Abstract
Purpose:
To report the visual outcomes of cataract surgeries performed at a network of rural secondary eyecare centres in southern and eastern India.
Methods:
The multicentric, retrospective data analysis was carried out on cataract surgeries of L V Prasad Eye Institute (Phacoemulsification or Manual Small Incision Cataract Surgeries (MSICS)) performed at 20 rural centres during 2016 to 2020. Patients aged ≥40 years and with the first eye operated during the study period were included. Other surgical procedures were excluded. Data were collected from electronic medical records on age, sex, free or paying surgeries, visual acuity (VA), operated eye, surgical techniques, surgeon category, intraoperative major complications, and associated ocular and systemic diseases. Preoperative and postoperative best-corrected VAs (BCVAs) between 3 and 11 weeks (spectacle appointment) are reported. Risk factors for poor outcomes were analyzed for pseudophakic eyes using univariable and multivariable regression analyses based on BCVA <6/12 and <6/18.
Results:
Of the 123,685 cataract surgeries performed, 82% were MSICS. The mean age of the patients was 62.75 years, and 71,542 (57.84%) were females. Free surgeries were offered to 75,158 (60.77%) patients. Ocular (7.86%) and systemic (5.22%) comorbidities were noted. Follow-up visit data at spectacle appointment were available for 98,999 (80%) patients. Preoperative BCVA <6/12 was noted in 110,037 (88.97%), and postoperative BCVA ≥6/12 at spectacle appointment was in 90,191 (91.1%) patients. The risk factors for poor outcomes on regression analysis for BCVA <6/12 were older age, free surgeries, MSICS, intraoperative complications, ocular comorbidities, and surgeries by fellows.
Conclusion:
Good cataract surgical outcomes are possible in rural secondary centres with the majority of surgeries being performed by the fellows and residents.
Keywords: Cataract, hospital base, MSICS, outcome, phacoemulsification, rural
Cataract and uncorrected refractive errors are the leading causes of blindness and visual impairment (VI) in the world.[1] A high burden of cataract is reported in older age groups, women, and those in the lower socioeconomic strata.[2,3] The 74th World Health Assembly (WHA) adopted two global targets for eye health: A 40% increase in effective refractive error correction coverage (eREC) and a 30% increase in effective cataract surgery coverage (eCSC) to be achieved by 2030 for achieving Integrated People Centred Eye Care (IPEC).[4] A recent Rapid Assessment of Avoidable Blindness (RAAB) survey conducted in a sample population comprising of those who were 50 years old and above in India showed eCSC for 6/18 cutoff visual acuity to be 57.3% with a quality gap of 36%.[5] Data from the Telangana State in India also showed the eCSC for 6/18 and 6/12 cutoff to be 52.2% and 39.7% and the quality gap was 4.5% and 14.7%, respectively.[6] Population-based outcomes in a given region are the reflection of outcomes of cataract surgeries performed at different hospitals in the region. Hence, it is important for hospitals to regularly monitor outcomes.
We have developed an Eye Health Pyramid model, spread across four states with surgical service delivery starting from Secondary Centres (SCs) in southern India.[7] In this model, the base is supported by Vision Health Guardians (VHG) for a 5000 population at base of the pyramid, followed by Vision Centres (VC) covering a 50,000 population. An SC serves a 500,000 population. Each Tertiary Centre (TC) serves a population of 5 million people, and the Centre of Excellence (CoE) at the top serves a population of 50 million people.[8] These SCs provide comprehensive eye care to all people in rural areas. These centres are in small towns, usually with a team of 20–25 members including an ophthalmologist or more, depending on the workload, supported by a team of vision technicians, operating room nurses, technicians, and an administrator and support staff. Fig. 1 shows the eye health pyramid with relation to the services delivered at the rural secondary centres. The main services at the SC include surgeries for cataract, glaucoma, corneal tears, pterygium, and chronic dacryocystitis; in the past 8 years, we have also added intravitreal injections for retinopathies and corneal transplantations and a few other subspecialty procedures.[9]
Figure 1.
Eye health pyramidal model of L V Prasad Eye Institute with secondary centres located in the four states of India
With this background, as a reflection of eCSC in the community, the aim of the study is to report the visual outcomes of cataract surgeries performed at rural secondary centres located in southern and eastern India and factors associated with poor outcomes.
