Visual impairment affects an estimated 223.4 million people globally, with 32.4 million of these being blind.1 Ninety percent of the blind live in developing countries. Eighty percent of blindness is treatable or preventable, with cataract as the leading cause.2 Cataract surgery has been shown to be the most cost-effective medical intervention in improving quality of life.3,4 The Global Action Plan 2014–2019, endorsed by the World Health Organization (WHO) in 2013, builds upon the platform of the VISION2020 initiative.5 Its vision is a world in which no one is needlessly blind and where those with unavoidable vision loss can achieve their full potential. As a part of these initiatives, significant investments have been and are being made in capacity-building ophthalmology residency training programs to increase the human resources needed in the developing world to meet the aims of the Global Action Plan. Donors who help support these programs are increasingly (and rightly) demanding quality results from the investment.
The Pacific Eye Institute (PEI), in Suva, Fiji, is an initiative of The Fred Hollows Foundation New Zealand. It seeks to provide quality training for ophthalmologists and other eye care personnel in the Pacific to enable eventual self-sustainability in eye health care. The curriculum is based on the generic International Council of Ophthalmology residency curriculum.6 It has been contextualized for the needs of the Pacific through a rigorous process of curriculum review with stakeholders and eye care education experts from the Royal Australia and New Zealand College of Ophthalmologists.
The training program has 2 phases. The first year, the Postgraduate Diploma of Ophthalmology, focuses on developing core competencies, including the completion of at least 100 cataract surgeries. The second phase, a 3-year Master of Medicine (Ophthalmology), builds on this by consolidating and reviewing in greater depth the core competencies of the diploma while also developing the additional competencies required to produce specialist ophthalmologists.
In the developed world, phacoemulsification (PE) is the standard surgical technique.7,8 Sutureless small incision cataract surgery (SICS), a modification of extracapsular cataract extraction (ECCE) carried out through a self-sealing scleral wound without sutures, is cheaper than PE, less reliant on sophisticated technology, and well-suited to low-resource environments. Sutureless small incision cataract surgery has been shown to produce comparable surgical outcomes to PE.9,10 Sutureless small incision cataract surgery is especially suited to high-volume, high-quality cataract surgery and has become the standard in the developing world.10 Since 2011, SICS has been the cataract surgical technique taught at the PEI.
Ophthalmologists exiting the PEI training program should produce quality surgical outcomes. The goals of VISION2020 require both quantity and quality of surgical interventions. The WHO has developed and promotes cataract outcome standards as indicators for quality service delivery.11 Reports of substandard cataract surgical outcomes from the developing world suggest that the problem could be widespread.12–14 Although there are many contributing causes to this, an important one is substandard resident teaching.15 There is limited published evidence of the quality of cataract surgical outcomes from residents in the developing world.16,17
We report the findings of the audited outcomes of all cataract surgeries performed during a PEI resident’s 4 years of training. These outcomes will be compared with WHO recommendations.
MATERIALS AND METHODS
A retrospective chart review was undertaken of all the cataract surgeries performed by a resident whose training at the PEI ended in 2013. Surgery was carried out at the PEI base hospital and at regular outreach sites throughout Fiji and other Pacific island countries, namely, Samoa, Solomon Islands, Tonga, and Vanuatu.
All adult patients aged 20 or older were included in the cohort. Patients were identified from the resident’s operation logbook and cross referenced with operating theater registers. Those with incomplete data were excluded. Each patient had a preoperative ophthalmic examination, including dilated fundus assessment, followed by ultrasound biometry, with intraocular lens power determined using the SRK-T formula.
The primary outcome measure was the final (40 days) postoperative vision in the operated eye. This was recorded as uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA), obtained by refraction or, if unavailable, pinhole. Visual acuities were recorded by trained ophthalmic nurses using a modified 3-m Snellen chart with occlusion of the contralateral eye. If a patient failed to return for a final postoperative visit, then the last documented postoperative visual acuity was used.
