Cataract surgical rates (CSR) help determine whether cataract services are reaching enough people. The CSR needed in each country depends on the population's age structure and incidence of cataract development. If the CSR is lower than the incidence, then the backlog of eyes requiring surgery will increase. Quality of cataract surgery is measured by cataract surgical outcomes, with fewer than 5% of patients unable to see 6/60 or better after surgery. Monitoring tools record information like visual acuity and complications from each surgery to identify areas for improvement.

1. Adviser: Dr. dr. Trilaksana Nugroho, Mkes, FISCM, Sp.M(K)
dr. Sandi Muslim

2. QUESTION
 How do we know if our cataract service is reaching
enough (and the right) people?
 How can we tell whether the quality of surgery is good
enough?
Understanding cataract indicators, and how to use
them, can help us to meet the community's needs

3. Overall trends and
patterns
INTRODUCTION

4. INTRODUCTION
Infection
disease
(trachoma,
onchocerciasi
s, Measles)
Cataract
cause most
blindness
improved
hygiene,
antibiotics,
ivermectin,
vaccinations and
vitamin A
distribution
eye infections
and
xerophthalmia
have become
less common

5. INTRODUCTION
Life expectancy
increased
Increase Incidence
of cataract

6. Advance’s in cataract surgery over
the past 30 years
allowed surgery
to be undertaken
earlier and vastly
improved
postoperative
visual outcomes
Advent of
microsurgery,
Introduction of IOLs
Transition from intra-
capsular to extra-
capsular
Small incision surgery
Indicators for
monitoring
services – and the
tools to collect
monitoring data

7. INDICATORS FOR MONITORING
CATARACT SERVICES

8. Quantity of cataract surgery
 Cataract surgical rate (CSR) = number of cataract
operations per million population per year
 A target CSR can be established based on the desired
output of the available cataract surgeons in the area, or on
the estimated incidence of operable cataract.
 The number of operations can be used to set and
monitor output targets and compare the efficiency of
cataract services and surgeons in different hospitals or
geographic areas :
- Average weekly output per cataract surgeon
- Annual output per cataract surgeon

9. Quality of cataract surgery
 The indicator for the quality of cataract surgery is
cataract surgical outcome (CSO), which is the
visual outcome in the operated eye

10. Quality of cataract surgery
According to the WHO, fewer than 5% of cataract patients should be unable to
see 6/60 (best corrected or presenting).
Quality of cataract surgery

11.  Paper-based and computerised software tools were
subsequently developed to monitor cataract surgical
outcome. The following information is recorded for each
operation:
• Visual acuity (VA) before surgery
• Surgical technique used
• Whether the outcome is good, borderline or poor, both
after surgery and at follow-up
• The type of complication.
• The major cause of each poor outcome.
Tools

12. The software is intended to provide insight as to where
and how modifications in the service can be made to
improve visual outcome further.
The system is definitely not intended to compare
individual eye surgeons or clinics, but to monitor
improvement in outcome over time for the same
surgeon or clinic

13. Population-based indicators
 Population-based information was needed that could
capture local variations in disease pattern,
environment and available resources
 Cross-sectional surveys can provide this information
on the eye care situation within a defined area, such as
a district, province or country  The information can
then be used to plan and monitor services

14. The Rapid Assessment of Avoidable
Blindness (RAAB)
 Methodology was specifically developed to collect data
that would make it possible to plan eye care services
for a population of between 0.5 and 5 million people.
 RAAB surveys are restricted to those aged 50 years and
above( sample size smaller and the survey is faster and
less expensive)

16. Equity of cataract services:
disaggregating indicators
 Cataract services are not used equally by people within
countries.
 For example, in many settings high quality cataract
surgery is provided to wealthy urban people, often
before visual impairment occurs. In contrast, similar
services are scarce or absent for the rural poor
 High cataract surgical rate would not automatically
mean that the coverage will be high or that the
prevalence of cataract blindness will be low

17.  All cataract indicators can be disaggregated (reported
separately) by gender, location (urban or rural),
socioeconomic status, or disability, etc
 Inequity is often identified
 Disaggregated cataract indicators are essential in order
to understand the nature and extent of inequality in
the population, to inform appropriate strategies to
reduce inequality, and to monitor whether
improvements in services (e.g. quality and access) are
experienced by the groups who need them most

18. Interpreting cataract indicators
 The current global action plan has chosen cataract
surgical rate (CSR) and cataract surgical coverage
(CSC) as its service delivery indicators, but a clearer
picture of cataract services emerges when data are
available for a broad range of indicators
 For example, a high CSR alone may not reflect ‘good’
cataract services, without considering the cataract
surgical outcomes (CSO) of the operations, who was
operated on (to ensure equity), and whether coverage
(CSC and effective cataract surgical coverage, or eCSC)
is improving

19. scenarios to illustrate the interpretation of
various RAAB cataract indicators

20. scenarios to illustrate the interpretation of
various RAAB cataract indicators

21. scenarios to illustrate the interpretation of
various RAAB cataract indicators

22. CRITICAL APPRAISAL

23. TITLE
Too long / short ?
Less than 12 words, can illustrate
the content generally
Illustrate the observed
variables ?
None
Non standard
Abbreviation?
None
Any corresponding
author and email ?
Author :
1. Hans Limburg
Consultant: Public Eye Health, Health
Information Services, Grootebroek,
Netherlands.
2. Jacqui Ramke
Senior Research Fellow: University of
Auckland, Auckland, New Zealand.
www.cehjournal.org