Methods
This is a multicentric, retrospective data analysis performed on the patients who had undergone cataract surgeries in 20 rural secondary centres of the Institute’s network. The Institutional Review Board approved the study. This analysis included only cataract surgeries performed during January 2016 to December 2020.
Patients included in the analysis were of age 40 years and older, who had cataract surgery performed as either phacoemulsification or Manual Small Incision Cataract Surgery (MSICS). If a patient had undergone cataract surgeries in both eyes during the study period, the first eye operated during the study period was included in the analysis.
Patients who had cataract surgeries performed by other techniques or combined surgeries such as glaucoma triple procedures or those whose age was less than 40 years were excluded. All patients had received intracameral antibiotics during cataract surgeries since October 2016.
Data collection: The patient data are routinely recorded as electronic medical records (EMR) by the surgeons operating at the SCs. The data were anonymized by removing personally identifiable information (names, addresses, and phone numbers) and subsequently cleaned by the authors for analysis. Data were collected from EMR for demographics, that is, age, sex, socioeconomic status (paying, i.e., paid surgeries, and nonpaying, i.e., free-of-cost), the eye operated on, surgical technique, surgeon category as faculty, fellows and residents, presence of major intraocular complications, implantation of and type of intraocular lens (IOL), and associated ocular and systemic diseases (diabetes mellitus and hypertension). The associated ocular disease included spheroidal degenerations, corneal scars, glaucoma, hypertensive retinopathy, diabetic retinopathy, age-related macular degeneration, and others.
The surgeons were categorized as Faculty, Fellows, and Residents. Faculty were defined as fellowship trained consultants. Fellows were ophthalmologists in their second year of their fellowship posting, and the residents were in the final year of residency posting at these rural centres. The major intraoperative complications included were posterior capsular rent, zonular dehiscence, IOL drop, and nucleus drop. Postoperative complications such as corneal edema, endophthalmitis, and high intraocular pressure are reported. The patients with IOL drop and nucleus drops were referred to TC for further management. These patients were followed up back at SCs after their management at TCs. The patients who have complications were transported in a vehicle to TC accompanied by a staff member during such visits.
Preoperative Presenting Visual Acuity (PVA) and Best Corrected Visual Acuity (BCVA) were recorded, and postoperative Uncorrected Visual Acuity (UCVA) and BCVA were measured at 1 day, 1 week (4–11 days), and 3–11 weeks (21–77 days, the spectacle appointment) following surgery. The spectacle appointment was defined as the visit between 21 and 77 days; whichever visit was the last was included in the analysis. Based on recent World Health Organization (WHO) definitions of outcomes, a very good outcome was defined as BCVA of 6/12 or better and good as 6/18 or better. For risk factors, analysis for a poor outcome is defined using two definitions: BCVA of <6/18 and <6/12 in the operated eye. For patients who were referred to TCs, the visual acuity for them is reported after their follow up at SCs from TCs.
Statistical analysis: Statistical analysis was performed using Stata 18.5 (Statacorp, Texas). Continuous variables were analyzed with Student’s t-test, while the Chi-square test was used for analysis of categorical variables. The risk factor analysis for a poor outcome (defined as BCVA of <6/12 and for BCVA of <6/18 at spectacle appointment) was performed using univariable and multivariable logistic regression models, only for pseudophakic eyes. Correlation between variables was checked using Variance Inflation Factor (VIF). A two-tailed P value of <0.05 was considered statistically significant.
Results
A total of 123,685 surgeries performed in 20 SCs across four states, Andhra Pradesh (n = 9), Telangana State (n = 6), Karnataka (n = 1), and Odisha (n = 4), between January 2016 and December 2020, were analyzed. Table 1 shows the demographic details of the patients who had undergone cataract surgeries, including the differences between those available for follow-up and those not available for follow-up at the spectacle appointment. Of the 123,685 surgeries performed, 1-day follow-up visit data were available for 117,893 (95%) patients, 1-week data for 108,097 (87%), and spectacle appointment data were available for 98,999 (80%) patients.
Table 1.
