Khartoum College of Medical Sciences Department of Community Medicine Outcome of Cataract Surgery In Makkah Eye Hospital

Done by :Ziryab Zein Elabdein Mohamed Supervisor : Dr Mona Muna Hassan, mbbsMBBS,MD Department of community medicine Khartoum College of medical sciences Email: mhmhs67@hotmail.com

CONTENTS
1. Introduction

2. Objectives 3. Literature review 4. Methodology 5. Results 6. Discussion 7. Conclusion 8. Annex: questionnaire 9. Recommendation 10.References

Introduction
A cataract is a clouding of the lens inside the eye which leads to a decrease in vision. It is the most common cause of blindness and is conventionally treated with surgery. Visual loss occurs because opacification of the lens obstructs light from passing and being focused on to the retina at the back of the eye.[1] It is most commonly due to biological aging but there are a wide variety of other causes. Over time, yellow-brown pigment is deposited within the lens and this, together with disruption of the normal architecture of the lens fibers, leads to reduced transmission of light, which in turn leads to visual problems. As cataracts develop very slowly most people do not know they have them at first. However, the clouding progresses and vision will gradually get worse. Stronger lighting and eyeglasses can help improve vision. Nevertheless, eventually the vision impairment affects the patient's ability to carry out everyday tasks. At this point the individual will need surgery. Fortunately, cataract surgery is usually a very effective and safe procedure. A mature cataract is one in which all of the lens protein is opaque while the immature cataract has some transparent protein. Those with cataract commonly experience difficulty appreciating colors and changes in contrast, driving, reading, recognizing faces, and experience problems coping with glare from bright lights.

Epidemiology and magnitude Age-related cataract is responsible for 48% of world blindness, which represents about 18 million people, according to the World Health Organization (WHO). In many countries surgical services are inadequate, and cataracts remain the leading cause of blindness. As populations age, the number of people with cataracts is growing. Cataracts are also an important cause of low vision in both developed and developing countries. Even where surgical services are available, low vision associated with cataracts may still be prevalent, as a result of long waits for operations and barriers to surgical uptake, such as cost, lack of information and transportation problems. In the United States, age-related lenticular changes have been reported in 42% of those between the ages of 52 to 64, 60% of those between the ages 65 and 74, and 91% of those between the ages of 75 and 85.

Causes of cataracts Aging Genetics Trauma Radiation Skin diseases Medication

Symptoms of Cataracts Cataracts usually form slowly and cause few symptoms until they noticeably block light. When symptoms are present, they can include: Vision that is cloudy, blurry, foggy, or filmy Progressive nearsightedness in older people often called "second sight" because they may no longer need reading glasses. Changes in the way you see color because the discolored lens acts as a filter. Problems driving at night such as glare from oncoming headlights. Problems with glare during the day. Double vision (like a superimposed image). Sudden changes in glasses prescription.

Diagnosis Either an ophthalmologist or an optometrist can examine patients for cataracts, but only ophthalmologists are qualified to treat cataracts. The eye professional can observe cloudy areas on the lenses with a direct physical examination, even before the cataracts begin to interfere with vision. Cameras can measure the cataract density. Various vision tests are also performed. Visual acuity test. This eye chart test measures how well you see at various distances. Dilated eye exam. Drops are placed in your eyes to widen, or dilate, the pupils. Your eye care professional uses a special magnifying lens to examine your retina and optic nerve for signs of damage and other eye

problems. After the exam, your close-up vision may remain blurred for several hours. Tonometry. An instrument measures the pressure inside the eye. Numbing drops may be applied to the eye for this test. Eye care professional also may do other tests to learn more about the structure and health of your eye.

