Patient PreoPerative exPectation for the outcome of cataract surgery and the actual PostoPerative exPerience. in judoauthors- Zelalem addisu - berhan solomon Presented @ OSE in 2008
Outline of the study report Introduction Literature review significance of the study Objectives Methodology Result and Discussion Conclusion and recommendations
Introduction cataract is the leading cause of blindness in the world. an estimated of 25 million people were blind due to cataract i.e. 50% or more of the global burden of blindness. Annually, at least 25 million eyes develop visual acuity <6/60 due to cataract. around 1% of Africans are blind
around 7.1 of the worlds 38 million blind people live in sub-Saharan Africa Around 60% of Africas blind are women Around 50% of blindness in sub-Saharan Africa is due to cataract The number of people blind from cataract in the world is increasing by approximately 1 million per year and the number of ‘operable’ cataract eyes with a visual acuity of less than 6/60 is increasing by 4–5 million per year. In NBS prevalence of BL and LV was 1.6 and 3.7% [50% and 41 %]
Globally, the need for cataract operations is at least 30 million per year, but only around 10 million cataract operations are performed annually For this reason intervention against cataract blindness has received priority attention in Vision 2020:
Global causes of blindness as a percentage of total blindness in 2002 cataract 47.8% Source: WHO 04.138
Outcome of cataract surgery is: the change in functional disability as a result of cataract operation usually expressed as visual acuity Purpose of monitoring cataract surgical outcome: Encourage eye surgeons to monitor their own results over time. Identify causes of poor outcome •Selection •Surgery •Spectacles •Sequelae�Address causes to improve future outcome
Outcome depends on:�skills and knowledge of eye surgeon�surgical technique used�surgical facilities and environment�post-operative care�optical correction provided�patient-related risk factors, like ocular co- morbidity (glaucoma, age-related macula degeneration
Patient satisfaction is an increasingly important objective for health services with satisfied patients reporting greater compliance, well-being, and treatment outcomes with satisfied patients both remaining with and recommending their provider ,and that a satisfied patient is the best defense against malpractice lawsuits. patient satisfaction with surgery is an important outcome measure to include in the assessment of surgical outcomes.
Monitoring outcomes could , therefore, be applied in a clinical setting,where the visua l outcome of cataract surgery(post-operative visual acuity) is primarily measured. In addition, studies based on activities of daily living(ADL), patient well being, quality of life and patient satisfaction may be instituted as a routine or, more commonly, on randomly selected post-operative patient groups.
In USA to assess the functional expectations and postoperative outcomes revealed very high and were unrelated to their demographic or ocular characteristics. The preoperative VF-12, score ,however, was positively correlated with expected postoperative VF-12 score. Only 61% of patients achieved or surpassed their expected level of postoperative functioning.
In Australia to assess expectations and outcomes in cataract surgery showed that the median v/a was 6/18, with a mean (SD) preoperative VF-14 score of 84.7 (14.8) and postoperative VF-14 score of 89.8 (16.4). The most unrealistic expectations involved driving at night, reading small print, and doing fine handiwork.
In British Columbia to assess VF post cataract surgery –of 47 people 28 (59.6%) had a perfect score postoperatively, 13 (27.6%) had a score of 90 or better, 5 (10.6%) had a score of 87 to 90, and 1 (2.1%) had a score of 67.Among the 200 people with a preoperative VFA score of 90 to 99, postoperatively the VFA score improved for 146 (73.0%), remained the same for 43 (21.5%) and worsened for 11 (5.5%).
In Indonesia to evaluate cataract surgical outcomes reported a total of 443 patients were operated and at one month after surgery, 76.08% was seen > 6/18. 2.48% < 3/60Intra & post-operative cxns were seen in 10.84% of all cases, mainly due to vitreous loss (66.67%). Intra-operative complications, systemic diseases present before the operation, and associated eye diseases were significant risk factors for poor outcome.
The results of hospital based prospective studies of cataract surgery in developing countries have usually reported good outcomes. In the Madurai intraocular lens study 1yr after ECCE + PC IOL , 0.6% of patients had a BCVA of < 6/60, and 98.1% had a BCVA of 6/18 or better. In a study from Kenya, 1.5% of eyes had a visual acuity of < 6/60 postoperatively, and 94.3% were 6/18 or better after ECCE and PC-IOL. These studies demonstrate that good outcomes can be obtained in the settings of developing countries. This has led to calls for the quality of cataract surgery to receive at least as much attention as the quantity of surgery.
At Kikuyu Eye Unit, to assess the visual outcome of patient undergoing cataract surgery and the result were: BCVA of 6/18 or better was obtained in 94.3% of eyes and an uncorrected vision of 6/18 or better in 78.2% of eyes. Six eyes (1.5%) had BCVA of < 6/60
At Menelik II Hospital revealed that out of the 214-study population, 174 (81.3%) were followed up to the 8th week and also completed the entire interview and examination. The uncorrected VA of the 174 patients was 6/18 or better in 74 (42.5%), while 100(57.5%) patients had low vision (<6/18). However, the final corrected post-operative visual acuity (VA) was 6/18 or better in 109 (63.0%) of the patients, and in 65(37%) patients it was found to be low (<6/18).
