Pone 0167708
Pone 0167708
Pone 0167708
1 Allen Foster Community Eye Health Research Centre, Gullapalli Pratibha Rao International Centre for
Advancement of Rural Eye care, L V Prasad Eye Institute, Hyderabad, India, 2 Brien Holden Institute of
Optometry and Vision Science, L V Prasad Eye Institute, Hyderabad, India, 3 Wellcome Trust / Department
of Biotechnology India Alliance Research Fellow, L V Prasad Eye Institute, Hyderabad, India
a11111
* rohit@lvpei.org
Abstract
OPEN ACCESS
Conclusions
Post cataract surgery, refractive errors remain an important correctable cause of MVI, in the
south Indian state of Andhra Pradesh. The correction of refractive errors is required to pro-
vide good visual recovery and achieve the benefit of cataract surgery.
Introduction
Cataract remains the leading cause of visual impairment (VI) worldwide though proportions
vary across regions. [1,2] Cataract surgery is one of the most commonly performed ophthalmic
surgical procedures, globally. Recent reviews concluded an improved quality of life after cata-
ract surgery. [3,4] Recent decades have witnessed technological advances in cataract surgery
and transition from intra capsular cataract extraction with aphakic spectacle correction to pha-
coemulsification and small incision cataract surgery with intraocular lens (IOL) implantation,
and more recently, femtosecond laser assisted cataract surgery. However, despite all these,
globally, in most developing countries, there are issues with outcomes of cataract surgeries
with poor outcomes ranging from as low as 11.4% to as high as 44%. [5–20]. Most of these
study setting was rural [7–9, 12, 13, 15,19] or mix of urban and rural population [10, 11, 14,
16–18, 20] and very few were urban. [5, 6] Risk factors identified in some of these studies
included increasing age [8, 11] female gender [5, 10] having no education [11, 13, 14] rural res-
idence [10, 11, 13 14], operated in government sector [11, 13] having free surgery [8, 13] and
presence of aphakia. [5, 13, 14]
In India the ‘camp based surgeries’ gave way to ‘hospital based surgeries’ which resulted in
better outcomes after cataract surgery, over time. [8,10] In India over 6.3 million cataract sur-
geries were performed during 2013–2014. [21] Being the most commonly performed surgical
procedure that impacts blindness prevention strategies; several researchers have highlighted
the importance of monitoring cataract outcomes. [22,23] India, owing to the large size of the
country, with huge regional variations in terms of coverage and outcomes, [5,8,10,13,14,24,25]
regional surveys are required for local planning of eye care services. [22]
In the year 2011–12, we undertook large population based cross sectional studies using
rapid assessment (RA) methodology in one urban (Vijayawada in Krishna district) and two
rural locations (Khammam and Warangal district), in the south Indian state of Andhra Pra-
desh, among those aged 40 years and older. [26] In our earlier papers, we reported on the prev-
alence and causes of visual impairment, spectacles use and barriers for the uptake of eye care
services. [26–28] The overall age and gender adjusted prevalence of visual impairment (VI) in
this study population was 14.3%. [26] In this paper we report visual outcomes, causes of VI
and risk factors for poor outcome following cataract surgery in this population.
neighbour. Each individual was free to decide on participation in the study. As the study used
a simple and non-invasive eye screening protocol, IRB granted permission for verbal consent.
The studies were carried out in phases during year 2011 and 2012. The written consent was
not obtained as the community where the study was conducted has lower levels of literacy and
participants are reluctant to give their thumb impression on the consent form. As this might
lead to poor response, IRB was had given approval for verbal consent. [26] In some villages,
the verbal consent process in documented in photographs.
The detailed methodology, including sampling procedures has been described elsewhere.