Treatment The symptoms of early cataract may be improved with new eyeglasses, brighter lighting, anti-glare sunglasses, or magnifying lenses. If these measures do not help, surgery is the only effective treatment. Surgery involves removing the cloudy lens and replacing it with an artificial lens. A cataract needs to be removed only when vision loss interferes with everyday activities, such as driving, reading, or watching TV. The patient and the eye care professional can make this decision together. In most cases, delaying cataract surgery will not cause long-term damage to your eye or make the surgery more difficult. Sometimes a cataract should be removed even if it does not cause problems with your vision. For example, a cataract should be removed if it prevents examination or treatment of another eye problem, such as age-related macular degeneration or diabetic retinopathy. If thr eye care professional finds a cataract, patients may not need cataract surgery for several years. In fact, they might never need cataract surgery. By having vision tested regularly, eye care professional can discuss if and when you might need treatment. If there is cataracts in both eyes that require surgery, the surgery will be performed on each eye at separate times, usually four to eight weeks apart.

Cataract surgery is the removal of the natural lens of the eye (also called "crystalline lens") that has developed an opacification, which is referred to as a cataract. Metabolic changes of the crystalline lens fibers over time lead to the development of the cataract and loss of transparency, causing impairment or loss of vision. Many patients' first symptoms are strong glare from lights and small light sources at night, along with reduced acuity at low light levels. During cataract surgery, a patient's cloudy natural lens is removed and replaced with a synthetic lens to restore the lens's transparency. Following surgical removal of the natural lens, an artificial intraocular lens implant is inserted (eye surgeons say that the lens is "implanted"). Cataract surgery is generally performed by an ophthalmologist (eye surgeon) in an ambulatory (rather than inpatient) setting, in a surgical center or hospital, using local anesthesia (either topical, peribulbar, or retrobulbar), usually causing little or no discomfort to the patient. Well over 90% of operations are successful in restoring useful vision, with a low complication rate. Day care, high volume, minimally invasive, small incision phacoemulsification with quick post-op recovery has become the standard of care in cataract surgery all over the world.

Types of surgery

Cataract surgery, using a temporal approach phacoemulsification probe (in right hand) and "chopper"(in left hand) being done under operating microscope at a Navy medical center

Cataract surgery recently performed, foldable IOL inserted. Note small incision and very slight hemorrhage to the right of the still dilated pupil.

There are a number of different surgical techniques used in cataract surgery: Phacoemulsification (Phaco) is the most common technique used developed countries. It involves the use of a machine with an ultrasonic handpiece equipped with a titanium or steel tip. The tip vibrates at ultrasonic frequency (40,000 Hz) and the lens material is emulsified. A second fine instrument (sometimes called a "cracker" or "chopper") may be used from a side port to facilitate cracking or chopping of the nucleus into smaller pieces. Fragmentation into smaller pieces makes emulsification easier, as well as the aspiration of cortical material (soft part of the lens around the nucleus).

After phacoemulsification of the lens nucleus and cortical material is completed, a dual irrigation-aspiration (I-A) probe or a bimanual I-A system is used to aspirate out the remaining peripheral cortical material.

Manual small incision cataract surgery (MSICS): This technique is an evolution of ECCE (see below) where the entire lens is expressed out of the eye through a self-sealing scleral tunnel wound. An appropriately constructed scleral tunnel is watertight and does not require suturing. The "small" in the title refers to the wound being relatively smaller than an ECCE, although it is still markedly larger than a phaco wound. Head to head trials of MSICS vs phaco in dense cataracts have found no different in outcomes, but shorter operating time and significantly lower costs with MSICS. Extracapsular cataract extraction (ECCE): Extracapsular cataract extraction involves the removal of almost the entire natural lens while the elastic lens capsule (posterior capsule) is left intact to allow implantation of an intraocular lens.

It involves manual expression of the lens through a large (usually 10 12 mm) incision made in the cornea or sclera. Although it requires a larger incision and the use of stitches, the conventional method may be indicated for patients with very hard cataracts or other situations in which phacoemulsification is problematic.

Intracapsular cataract extraction (ICCE) involves the removal of the lens and the surrounding lens capsule in one piece.

The procedure has a relatively high rate of complications due to the large incision required and pressure placed on the vitreous body. It has therefore been largely superseded and is rarely performed in countries where operating microscopes and high-technology equipment are readily available.

