Outcome of Cataract Surgery from Outreach Eye Camp

Outcome of Cataract Surgery from Outreach Eye Camp Delhi J Ophthalmol 2014; 25 (2): 90-94 DOI: http://dx.doi.org/10.7869/djo.85 Suraj Senjan, Praveen Vashist, Sumit Malhotra Community Ophthalmology, Dr R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delh i110029 *Address for correspondence Suraj Senjam MD Assistant Prof. of Community Medicine Community Ophthalmology Dr R P Centre for Ophthalmic Sciences, All India Insitute of Medical Sciences New Delh i110029 Email: drsurajaiims@gmail.com Purpose: To share the concept of Reach in Programme (RIP) outreach eye care model and presents its outcome for the last five years of services (2009-13). Methodology: Reach in Programme: RIP is primarily Public-Private partnership model for outreach cataract intervention services with occasional involvement of Panchayati Raj Institution. Operable cataract patients were identified and referred to base hospital for intervention. Review of the RIP files and registers as primary sources of the data and cataract surgical records as secondary sources was done during June & July of 2013. Data were collected on those patients who had undergone surgery through outreach eye care services only. Data were entered in Microsoft excel and analyzed descriptively. The outcome was presented in terms of quantity and visual acuity status as a dichotomized optotype with a cut off of 6/60. Results: A total of 8735 (M=47.5%; F=52.5%) patients were operated in either eye during the five year period (2009-13) out of 9729 admitted. Of the total operated, 19% of them were less than 50 years of age. Very few were conventional surgery (2.2%); rests were phaco-emulsification technique. Preoperatively, 60% had visual acuity <6/60 in the operated eye. Six weeks after surgery, 9.5% had poor visual outcome (<6/60) out of total follow up (415/5241) without any correction. Records of 61 patients were available for poor visual outcome that was attributed to surgical complications. Bullous keratopathy (27), posterior capsular opacity (16), uveitis (10) were maximally documented in decreasing numbers. Conclusions: Quite an amount of cataract surgery was conducted through our outreach eye care services with reasonably good quality. Strategy needs to be developed to improve follow up compliance as well as the reasons of poor outcome records. Keywords : community ophthalmology outreach eye camp public-privatepartnership cataract blindness Cataract and refractive errors are two major public health problems in the context of ocular health in developing countries like India. Currently, India is the second highest country next to China in contributing to the total burden of world blindness. 1 Cataract is the most common cause of blindness (62.4%) followed by uncorrected refractive error (16.65%). 2 Of this total burden of blindness more than eighty five percent of them are preventable if appropriate eye care services are provided. 3 However, the issued and concerned of the health care planners & professionals are that a considerable proportion of these visually challenged population are concentrated in rural, underserved area where public health services are not effectively functioning. This attributes a huge barrier in making efforts to achieve the goal of National Program for Control of Blindness (NPCB) i.e. reduction of the prevalence of avoidable blindness from 1.4% to 0.3% by 2020. In order to deal this hard to reach area, NPCB encourages to adopt two different strategies under the term Reach Out and Reach In outreach eye camp. Reach out is a makeshift surgical camp and was adopted at the initial period of program in which the team usually stays at the camp site for a few days and conducted the surgical procedure during the camp. Later, this makeshift camp strategy was withdrawn from the programme due to certain issues like impossible to move phaco equipment along with its support system to a remote location and complications reported in 2001-02 NPCB National Survey. 4 Currently, the NPCB Ministry of Health and Family Welfare, Government of India encourages to adopt an outreach eye camp model in which camps were organized at the remote & rural area, and patients were transported to the base hospital for surgical 90

Senjam S et al ISSN 0972-0200 interventions. So, in this approach, patients get all necessary precautions and care like routine hospital patients. The model is shown in (Figure 1). Our community ophthalmology unit of ophthalmology department, one of its kind in the public health sector is actively involved in providing cataract surgical service by organizing outreach eye camp at the underprivileged Figure 1: Reach in Program model remote area under the name of Reach in Programme (RIP). The model is primarily based on the Public-Private Non Government Organizations partnership. Local Panchayati Raj Institution (PRI) is also involved occasionally as per their feasibility. Our outreach Reach in Program eye care model provides service in a comprehensive way despite primary focus is on detection and treatment of cataract and uncorrected refractive error. The RIP model is designed with due consideration of the socioeconomic and cultural background of the community so that there will be good community participation thereby allow to use of locally available community resources. To the best of our knowledge the other health institute of India where such