Global Blindness: Managing cataract outcome
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Increasing the number of cataract surgeries should not be achieved at the expense of surgical quality. The success of this sight-restoring intervention is central to acceptance and sustaining service provision. In this presentation we look at managing cataract outcome, or the quality of eye surgery. How do you think monitoring of cataract outcome benefits surgical services? What are the factors that can influence cataract outcome? Why is it important not to compare the outcomes of surgeons and clinics? © 2016 International Centre for Eye Health, London School of Hygiene & Tropical Medicine. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license. Taken from the free online course: Global Blindness: Planning and Managing Eye Care Services. We encourage the use and adaptation of this resource for teaching and learning. Find more Open Educational Resources for eye care on our website at http://iceh.lshtm.ac.uk/oer
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Global Blindness: Managing cataract outcome
- 1. Global Blindness: Planning and managing eye care services Managing cataract outcome
- 2. Learning outcomes Describe the impact of outcome on surgical services Understand the World Health Organization guideline for cataract outcome Relate to managing and monitoring cataract surgical outcome
- 3. Sustainability of cataract services High output High outcome Low cost Patient demand Sustainability
- 4. Quality of cataract surgery Psychological Physiological Functional Patient satisfaction Activities before and after Vision in the operated eye
- 5. Cataract surgical outcome 2005 data from population and rapid assessment surveys found: • Poor outcomes (less than 6/60) in 21 – 53% of all operated eyes across a range of eye units
- 6. Cataract surgical outcome Since then: •Intraocular lens (IOL) implantation •Small incision cataract surgery (MSICS) •Phacoemulsification
- 7. WHO guideline on cataract surgery outcome Visual outcome Available correction Best correction Good > 6/18 >80% >90% Borderline <6/18 - 6/60 <15% <5% Poor < 6/60 < 5% <5%
- 8. Impact of poor outcome Direct impact on individual patient Impact on service reputation Decrease in output Higher costs Challenge to sustainability
- 9. Causes of poor outcome Selection e.g. co-morbities Surgery complications Sequelae late post-operative complications Spectacles correct refractive error
- 10. Admission Clear examination protocol and vision assessment
- 11. Pre-operative Case selection protocol Patient preparation and counselling
- 15. Monitoring cataract outcomes Reduce complication rates Provide a reliable quality of service Provide team feedback
- 16. Monitoring cataract outcomes Should not be used to compare outcomes between surgeons or eye units
- 17. Monitoring cataract outcomes Manual tallysheet for every 20 patients Post-operative vision is recorded at discharge and again at follow-up at 4 – 6 weeks Discharge Follow up
- 18. Monitoring cataract outcomes Manual tallysheet for every 20 patients Information is collected for 100 cases and then assessed Discharge Follow up
- 19. Monitoring cataract outcomes Software Automatic reports for every 100 cases
- 20. Monitoring reports Direct information: •Percentages of good, borderline and poor outcomes •Causes of poor outcomes at discharge and follow-up ----- ----- ----- i ----- ----- ----- i ----- ----- ----- i
- 21. Monitoring reports Additional information: •Age and gender of patients •1st or 2nd eye operations •Visual acuity pre- & post-operatively •Percentage IOL implantations •Operative complications by month ----- ----- ----- i ----- ----- ----- i ----- ----- ----- i
- 22. Three steps to good cataract surgical outcome 3. Take measures to avoid complicat- ions 2. Know your outcomes by monitoring services 1. Use IOLs in everyone Always refract post- operatively
- 23. Good outcomes of cataract surgery leads to high volume, sustainable eye care services.
- 24. Written by Dr Daksha Patel © 2016 International Centre for Eye Health, London School of Hygiene & Tropical Medicine. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license. Taken from the free online course: Global Blindness: Planning and Managing Eye Care Services. We encourage the use and adaptation of this resource for teaching and learning. Find more Open Educational Resources for eye care on our website at http://iceh.lshtm.ac.uk/oer
Editor's Notes
- Welcome to this presentation on managing cataract outcome. By the end of it you should be able to: Describe the impact of outcome on surgical services Understand the World Health Organization guideline for cataract outcome Relate to managing and monitoring cataract surgical outcome in eye units
- There are several inter-connected factors that affect the sustainability of cataract services. Firstly, to deliver efficient surgical services we need to maintain high output. This has to be balanced with providing high outcomes of surgery to maintain patient confidence. Low cost of surgery is another key factor that helps fuel demand for services. It is essential to achieve sustainable eye care for a population within their health system, in order to reduce blindness from avoidable causes.
- Quality of cataract surgery can be measured in three ways Psychological – the patient perspective. This is often linked with satisfaction with surgery Functional - what patients are able to do before and after surgery Physiological – a measurement of the vision in the operated eye Psychological and functional measurements are subjective and very difficult to standardise. The physiological measurement uses the change in visual acuity to provide an objective perspective on a patient’s status, before and after surgery.
- In 2005, a review of data from many population-based, and rapid assessment, surveys indicated that poor outcomes (less than 6/60) were being found in between 21 and 53% of all operated eyes across a range of eye units. Most of these poor outcomes were due to aphakia or breakage of spectacles.