Baseline demographics and surgeries and follow-up availability
| Variable | Subgroups | Baseline n (%) | At glass appointment n (%) |
||
|---|---|---|---|---|---|
| Total surgeries performed | Available for follow-up | Not available for follow-up | P | ||
| n=123685 | 98999 (80.04%) | 24686 (19.96%) | |||
| Age group | 40 to 49 years | 8594 (6.95%) | 7259 (84.47%) | 1335 (15.53%) | |
| 50 to 59 years | 27766 (22.45%) | 22983 (82.77%) | 4783 (17.23%) | ||
| 60 to 69 years | 59403 (48.03%) | 47700 (80.3%) | 11703 (19.7%) | ||
| >=70 years | 27922 (22.58%) | 21057 (75.41%) | 6865 (24.59%) | <0.05 | |
| Gender | Male | 52143 (42.16%) | 40717 (78.09%) | 11426 (21.91%) | |
| Female | 71542 (57.84%) | 58282 (81.47%) | 13260 (18.53%) | <0.05 | |
| Economic status | Paying | 48527 (39.23%) | 43229 (89.08%) | 5298 (10.92%) | |
| Free-of-cost | 75158 (60.77%) | 55770 (74.2%) | 19388 (25.8%) | <0.05 | |
| Surgeon category | Faculty | 27662 (22.36%) | 23112 (83.55%) | 4550 (16.45%) | |
| Fellow | 86342 (69.81%) | 68320 (79.13%) | 18022 (20.87%) | ||
| Resident | 9681 (7.83%) | 7567 (78.16%) | 2114 (21.84%) | <0.05 | |
| Eye | Right eye | 67409 (54.5%) | 54167 (80.36%) | 13242 (19.64%) | |
| Left eye | 56276 (45.5%) | 44832 (79.66%) | 11444 (20.34%) | 0.002 | |
| Surgical technique | Phacoemulsification | 22300 (18%) | 19867 (89.09%) | 2433 (10.91%) | |
| MSICS | 101385 (82%) | 79132 (78.05%) | 22253 (21.95%) | <0.05 | |
| Ocular disease | Absent | 113958 (92.14%) | 91176 (80.01%) | 22782 (19.99%) | |
| Present | 9727 (7.86%) | 7823 (80.43%) | 1904 (19.57%) | 0.323 | |
| Systemic disease | Absent | 117232 (94.78%) | 93379 (79.65%) | 23853 (20.35%) | |
| Present | 6453 (5.22%) | 5620 (87.09%) | 833 (12.91%) | <0.05 | |
| IOL status | PCIOL | 121973 (98.62%) | 97703 (80.1%) | 24270 (19.9%) | |
| ACIOL | 942 (0.76%) | 743 (78.87%) | 199 (21.13%) | ||
| Aphakia | 770 (0.62%) | 553 (71.82%) | 217 (28.18%) | <0.05 | |
| Major intraoperative complications | No | 119806 (96.86%) | 95990 (80.12%) | 23816 (19.88%) | |
| Yes | 3879 (3.14%) | 3009 (77.57%) | 870 (22.43%) | <0.05 | |
MSICS – Manual Small Incision Cataract Surgery. PCIOL – posterior chamber intraocular lens. ACIOL – anterior chamber intraocular lens
The mean age of the patients was 62.75 years (SD: 8.65 years, range: 40–101 years). Nearly 71% of surgeries were performed on patients who were 60 years and older, and 71,542 (57.84%) were performed in females. Cataract surgeries were performed free-of-cost in 75,158 (60.77%) patients. A majority of surgeries, that is, 96,023 (77.6%), were performed by fellows and residents, and the rest by faculty. Pre-existing ocular morbidities were noted in 9727 (7.86%) patients, and systemic comorbidities were seen in 6453 (5.22%) patients. A majority of patients, 101,385 (82%), underwent surgeries by the MSICS technique. Posterior chamber IOL was implanted in 98%, and 1% each either had anterior chamber IOL or were left aphakic. Major intraoperative complications were noted in 3951 (3.19%) surgeries.
Postoperative corneal edema and Descemet’s membrane folds were noted in 553 (0.56%) patients, a high intraocular pressure of 22 mmHg or more was noted in 159 (0.16%) patients, glaucomatous disc changes in 299 (0.30%) patients, and 78 (0.06%) patients had acute postoperative endophthalmitis.
Table 2 shows the preoperative and postoperative visual acuity of the operated eye at 1 day, 1 week, and spectacle appointment. Preoperatively, based on BCVA, 51,424 (41.58%) had visual acuity of <3/60 and 13,648 (11.03%) were 6/12 or better. Postoperatively, day 1 UCVA and BCVA of 6/12 or better were noted in 71,133 (60.34%) and 86,914 (73.72%) patients, respectively. At the spectacle appointment, UCVA and BCVA of 6/12 or better were achieved in 66,443 (67.11%) and 90,191 (91.1%) patients, respectively, and 954 (0.96%) patients had BCVA of <3/60 on the day of the spectacle appointment. BCVA of 6/12 or better at the spectacle appointment in the age group of 40–60 years was 97% in the phacoemulsification group and 94% in MSICS group. The faculty, fellows, and residents achieving a BCVA of 6/12 or better at the spectacle appointment with phacoemulsification in the 40–60 years age group was 98%, 97%, and 96%, respectively. A BCVA of 6/12 or better in MSICS was 94% for faculty and residents, and 93% for fellows.