Study done in Jimma zone showed that out of 617pts operated, 77 eyes (18.4%) had final visual acuity (V/A) of >6/18; 388 eyes (92.6%) had V/A of >6/60 and 395 eyes (94.3%) had V/A > 3/60.
Significance of the study Calculates the visual outcome and assesses the quality of cataract surgery encouraging eye surgeons to monitor their own results, over time, in itself will lead to better outcomes of cataract surgery. Provide base line data for the eye unit to design appropriate strategies in order to provide the highest level of satisfaction and improve results of cataract surgery as improved outcome will motivate more patients to come forward for surgery.
OBJECTIVESGENERAL OBJECTIVIES To describe the relationship between patients preoperative expectations regarding the outcome of cataract surgery and actual postoperative experience. To evaluate post operative visual outcome of cataract surgery
SPECIFIC OBJECTIVES To assess patients preoperative expectations for postoperative outcomes and actual postoperative experience To evaluate post operative outcome of cataract surgery at first day postoperative and at 4 weeks after the operation To identify the cause of poor outcome.
Study area and period. Ham 16/1999- Hed 10/00 Study Design Population Source Population Study Population Sample size PROCEDURE AND MEASURES - Structured questionnaire - Preop assessment VA , slit lamp bio microscopy, & dilated funduscopy. Keratometry and A-scan biometry
VF were measured using a 15-item visual function assessment with final score ranging from 0 (no visual ability) to 100 (no visual disability). Patients were then asked to rate their expected postoperative functional outcome for each of the 15 items on the VF-15 scale. The visual status was classified using the World Health Organization (WHO) category of Visual Impairment and Blindness. Data collections were conducted Validity and reliability Data analysis Ethical consideration Limitation of the study
200 patients were approached. Of these, 179 (89.5%) were followed up to the 5th week follow up.Table 1.patient characterstics, Jimma University, ophthalmology department, 2007. Characteristics preoperative 5 th wks Post operative No. of patients 200 179 Age mean (SD) 58.7(14.6) No of women (%) 60 (40 %) VF-15 score, mean (SD) 54.19 (34.1) 94.1 (15.9) Overall satisfaction Very much improved 132(73.7%)
Table 2.preoperative visual acuity of patients, Jimma University, Ophthalmology Department, 2007. V/A No % 6/24-6/60 1 0.5 <6/60-3/60 9 4.5 <3/60-LP 190 95.0 Total 200 100
Fig.1 .cataract type (N=200), Jimma University, ophthalmologydepartment, 2007.
Table 4.Surgeon that did the surgery &type of IOL inserted, Jimma University, Ophthalmology Department, 2007. Surgeon PC IOL AC IOL aphakic TotalOphthalmologist 139 4 0 143Resident /trainee/ 12 0 0 12Cataract Surgeon /trainer/ 42 1 2 45 Total 193 5 2 200
Table 5. Intraoperative complications in operated eye ,Jimma University, Ophthalmology Department, 2007 . Intraoperative complication No % None 181 90.5Capsular rupture with vitreous loss 8 4.0Iris damage(inadverteal PI,iridodialysis 4 2.0Retrobulbar hemorrhage 4 2.0Capsular rupture without vitreous loss 2 1.0Zonular dehiscence 1 .5Total 200 100.0 NB at Kikuyu OF 388 PCR 27 (7.0) ,Z 2(0.5) ,V 16(4.1) at Kaduna PCR10 eyes (5.7%), v 3% NZ PCR 4.45 % FINLAND 5.4%. Aravind 1.7% of 898 eyes 10% in Ghana and 11.4% in Sierra Leone.