After lens removal, an artificial plastic lens (an intraocular lens implant) can be placed in either the anterior chamber or sutured into the sulcus. Cryoextraction is a form of ICCE that freezes the lens with a cryogenic substance such as liquid nitrogen. In this technique, the cataract is extracted through use of a cryoextractor a cryoprobe whose refrigerated tip adheres to and freezes tissue of the lens, permitting its removal. Although it is now used primarily for the removal of subluxated lenses, it was the favored form of cataract extraction from the late 1960s to the early 1980s

Research objectives

General objectives The objective of this study is to determine the outcome of Cataracts surgery in Makkah eye hospital.

Specific objectives To determine the most common outcome of cataracts surgery at Mekka Eye hospitalwhether its success of failure. To determine the Visual acuity of the study sample before and after the operation To determine if anthey association exists between the outcome of the cataract surgery and the age of the patient. To determine if anythe association exists between the outcome of the cataract surgery and any presentother ocular diseases

 To determine if anythe association exists between the outcome of the the cataract surgery and any present systemic disease

Literature review
Previous studies have been conducted on the outcome of cataracts surgery and their results were as follows:1: Visual outcome of cataract surgery; Study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery. PURPOSE: To analyze the visual outcome after cataract surgery. SETTING: Cataract surgery clinics in 15 European countries. DESIGN: Database study.

Comment [a1]: Rather than listing the abstracts of previous studies In the literature review you summarize the results of other studies under subheadings : Eg Outcome of cataract surgery : What did other studies find regarding the success and failures 2. factors affecting the outcomes of the surgery what was the effect of age on outcome according to other studies etc

METHODS: Data were drawn from case series of cataract extractions reported to the European Registry of Quality Outcomes for Cataract and Refractive Surgery database. These data were entered into the database via the Web by surgeons or by transfer from existing national registries or electronic medical record systems. The database contains individual anonymous data on preoperative, intraoperative, and postoperative measurements. RESULTS: Data on 368256 cataract extractions were available for analysis. The best visual outcome was achieved in age groups 40 to 74 years, and men showed a higher percentage of excellent vision (1.0 [20/20] or better) than women. A corrected distance visual acuity (CDVA) of 0.5 (20/40) or better and of 1.0 (20/20) or better was achieved in 94.3% and 61.3% of cases, respectively. Ocular comorbidity and postoperative complications were the strongest influences on the visual outcome; however, surgical complications and ocular changes requiring complex surgery also had a negative influence. Deterioration of visual acuity after the surgery (n= 6112 [1.7% of all cases]) was most common in patients with a good preoperative visual acuity. CONCLUSIONS: The visual outcomes of cataract surgery were excellent, with 61.3% of patients achieving a corrected distance visual acuity of 1.0 (20/20) or better. Age and sex influenced the visual outcomes, but the greatest influences were short-term postoperative complications, ocular comorbidity, surgical complications, and complex surgery. A weakness of the study could be that some of the data is self-reported to the registry.

2: National study of cataract surgery outcomes. Variation in 4month postoperative outcomes as reflected in multiple outcome measures. BACKGROUND Although ophthalmologists have long recognized that visual acuity alone is an inadequate measure of visual impairment, the need for and outcomes of cataract surgery historically have been assessed in terms of visual acuity. PURPOSE To examine the relation among different cataract surgery outcome measures, including a 14-item instrument designed to measure functional impairment caused by cataract (the VF-14), at 4 months after cataract surgery. METHODS The authors performed a longitudinal study of 552 patients undergoing first eye cataract surgery by 1 of 75 ophthalmologists practicing in Columbus, Ohio, St. Louis, Missouri, or Houston, Texas. Patients were interviewed, and clinical data were obtained preoperatively (July 15, 1991-March 14, 1992) and 4 months postoperatively.