Secondary outcome measures were ocular comorbidities and sentinel complications. Ocular comorbidities are presented in Table 1. Sentinel complications and the WHO recommended target percentages of such events11 include the following:
- posterior capsular rupture (PCR), defined as a breach in the posterior capsule without vitreous loss (should be <5%)
- vitreous loss, defined as PCR accompanied by the loss of vitreous requiring anterior vitrectomy (should be <5%)
- endophthalmitis, defined as severe inflammation due to infection (should be <1%)
Data were analyzed using Excel 2010. Statistical methods including odds ratio (OR) and Fisher exact P values were used to describe significance. All patients gave informed consent for the surgeries and data were anonymized. Ethics approval for this work (FNRERC Ref Number 2013 91) was obtained from the Fiji National Health Research Committee (Chairperson Dr Devina Nand) on December 5, 2013.
Seven hundred twelve cataract surgeries were performed during residency, all under local anesthesia. Three hundred twenty-five (46.4%) took place at the PEI base hospital and 387 (53.6%) during outreach. When patients younger than age 20 or with incomplete data were excluded, a total of 670 cataract surgeries qualified for analysis. Of these, 356 (53.1%) were female and 314 (46.9%) were male, and the mean ± SD age was 64.8 ± 11 years. Five hundred eighty-nine (87.9%) had preoperative presenting vision of less than 6/60, and 3 (0.45%) had preoperative presenting vision of 6/18 or greater.
Five hundred sixty-six (84.5%) surgeries were SICS, 100 (14.9%) were ECCE, and 4 (0.6%) were intracapsular cataract extractions (ICCEs) with anterior chamber intraocular lens (ACIOL). Indications for ICCE included a history of traumatic anterior lens dislocation with secondary glaucoma, traumatic cataract with zonular dehiscence, and a subluxated lens.
Eighty-eight percent of patients who underwent surgery at the base hospital attended follow-up between 30 to 120 days postoperatively. For those patients operated on at outreach, 100% had follow-up within 1 week of surgery.
Sentinel surgical complications occurred in 26 surgeries (4.0%). They included vitreous loss [18 (2.7%)], posterior capsule rupture without vitreous loss [7 (1%)], and postoperative endophthalmitis [1 (0.15%)]. Other complications [21 (3%)] included hyphema, corneal decompensation, iris prolapse, wound leaks, zonular dehiscence, retained cortex, and an acute rise in postoperative intraocular pressure.
There was no significant difference in the overall rate of complications between ECCE (6%) and SICS [6.9%; OR, 0.86; confidence interval (CI), 0.36–2.09; P = 0.4734]. ICCE had the highest risk of complications (OR, 0.073; CI, 0.01–0.53; P = 0.0264). A good final UCVA outcome was obtained in 63% of ECCE compared with 70.3% of SICS. Both surgical techniques, however, had comparable, statistically insignificant BCVA of 87% and 87.5%, respectively (OR, 0.96; CI, 0.51–1.81; P = 0.503).
Pre existing ocular comorbidities were documented in 87 eyes (13.0%). Diabetic retinopathy [50 (57.5%)] was the most common. Comorbidities accounted for 36 (41.4%) of borderline or poor final BCVA outcomes. Fifteen (42%) of these were due to diabetic retinopathy.
Final UCVA and BCVA in the operated eye were aggregated according to WHO recommendations as good, borderline, or poor (Table 2). Overall, 583 (87%) achieved good final BCVA outcomes, 52 (7.8%) borderline, and 35 (5.2%) poor. Excluding the 36 eyes with vision-affecting comorbidities, good, borderline, and poor final UCVA were 72.9%, 24.4%, and 2.7%, respectively, whereas final BCVAs were 92.0%, 5.7%, and 2.4%, respectively. Of note, 120 (77.4%) of 155 borderline UCVA outcomes improved to good BCVA outcomes.
