Annals of African Medicine

ORIGINAL ARTICLE
Year
: 2014  |  Volume : 13  |  Issue : 1  |  Page : 25--29

Outcome of cataract surgery in rural areas of Kaduna State, Nigeria


Kehinde K Oladigbolu, Abdulkadir L Rafindadi, Abiodun F Mahmud-Ajeigbe, Dominic Chinda, Victoria Pam, Elsie Samaila 
 Department of Ophthalmology, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Nigeria

Correspondence Address:
Victoria Pam
Department of Ophthalmology, Ahmadu Bello University Teaching Hospital, Shika, Zaria
Nigeria

Abstract

Aim: To evaluate the visual outcome of all patients who had cataract surgery with intraocular lens implant in five Local Government Areas (LGAs) of Kaduna State and to identify reasons for poor outcome and to proffer suggestions to improve outcome. Materials and Methods: A prospective study using the WHO cataract surgery record form to collect data from consecutively screened and operated cataract patients over a period of 18 months (January 2006-June 2007). Data was analysed using Monitoring Catarct Surgery Outcome V2.3 software by the WHO. Results: A total of 690 eyes of 644 patients were operated, ECCE+PCIOL implantation was achieved in 664 (96.2%) while 26(3.8%) had anterior chamber lens implant. The age range was 40 - 99 years and male to female ratio was 1: 0.9. Good outcome was obtained in 239 (34.6%) and 370(53.6%) of patients at 2 and 8 weeks respectively in the postoperative period. Surgical complications like striate keratopathy/corneal oedema (18.3%), cortical reminant (4.2%) and posterior capsular rupture (2.9%), and uncorrected refractive error were identified as reasons for poor outcome. Conclusion: A good outcome of greater than 80% at 8 weeks postoperative period was not achieved. Provision of postoperative correction of residual ametropia in the rural community, as well as improved surgical techniques of surgeons, will go a long way to improve the visual outcome and cataract surgery uptake.



How to cite this article:
Oladigbolu KK, Rafindadi AL, Mahmud-Ajeigbe AF, Chinda D, Pam V, Samaila E. Outcome of cataract surgery in rural areas of Kaduna State, Nigeria.Ann Afr Med 2014;13:25-29


How to cite this URL:
Oladigbolu KK, Rafindadi AL, Mahmud-Ajeigbe AF, Chinda D, Pam V, Samaila E. Outcome of cataract surgery in rural areas of Kaduna State, Nigeria. Ann Afr Med [serial online] 2014 [cited 2019 Aug 18 ];13:25-29
Available from: http://www.annalsafrmed.org/text.asp?2014/13/1/25/126943


Full Text

 Introduction



Most of the estimated 20 million people who are blind with cataracts [1],[2],[3] live in the rural areas of the developing countries. Cataract blindness is curable through cataract surgery. It is one of the most successful and cost effective of all health interventions and forms an integral part of global strategy for prevention of avoidable blindness. [1],[2]

Cataract outreach program aims at the delivery of cataract surgical service to persons with cataracts in their communities making it available, accessible and affordable. In addition, this system reduces the stress, the risk of travel outside a familiar environment to which the patient is used to and the extra financial burden of an escort on the already impoverished cataract patient.

In pursuance of the Vision 2020 objective of elimination of preventable causes of blindness including cataract by the year 2020, Guinness Ophthalmic Unit (GOU), Ahmadu Bello University Teaching Hospital (ABUTH), Zaria in partnership with the Kaduna State Government and Sight Savers International (SSI) provided cataract surgery to some rural communities in five Local Government Areas (LGAs) of Kaduna State (Giwa, Ikara, Kudan, Lere and Makarfi LGAs) between January 2006 and June 2007 [Figure 1].{Figure 1}

The impact of cataract surgery in any population can be assessed by the visual outcome. A good outcome advertises the program and increases uptake of cataract surgery in most communities. On the contrary a poor visual outcome may have a negative impact on the uptake of this program. A good outcome is defined (WHO classification) as visual acuity of 6/6 - 6/18 in 80-90% of patients, borderline outcome of < 6/18 - 6/60 in less than 5% of patients and poor outcome of < 6/60 in less than 5% patients. [2],[3]

In keeping with the recommendation of regular clinical audit and reporting of outcome of cataract surgery, GOU analysed data from the five rural communities that benefited from the cataract outreach program during the period January 2006 - June 2007.