RESULTS The percentage of patients judged to be improved at 4 months after cataract surgery varied by the outcome measure used: Snellen visual acuity (96%); VF-14 score (89%); satisfaction with vision (85%); selfreported trouble with vision (80%); and Sickness Impact Profile score (67%). The change in patients' ratings of their trouble with vision and their satisfaction with vision were correlated more strongly with the change in VF-14 score than with the change in visual acuity (operated eye or better eye). The average change in VF-14 score was unrelated to the preoperative visual acuity in the eye undergoing surgery. CONCLUSION Estimates of the proportion of patients benefiting from cataract surgery vary with the outcome measure used to measure benefit. Change in VF14 score, a measure of functional impairment related to vision, may be a better measure of the benefit of cataract surgery than change in visual acuity.

3: Visual functional outcomes of cataract surgery in the United States, Canada, Denmark, and Spain: report of the International Cataract Surgery Outcomes Study.

To compare functional outcomes after cataract surgery performed at 4 sites in 4 countries that have been described as having significant differences in the organization of care and patterns of clinical practice. SETTING Multicenter cohort study from the United States, Canada, Denmark, and Spain. METHODS Clinical data and patient interview data were collected preoperatively and 4 months postoperatively. Functional outcomes were assessed by the Visual Function Index (VF-14), a self-reported measure of visual function. Scores on the VF-14 range from 0 (maximum impairment) to 100 (no impairment). RESULTS Unilateral surgery was performed in 1073 patients. In this subgroup, the odds of achieving an optimal functional outcome (VF-14 score > or =95) were similar among sites after controlling for differences in case mix. Bilateral surgery was performed in 211 patients. A postoperative visual acuity of 0.50 or better in both eyes was reported in 155 patients. However, 37% of these patients reported visual function impairment (VF-14 score <95).

CONCLUSIONS A previously identified variation in treatment modalities among the 4 sites did not have a significant effect on the odds of achieving an optimal functional outcome. In addition to visual acuity measurements, the VF14 index provides information on functional outcomes that is useful, especially in studies assessing the benefits of cataract surgery in a public health care setting.

4: Outcome and Monitoring of Cataract Surgical Services at Takeo Province, Cambodia Purpose To evaluate outcome and monitoring of cataract surgical services at Takeo Eye Hospital, Cambodia Design A prospective, hospital-based report using a cataract surgical record form from the International Center for Eye Health, London. Methods Data including preoperative and postoperative visual acuity (VA), proportion of ocular pathology, intraoperative and postoperative complications, type of surgery, and causes of poor outcome of all patients with cataract were collected. Exclusion criteria were age of patients being younger than 20 years, combined cataract-glaucoma surgeries, and having traumatic cataract.

Results A total of 8211 cataract surgeries were performed from January 2007 to December 2011. Preoperatively, the presenting VA was less than 6/60 in 65.8%. At discharge, 51.8% had a presenting VA of 6/18 or better. Outcome was poor (VA < 6/60) in 10.6%. Over 5 years, the percentage of patients with poor outcome decreased from 12.6% to 8.5%. Total operative complications decreased from 18.2% in 2007 to 3.3% in 2011, with a reduction of vitreous loss from 6.5% to 1.8%. Of all surgeries, 21.2% were performed by resident physicians. At the first follow-up 1 to 3 weeks postoperatively, 62.6% of the patients presented, whereas 23.9% presented for a second follow-up after 4 to 6 weeks. Conclusions Monitoring of cataract surgical services indicated an increase in quantity and quality. Hospital-based data collection as recommended by the World Health Organization action plan for the prevention of avoidable blindness is possible, but biased data collection has to be considered in the interpretation of the data.

5: Monitoring visual outcome of cataract surgery in India Materials and methods The methods consisted of examining the records of patients who had undergone cataract surgery.