Table 2.
Visual acuity in the operated eyes at different follow-up intervals after cataract surgeries
| Categories | Preoperative Visual acuity | Postoperative Visual Acuity |
||||||
|---|---|---|---|---|---|---|---|---|
|
n=123,685 |
Day 1 | 1 week | 3–11 weeks (Glass appointment) | |||||
|
n=117,893 (95%) |
n=108,097 (87%) |
n=98,999 (80%) |
||||||
| PVA | BCVA | UCVA | BCVA | UCVA | BCVA | UCVA | BCVA | |
| <3/60 | 53300 (43.09%) | 51424 (41.58%) | 5549 (4.71%) | 5202 (4.41%) | 2120 (1.96%) | 1777 (1.64%) | 1352 (1.37%) | 954 (0.96%) |
| 3/60-<6/60 | 22092 (17.86%) | 12837 (10.38%) | 2797 (2.37%) | 2138 (1.81%) | 1319 (1.22%) | 836 (0.77%) | 1092 (1.1%) | 527 (0.53%) |
| 6/60-<6/18 | 36647 (29.63%) | 30478 (24.64%) | 18364 (15.58%) | 11846 (10.05%) | 10972 (10.15%) | 5090 (4.71%) | 13111 (13.24%) | 3488 (3.52%) |
| 6/18<6/12 | 6932 (5.6%) | 15298 (12.37%) | 20050 (17.01%) | 11793 (10%) | 14740 (13.64%) | 6158 (5.7%) | 17001 (17.17%) | 3839 (3.88%) |
| 6/12 or better | 4714 (3.81%) | 13648 (11.03%) | 71133 (60.34%) | 86914 (73.72%) | 78946 (73.03%) | 94236 (87.18%) | 66443 (67.11%) | 90191 (91.1%) |
PVA – Presenting visual acuity, UCVA – uncorrected visual acuity, BCVA – Best corrected visual acuity
Table 3 shows the baseline characteristic difference between those with good outcome (6/18 or better) and poor outcome (<6/18) of the operated eye at glass appointment Among the 98,999 patients who followed up for spectacle appointment, 94.98% (n = 94,030) achieved a postoperative BCVA of 6/18 or better. Demographic, clinical, and surgical factors were significantly associated with BCVA of less than 6/18. Patients aged ≥70 years had the highest rate of poor BCVA (8.86%), compared to only 2.53% in the 40–49-year age group (P < 0.001). Patients undergoing surgery free of cost had a higher proportion of poor outcomes (5.79%) than those who paid for their surgeries (4.02%) (P < 0.001). Females had statistically significant better outcomes than males (P = 0.005). Phacoemulsification resulted in better visual outcomes compared to manual small-incision cataract surgery (MSICS), with only 2.35% of phacoemulsification cases resulting in BCVA <6/18 versus 5.69% in MSICS (P < 0.001). Intraoperative complications were strongly associated with poor visual outcomes; 21.43% of patients with complications had BCVA <6/18 compared to 4.49% in those without complications (P < 0.001). The type of intraocular lens (IOL) implanted also had a significant impact: Eyes with posterior chamber IOLs (PCIOL) had the best outcomes (4.62% poor BCVA), whereas those with anterior chamber IOLs (ACIOL) and aphakia had markedly worse outcomes in 25.84% and 46.84%, respectively, P < 0.001. Surgeon experience showed a modest but significant association, with faculty-performed surgeries having slightly better outcomes (4.64% poor BCVA) than those performed by fellows (5.14%) or residents (5.06%) (P = 0.011). The presence of ocular comorbidities was significantly associated with poorer outcomes (13.69% vs. 4.28% without ocular disease; P < 0.001), whereas systemic comorbidities had no significant effect on BCVA (P = 0.533).
Table 3.
