Publichealthandcataract

blindness

Overview
Thispresentationcoversthefollowingtopics:

Definitions
Epidemiologyofcataract
Publichealthapproachestocontrol
cataractblindness
Conclusion

Notessectionamoredetailedexplanationisprovidedinthe
notesalongwithkeyreferences.

Definitionandclassificationof
Cataract
Definition:
Abnormalmorphology
Decreasedlight
transmission
Decreasedvisualacuity

Aetiology:
Agerelated
Congenital
Traumatic
Secondary
Locationoftheopacity:
Cortical
Nuclear
Posteriorsubcapsular

Cataractgradingsystems
WHOsimplified
grading

LOCSS

photographicmethod
rapidmethod
Usedincasecontrol
studies/crosssectional
designedforsurveys
surveys
undilatedpupil
verygoodinterobserver dilatedpupil
verygoodinterobserver
agreement
agreement

Magnitude:prevalenceofcataract
Studyandlocation
BeaverDam
USA198890
BlueMountains
Australia199294
SouthWest,Nigeria
200607

INDIEYE:2centres
200708

Sample

Years

Nuclear

Cortical

PSC

4926

5564
6574
7584

6.6
27.4
57.4

10.9
25.4
42.4

4.3
8.4
14.3

3654

5564
6574
7584

3.9
21.8
48.5

13.1
28.4
46.7

3.8
6.5
11.7

1031

5059
6069
70+
All50+

11.5
20.4
29.2
17.4

9.3
20.4
22.7
15.2

3.2
8.8
15.8
7.2

5871

60+

42.8

9.0

19.1

Magnitude:prevalenceofcataract
blindness
Prevalencedatafrom:
1.Prevalencesurveyspopulationbased
2.Rapidassessmentmethodsinadultsover
50yearsofage
Ingeneral:
50%ofallcausesofblindness
18millioncataractblind
Higherprevalenceindevelopingcountries

Cataractriskfactors
Modifiable:

Nonmodifiable

Age
Femalegender
Genetics

Smoking
Diabetes
MJC1
Steroids I3
ChronicUV
exposure

Slide 7
MJC1

Technically this is modifiable but for some patients on long-term administration it's hard to find an alternative.

I3

Agree, this point is discussed on the subtext on the primary prevention slide.I have also included it below for further clarity.

Marissa Carter, 6/2/2011

ITD, 7/5/2011

Managementofcataract:surgery
Technique
Visualoutcome
OperatingTime
Cost
Training

Phaco
Sameat6weeks
postop.
Longer
Expensive
DifficultforECCE
surgeons.

MSICS

Shorter
Cheaper
EasierforECCE
surgeons

MSICS:techniqueofchoiceindevelopingcountries
Phacoemulsification:techniqueofchoicein
developedcountries

Publichealthstrategiesforcataract
Primaryprevention:preventcataractfrom
forming
Secondaryprevention:preventprogression
tocataractblindnessinpatientswith
cataract
Tertiaryprevention:treatthecataractblind

Primarypreventionofcataract
Healtheducationorientatedtomodifyrisk
factorswhichmayonlydelaythe
developmentbutnotpreventit.
Smoking:cessationcampaigns
Diabetes:tightcontrolofbloodsugar
Steroids:avoidlongtermtreatmentsif
possible
UVexposure:usesunglassesandhats

Secondarypreventionofcataract
Surgeryinpatientsbeforetheyareblindfrom
cataract:
awarenesscampaigns
earlysurgeryisroutineindeveloped
countries
indevelopingcountriesprioritytooperate
onthecataractblind?
Improvingaccessibilityandaffordabilityof
services

Tertiaryprevention:surgeryto
restoresightinblindeyes
Cataractsurgerycontrolstrategies:
1.Cataractoutput:quantityhowmany
operationsdoneandinhowmanyblind
patients?
MJC2
I5
2.Cataractoutcome:qualitywhatarethe
resultsandhowdowemonitorthem?
3.Cataractoutlay:costwhatisthecost/cost
effectiveness?

Slide 12
MJC2

Just a note that compared to other slides, in the notes section there are no comments on points 2 and 3

I5

This slide is just an outline of what is discussed in the following ones. No much point on repeating what will be said later, but the small
paragraph and references will hopefully aid students structure topic.

Marissa Carter, 6/2/2011

ITD, 7/5/2011

MJC3
I2

SchematicviewofthecataractBurden

Backlognumberofcataract
casesnotoperatedinagiven
population.
Backlogcanbedefinedfor
blindness,oranagreedoperable
visualacuitycutoff
Backlog+receivedsurgery=
burdenofcataract
Incidencenumberofnewcases
developingcataract/year
CSRcataractsurgicalrate
surgeries/million/year

Slide 13
MJC3

Notes: "In many developed countries this can be at even at 6/6..." Is this a typo? Maybe 6/60? Really should be 6/18 or 20/40.