Table 7. Postoperative visual acuity of patients (after 4wks), Jimma University, Ophthalmology department, 2007. Post operative V/A without correction with pin hole No % No % Good >6/18 102 57.0 126 70.4 Borderline <6/18-6/60 55 30.7 39 21.8 Poor <6/60 22 12.3 14 7.8 Total 179 100 179 100 In Nepal – uncorrected 47.9% of cases - corrected 77.4% of cases. at Kikuyu 73.1% had uncorrected 2 m. In Menelik Without correction 74(42.5%) With pin hole 110(63.2%) (1999) 174
Best corrected vision after 1 year in clinical trials: LAHAN ARAVINDVisual Acuity ICCE + ICCE + ICCE + ECCE + PC-IOL specs AC-IOL specs6/6 - 6/18 93.2 89.9 95.5 96.6 < 6/18 - 6/60 4.6 7.5 2.9 1.1< 6/60 2.2 2.6 1.6 2.3 n= 914 906 1401 1474 follow-up 91% 85% WHO guideline for evaluating the outcome of cataract surgery Post-operative Available correction Best correction visual acuityGood 6/6–6/18 >80% (70.4%) >90%Borderline <6/18–6/60 <15% (21.8%) <5%Poor <6/60 <5% (7.8%) <5%
Table 9. Causes of poor outcome (best corrected acuity <6/60) in 200 pts seen at 2 month follow up Factors No Pre-existing ocular comorbidity 7(50%) Central corneal opacity 1 Pseudoexfolation and Glaucoma 2 Pseudoexfolation and ARMD 2 Others 3Surgical events 3(21.4%) PC tear 2 Iris damage(inadverteal PI,iridodialysis 1Post-surgical conditions 4(28.6%) PCO 3 RD 1 Total 14
Table 10. Mean of pt. Expectation and outcome for visual function index (VF-15) items, Jimma University, ophthalmology department, 2007. VF-15 Item Expectation Outcome Mean (SD) Mean (SD) P-value1. Performing manual tasks? 87.6(21.4) 93.1(17.93) 0.122. Going out by your self? 94.5(13.1) 94.5(17.02) < 0.0013. Reading small print? 91.7(14.89) 91.5(22.65) 0.0264. Reading large print such as posters, numbers on a Telephone? 97.8(8.09) 96.1(15.54) 0.75. Recognizing people? 96.3(10.55) 94.3(17.13) < 0.0016. Doing fine hand works like sewing, knitting or wood working? 89.6(18.29) 83.1(30.00) < 0.0017. Cooking, dressing or other self-care activities? 95.4(11.77) 93.4(18.79) 0.078. Participating in social activities? 95.9(10.86) 93.0(20.18) 0.0019. Going to shops/Markets? 94.9(13.56) 92.2(21.89) < 0.00110. Working just like you did before? 94(13.31) 93.0(19.11) < 0.02111. Choosing clothes to wear? 98(8.44) 98.2(9.92) < 0.00112. Taking a bath by yourself? 98(8.44) 98.2(9.92) < 0.00113. Getting dressed by yourself? 98.4(7.95) 98.4(9.77) < 0.00114. Visiting your friends? 96.9(10.00) 93.7(19.08) 0.1815. Watching Television? 94.7(13.95) 98.0(8.66) 0.17
In Sydney Private Hospital, Sydney, of 121pts 80 patients (66%) failing to equal or exceed their expectations at 1-month follow-up.
Table 11. Sperman rank correlation with patient satisfaction for visual function Index (VF-15) items, JimmaUniversity, Ophthalmology department 2007Correlation with satisfaction VF-15 Item Preoperative post operative Expectation outcome1. Performing manual tasks? NS 0.842. Going out by your self? NS 0.883. Reading small print? NS 0.534. Reading large print such as posters, numbers on a Telephone? NS 0.885. Recognizing people? 0.26(0.002) 0.886. Doing fine hand works like sewing, knitting or wood working? 0.26(0.002) 0.637. Cooking, dressing or other self-care activities? NS 0.89
8. Participating in social activities? 0.16(0.048) 0.929. Going to shops/Markets? NS 0.9210. Working just like you did before? NS 0.8211. Choosing clothes to wear? NS 0.3712. Taking a bath by yourself? NS 0.3713. Getting dressed by yourself? NS 0.3714. Visiting your friends? NS 0.7615. Watching Television? NS 0.70Abbreviations: NS, not significant;P values (outcome) <0.001
Table 12.Sperman correlation with patient satisfaction for composite measures, Jimma University, ophthalmology department, 2007. Measure Correlation p-value With satisfactionExpected VF -15 score improvement 0.004 NSActual VF -15 score improvement 0.19 NSActual post operative VF -15 score 0.38 .010NB. Expected VF -15 score improvement 0.21 0.02 Actual VF -15 score improvement 0.11 NS Actual post operative VF -15 score 0.32 .004
CONCLUSION Expectations regarding visual functioning after cataract surgery were very high, and in most cases such expectations are fulfilled. The visual outcome of cataract surgery performed during the sample period was satisfied the patients by the results achieved and very encouraging to consider it in the future. With adequate surgical skills, ECCE with PC IOL implantation offers good visual rehabilitation even with training conditions. The need for measuring outcomes, preferably over a wider spectrum than the mere visual outcome, is a critical element in measuring and tracking our achievements towards the goal of eliminating avoidable blindness by 2020.
RECOMMONDATIONS Prospective standardized monitoring of cataract surgical outcomes with regular analysis of the causes of poor outcome is an important tool, in which the ophthalmic surgical teams can use to improve the results of their cataract surgery. Surgeons have to emphasize the importance of controlling their patients’ expectations. (B/c controlling patient expectations may be more effective than improving patients’ postoperative outcome in terms of maximizing patient satisfaction).
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