The aim of this study was to evaluate the visual outcome of all the patients who had cataract surgery with intraocular lens implant in the five LGAs (Giwa, Ikara, Kudan, Lere and Makarfi) of Kaduna State, to identify reasons for poor outcome and to suggest ways of improving outcome.

 Materials and Methods



All adult cataract blind (VA < 3/60) and uniocular cataract patients screened in several villages and wards of five Local Government Areas of Kaduna State by the Community Ophthalmic Nursing Officers (CONOs) and the Community Health Extension Workers (CHEWs) between January 2006 and June 2007 were enrolled in the study.

Visual acuity (Snellen's and illiterate E chart) and intraocular pressure (Shiotz) assessment as part of the screening exercise were carried out at venues of the eye screening. Non ophthalmic assessment at the base hospital included blood haemogram, urinalysis and blood pressure.

Re- screening with pen-torches and direct ophthal moscopes was by the authors (mainly senior registrars) at the base hospital of each of the LGAs. Bio data and clinical data on each patient for cataract surgery were entered into the World Health Organization (WHO) Cataract Surgery Form.

The study was approved by the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria Ethic Research Committee (ERC) and was conducted following research principles as contained in the Declaration of Helsinki. Consent for cataract surgery with intraocular lens implant was obtained from all the patients or their relatives.

Standard extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PC IOL) implantation were performed using either corneal or limbal based section. There were no facilities for biometry therefore; posterior chamber IOLs of power range 19-22 dioptre was used. However, few anterior chamber IOLs of power range 17-19 dioptre were also implanted in some patients.

The medical records of all the patients were used for analysis of personal data, preoperative and postoperative VA at discharge and two and eight weeks after discharge, and intraoperative and postoperative complications.

Definitive postoperative refraction had not been done for all the patients, so uncorrected and pinhole acuity was recorded. Data was analysed using the Monitoring Cataract Outcome V2.3 software by WHO.

 Results



A total of 690 eyes of 644 patients had extracapsular cataract extraction (ECCE) and intraocular lens (IOL) implantation in the 5 LGAs [Table 1]. Forty-six patients had bilateral ECCE with IOL implants at different period (average of 4 weeks to 1year).{Table 1}

The patients' age range was 40-99 years with 186 (27%) of them in the age group 56-60 years [Figure 2]. The male to female ratio was 1: 0.9. The pre-operative visual acuity (VA) was hand motion (HM) in 367 (53.2%) and perception of light (LP) in 124 (18.0%).{Figure 2}

Six hundred and sixty four (96.2%) patients had extracapsular cataract extraction with posterior chamber intraocular lens implantation (ECCE + PCIOL) while 26 (3.8%) had anterior chamber IOL.

[Figure 3] shows the visual acuity at discharge (24-48 hours post-operative), two and eight weeks post-operative. The most common 29 (4.2%) intra-operative complication recorded was cortical remnants while striate keratopathy (SK) 126 (18.3) was the most common post- operative complication encountered [Table 2]. The dreaded endophthalmitis was seen in only two patients (0.3%).{Figure 3}{Table 2}

At 2 and 8 weeks post- operative period 7.3% and 20.8% of patients respectively were lost to follow up.

 Discussion



Senile cataracts were diagnosed in patients aged 40 years and above in the 5 LGAs with increasing frequency as the age of the patient increased. No significant difference was observed in the male / female uptake of cataract surgery. This observation dispels the fear of gender inequality in the uptake of cataract surgery in a male dominated environment.

The pre-operative visual acuity (VA) was hand motion in more than 50% of the patients. Visual needs of most rural dwellers who are either farmers or petty traders by profession are not as high as for skilled professionals living in the urban areas or cities; hence a delayed access to cataract surgical uptake by patients. Extracapsular cataract extraction with posterior chamber intraocular lens (ECCE-PCIOL) implant was the surgical procedure in 96.2% and extracapsular cataract extraction with anterior chamber intraocular lens (ECCE-ACIOL) implant in 3.8% patients with posterior capsular rupture.