24. ABSTRACT
Consists of 4 parts:
background, method,
result, and conclusion ?
No
Any keywords ? No
Do the abstract is wholly
appropriate ?
No
AIM & BENEFIT OF THE RESEARCH
Does the aim explained ?
Understanding cataract indicators, and how
to use them, can help us to meet the
community's needs
Does the benefit
explained ?
Yes

25. METHODS
Is there any research
design ?
None
Population & samples None
Inclusion-Exclusion
Criteria
None
Sampling & Sample size
formulation
None
Did the subject selection
is appropriate?
Is there any bias ?
None
Treatment None

26. METHODS
Did the measurement
blind ?
None
Is there any bias on
procedure, means, and
subject obedience ?
None
Is there any explanation
about independent &
dependent variables ?
None
Is there any operational
definition ?
None
Is there any ethical
clearance consent ?
None
Data analysis ? None

27. RESULTS
Any Drop out ? -
Is there any subject
characteristic table ?
-
Is there any aim for the
results?
-
What is the main result
of the research ?
-
DISCUSSION
Did the result suits the
theory ?
None
Is there any comparison
with another research ?
None

28. CONCLUSION
Could this research be
applied for patients ?
Applicable

29. Thank you

30. Add slide

31. Cataract surgical rates
 CSR needed in each country (the target CSR) is
determined by the number of eyes that will develop
cataract in one year (the incidence).
 Incidence is affected by the age structure of a
population. Older populations have a higher incidence
of cataract than younger populations
 If the number of new cases (the incidence) is higher
than the cataract surgical rate, then the backlog (the
number of eyes that require cataract surgery), will also
be high.

32. CSR, INCIDENS AND BACKLOG

36. Overall trends and
patterns

41. 5 Strategi Percepatan Penanggulangan
Gangguan Penglihatan di Indonesia
1) Identifikasi besarnya permasalahan gangguan
penglihatan melalui survey Rapid Assessment of Avoidable
Blindness (RAAB)
2) Analisa situasi dan pembuatan Plan of Action
3) Pelatihan sumber daya manusia untuk kesehatan
penglihatan
4) Penguatan sistem rujukan kesehatan
5) Integrasi pelayanan kesehatan penglihatan dengan
Jaminan Kesehatan Nasional (JKN)

42. Major problems in programmes for
eye care in Indonesia:
(1) Lack of political will and national commitment. Eye care
receives only a very small proportion of the total health
budget
(2) Eye care services are heavily dependent on NGO support,
making them vulnerable to donor sensitivities.
(3) Inadequate number, inappropriate mix and unequitable
distribution of eye health manpower. Most of Indonesia’s
600 ophthalmologists and 700 refractionists work only in
big cities.
(4) The high burden of blindness is further compounded by
geographical difficulties. Two hundred and ten million
Indonesians are scattered in 17 000 islands
Report of SEARO/IAPB Meeting 1999

44. Sample of
cataract surgery
record

45. The Manual Tally Sheet: Discharge
The Manual Tally Sheet: >4 Weeks Post-operatively

46. The causes of poor outcome can be
divided into four categories:
1. Selection: patient-related risk factors, e.g.,
concurrent diseases affecting vision
2. Surgery: surgical or immediate post-operative
complications
3. Spectacles: uncorrected refractive error, wrong
power IOL
4. Sequelae: late post-operative complications.

47. The following guidelines are useful to
evaluate quality of Cataract operation:
1. Proportion of cases with IOL: a target percentage can be set
according to local circumstances– If less, improve availability
and affordability of IOLs and ensure that all surgeons are
adequately trained in IOL surgery and have the necessary
equipment.
2. Percentage of complications should be less than 10%, with
posterior capsule rupture and vitreous loss each not
exceeding 5%– If more, improve surgical technique by asking
for advice from a good and experienced cataract surgeon.
Also, ensure that all surgeons are adequately trained in IOL
surgery and have the necessary equipment.
3. At discharge, more than 50% of cases should have good
presenting vision and less than 10% poor outcome

48. 4. At 4 weeks or more post-operatively, more than 80% of
cases should have good presenting vision and less than
5% poor outcome
5. At 4 weeks or more post-operatively, more than 90% of
cases should have good vision with best correction and
less than 5% poor outcome– If not, analyse the causes of
poor outcome. If surgical, take action as above. If
refraction, provide at least best spherical correction
spectacles at an affordable price.
6. The trend over time is static outside the recommended
limits, or worsening– Carefully analyse the reasons for
lack of improvement and deal with identified problems.

50. Insidence and prevalence
 Incidence is the rate of new (or newly diagnosed) cases
of the disease.
 Prevalence is the actual number of cases alive, with the
disease either during a period of time (period
prevalence) or at a particular date in time (point
prevalence). Period prevalence provides the better
measure of the disease load since it includes all new
cases and all deaths between two dates, whereas point
prevalence only counts those alive on a particular date.

52. cataract surgical coverage
 The cataract surgical coverage of people, or the
proportion of people needing surgery who had
undergone cataract surgery
 was calculated by dividing the number of cataract
surgeries (sum of the number of people with bilateral
pseudophakia or aphakia and the number of people
with unilateral pseudophakia or aphakia and unilateral
visual impairment) by the sum of the number of
surgeries and the number of people visually impaired
from cataract

53.  It indicates to what extent the services have covered
the needs.
 It measures the effectiveness of the cataract
intervention programme in providing surgical services
and, as such, it is an output indicator
 does not measure the quality of cataract intervention.

54. RAAB in Indonesia