[26]
As this study was a part of much larger study that was designed to assess the prevalence of
blindness, sample size was not specifically calculated for this study. [26] The sample size was
calculated with an expected prevalence of blindness of 6%, precision 20% with 95% error
bound, and 10% non-response rate. The sample size is calculated to be approximately 2600
from each of the three study areas and the total sample size was 7800. This sample size is ade-
quate for assessing the visual outcomes after cataract surgery. [26]
A multi-stage sampling procedure was used to select the study sample. [26] In total, 52 clus-
ters are randomly selected from each of the three study districts. In each cluster, the area was
demarcated, mapped and segmented in such a way that each segment contained the required
number of households to provide at least 50 individuals aged 40 years and older. [26] One of
the segments was randomly selected for the study. Villages and municipals wards were used as
clusters in rural and urban area respectively. All the individuals in each of the selected house-
hold fulfilling the age criteria were listed and all those available were examined. [26] At least
two attempts were made to examine those who were not available at the first visit. Those who
were still not available after repeated attempts were considered as not available and were not
substituted so that bias in recruitment could be minimized. [26]
In brief, one of the three teams, each of which comprised of a vision technician and a com-
munity eye health worker, visited the selected households and conducted eye examinations on
all the eligible participants. Information on demographics, which include age, gender and edu-
cation, was collected. Those who have undergone at least primary education were classified as
‘educated.’ Distance visual acuity (VA) was measured using a Snellen chart with tumbling E
optotypes at a distance of 6 meters. Presenting and pinhole VA were assessed and for those
wearing glasses, additionally unaided VA was assessed. Spectacle use was defined as those who
were using spectacles at the time of examination. Torchlight examination and distance direct
ophthalmoscopy were performed to assess the lens status in each eye and it was marked as
‘Normal lens’, ‘Cataract’, ‘Pseudophakia’ or ‘Aphakia’. If lens could not be examined, it was
marked as ‘No view of lens’ and the reason was documented.
Questions were asked on utilization of eye care services in the past, including cataract sur-
gery and intraocular lens implantation. If a subject reported past cataract surgery, then the
place of surgery (government hospital, private hospital, Non-government hospital, in ‘make-
shift’ eye camp), cost of surgery (free or paid) and duration of time in years since the surgery
were asked. Though makeshift surgical eye camps are no more conducted in India, it was a
practice that was widely prevalent more than a decade ago. If the subjects had previous
consultation, the reports are reviewed, if available for any further information on ophthalmic
consultation. Definitions of cataract and refractive error have been described elsewhere.
[26] Cataract was defined as opacity of crystalline lens obscuring the red reflex partially or
completely on distant direct ophthalmoscopy and causing visual impairment. Refractive error
was deemed to be present if presenting distance VA was worse than 6/18 and improving to
6/18 or better with pinhole.
If there were no media opacities and vision did not improve with pinhole, the cause was
attributed to posterior segment pathology. Visual outcome was defined as described by World
Health Organization (WHO). [29] Poor outcome after cataract surgery is defined as presenting
VA worse than 6/18 in the operated eye. This is based on the surgical history given by the par-
ticipant and the clinical examination. It was categorised as ‘0’ for good outcome i.e. presenting
visual acuity in the operated eye as 6/18 or better and ‘1’ for poor outcome i.e. presenting visual
acuity worse than 6/18 in operated eye. Risk factors included age categories (less than 60 years;
60–69 years and more than or equal to 70 years), gender (male versus female), education (any
education versus no education), area (urban versus rural), lens status (aphakia versus pseudo-
phakia), duration of time in years since the surgery (less than or equal to 5 years and more
than 5 years) place of surgery (government hospital, private hospital, Non-government hospi-
tal, in ‘makeshift’ eye camp) and cost of surgery (free or paid).
Statistical analyses
The data analyses were conducted using Stata 12. [30] The point prevalence of poor outcome
estimates were calculated and presented with 95% confidence intervals. The chi-square test
was used to test the association between the categorical variables such as poor outcome with
age groups, gender and other categorical variables. Univariable and multivariable analysis for
risk factor for those having VA less than 6/18 in operated eye was done using generalized esti-
mating equation (GEE) along with robust variance estimation to account for correlation
between the two eyes of an individual. The fitness of the regression model was assessed using
Hosmer-Lemeshow test for goodness of fit. The adjusted odds ratios (OR) with 95% CI are
reported.
Results
Baseline characteristics
In total, 7800 subjects aged 40 years and older were enumerated of whom 7378 (94.6%) were
examined. The demographic profile of the study participants is published. [26] Of these, 1228
eyes of 870 individuals were operated for cataract. The prevalence of cataract surgery was
11.8% (95% CI: 11.0–12.5) and bilateral cataract surgery was 4.6% (95% CI:4.4–5.3).
Table 1 shows the demographic details of the operated subjects stratified by area of resi-
dence (urban versus rural). The mean age of operated subjects was 63.7 years (SD:10.7 years).
In total, 56.3% of those operated were women, 76% were illiterate, 42% of them were using
spectacles after cataract surgery and 58.9% were cases of unilateral cataract surgery. While
those operated upon in urban and rural areas are similar in terms of age (p = 0.33), cataract
surgery was more common among women in urban area compared to rural (p = 0.04) and
those operated upon in rural area were more likely to be illiterate than those in urban areas
(p = 0.04). Bilateral cataract surgery was higher in urban area than in rural areas (p<0.01).