Extracapsular cataract extraction with posterior chamber intraocular lens implant (ECCE-PCIOL) is not new to Nigeria; the first report [4] was published about a decade and half ago with encouraging outcome. Furthermore, in the last decade several ophthalmologists in ophthalmic institutions and clinics in Nigeria have undergone microsurgical training and have converted from intracapsular cataract extraction (ICCE) to ECCE+ PCIOL and more recently the small incision cataract surgery (SICS). Good outcome of 12 - 28% on discharge [4],[5],[6],[7] and a steady improvement [5],[6],[8],[9],[10],[11] have been reported from some tertiary and secondary eye facilities in Nigeria where the surgical environment is different from what obtains in the rural areas.

In this study a good outcome of 16.0% was obtained on discharge. This value falls far below WHO category of a good outcome in 80 - 90% of cases. However, the percentage of patients with good outcome doubled by the end of the 2 nd postoperative week [Figure 3]. At the end of 8 th post-operative week 53.6% of the patients achieved good outcome. In a study of outcome of cataract surgery in Nepal [12] under a similar operating environment a good outcome was obtained in 54.4% of cases at the end of 8 weeks. However, after refraction and correction 87.1% was achieved. A similar study in Plateau reported 73.6% good outcome with best available correction at 8 weeks. [13]

Surgical and post-operative complications contributed to the poor outcome of less than 10% at the end of 8 weeks. Other factors which contributed to the borderline and poor outcome include the lack of pre-operative biometry, uncorrected residual post-operative refractive error and also failure to detect pre-existing eye pathology due to the lack of adequate technology (e.g. slit- lamp) at the outreach post.

The authors believe that a good outcome of more than 80% is possible eight weeks post-operative even in the rural environment as has been demonstrated in the Nepal [12] study.

Refraction and correction of residual post-operative ametropia will improve the visual outcome. Furthermore, regular retraining of ophthalmic surgeons in operating techniques and management of intra-operative / post-operative complications will enhance a good outcome. In addition, provision of minimum technology such as a portable slit lamp can improve the quality of pre-operative assessment of cataract patients and reduce the effect of co-existing ocular morbidity on the final outcome.

 Acknowledgement



We wish to acknowledge the immense contribution of the Sight Savers International to the Kaduna State Eye Care Programme. We are also grateful to Kaduna State for her contribution and the Local Government Areas for the enabling environment to operate on their patients. To the management of Ahmadu Bello University Teaching Hospital, Zaria we appreciate the support we have always received during the cataract outreaches.

References

1Thylefors B, Negrel AD, Pararajasearam R. Global data on blindness. Bull World Health Organ 1995;73:115-21.
2Global Initiative for the Elimination of Avoidable Blindness, Geneva, July 1996.WHO / PBL / 97. 61. Rev. 1 p. 3
3Hall A, Rosenthal AR. Cataract. In: Yanoff, D, editors. Textbook of Ophthalmology. London: Mosby International Publishers; 1999. p. 4,9,1.
4Agbeja AM. Intraocular lens implantation, the Nigerian experience. Afr J Med Sci 1994;23:233-7.
5Adejor GO. Early experience with posterior chamber intraocular lens implantation in Kaduna, Nigeria. Niger J Ophthalmol 1997:6-12.
6Nwosu SN, Onyekwe LO. Intraocular lens implantation surgery in Onitsha, Nigeria. Niger J Ophthalmol 2002;1:5-9.
7Eruchalu UV, Pam VA. A preliminary review of extracapsular cataract extraction with posterior chamber intraocular lens implantation in Kaduna, Nigeria. Niger J Med 2004;13:26-31.
8Mypet CD, Ahmad UI. Initial experience with posterior chamber lens implant, NJSR 2000;2:135-8.
9Bekibele CO. Evaluation of the outcome of ECCE surgery with PC IOL at Ago-Iwoye, Ogun State, Nigeria. Niger J Ophthalmol 2001;1:32-6.
10Ashaye AO, Komolafe OO. Visual outcome of cataract surgery in UCH, Ibadan, Nigeria. West Afr J Med 2009;28:102-5.
11Alhassan MB, Kyari F, Achi IB, Ozemela CP, Abiose A. Audit of outcome of an ectracapsular cataract extraction and posterior chamber intraocular lens training course. Br J Ophthalmol 2000;84:848-51.
12Pokhel GP, Selvaraj S, Ellwein LB. Visual function and quality of life outcome among cataract operated and unoperated blind populations in Nepal. Br J Ophthalmol 1998;82:606-10.
13Odugbo OP, Babalola OE, Morgan RE. Outcome of cataract surgeries in Plateau State, Nigeria. Highland Res Med J 2009;8:30-6.