Difference between those with BCVA of 6/18 or better or <6/18 at Spectacle appointment in the operated eyes
| Variable | Subgroups | BCVA 6/18 or better | BCVA <6/18 | P |
|---|---|---|---|---|
| Total | 94030 (94.98%) | 4969 (5.02%) | ||
| Age category | 40-49 years | 7075 (97.47%) | 184 (2.53%) | |
| 50-59 years | 22320 (97.12%) | 663 (2.88%) | ||
| 60-69 years | 45444 (95.27%) | 2256 (4.73%) | ||
| >=70 years | 19191 (91.14%) | 1866 (8.86%) | <0.001 | |
| Paying status | Paying | 41490 (95.98%) | 1739 (4.02%) | |
| Free-of-cost | 52540 (94.21%) | 3230 (5.79%) | <0.001 | |
| Gender | Male | 38579 (94.75%) | 2138 (5.25%) | |
| Female | 55451 (95.14%) | 2831 (4.86%) | 0.005 | |
| Surgical technique | Phacoemulsification | 19400 (97.65%) | 467 (2.35%) | |
| MSICS | 74630 (94.31%) | 4502 (5.69%) | <0.001 | |
| Major complications | No | 91618 (95.51%) | 4311 (4.49%) | |
| Yes | 2412 (78.57%) | 658 (21.43%) | <0.001 | |
| Presence of IOL | PCIOL | 93185 (95.38%) | 4518 (4.62%) | |
| ACIOL | 551 (74.16%) | 192 (25.84%) | ||
| Aphakia | 294 (53.16%) | 259 (46.84%) | <0.001 | |
| Surgeon category | Faculty | 22039 (95.36%) | 1073 (4.64%) | |
| Fellow | 64807 (94.86%) | 3513 (5.14%) | ||
| Resident | 7184 (94.94%) | 383 (5.06%) | 0.011 | |
| Systemic disease | No | 88702 (94.99%) | 4677 (5.01%) | |
| Yes | 5328 (94.80%) | 292 (5.20%) | 0.533 | |
| Ocular disease | No | 87278 (95.72%) | 3898 (4.28%) | |
| Yes | 6752 (86.31%) | 1071 (13.69%) | <0.001 |
MSICS – Manual Small Incision Cataract Surgery. PCIOL – posterior chamber intraocular lens. ACIOL – anterior chamber intraocular lens
Table 4 shows the univariable and multivariable analyses for risk factors in pseudophakic patients with a postoperative BCVA cutoff of <6/12 and <6/18 at spectacle appointment The univariable and multivariable logistic regression analyses show that the risk factors for poor visual outcome (BCVA <6/12 and BCVA <6/18) in pseudophakic patients were increasing age, a free operation, those operated with MSICS technique, intraoperative complications, and ocular comorbidities. Sex was significant for poor outcome on multivariable analysis in females for BCVA <6/12 and on univariable analysis for BCVA of <6/18. Surgeries done by fellows were significant on both univariable and multivariable analyses for BCVA <6/12 and on univariable analysis for BCVA <6/18, but not significant on multivariable analysis for BCVA <6/18.
Table 4.
Univariable and multivariable analyses of risk factors for BCVA <6/12 and <6/18 in 98446 pseudophakic patients at spectacle appointment of the operated eyes
| Variables | Subgroups | BCVA <6/12 |
BCVA <6/18 |
||
|---|---|---|---|---|---|
| Univariable analysis | Multivariable analysis | Univariable analysis | Multivariable analysis | ||
| OR (95%CI) | OR (95%CI) | OR (95%CI) | OR (95%CI) | ||
| Age category | 40-49 years | Reference | Reference | Reference | Reference |
| 50-59 years | 1.00 (0.89-1.13) | 0.92 (0.82-1.04) | 1.12 (0.95-1.33) | 1.03 (0.87-1.22) | |
| 60-69 years | 1.68* (1.51-1.88) | 1.42 *(1.27-1.59) | 1.88* (1.61-2.19) | 1.56 *(1.33-1.82) | |
| >=70 years | 3.22* (2.88-3.60) | 2.56* (2.28-2.87) | 3.60* (3.08-4.20) | 2.76*(2.36-3.24) | |
| Gender | Male | Reference | Reference | Reference | Reference |
| Female | 0.96 (0.92-1.01) | 1.06* (1.02-1.12) | 0.93* (0.88-0.99) | 1.04 (0.98-1.10) | |
| Socioeconomic Status | Paying | Reference | Reference | Reference | Reference |
| Free surgeries | 1.45* (1.39-1.52) | 1.12* (1.06-1.18) | 1.44* (1.35-1.53) | 1.10* (1.03-1.18) | |
| Surgical Technique | Phacoemulsification | Reference | Reference | Reference | Reference |
| MSICS | 2.37* (2.20-2.54) | 1.93* (1.79-2.09) | 2.45* (2.22-2.70) | 1.99* (1.80-2.21) | |
| Surgeon category | Faculty | Reference | Reference | Reference | Reference |
| Fellow | 1.15* (1.09-1.22) | 1.11* (1.05-1.17) | 1.11* (1.04-1.20) | 1.07 (1.00-1.15) | |
| Resident | 1.10 (1.00-1.20) | 0.99 (0.90-1.09) | 1.05 (0.92-1.18) | 0.95 (0.83-1.08) | |
| Intraoperative complications | No | Reference | Reference | Reference | Reference |
| Yes | 3.18*(2.87-3.52) | 2.95* (2.65-3.27) | 3.63 * (3.22-4.09) | 3.32*(2.93-3.75) | |