Results Data from a total of 4168 recent cataract surgical record forms were analysed using customized software (written in Epi Info, version 6.04). Of the surgical procedures undertaken, 54% were performed on males, 65% were on one eye, and 57% were carried out in eye camps. The following surgical techniques were used: intracapsular cataract extraction with spectacles (46% of eyes), extracapsular cataract extraction with spectacles (42%), and extracapsular cataract extraction with intraocular lensimplantation (11%). The majority of operations (83.4%) were performed on eyes with a preoperative visual acuity of <3/60. Postoperative outcome was good in 37.8% of eyes, borderline in 45.6%, and poor in 16.6%. Of the 4168 procedures, 476 (11%) involved an intraocular lens implantation. In this group, the outcome was good in 27.1%, borderline in 49.2%, and poor in 23.7%. For the remaining 3692 eyes, the outcome was good in 39.2%, borderline in 45.1%, and poor in 15.6%. For the 1806 eyes treated in hospitals, the outcome was good in 55.4% and poor in 11.4%; and for the 2362 eyes treated in eye camps, the outcome was good in 24.3% and poor in 20.5% (see Table 2). Of the 931 persons who were blind prior to surgery, 59 remained so postoperatively, giving a net reduction of 872, and for 4168 procedures an SRR of 21% (Table 3). The results of the assessment of long-term postoperative visual acuity through population-based surveys in Karnataka and Ahmedabad district of Gujarat are presented in Table 4. Of the 21 950 persons aged550 years examined in Karnataka, 1843 (8.4%) had undergone cataract

surgery, with a followup period of 032 years (mean, 6 years) (7). In all, 558 persons had bilateral aphakia and 1285 unilateral aphakia, giving a total of 2401 operated eyes. Of these, 123 (5.1%) were pseudophakic. For all operated eyes, outcome was good in 43.5% and poor in 26.4%. For the 2278 aphakic eyes, the outcome was good in 41.4% and poor in 27.2%, with the available correction. For 31% of eyes with a poor outcome, the patients had lost or broken their spectacles. Since best corrected vision was not measured, it is difficult to assess how many cases of poor and borderline outcome might have benefited from full spectacle correction. For the 123 pseudophakic eyes, the outcome was good in 82.1% and poor in 11.4%. Of the 1962 persons aged550 years examined in Ahmedabad district, 484 (24.7%) had undergone cataract surgery, with a follow-up period of 030 years (mean, 5.5 years) (Limburg et al., unpublished data, 1999). In all, 292 persons had bilateral aphakia and 192 unilateral aphakia, giving a total of 776 operated eyes. Of these 189 (24%) were pseudophakic. For all operated eyes, outcome was good in 49.9% and poor in 23.9% with the available correction. For the aphakic eyes, outcome was good in 44.2% and poor in 28%; and for the 189 pseudophakic eyes, outcome was good in 67.2% and poor in 11.6%.

METHODOLOGY
Study design Type of study to used was observational descriptive cross-sectional and comparative study. It was based on a single examination of the study population. It was more suitable and less time consuming than longitudinal Studies.

Study area Makkah Eye Hospital, Khartoum. Department of surgery

Study population Records of Patients that underwent cataract surgery in Makkah Eye Hospital, Khartoum Inclusion criteria: Age Gender.. Duration after surgery.
Comment [a2]: Patients or patients records?

Sampling method Systematic sampling, individuals were chosen at regular Intervals of every 5th person that underwent cataract surgery.
Comment [a3]: Every fifth based on what? How did you calculate the interval It is usually calculated by dividing the total number of population by the sample size

Sample frame Included all people that underwent cataract surgery in Khartoum Makkah eye hospital

Comment [a4]: This comes before the sampling method

Sample size Sample size= p*q*z2 D2 Used 0.1 as prevalence Q=1-0.1 = 0.9 And constants: z=1.96 ; d=0.05 Sample size= 138

Data collection method Data base record collection using a check list including:
Comment [a5]: Put the list of variables

Data analysis and management Microsoft Excel and SPSS were used for data analysis.

Results
Below is the table used for classifying the resultsthe outcome of cataract surgery. There was no missing data in the results.
Formatted: Tab stops: 2.17", Left Comment [a6]: Move this table to the methodology section and a heading: Case definitions

Categories of Visual Impairment Corrected CATEGORY VA-Better WHO Definition Eye 0 1 2 3 4 6/6-6/18 Normal

Working

Indian Definition

Normal Low Vision

Normal Low Vision Blind Blind Blind

<6/18-6/60 Visual Impairment

<6/60-3/60 Severe Visual Impairment Low Vision <3/601/60 Blind <1/60- PL Blind Low Vision Low Vision