I2

Not a typho: refering to the fact tha in developed countries patients can get cataract surgery as soon as they are symptomatic, despite
of very good visual acuity when measured. 6/6 is probably not so common, I have changed to 6/9 which is not an uncommon scenario
in the UK and ammended the comments to make them a bit clearer

Marissa Carter, 6/2/2011

ITD, 7/5/2011

CataractOutput:
Cataractsurgicalrate
CSR:performanceindicatornumberofsurgeries
performedpermillionpopulationperyear
MinimumCSRmustbeequaltotheincidenceof
operablecataract,butconsiderthatnotall
operatedeyesareblind
Mustincludeallsectors:private/public/NGO
Cautionwhencomparingacrossregionsas
prevalenceandincidenceofdiseasevaries.

MJC

Slide 14
MJC4

in the Notes section: "It simply indicates the extent of the efforts to control cataract blindness in a particular region. (1)" This may
have been what the authors said but I strongly disagree. CSR and blindness due to cataract do not correlate!
Marissa Carter, 6/2/2011

I6

I have refrased this, to account for the fact that most patients are probably not blind preop. Hope it is clearer this way?
ITD, 7/5/2011

CSRworldmap2006

CataractOutput:
Cataractsurgicalcoverage
CSC:impactindicator:proportionofoperablecataract
casesoperatedatapointintime.surveydata
CSCforpersonsproportionofpeople,withbilateral
operablecataractthathavehadsurgeryinoneorboth
eyesatapointintime.
CSCforeyesproportionofeyesthatreceivedsurgery
atapointintime.Itrelatesmoretothetotalsurgical
workloadfortheophthalmologists.IfCSCeyes>than
CSCpersonlikelythatbilateralsurgerywasdone
idealCSCshouldbeabout85%andmore

MJC6
I7

Slide 16
MJC6

Not quite true; also depends on how CSC is calculated at what visual acuity measurement.

I7

Clarified

Marissa Carter, 6/2/2011

ITD, 7/5/2011

Cataractsurgicalcoverage
CSC(persons)(VA)=x+y/x+y+zx100
X=numberofpersonswithunilateralpseudoaphakiaand
operablecataractintheothereye
Y=numberofpersonswithbilateralpseudoaphakia
Z=numberofpersonswithbilateraloperablecataract

CSC(eyes)(VA)=a/a+bx100
A=pseudoaphakiceyesb=eyeswithoperablecataract

ThelargerthedifferencebetweenCSCpersonsand
CSCeyes,thegreaterthepreferencethathasbeen
giventooperateonfirsteyesabovesecondeyes.

Cataractoutcome
Thechangeinfunctionaldisabilityasaresult
ofcataractoperation.Indicators:
Visualoutcome:visualacuity
Visualfunctioning:impactofvisionin
activitiesofdailylife*
Qualityoflife:wellbeing,mobility,mental
outlook*

WHOcataractoutcomeguidelines
Postoperativeacuity
Good(6/66/18)

Available
Best
correction correction
>80%
>90%

Borderline(<6/186/60)

<15%

<5%

Poor(<6/60)

<5%

<5%

Additionalguidelines:
>90%shouldbeIOLsurgery
Surgicalcomplications<10%:capsularrupture<5%and
vitreousloss<5%

Causesofpooroutcome

Selection:patientrelatedriskfactors
Surgery:surgicalorearlypostoperativecomplications
Spectacles:uncorrectedrefractiveerror
Sequelae:latepostoperativecomplications

Monitoringofcataractsurgicaloutcomesis
essentialsuitablemanual/electronictoolsare
available

MJC7
I4

Cataractoutlay

Cataractsurgeryisacosteffectivehealth
intervention
Thecosttotheprovidermustbelowerthanthe
pricetoachievefinancialsustainability
Indirectcoststothepatientareimportant
Cataractsurgicalservicesindevelopingcountries
mustbeaffordable,sustainable,andavailabletoall
Costcontainment,costrecovery,andincome
generationstrategieshelpachievethesegoals

Slide 21
MJC7

Should add Lansingh et al 2008 ref in Notes section.

I4

I included the 2007 paper, is this the one you had in mind?

Marissa Carter, 6/2/2011

ITD, 7/5/2011

Cataractoutlay
Costperunitincataract
surgery=F/S+C

Ffixedcost,Snumberofsurgeries,
Ccostofaconsumable

Ifproductivityincreases,costper
unitdecreases
Ifthecostofconsumables
decreases,costperunit
decreases

Barrierstocataractsurgerymust
beidentifiedandaddressed
Consumerbarriers:
Costofsurgery:Direct
andindirectcost
Distancetohospital
Socialbarrierse.ggender
issues,nooneto
accompanypatientetc
Awarenessofservices
Trustinoutcomeof
surgeryfearofsurgery

ProviderBarriers:
Longwaitinglist
Insufficientmanpower,
materialsormoney.
Poorsurgicalskillsand
outcomesaffects
reputation
Inaccessiblee.g.toofar
forruralpatients
highcostduetopoor
management

Conclusion
Cataractisthemaincauseofblindnessworldwide
Theprevalenceofcataractblindnessishigherin
developingcountriesandisincreasingwithpopulation
growthandaging.
Therearenoeffectivepreventionstrategiesfor
cataract,themajorriskfactorisage.
CSRandCSCindicatorsthatmeasuretheoutputof
cataractsurgeryinpopulations
Monitoringofcataractsurgicalservicesisessentialto
maintainquality
Barriersofdifferentpopulationshavetobeaddressed
toincreasedemandforservicesandincrease
productivitytoaddressthebacklogofcataract
blindness