| Ocular disease | No | Reference | Reference | Reference | Reference |
| Yes | 2.96* (2.79-3.15) | 2.70* (2.53-2.87) | 3.51* (3.26-3.78) | 3.17*(2.94-3.42) | |
| Systemic disease | No | Reference | Reference | Reference | Reference |
| Yes | 0.98 (0.89-1.08) | 1.05 (0.95-1.16) | 1.06 (0.93-1.19) | 1.13 (1.00-1.28) | |
OR – Odds Ratio. CI – Confidence Intervals. *Significant P<0.05
Discussion
In this study, we report the outcomes of cataract surgeries performed in rural setups in India. We show that it is feasible to achieve UCVA of 6/12 or better in 67.11% of patients and BCVA of 6/12 or better in 91.1% of patients in such settings at spectacle appointment. This is better than the outcomes reported from an African country where 38.55% (UCVA) and 82.54% (BCVA) of the participants had 6/12 or better visual acuity.[10] Another study from India reported BCVA of 6/12 or better in 84% of those cases operated by trainees.[11] Our study’s results of UCVA of 6/12 or better in 67.11% are better than those reported as 47.3% of UCVA of 6/12 or better from a multicentric study on for cataract surgery outcomes from low-resource settings.[12]
Similar to other studies, older age was a risk factor for poor outcomes.[5,13,14] Old age is associated with additional systemic and ocular comorbidities as well as harder cataract; thus, these patients are at increased risk of complications. Females had a higher risk of poor outcomes of BCVA <6/12 on multivariable analysis and <6/18 on univariable analysis. This has also been reported in other studies.[15] In most communities, men are prioritized over women of the same family for health care uptake, with women ending up deferring health care, including cataract surgeries. This delay could lead to harder and more complicated cataracts in women, leading to poor outcomes. Unlike other studies where there was no difference in BCVA outcomes in MSICS versus phacoemulsification,[16] we reported poor outcomes in MSICS compared to phacoemulsification. It is likely that MSICS was performed for more complicated cataracts where the fellows, residents, and faculty were not comfortable performing phacoemulsification. Surgeries in complicated cataracts would have led to more complications and thus poor outcomes. The faculty and residents had better visual outcomes compared to fellows. This may be due to faculty gaining experience over the years and the residents performing simpler cases compared to fellows.
A previous study from rural secondary centres showed poor outcome of <6/18 in patients having intraoperative complications, where the elderly, women, and the presence of comorbidities were the risk factors.[17] This study found the same risk factors too. Similar to other studies, those with intraoperative complications had poor outcomes.[10,18] Lundstrom et al.[19] have reported reduced posterior capsule complications as one gains experience. Similar to other studies, the presence of ocular disease was one of the risk factors for poor visual outcome in our study too.[10,13,20]
Cataract is a global cause of blindness, and surgery is the only known treatment. Providing high-quality cataract surgery is critical to reducing blindness and visual impairment after surgery as well as having an impact on eCSC. A study from South India has reported that though clinical outcomes improved after cataract surgery, poor vision due to refractive errors after cataract surgery and unavailability of glasses is still an issue.[21] In this study, though BCVA is more than 90%, UCVA is still less than expected and this may be due to the induced astigmatism after cataract surgery, mainly by MSICS. A meta-analysis has reported that UCVA was better with phacoemulsification than with MSICS and that there was no difference in BCVA of 6/18 with both techniques, the reason for this variance being high astigmatism with MSICS.[22] Placing a foldable IOL may not change the UCVA after MSICS as the incision size of surgery may remain the same, thus leading to high astigmatism Hence, in order to improve eCSC, it would be good to implement modifications to MSICS techniques that reduce astigmatism.