NPL

Blind

Total Blindness Total Blindness

Frequency Tables

Table (1) showing the Age distribution of the study population, Mekka Eye hospital, Khartoum, 2013 Frequency 1-30 31-60 61-90 Total 8 51 86 145 Percent 5.5 35.2 59.3 100.0

Comment [a7]: Write the title in full like this for all other tables as shown

The majority of the study population (59.3%) was in the age group 61 to 90 years , followed by those in age group 31- to 60 (35.2%)

Comment [a8]: You should write a brief description below each table

Gender Frequency Female Male Total 44 101 145 Percent 30.3 69.7 100.0

Diagnosed Eye Frequency Left Right Total 69 76 145 Percent 47.6 52.4 100.0

Diagnosis Frequency Percent

Cataract Immature Cataract - Mature Total

125 20 145

86.2 13.8 100.0

Associated Disease Frequency Absent Present Total 133 12 145 Percent 91.7 8.3 100.0

Comment [a9]: Bring you previous table which contains the details of the associated deisese this is used for cross tabulation only

Comment [a10]: Details

Systemic Diagnosis

Comment [a11]: The same as for above

Frequency

Percent

Absent Present Total

117 28 145

80.7 19.3 100.0

Comment [a12]: Details

Type Of Surgery

Frequency

Percent

ECCE ECCE + PC IOL ICCE + IOL Phaco + PC IOL Total

3 16 1 125 145

2.1 11.0 .7 86.2 100.0

Pre-operative VA Frequency 18 1 9 8 10 1 10 24 Percent 12.4 .7 6.2 5.5 6.9 .7 6.9 16.6

Comment [a13]: Delete this table

3/60 6/12 6/18 6/24 6/36 6/6 6/60 FC 1 ft

FC 2 ft HM LP Total

8 38 18 145

5.5 26.2 12.4 100.0

Pre-Operative VA (WHO classification) Frequenc Percent y Normal Visual Impairment Severe visual impairment 11 28 18 7.6 19.3 12.4

Blind Total

88 145

60.7 100.0

Post-operative VA Frequency Percent

Comment [a14]: Delete this table

3/36 3/60 6/12 6/18 6/24 6/36 6/6 6/60

1 26 17 34 8 15 2 7

.7 17.9 11.7 23.4 5.5 10.3 1.4 4.8

6/9 FC 1 ft FC 2 ft HM Total

6 16 3 10 145

4.1 11.0 2.1 6.9 100.0

Post-Operative VA (WHO classification ) Frequency Percent 59 29 27 30 145 40.7 20.0 18.6 20.7 100.0

Normal Visual impairment Severe visual impairment Blind Total

Surgery Outcome Frequency 116 29 145 Percent 80 20 100

Success Failure Total Bar Charts

Comment [a15]: You either put a table or diagram for the same result No need to put them both

Surgery Outcome * the association between age of the patient and the cataract surgeru outcome Age Cross tabulation

Formatted Table

Age 1-30 Surgery Success Outcome Failure Total Chi square= 2.586 31-60 61-90

Total

87.5% 86.3% 75.6% 80.0% 12.5% 13.7% 24.4% 20.0% 100.0 100.0 100.0 100.0 % % % % p value = .275

There was no statistically significant effect of patiens age on the outcome of cataract surgey (p value> 0.05) Chi-Square Tests Value df Asymp. Sig. (2sided)

2.586a Pearson Chi-Square

.275

Surgery Outcome * Gender Cross tabulation

Gender Female Success Surgery Outcome Failure Total 22.7% 100.0% 18.8% 100.0% 77.3% Male 81.2%

Total

80.0% 20.0% 100.0%

Chi-Square Tests Value df Asymp. Sig. (2sided)

.294a Pearson Chi-Square

.588

Surgery Outcome Associated Diagnosis Cross tabulation

Associated Diagnosis Absent Present Succe ss Failur e 80.5% 75.0% 19.5% 25.0% 100.0 % 100.0 %

Total

80.0% 20.0% 100.0%

Surgery Outcome

Total

Chi-Square Tests Value df Asymp. Sig. (2sided)

