with the two most common POD 1 complications (corneal edema and iris prolapse/damage)

 No significant associations Intra-operative and POD 1 complications

 But, 24% of patients with POD 1 corneal edema suffered a capsule tear/rupture intra-operatively p=0.66 Capsule tear/rupture, Corneal edema, POD 1 intra-op No Yes Total 14 13 27 No 87.5% 76.5% 81.8% 2 4 6 Yes 12.5% 23.5% 18.2% 16 17 33 Total 100% 100% 100% Surgical techniques

ECCE SICS Phacoemulsification (Sutures required) (Suture-free)

surgeryencyclopedia.com Surgical techniques at Ruharo

Technique Frequency Percentage ECCE 22 61.1 SICS 14 38.9 Total 36 100.0

Ruit et al. Am J of Ophth (2007), 143, 32-7. Surgical technique and complication rate

 Increased frequency of intra-operative complications with ECCE

Intra-operative complications Capsule Incomplete Vitreous Iris Othe Technique tear/rupt cortical Total loss prolapse r ure cleanup ECCE 5 3 1 5 1 15 SICS 2 1 0 0 2 5 Total 7 4 1 5 3 20 p-value 0.68 1.0 1.0 0.13 0.55 - Surgical technique and complication rate

 POD 1 complications more commonly occur with SICS

POD 1 complications Iris Techniqu Corneal prolapse/da Raised IOP Other Total e edema mage ECCE 8 1 1 1 11 SICS 9 3 0 2 14 Total 17 4 1 3 25 p-value 0.29 0.29 1.0 0.56 -

Intra-operative complications and VA, POD 1

 No significant association between intra-operative complications and poor visual outcome at POD 1

Intra-operative complication Capsule Incomplete Vitreous VA, POD 1 tear/ruptur cortical Other Total loss e cleanup Poor, <6/60 5 3 3 3 14 Good, >6/60 1 0 1 0 2 Total 6 3 4 3 16 p-value 1.0 0.55 1.0 0.54 - Summary

 No significant associations  BUT…

 We can still draw some “eye-opening” conclusions

 May be relevant to future research Research questions, re-visited

1. What are the most common complications of cataract surgery at Ruharo?

 Intra-operative: (1) capsule tear/rupture, (2) incomplete cortical cleanup

 American veterans, ECCE - (1) capsule rupture, (2) vitreous loss

 POD 1: (1) corneal edema, (2) iris prolapse/damage

 American veterans, ECCE - (1) posterior capsule opacification

 Australia, ECCE/SICS – (1) , (2) wound dehiscence

Clark et al., 2011 (in press) Research questions, re-visited

2. Do intra-operative complications predict post- operative complications?

 No, but capsule damage may be associated with corneal edema at POD 1

3. What is the relationship between surgical technique and complications?

 Intra-operative complications occur more commonly with ECCE

 POD 1 complications occur more commonly following SICS Research questions, re-visited

4. What is the relationship between intra-operative complications and VA, POD 1?

 Majority of patients at POD 1 had a VA of ≤ 6/60

 POD 14 VA would be a better comparison Challenges

 Small sample size

 Goal: 100 patients

 Based on data from March 2011 at Ruharo - 138 cataract patients

 Reality: 36 patients  Poor follow-up at POD 14 (only 19.4%) Future

 With increasing life expectancy and improving general medical care

 Increasing cataract burden  Ruharo is a major referral center for East Africa

 Performs a large number of cataract extractions/year

 Volume may increase

 Opening new department at MUST, Vision 20/20 goals Future

 Value in exploring complications unique to geographical and medical environment that Ruharo serves

 Identification of areas of weakness for residents and specialists

 Outcome presentations on a regular basis

 Future efforts can be made to reduce complications

 Good outcome reports to local villages

 Improved attendance at Ruharo/MUST Future

 April is not a good month for data collection

 May be related to Easter or the rainy season

 On Tuesday there were 9 cataract cases (more than on any of my data collection days)

 Improve efforts to facilitate follow-up

 Call patients

 Retrospective References

 Bourne R, Minassian D, Dart J, Rosen P. Ophthalmology (2004) 111, 679-85.  Brilliant GE, Lepkowski JM, Zurita B et al. Arch Ophthalmol (1991) 109, 584-9.  Clark A, Morlet N, Ng J, et al. Am Acad of Ophth (2010) in press.  Desai P, Minessian D, Reidy A. Br J Ophthalmol (1999) 83, 1336-40.  Gupta SK and Murthy GVS. Arch Ophthalmol (1995) 113, 1337-40.  Johnson GI. Eye (2004) 18, 1235-50.  Mbulaiteye SM, Reeves BC, Mulwanyi F, Whitworth JAG, Johnsons G. Br J Ophthalmol (2003) 87, 829-33.  Whitworth J, Pickering H, Mulwanyi F, Ruberanthwari A, Dolin P, Johnson G. Health Policy and Planning (1999) 14, 77-1 Thank you

QUESTIONS? COMMENTS? CONSTRUCTIVE CRITICISMS?