designated community ophthalmology unit does not exist, normally such kind of outreach eye camp is usually conducted by the ophthalmology department itself. Even though such outreach service in the eye health care is organized at their own setting, there are very few published reports on nature of camp organization and outcome of surgery. Therefore, the primary purpose of this paper is to share the concept of our Reach in Programme eye care model and presents its outcome for the last the five years (2009-13). Organization of Reach in Programme: Reach in Programme is to be organized either felt need from base hospital or on the demand of local private Non-Governmental Organizations (NGOs), or Sarpanch of Gram Panchayat. Most commonly, RIP is organized by request from NGOs. The usual site of camp is school building, temple, ashram or community hall of the village. Good coordination is must among all stakeholders during preparation and planning; most importantly while implementation of camp. To avoid hasslefree during the camp, maintaining systemic flow of patients is also critically important. Flow chart for the patients management and some photographs were presented in (Figure 2 & 3). On an average, we conducted outreach eye camp twice in a month within the National Capital Region. Role of base Hospital: Base Hospital is responsible for detail planning, implementation of RIP in a feasible way. This plan is shared with other stakeholders well in advance. This exercise is done by RIP manager and coordinator of the base hospital. The coordinator made a pre-camp visit to check Figure 2: Implementation chart for RIP camp 91 Del J Ophthalmol 2014;25(2)

Outcome of Cataract Surgery from Outreach Eye Camp the feasibility of every forthcoming camp. RIP team which is constituted by ophthalmologists, optometrists, health workers, laboratory technician were deputed on camp day. Their number varies according to patient expectation during camp. Local volunteer training, examination of the patients during camp as well as in hospital, health talk, and counseling & rehabilitation service are responsible tasks of base hospital. In Patients Care Services: A separate twenty four bedded ward is existed within the in-patient facility of base hospital since inception of the community ophthalmology. Not only RIP patients, other patients coming from primary eye care centers and poor unaffordable patients who are coming to routine out patients department were also admitted in these wards and thereby provided necessary surgical interventions. One heath worker and one data entry operator was being assigned for the purpose of data collection and compilation in electronic format since the beginning of the services. Health worker filled up the cataract surgical record form (CSR) for each patient one day after operation on a daily basis from this community wards. Next day, CSR form has passed to data entry operator for compilation in electronic format. Post-operative follow up is usually done after six week in the camp site or in our community eye care centers as well as in the department. Role of NGO or Community Based Organization: Identification of site, wide publicity, arrangement of infrastructure, patient transportation from camp to base hospital and vice-versa are responsible tasks for a partnership NGO. Role of Panchayati Raj Institution (PRI): Involvement of PRI is important in organizing well successful community based outreach eye camp. In our setting, Panchayati Raj Institution involvement is either direct or indirect with base hospital. Frequently, their involvement is through NGOs. Discussion is done with all stakeholders that how the community will accept the program for example choosing camp site, day of camp, even community behaviors, norm & beliefs, any gender or religious matter apart cultural aspects. PRI helps in sensitizing the community in a culturally appropriate manner. Apart from this, other activities are also done like publicity, transport of disabled patients with locally available conveyance, provision of requisite furniture etc. Methodology of Review We decided that data pertaining to outreach eye care services will be presented for the last five years starting from January 2009 to December 2013 since these data were more readily available in registers and files. Apart from camp statistics, it has also maintained data on six weeks post operative visual acuity status of operating outreach patients. These records were maintained by health workers. In addition to this, we also check the CSR form for the corresponding years. This CSR form was introduced by the National Programme for Control of Blindness in 1996 and used to collect the information of the patients who had undergone cataract surgery. 