- Since then, intraocular lens (IOL) implantation has become the norm in cataract surgery. There have been additional improvements in surgical techniques such as small incision cataract surgery and phacoemulsification. As a result, we can now expect much lower rates of poor outcome. Image credit: Boateng Wiafe. Published in the Community Eye Health Journal www.cehjournal.org.
- The World Health Organization has produced a guideline for the visual outcomes that should be expected from cataract surgery. Outcomes are classified as good, borderline or poor: An outcome is good if visual acuity after surgery is equal to better then 6/18 in the operated eye It is borderline if acuity is worse than 6/18 but equal to or better than 6/60. And any acuity less than 6/60 is classified as a poor outcome. Eye units should aim to have good outcomes in over 80% of all operated cases at 2 month follow up with available correction, or 90% with best correction. Ideally borderline and poor outcomes should be found in less than 5% of all cases with best correction, or in up to 15% of cases with available correction. These guidelines can be applied in high and low volume settings and across static and outreach service delivery models.
- Impact of poor outcome. Vision less than 6/60 after surgery has a range of impacts. Naturally it is has a direct, and devastating, impact on the individual patient whose expectations have not been met. It also impacts on the reputation of the hospital or service provision at a community level, often creating a long term mistrust of health providers. Reputation at the professional level needs attention as issues for training and ethics. Poor outcome means fewer patients and decreased output. Fewer cases done means higher costs. Over time, this will challenge the sustainability of service delivery and the whole eye care programme may fail. Eye units need to look at outcome measures as a high priority and take corrective action.
- There are several causes of poor outcome: The selection of patients for surgery. Co-morbidities, for example can impact on final outcome Surgical complications resulting from technique, procedure or even lack of facilities Failure to provide spectacles to correct post-operative refractive error can reduce benefit to the patient Sequelae - which are late post-operative complications such as posterior capsule opacification.
- Management to minimise poor outcomes begins at admission stage. A clear examination protocol and vision assessment should provide a sound understanding of any underlying co morbidities. Image credit: Daisy Wilson. Published in the Community Eye Health Journal www.cehjournal.org
- Pre-operative selection of cases, particularly in busy, high volume settings, should follow a protocol so that patients with pre-existing eye diseases, such as glaucoma or posterior segment disease, are not missed. Patients need to be prepared and counselled accordingly. Image credit: Paul Courtright. Published in the Community Eye Health Journal www.cehjournal.org
- Surgical complications, such as technique, infections or appropriate IOL, are important issues which are often overlooked in under resourced settings. They are all due to human and infrastructure factors and can be addressed through good management and training. Image credit: ICEH/LSHTM. Published on Community Eye Health Flickr https://www.flickr.com/photos/communityeyehealth/8488645107
- In the post-operative period, spectacle correction is often a simple intervention that is missed out in poor resource settings but should be considered an essential component of service provision. Patients should be made aware of sequelae and appropriate intervention provided. Image credit: Laura Crow / Sightsavers. Published in the Community Eye Health Journal www.cehjournal.org
- Evidence from high volume settings that follow rigid protocols shows that they also achieve high outcomes.
- Eye units need to monitor their cataract surgical outcome, to reduce overall complication rates, and provide a reliable quality of service It is also important to provide the team with feedback to give insight into their achievements and take corrective action when needed.
- Monitoring should not be used to compare outcomes between surgeons or eye units as outcome is dependent on many factors besides the skills of a surgeon. It is essential that this is explained to the team before monitoring is implemented.
- Monitoring can be implemented manually in low resource settings. It uses a relatively simple tally sheet to record information at two stages on every 20 patients operated for cataract surgery. Information is noted on each surgery (including any problems), IOL implantation and surgeon. Post-operative vision is recorded at discharge and again during follow up at 4-6 weeks and classified into good, borderline or poor. If the outcome is poor, the reason is given - selection, surgery or spectacles.
- Information is collected for 100 cases and then a report prepared for the team to assess. Management should identify and train a nurse or clerk on how to enter and analyse all the data.
- In settings with computers there is software available with a similar data entry form. The advantage here is that the reports can be generated automatically for every hundred cases and be made available graphically. The software is free to download from the internet.
- Monitoring reports provide direct information on the percentage of good, borderline and poor outcomes, and also on the causes of poor outcomes at discharge and follow up.
- Additional information can also be gained on: The age and gender of patients 1st or 2nd eye operations Visual acuity pre and post-operatively. This can be used to understand sight restoration rate. Percentage of IOL implantations Operative complications by month. This is important for infection control.
- In conclusion: For good cataract surgical outcome there are three clear steps to follow. Step 1 Use IOLs in everyone Always refract post-operatively Step 2 Know your outcomes by monitoring service provision using a manual tally sheet or computer software Step 3 Take practical measures to avoid complications Good outcomes of cataract surgery leads to high volume, sustainable eye care services.
- Good outcomes of cataract surgery leads to high volume, sustainable eye care services.