KAREN REVERE, MS IV

UNIVERSITY OF PENNSYLVANIA SCHOOL OF MEDICINE, PHILADELPHIA, PA, USA

RUHARO EYE CENTRE, MBARARA , UGANDA

MENTOR: DR. KENNETH KAGAME

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

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, 1235-50Sandford-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

Case # DatePt. #

Pt. Name

Dx Age SexOcular

co-morbidity

HIV DM Smoke HTNVA,

pre-op

Case # Nurse Res. Attg. Eye Tech.Capsulerupture

Vitreous loss

Irisprolapse

Incomplete Corticalcleanup

Other

Case # VA, POD#1Corneal Edema

Iris prolapse/damageRaised

IOPAnterior uveitis Other

Case # POD # VA InfectionIris

capturePosterior synechiae

IOL displacement Other

Ba

ckg

rou

nd

Intr

a-o

pP

OD

#1

PO

D #

14

Results

Gender and cataract type

p<0.05

SexCataract Type

TotalTraumatic Mature Hypermature PSC

Female0

0%9

42.9%5

83.3%1

16.7%15

41.7%

Male3

100%12

57.1%1

16.7%5

83.3%

2158.3%

Total3

100%21

100%6

100%6

100%36

100%

Age and cataract type

p<0.05

AgeCataract Type

TotalTraumatic Mature Hypermature PSC

< 603

100%5

23.8%1

16.7%3

50.0%

1233.3%

> 600

0%16

76.2%5

83.3%3

50.0%

2466.7%

Total3

100%21

100%6

100%6

100%36

100%

Visual acuity

Pre-op POD 1 POD 14

VA Frequency, % Frequency, % Frequency, %

6/6-6/18 25.6%

415.2%

114.3%

6/24-6/36 411.1%

618.2%

571.4%

≤6/60 3083.3%

2367.0%

114.3%

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 tear/rupture

7 19.4

Incomplete cortical cleanup

5 13.9

Vitreous loss 4 11.1

Other: accidental iridectomy (x2),

iridodialysis

3 8.6

Iris prolapse 1 2.8

Total 20 55.6

Post-operative complications

Complications Frequency Percentage

POD 1 Corneal edema 17 51.5

Iris damage/prolapse

4 12.1

Other: hyphema, fibrin in AC, IOL

displacement

3 9.1

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, intra-op

Corneal edema, POD 1

No Yes Total

No14

87.5%13

76.5%27

81.8%

Yes2

12.5%4

23.5%6

18.2%

Total16

100%17

100%33

100%

Surgical techniques

PhacoemulsificationECCE

(Sutures required)

surgeryencyclopedia.com

SICS(Suture-free)

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

TechniqueCapsule

tear/rupture

Vitreous loss

Iris prolapse

Incomplete cortical cleanup

Other

Total

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

Technique

Corneal edema

Iris prolapse/da

mageRaised IOP Other Total

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

VA, POD 1 Capsule

tear/rupture

Vitreous loss

Incomplete cortical cleanup

Other Total

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

Q U E S T I O N S ?

C O M M E N T S ?

C O N S T R U C T I V E C R I T I C I S M S ?

Thank you