Most, 37 (79%), complicated cataract surgeries had good BCVA outcomes. Ten (21%) had borderline or poor final BCVA outcomes, and preexisting ocular comorbidities were the cause for half of these outcomes.
After surgery, 668 eyes (99.7%) were pseudophakic. Of these, posterior chamber intraocular lenses were implanted in 656 (98%) and 12 (2%) received an ACIOL. All 4 patients who underwent ICCE had an ACIOL implanted. Two patients (0.3%) remained aphakic, both of whom had preexisting ocular comorbidities—one with central retinal vein occlusion; the other with untreated retinal detachment.
Of the 12 ACIOLs inserted, 8 (67%) attained good BCVA outcomes. Endophthalmitis in one and a preexisting but undetected retinal detachment in another were responsible for the 2 poor visual outcomes. Two (17%) had borderline visual outcomes. Of these, both had preexisting ocular comorbidities—epiretinal membrane in one and traumatic anterior dislocation of the crystalline lens with secondary glaucoma in the other—accounting for the suboptimal outcomes.
This retrospective chart audit is the first report on cataract surgical outcomes in the entire acquisition period of this core ophthalmic competency for a resident in developing countries in the Pacific.
The overall sentinel surgical complication rate of 4% is comparable with WHO standards. The PCR or vitreous loss rate of 3.7% is at the lower end of reported rates from other training programs in the developing and developed world (1.92%–14.9%).16–21 Although final UCVA outcomes fell below WHO standards, final BCVA outcomes were comparable. Most borderline UCVA outcomes [120/170 (70.6%)] improved to a good BCVA outcome. These results are similar to other reports and suggest that improved biometry techniques would help increase the number of good final UCVA outcomes.16
Poor postoperative follow-up rates, as low as 20% to 30%, are unfortunately usually the norm in the developing world.22–25 This confounds the qualitative assessment of outcomes. A remarkable 88% of base hospital cases were able to attend final follow-up for this study. Outreach surgery follow-up in the Pacific is problematic. A similar dilemma faces most developing world training programs with outreach components. The reality of follow-up is typically limited to less than 1 week. In this series, 53.6% of surgeries were performed on outreach, all of whom attended follow-up within 1 week of surgery, but with little reliable longer term data. It is thus reassuring that a recent multicenter report found early (within 72 hours) postoperative outcomes correlated well with final outcomes assessed 40 or more days postoperatively.15
Eighty-seven (13%) of the cohort had ocular comorbidities. The most common was diabetic retinopathy [50 (57.5%)]. Currently, 6 of the top 10 countries in the world for diabetes prevalence are in the Pacific Islands.26 Unsurprisingly, 46.3% of this cohort were diabetic. Eyes with coexisting ocular comorbidities accounted for almost half of the borderline and poor final BCVA outcomes [36 (41.4%)]. Coexisting ocular diseases have been found to be a significant cause of impaired visual outcomes in other low-resource settings.24,27
This study has limitations. It is retrospective and involves only a single resident. It is possible that the results could reflect the quality of the surgeon rather than the quality of the residency program. The learning curves of all residents in the program are being tracked as part of an ongoing quality assurance program, which should better answer this question in the future.
The intention of the study, however, was to be indicative of outcomes obtained during the competency learning curve of a resident in a low-resource program. The total number of cases, the mix of surgical techniques (representing the residency program’s change of preferred cataract surgical technique from ECCE to SICS during the resident’s training), and the high follow-up rates strengthen the conclusions from the data. The results illustrate that quality outcomes are achievable during an ophthalmologist’s training in a low-resource developing world setting. The BCVA outcomes and sentinel complication rates are comparable with WHO recommendations.
This report may be of value as a quality benchmark for other programs in low-resource settings. It speaks to a residency program producing a competent surgeon suitably prepared to help ensure that the aims of the Global Action Plan 2014–2019, and ultimately VISION2020, are realized in their environment.
The authors wish to acknowledge Drs Roger Dethlefs, John Szetu, and Erika Damato for their encouragement and suggestions.
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