Intra-operative and acute post- operative complications of cataract surgery at Ruharo Eye Centre
KAREN REVERE, MS IV UNIVERSITY OF PENNSYLVANIA SCHOOL OF MEDICINE, PHILADELPHIA, PA, USA
RUHARO EYE CENTRE, MBARARA , UGANDA 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
Cataracts are #1 cause
Trachoma (Chlamydia trachomatis infection)
Glaucoma
Xerophthalmia (vitamin A 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?
Lens: accommodation organ within the eye Normally clear With opacification, a cataract develops Cataracts
Causes:
Old age
Prolonged sun exposure, vitamin A deficiency, chronic dehydration
Systemic: DM, chronic renal failure, steroid use
Ocular: trauma, uveitis, glaucoma, myopia, 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 Ophthalmology (EACO) Conference, April 2011, Kampala, 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 Ankole Diocese
10% from Mbarara District 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 complication 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 Iris 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), iridodialysis
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: hyphema, 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) endophthalmitis, (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?