.204a Pearson Chi-Square

.651

Surgery Outcome * Systemic Diagnosis Cross tabulation

Systemic Diagnosis Absen Presen t t Succe ss Failur e 79.5% 82.1% 20.5% 17.9% 100.0 100.0 % %

Total

80.0% 20.0% 100.0%

Surgery Outcome

Total

Chi-Square Tests Value df Asymp. Sig. (2sided)

Pearson Chi-Square

.294a

.588

Discussion
The research has shown that the majority of patients are of the elderly category which is understandable as cataract is a disease of mainly caused by aging. Patients ranging from 61-90 were the majority of the cases observed; they made up 59% of the total number of cases presented at the hospital. First discuss the outcome of cataract surgery, is it good compared to other studies? By running cross tabulation by chi square test, it was determined that age is not associated with the outcome of the surgery and has no impact on the results of the operation. This finding is similar to the previous researches.
Formatted: Highlight

Comment [a16]: Which research , where?

The male to female ratio was 2.2:1 with 101 males (69.7%) and females at 44(30.3%) of the total 145 cases. However this is not to be taken as an indicator that males have a higher incidence of cataract than females do . By running cross tabulation by chi square test, it was determined that gender does not play any significant role on the outcome of the surgery.

86.2% of the cases were diagnosed as immature cataract while only a minority of 13.8 were diagnosed as mature . This an indication of the very slowly progressive nature of cataracts, and a long time in needed for the disease to progress to mature cataract where the lens is completely opacified.

There was a total of 12 cases with an associated disease accompanying the cataract. 6 were retinal disease and the other 6 were glaucoma. By running cross tabulation by chi square test, it was determined that associated disease does not have a significant impact on the outcome of the surgery.

There were a total of 29 cases with systemic diseases, 17 of which were Hypertension while the remaining 12 were diabetes. These diseases are common among the elderly population and constituted 19.3% of the total number of cases. By running cross tabulation by chi square test, it was determined that the presence of systemic disease does not have a significant impact on the outcome of the surgery.

There were four main types of surgery performed: Extra capsular cataract extraction (ECCE) Extra capsular cataract extraction + posterior chamber intraocular lens (ECCE + PC IOL) Phacoemulsification + posterior chamber intraocular (Phaco+ PC IOL) Intracapsular cataract extraction + intraocular lens (ICCE + IOL)

Phaco+ PC IOL was the most common performed making up 86.2% of all the surgeries performed. It is the most common technique used in developed countries.

The pre-operative visual acuities were recorded. 60% of the patients had a visual acuity which was below 3/60, which is classified as blind by the World Health Organization categories for visual impairment. 12.4% were severely visually impaired, 19.3% were visually impaired and only 7.6% were among the normal range of visual acuity.

Comment [a17]:

The post-operative visual acuities of the patients were recorded 1 day after the operation in the follow up clinic and showed a vast improvement. As the percentage of blind decreased to 20.7%, patients with a normal visual acuity increased to 40.7%. The visually impaired and severely visually impaired have also increased in number but this can be attributed to the fact that the increase is from patients who were blind before the operation and now have moved to a these categories. Which overall, is considered a success.

80% of the surgeries performed were categorized as successful while 20% were categorized as a failure.

Comment [a18]: Move this to the start of discussion

The determinants of success and failure in this research were that , any improvement in the visual acuity of the patient after the surgery would constitute a success , while if the visual acuity remained unchanged or deteriorated , that would constitute a failure .

Better results and a more through approach could not be obtained due to the fact that the patient records in the data base only included the visual acuity 1 day post the operation and nothing more. Information on changes to the visual acuity or any complications that might have taken place over a longer period of time was not present.

Previous researches had longer follow-up periods and were able to collect data on the patients for up to 5 years after the surgery had taken place. They also used different methods of assessing the post-operative results such as: satisfaction with vision self-reported trouble with vision and Sickness Impact Profile score

Conclusion
The outcome of cataract surgery in Makkah Eye Hospital was that the vast majority of the surgeries performed were successful and the majority of the patients had their vision improved afterwards. The visual acuities of all the patients were obtained pre-operatively and post-operatively from the database. Factors such as age, gender, ocular disease and systemic disease were recorded in the patients and measured against the outcome of the surgery. It was determined that no significant association exists between those factors and the outcome of cataract surgery .