Table 2 shows the ocular characteristics of operated eyes stratified by urban and rural popu-
lation. IOL implantation was seen in 86.2% of eyes. Nearly two third of the surgeries were per-
formed in the last five years. In total, 38.8% of surgeries were conducted in government
hospitals and 30.5% in hospitals managed by non-government organization. Overall 71.3% of
the surgeries were done free of cost. Good outcomes were seen in 73% of the operated eyes. As
compared to rural areas, those in urban areas had higher proportion of surgeries done in pri-
vate clinic (44.2% versus 20.9%; p<0.01) and had lower prevalence of free surgeries done
(54.4% versus 80.4%; p<0.01). A higher proportion of subjects in urban area had good out-
come as compared to rural area (77.6% versus 70.6%; p = 0.01). The visual outcome was also
better among the eyes with pseudophakia compared to aphakia (Table 3).
doi:10.1371/journal.pone.0167708.t001
Table 4 shows the causes of VI in urban and rural areas. Uncorrected refractive errors
accounted for 28.7% of the VI followed by posterior segment diseases which accounted for
26.9% and surgery related complications accounted for 21.1%. Following refractive error, pos-
terior segment disorder predominated in urban areas, surgery related complications predomi-
nated in rural areas, as cause for MVI. Similarly, posterior segment disease, uncorrected
aphakia and surgery related complications were the leading causes of blindness after cataract
surgery in operated eyes in both urban and rural areas.
Table 5 shows the risk factors for poor outcome (<6/18) after cataract surgery. Visual out-
comes were poor among those aged 70 years (OR: 1.9, 95% CI: 1.3–2.8); among rural resi-
dents (OR: 1.3, 95% CI:1.0–1.8). and in those with aphakia (OR: 8.9, 95% CI: 5.7–13.8). The
odds of having poor outcome among those operated upon more than 5 years ago were of bor-
derline significance (OR: 1.3; 95% CI: 0.9–1.8). The visual outcomes were not associated with
gender, education, place of surgery and whether the participant paid up or was operated upon
for free.
Discussion
We reported population based visual outcomes after cataract surgery in the south Indian state
of formerly undivided Andhra Pradesh, India and reported the urban and rural differences.
Though different outcome based studies in India had both urban and rural population, [10,11]
only Chennai Glaucoma Study (CGS) [14] reported the urban and rural differences in out-
comes. The overall prevalence was 11.8% and was comparable with some of the studies done
in India [5,8,10,13,14,25] but higher than those reported from neighboring countries such as
Nepal, Bangladesh and China. [6,7,12,31] Unlike, CGS, there was no difference in the preva-
lence of cataract surgery in urban and rural areas (11.9% versus 11.5%; p = 0.56), suggesting an
increase in uptake of surgeries in rural areas too.
doi:10.1371/journal.pone.0167708.t002
Overall, 56.3% of surgeries were done in female patients and similar trends were seen across
other studies in India. [8,10,11,13,14,25] It’s known that females live longer and show higher
prevalence of cataract surgery, which could be one of the reasons for more number of surgeries
in female patients. The percentage of surgeries in females in the urban area was higher than in
rural areas and this could be likely due to increased awareness and education in females in
urban areas as compared to rural areas. This could also explain the reason for the higher preva-
lence of bilateral cataract surgeries as well as surgeries on literates in urban areas as compared
to rural areas.
Overall 86.2% of surgeries were with IOL and unlike CGS, [14] there was no difference
between urban and rural areas. Our study was almost a decade later than CGS and nearly two-
third of surgeries in our cohort were done in the last 5 years. This is a welcome trend
doi:10.1371/journal.pone.0167708.t003
suggesting higher IOL implantation in rural areas too. Most of the surgeries in urban areas
were done in private clinics and in rural areas by government and non-governmental organi-
zation (NGO) hospitals. This is due to the fact that most of the private clinics are located in
urban areas and government and NGO hospitals operate upon most patients from rural areas
through their outreach programs.
Table 5. Logistic regression analysis showing the risk factors for poor visual outcomes after cataract surgery (n = 1203 eyes).
