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
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