Abstract
Poor follow-up after cataract surgery in developing countries makes assessment of operative quality uncertain. We aimed to assess two strategies to measure visual outcome: recording the visual acuity of all patients 3 or fewer days postoperatively (early postoperative assessment), and recording that of only those patients who returned for the final follow-up examination after 40 or more days without additional prompting. Each of 40 centres in ten countries in Asia, Africa, and Latin America recruited 40-120 consecutive surgical cataract patients. Operative-eye best-corrected visual acuity and uncorrected visual acuity were recorded before surgery, 3 or fewer days postoperatively, and 40 or more days postoperatively. Clinics logged whether each patient had returned for the final follow-up examination without additional prompting, had to be actively encouraged to return, or had to be examined at home. Visual outcome for each centre was defined as the proportion of patients with uncorrected visual acuity of 6/18 or better minus the proportion with uncorrected visual acuity of 6/60 or worse, and was calculated for each participating hospital with results from the early assessment of all patients and the late assessment of only those returning unprompted, with results from the final follow-up assessment for all patients used as the standard. Of 3708 participants, 3441 (93%) had final follow-up vision data recorded 40 or more days after surgery, 1831 of whom (51% of the 3581 total participants for whom mode of follow-up was recorded) had returned to the clinic without additional prompting. Visual outcome by hospital from early postoperative and final follow-up assessment for all patients were highly correlated (Spearman's rs=0·74, p<0·0001). Visual outcome from final follow-up assessment for all patients and for only those who returned without additional prompting were also highly correlated (rs=0·86, p<0·0001), even for the 17 hospitals with unprompted return rates of less than 50% (rs=0·71, p=0·002). When we divided hospitals into top 25%, middle 50%, and bottom 25% by visual outcome, classification based on final follow-up assessment for all patients was the same as that based on early postoperative assessment for 27 (68%) of 40 centres, and the same as that based on data from patients who returned without additional prompting in 31 (84%) of 37 centres. Use of glasses to optimise vision at the time of the early and late examinations did not further improve the correlations. Early vision assessment for all patients and follow-up assessment only for patients who return to the clinic without prompting are valid measures of operative quality in settings where follow-up is poor. ORBIS International, Fred Hollows Foundation, Helen Keller International, International Association for the Prevention of Blindness Latin American Office, Aravind Eye Care System.
Highlights
Unoperated cataract remains the most common cause of blindness worldwide,[1] even though the disorder can be effectively and inexpensively treated with a standard procedure
Visual outcome from final followup assessment for all patients and for only those who returned without additional prompting were highly correlated, even for the 17 hospitals with unprompted return rates of less than 50%
The early postoperative examination was done on the first postoperative day for 3062 (85%) of 3601 patients for whom the date was recorded. 3441 (93%) patients completed the final followup examination at 40 or more days postoperatively
Summary
Unoperated cataract remains the most common cause of blindness worldwide,[1] even though the disorder can be effectively and inexpensively treated with a standard procedure. When treated by skilled surgeons, 90% of patients can achieve good vision (best-corrected visual acuity of 6/12 or better),[2,3,4] and an equal proportion are satisfied with their surgical result.[5]. Poor surgical outcomes and inadequate access to surgery are major impediments to the reduction of blindness from cataract, in low-resource settings.[6,7,8,9,10,11,12,13] Improving surgical capacity by training additional surgeons and providing equipment could help to address both issues,[14,15] but success depends on monitoring surgical quality. Visual acuity after cataract surgery has traditionally been measured weeks to months after the operation, since wound healing can change refractive power, and gradual resolution of common complications such as corneal oedema can substantially improve vision. Visual decline from surgical complications can occur
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