Recommendations
What are your recommendations regarding the cataract surgery itself? The hospital keeps more organized online records as some of the patient records had important missing data. Follow- up of patients for a number of weeks after the operation.

More data on the patients be collected and entered into their records in the online database. Example: infection before or after the surgery, or any complications. Different methods of assessment of visual acuity after the operation such as patient satisfaction and self-reported trouble with vision. Spreading awareness about cataracts and its symptoms can help in diagnosis and treatment Following the doctors instructions and showing up for the specified follow-up dates will help in avoiding complications and a more satisfactory end result

References :

Comment [a19]: Add list of references

KHARTOUM COLLEGE OF MEDICAL SCIENCES DEPARTMENT OF COMMUNITY MEDICINE OUTCOME OF CATARACT SURGERY IN MAKKAH EYE HOSPITAL 1. 2. 3. 4. Age ( )

Gender: 1.male 2. Female Type of Cataract? 1. Mature Eye affected by cataract? 1. Left 2.right ) no ( ) 2.Immature

5. 6. 7. 8.

Any associated diagnosis? Yes ( If yes, specify

Systemic disease(s) with the cataract? Yes ( If yes, specify

) no (

9. Type of surgery performed? 1.ECCE+PC IOL 2. PHACO+PC IOL 3.ICCE+IOL 10. 11. Visual acuity before surgery: left eye ( Visual acuity after surgery: left eye ( ) right eye ( ) right eye ( ) )

References
1- Steinberg EP, Tielsch JM, Schein OD, Javitt JC, Sharkey P, Cassard SD, Legro MW, Diener-West M, Bass EB, Damiano AM, et al. Johns Hopkins University School of Medicine, Baltimore, MD. 2- Department of Clinical Sciences, Ophthalmology (Lundstrm), Faculty of Medicine, Lund University, Lund, Sweden; the Royal Victoria Eye and Ear and St. Vincent's University Hospital (Barry), Dublin, mats.lundstrom@karlskrona.mail.telia.com. 3-University Eye Clinic, Frederiksberg Hospital, Copenhagen, Denmark. jens.c.norregard@fh.hosp.dk 4-http://www.who.int/blindness/causes/priority/en/index1.html 5-Extracapsular Cataract Extraction - Definition, Purpose, Demographics, Description, Diagnosis/preparation, Aftercare, Risks, Normal results, Morbidity and mortality rates, Alternatives 6-Charters, Linda Anticipation is key to managing intra-operative floppy iris syndrome. Ophthalmology Times. June 15, 2006. 7-Categories of Visual Impairment in India http://www.medindia.net/health_statistics/general/visualimpairment.asp#ixzz2SMF5g1JQ

8-Facts About Cataract : http://www.nei.nih.gov/health/cataract/cataract_facts.asp 9-Quillen DA (July 1999). "Common causes of vision loss in elderly patients". Am Fam Physician 10-"Posterior Supcapsular Cataract". Digital Reference of Ophthalmology. Edward S. Harkness Eye Institute, Department of Ophthalmology of Columbia University. 2003.

11-Outcomes of small incision cataract surgery. Uusitalo RJ, Tarkkanen A. Department of Ophthalmology, Helsinki University Central Hospital, Finland.

12-Outcomes of small incision cataract surgery. Uusitalo RJ, Tarkkanen A. Department of Ophthalmology, Helsinki University Central Hospital, Finland.

13-Visual Acuity following Cataract Surgeries in Relation to Preoperative Appropriateness Ratings http://hinari-gw.who.int/whalecommdm.sagepub.com/whalecom0/content/23/2/122.abstract 14 -Madan Mohan. National Survey of Blindness India: NPCB-WHO report 1989. New Delhi, All India Institute for Medical Sciences, 1991.