5 The CSR form has information on age, sex, pre-postoperative presenting visual acuity of each eye, place & type of surgery and 6th weeks post operative visual acuity status and complications. Measures of visual acuity outcome as per CSR form is classified as good ( 6/18), borderline (6/24 to 6/60) and poor outcome (<6/60). But for the present study, visual acuity status was dichotomized by using visual acuity to cut off at optotype 6/60 i.e. less or better than 6/60. This is the lowest visual acuity cut off optotype according to World Health Organization guideline to monitor the outcome of cataract surgery. Therefore, we categorized visual acuity outcome as satisfactory ( 6/60 or good & borderline) and unsatisfactory (<6/60 or poor) only. Performance was measured in terms of quantity of surgery conducted. In the present paper as a primary source of the data, the outreach eye care services registers and files were reviewed for the said study periods. Whereas, CSR form as a secondary source, were reviewed for pre & postoperative visual acuity status and cross checking with the primary data of the outreach camp. We presented data of those patients who were operated through our outreach eye care services only i.e. reach in programme and primary eye care clinics. We excluded poor patients coming to base hospital but admitted in community wards. Follow up data six weeks after surgery were also presented. Data were analyzed descriptively in Microsoft excel (Microsoft Corp., Redmond, WA, USA). Results The result of the cataract surgery performed during five years is summarized in (Table 1) whereas information on the dichotomized visual acuity status both pre and six weeks post operative in (Table 2). A total of 9729 (M=47.2%; F=52.8%) patient was reported at the base hospital for cataract surgery in either eye; of this 8735 (89.9%; M=47.5%; F=52.5%) patients were operated during the study periods (2009-13; Table 1). While maximum surgery was conducted in the age group 60-69 years (37%); another 19% was in less than 50 years of age groups (Figure 3). Very few in numbers (2.2%) were conventional whereas rests were IOL surgery with phaeco-emulsification technique. Pre-operatively, 5241 (60%; Table 2) patients had vision acuity <6/60 in the operated eye out of total. Whereas six weeks after surgery, 4362 (49.9%; M=46.5%; F=53.5%) were examined during outreach follow up. Of these, 415 (9.5%) had poor visual outcome i.e. visual acuity less than 6/60 in the operated eye without any correction. Records were available regarding reasons for the poor outcome of the 61 patients only which was attributed to surgical complications. They were bullous keratopathy (27), posterior capsular opacity (16), uveitis (10), vitreous hemorrhage (4), vitreous loss (2) and endophthalmitis (2) etc. (Table 3). Table 1: Cataract surgery performed during the 2009-13 Gender Reported (%) Surgery Conducted(%) Male 4592 (47.2) 4152 (47.5) Female 5137 (52.8) 4583 (52.5) Total (N) 9729 8735 92

Senjam S et al ISSN 0972-0200 Figure 3: Age distribution of cataract surgery (N=8735) Table 2: Visual Acuity before and after cataract surgery in the operated eye Visual acuity Pre-operative (N=8735) Post-operative (n=4362)* Male (%) Female (%) Total Male (%) Female (%) Total <6/60 2370 2887 5241 191 224 415 (57.1) (62.8) (60) (9.4) (9.6) (9.5) 6/60 1782 1696 3494 1836 2111 3947 (42.9) (37.2) (40) (90.6) (90.4) (90.5) Total 4152 4583 8735 2027 2335 4362 *follow up after six weeks of surgery Table 3: Documented surgical complication leading to poor outcome (2009-13) Complications No. of patients n=415 Bullous keratopathy 27 Posterior capsular opacity 16 Uveitis/Infection 10 Vitreous hemorrhage 4 Vitreous loss 2 Endophthalmitis 2 Other complications 354 Discussion Outreach eye care service is one of the most important strategies to tackle the prevailing burden of avoidable blindness attributed to cataract and uncorrected refractive error in India. The present eye camp model may or may not be same with others existing institute s model but paper shared the model and outcome of cataract surgery performed with valid methodology. There is little published information on the outcome of cataract surgery performed in eye camps in India. 6 This study provides others stakeholders to compare the model and the outcome to their setting. Evaluation of cataract surgical services outcome can be undertaken by two different valid methods. 7 The first method consists of examining the records of all patients who had undergone cataract surgery. The second method involved a population based assessment of a random sample from a population. This second method is the ideal and information obtained is representative of the population but it is very resource intensive. While conducting the evaluation, the assessment could be in terms of performance measurement or visual acuity status of the operated eye or ability to perform routine function 8 or quality of life 9 or economic rehabilitation 10 or combination of these indicators. In a similar way, the present paper presented the outcome of outreach cataract surgical services by examining the available records for the year period of five years i.e. 2009. Limburg H et al. monitoring visual outcome following cataract surgery by using standardized patient surgical records is a valid method. 7 Country like India where resources are already limited the population based assessment of visual outcome following cataract surgery may not be feasible method. The results revealed that ninety percent of the reported patients were undergone for cataract surgery; of this nineteen percents were less than 50 years age groups. Anecdotal evidence showed that the reasons for not conducting cataract surgery were systemic health problems like hypertension, diabetes and other co-ocular morbidities. Appropriate strategy needs to be taken to follow up for those left out patients. Conducting surgery in younger age groups showed the need of further epidemiological research related to cataract and the nature of visual acuity demands among 50 years of age and below. Because, it may be possible, due to continuous increased in visual demand, people may opt for early cataract surgery even in mild to moderate visual impairments. The result also showed that 49.9% of the total operated patients were returned for follow up examination at six weeks after surgery. In the developing countries, as per highlighted by Congdon N et al, the follow up rate was as low as 20-30%. 