The strength of this study is its large number of patients operated in different rural areas in secondary centre settings and by multiple different surgeons. The results show that it is possible to achieve good outcomes in rural setups. Its limitations include nearly 20% who were lost to follow-up for the final refraction. Nearly 75% of patients who were lost to follow-up were above the age of 60 years, >50% were women, and >75% of surgeries were performed free, and were MSICS. Assuming that if 67% of these patients achieved a UCVA of 6/12 or better, it means that nearly a third did not achieve a UCVA of 6/12 or better. This high percentage would have an impact on eCSC as presenting visual acuity in these patients would be suboptimal. In addition, there may be missing data, or the data may not be recorded appropriately, which may change the statistical power of the study outcome, induce bias, and may not give a valid conclusion. Apart from these limitations, it is likely that those who got spectacles at the final follow-up visit may require a change of spectacles over a period of time. This may be due to multiple reasons, including losing the spectacles or breaking them.
Conclusion
This study shows that it is possible to achieve good visual outcomes in rural setups. A BCVA of 6/12 or better was noted in 91% of patients. The intraoperative complication rate was 3.14%. Older age, those with poor socioeconomic status, those operated with the MSICS technique, operated by fellows, those with the presence of major intraoperative complications, and presence of ocular comorbidities were associated with poor BCVA of <6/12 or <6/18. Monitoring the risk factors to achieve good outcomes after cataract surgery is crucial to improve eCSC. However, efforts need to be made to improve the UCVA in MSICS and reduce the number of patients lost to follow-up at the final refraction visit.
Conflicts of interest:
There are no conflicts of interest.
Acknowledgement
We thank Mr Tejah Balantrapu for the language editing.
Funding Statement
Hyderabad Eye Research Foundation
References
- 1.Cicinelli MV, Buchan JC, Nicholson M, Varadaraj V, Khanna RC. Cataracts. Lancet. 2023;401:377–89. doi: 10.1016/S0140-6736(22)01839-6. [DOI] [PubMed] [Google Scholar]
- 2.Fang R, Yu YF, Li EJ, Lv NX, Liu ZC, Zhou HG, et al. Global, regional, national burden and gender disparity of cataract: Findings from the global burden of disease study 2019. BMC Public Health. 2022;22:2068. doi: 10.1186/s12889-022-14491-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Dandona R, Dandona L, Srinivas M, Giridhar P, Prasad MN, Vilas K, et al. Moderate visual impairment in India: The Andhra Pradesh Eye Disease Study. Br J Ophthalmol. 2002;86:373–7. doi: 10.1136/bjo.86.4.373. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Available from: https://www.who.int/publications/i/item/9789240058002 . [Last accessed on 2024 Dec 30] [Google Scholar]
- 5.Gupta V, Vashist P, Sarath S, Gupta N, Senjam SS, Shukla P, et al. Effective cataract surgical coverage in India: Evidence from 31 districts. Indian J Ophthalmol. 2024;72:S650–7. doi: 10.4103/IJO.IJO_2835_23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Marmamula S, Saha R, Khanna RC. Effective cataract surgical coverage in four large districts in Telangana, India - Results from rapid assessment of visual impairment study. Ophthalmic Epidemiol. 2025;32:69–75. doi: 10.1080/09286586.2024.2336498. [DOI] [PubMed] [Google Scholar]
- 7.Rao GN. The Barrie Jones Lecture-Eye care for the neglected population: Challenges and solutions. Eye (Lond) 2015;29:30–45. doi: 10.1038/eye.2014.239. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Rao GN, Khanna RC, Athota SM, Rajshekar V, Rani PK. Integrated model of primary and secondary eye care for underserved rural areas: The L V Prasad Eye Institute experience. Indian J Ophthalmol. 2012;60:396–400. doi: 10.4103/0301-4738.100533. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Rathi VM, Murthy SI, Vaddavalli PK, Khanna RC. Feasibility and outcomes of corneal transplantation performed at rural centres: An extension of the pyramidal model of enhanced eye care at rural outreach. Cornea. 2022;41:211–8. doi: 10.1097/ICO.0000000000002839. [DOI] [PubMed] [Google Scholar]