Unadjusted Odds ratio 95% CI Adjusted Odds Ratio 95% CI
Age group (years)
< 60 1.0 1.0
60–69 1.3 0.9–1.9 1.0 0.7–1.5
70 2.8 2.0–4.0 1.9 1.3–2.8
Gender
Male 1.0
Female 1.0 0.8–1.3 0.9 0.6–1.2
Education
Any education 1.0
No education 1.9 1.4–2.6 1.6 1.0–2.4
Area
Urban 1.0
Rural 1.4 1.1–2.0 1.3 1.0–1.8
Lens Status
Pseudophakia 1.0
Aphakia 11.7 7.8–17.4 8.9 5.7–13.8
Duration since surgery
< = 5 years
> 5 years 2.6 2.0–3.3 1.3 0.9–1.8
Place of surgery
Private clinic 1
NGO Hospital 1.4 1.0–2.0 1.2 0.6–2.1
Govt hospital 2.6 1.9–3.6 1.7 0.9–3.3
Make-shift eye camp 6.2 2.5–15.3 0.8 0.2–2.2
Cost of surgery
Paid 1.0
Free 2.1 1.6–2.9 1.2 0.6–2.2
doi:10.1371/journal.pone.0167708.t005
Overall visual acuity of more than 6/18 was seen in more than 70% of the participants.
This was much higher than those reported from other studies in India and other developing
countries, [5–7,10–14,25,31,32] however this was similar to one of the recent studies. [8] It
could be due to the fact that, as compared to other studies, the percentage of aphakia was
lower in our study. Outcomes were also good among pseudophakic participants as compared
to aphakic participants due to use of IOLs. Apart from that, with time, more and more
sutureless surgeries (manual small incision cataract surgery and phacoemulsification) are
being performed across the country, thus causing less astigmatism and better uncorrected
visual acuity.
Like other studies, [5,8,10,13,14,24,25] increasing age was a risk factor for poor outcome
and it is likely that with increasing age, there are other co-existing morbidities, which could
affect outcomes. Similarly, those in rural areas were also having poor outcomes and it could
be due to the fact that most of these surgeries were done in government and NGO hospitals,
including free of cost surgeries. Most of these surgeries in rural areas are done through out-
reach programs as part of the National Program for Control of Blindness (NPCB) activity
where they are transported to the base hospital for surgeries and given one-time free glasses
six weeks after cataract surgery. It is seen that, if the glasses are broken or lost, many of these
patients do not get a replacement of a new pair of glasses, and manage with the existing
vision, thus affecting outcomes. Outcomes were also better with the use of spectacles as well
as in pseudophakia. The major cause of MVI in urban and rural areas was refractive error fol-
lowed by posterior segment disorder in urban areas and surgery related complications in
rural areas.
The major cause of blindness in both urban and rural areas was posterior segment disorder
uncorrected aphakia and surgery related complications. This was similar to other studies in
India too. [5,10,13,14,24,25,32] One of the major strengths of this study was large sample as
well as urban and rural mix, giving an opportunity to look at the differences. Apart from this,
the use of rapid assessment methods allows comparison with other studies using similar meth-
odology. One of the major limitation of the study was use of pinhole visual acuity as a surro-
gate for best-corrected visual acuity. To overcome this, we have used the presenting visual
acuity for our analysis.
Apart from this, another limitation was attributing posterior segment disorder as the cause
of VI if the vision did not improve with pinhole and the media was clear. This is likely to lead
to an overestimate of posterior segment disorder as the cause of VI. Apart from this other limi-
tation include non-availability of pre-operative, intra-operative as well as post-operative surgi-
cal records of these participants, limiting the ability to pin point the exact cause of uncorrected
refractive error.
In summary, the study showed a trend in improvement of outcomes in population as com-
pared to previous study. However, the outcomes are still below the accepted WHO norms.
[29] One of the major reasons was lack of use of spectacles by more than 50% of the partici-
pants in the post-operative period. Hence, emphasis should also be paid to ensuring regular
use of spectacles in the post-operative period as well as later.
Acknowledgments
Authors thank Narsaiah Saggam, Eswararao Kunuku, Rajesh Challa, Susheel Kumar Dagde,
N. Raja Shekar Reddy, Raghavendra Byagari and Raghuswamy Dasari for their assistance in
field work and data collection. LVPEI acknowledges the volunteers for their participation the
study. Dr. Sreedevi Yadavalli is acknowledged for her language inputs on earlier versions of
the manuscript.
Author Contributions
Conceptualization: SM.
Data curation: KS.
Formal analysis: SM RCK.
Funding acquisition: GNR.
Investigation: SM RCK.
Methodology: SM, RCK.
Project administration: MS.
Resources: SM RCK GNR.
Software: NA.
Supervision: GNR.
Validation: NA.
Visualization: RCK MS.
Writing – original draft: RCK MS GNR.
Writing – review & editing: RCK MS GNR.
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