11 In our setting, follow up examinations were done at the camp site or at our outreach primary eye care clinics. Probably, this makes convenient for the patients to come for examination. However, more qualitative research is warranted to identify the reasons for not returning the rest of the operated patients. The study also showed that poor or unsatisfactory visual acuity outcome (VA less than 6/60 in the operated eye) out of the total follow up was 9.5% which is higher than World Health Organization (WHO) recommended standard cutoff (less than 5%) of postoperative poor visual outcome with available correction. 12 The proportions of poor outcome with available correction reported in developing countries are in the range of 3-10%. 13-16 However, in our setting, this figure was recorded before correction, but ideally it should be after corrections as per WHO guideline. This could be the reason why the value was higher. Moreover, the records revealed that quit number of postoperative patients were prescribed spectacles. This implies that uncorrected refractive errors might be the major reasons for the poor vision outcome in the present study. As per record, the other documented reasons for poor outcome of the 61 patients are bullous keratopathy, posterior capsular opacity and uveitis. The other factors for poor outcome could be the presence of pre-existing ocular co-morbidity. Nevertheless, strategy needs to be developed to improve the follow up compliance and documentation of the reasons for poor outcomes. Improvement in the 93 Del J Ophthalmol 2014;25(2)

Outcome of Cataract Surgery from Outreach Eye Camp surgeon s skill and ruling out the presence of existing or pre-existing ocular pathology probably may help in dealing many of the complications that were reported. Another debatable issue is patients who returned for follow up examination after cataract surgery, will be representative of the entire operated cohort or not. In our review, it may not be representative of the operated cohort since followed up rate was low (49.9%). Patients who returned without additional prompting for the follow up after cataract surgery might be represent a biased sample. They might be more likely to have symptomatic surgical complications as compared to who did not return, therefore, more likely to have higher proportions of poor outcome. However, the validity of assessment of cataract surgical visual outcome by examining only returned cohort where follow up is poor, are highlighted in some of the studies also. 6,12 The present paper also revealed that a quite reasonable proportion of cataract surgeries were undertaken through outreach eye care services of the community ophthalmology unit i.e. on an average 1800 surgeries per annum. Unfortunately, the authors are not able to compare the performance of cataract outreach services from other centers where there is no designated community ophthalmology unit but organized such type of outreach eye camp either due to paucity of published data or camp are being organized in less frequent hence very less data in their records. However, from the evidence of the present paper, it can be concluded that institutes have such department or unit certainly will be able to perform outreach eye care services in a more regular fashion and thereby help in capturing underprivileged area in a wider scale. Meanwhile, sensitization of Panchayati Raj Institution s members to involve in outreach eye care services should also be given due importance. Such kind of partnership strategy will certainly help in clearing the remaining pocket of cataract blindness and should be a pivotal strategy to wipe out the last remaining avoidable cataract blindness pocket from India. The present paper has some weakness and limitations. One of the weaknesses is, postoperative details data for the study periods was not able to get for analysis purpose, therefore partial data were highlighted. Another is, we are not able captured preoperative visual acuity details of the below 50 years patients. It will be fruitful if it reports how many of them had visual acuity better than 6/60 but opted for surgery. This highlights individual visual acuity demands. Apart from inherent limitations of retrospective data collection and analysis, more advance statistical analysis could have been performed if sufficient data were available especially the category of visual outcome and demographic profile of operated patients. Since, analysis is based on available CSR form; the information obtained may not be representative. However, the present review paper provided scope to improve the existing recording system of cataract surgical outcome in the future. Financial & competing interest disclosure The authors do not have any competing interests in any product/ procedure mentioned in this study. The authors do not have any financial interests in any product / procedure mentioned in this study. References 1. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. 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