- 10.Khanna RC, Rathi VM, Guizie E, Singh G, Nishant K, Sandhu S, et al. Factors associated with visual outcomes after cataract surgery: A cross-sectional or retrospective study in Liberia. PLoS One. 2020;15:e0233118. doi: 10.1371/journal.pone.0233118. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Khanna RC, Kaza S, Palamaner Subash Shantha G, Sangwan VS. Comparative outcomes of manual small incision cataract surgery and phacoemulsification performed by ophthalmology trainees in a tertiary eye care hospital in India: A retrospective cohort design. BMJ Open. 2012;2:e001035. doi: 10.1136/bmjopen-2012-001035. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.McGuinness MB, Moo E, Varga B, Dodson S, Lansingh VC, Resnikoff S, et al. The Better Operative Outcomes Software Tool (BOOST) prospective study: Improving the quality of cataract surgery outcomes in low-resource settings. Ophthalmic Epidemiol. 2024;32:76–86. doi: 10.1080/09286586.2024.2336518. [DOI] [PubMed] [Google Scholar]
- 13.Lundstrom M, Barry P, Henry Y, Rosen P, Stenevi U. Visual outcome of cataract surgery; study from the European Registry of Quality outcomes for cataract and refractive surgery. J Cataract Refract Surg. 2013;39:673–9. doi: 10.1016/j.jcrs.2012.11.026. [DOI] [PubMed] [Google Scholar]
- 14.Rono JK, Nirghin U. Visual outcome after small incision cataract surgery of patients in a Kenyan Hospital Contributors. Afr Health Sci. 2023;23:469–77. doi: 10.4314/ahs.v23i2.54. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Ben-Eli H, Cnaany Y, Halpert M, Chowers I, Goldstein A. Investigating the impact of age and sex on cataract surgery complications and outcomes. Sci Rep. 2025;15:1242. doi: 10.1038/s41598-024-84382-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Okoye GS, Bonabe D, Obasi CU, Munikrishna D, Osho F, Mutali M, et al. Visual outcomes and complications after phacoemulsification and small incision manual cataract surgery in two eye hospitals. J Fr Ophtalmol. 2024;48:104353. doi: 10.1016/j.jfo.2024.104353. [DOI] [PubMed] [Google Scholar]
- 17.Matta S, Park J, Palamaner Subash Shantha G, Khanna RC, Rao GN. Cataract surgery visual outcomes and associated risk factors in secondary level eye care centres of L V Prasad Eye Institute, India. PLoS One. 2016;11:e0144853. doi: 10.1371/journal.pone.0144853. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Elhusseiny AM, Toma J, Fouad YA, Soliman MK, Ibrahim SN, Shakarchi AF, et al. Outcomes of cataract surgery complicated with zonular dialysis: A multicentre comparative study. Curr Eye Res. 2025;50:258–63. doi: 10.1080/02713683.2024.2421929. [DOI] [PubMed] [Google Scholar]
- 19.Lundstrom M, Behndig A, Kugelberg M, Montan P, Stenevi U, Thorburn W. Decreasing rate of capsule complications in cataract surgery: Eight-year study of incidence, risk factors, and data validity by the Swedish National Cataract Register. J Cataract Refract Surg. 2011;37:1762–7. doi: 10.1016/j.jcrs.2011.05.022. [DOI] [PubMed] [Google Scholar]
- 20.Noertjojo K, Mildon D, Rollins D, Law F, Blicker J, Courtright P, et al. Cataract surgical outcome at the Vancouver Eye Care Centre: Can it be predicted using current data? Can J Ophthalmol. 2004;39:38–47. doi: 10.1016/s0008-4182(04)80051-6. [DOI] [PubMed] [Google Scholar]
- 21.Marmamula S, Khanna RC, Shekhar K, Rao GN. Outcomes of cataract surgery in urban and rural population in the South Indian State of Andhra Pradesh: Rapid assessment of visual impairment (RAVI) project. PLoS One. 2016;11:e0167708. doi: 10.1371/journal.pone.0167708. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Gogate P, Optom JJ, Deshpande S, Naidoo K. Meta-analysis to compare the safety and efficacy of manual small incision cataract surgery and phacoemulsification. Middle East Afr J Ophthalmol. 2015;22:362–9. doi: 10.4103/0974-9233.159763. [DOI] [PMC free article] [PubMed] [Google Scholar]