FP276 : Level of Primary Surgeon’s Experience: a Factor Affecting Secondary IOL Implantation

Dr. Satyam Gupta, Dr. Mehul Ashvin Kumar Shah, Dr. Ashit Hasmukhlal Shah, Dr. Mihir Mehta

Authors : Dr Satyam Gupta, Dr Mehul Shah, Dr Mihir Mehta, Dr Ashit Shah

INTRODUCTION

Unoperated Cataracts are responsible for 33% of all cases of visual impairement worldwide(1-WHO).

The epidemiological impacts of cataracts are uneven among different countries, and the rate is associated

with economic conditions. In developed countries, where healthcare is good, cataracts account for only 5% of cases of blindness, whereas cataracts are still responsible for 50% of such cases in developing countries.

It also provides insight into political, socio‑economic, and cultural factors that adversely affect the availability of healthcare in developing countries, making cataracts a major public health problem and an obstacle to development¹.

The prevalence of cataracts increases with age. As the world’s population ages, the incidence rates of cataract-induced visual dysfunction and blindness are increasing, which represents a significant global problem.

The challenges include preventing or delaying cataract formation and treating cataracts that occur. However, reducing ocular exposure to UV-B radiation and stopping smoking are the only known

interventions that can reduce the risk for cataract.

Cataracts are cured by surgery, but this is not equally available, and the surgicalmethods that are available do not produce equal outcomes. Readily available surgical services capable of delivering good visual

rehabilitation must be standard and accessible to all in need, regardless of their circumstances.

India is a signatory to the World Health Organization Resolution on Vision 2020. Efforts of all stakeholders

have resulted in an increase in the number of cataract surgeries performed in India. However,

the impact of these efforts on the elimination of avoidable blindness is unknown.²

Surgery statistics

In India as per NPCB report, a total of 6304177 cataract surgeries were performed against a target of 6600000 during 2015-2016 .

Training personnel to perform cataract surgery is an important action plan adopted by the National Program Control of Blindness and Vision 2020.

Training programs

Various postgraduate training programs in cataract surgery are currently available in India (MS, DO, DNB) at different government and non-government institutions with a range of facilities. Post-doctoral fellowship

programs are available at different government and non-government hospitals. Doctors in government services or in private practice are also trained by various institutes.

Challenges for training programs

Difference in infrastructure, patient load, and  skill of the faculty at various training facilities lead to the acquisition of differing skill levels as well as differing surgical results.

If facilities are unavailable or the trainee does not have sufficient skill to deal effectively with the complications that may occur, this can result in a further reduction in performance at a given medical center.

MATERIALS & METHODS

This was a retrospective study. It includedall cataract cases without comorbidity that were treated surgically (either PHACO or SICS) by trainees/consultants of the facility and that includedthe development of capsular complicationsduring surgery handled by senior vitreo-retinal surgeonsduring the same sitting or as a second surgery (3^rdday )in the form of vitrectomy and lens implantationin the sulcus, remaining bag, scleral fixation,or anterior chamber from a period of 2003 to 2015.

Cases were distributed according to Surgeon seniority.

Surgeons were divided into categories. (1) Experience < 500 cases, (2) 500-1000 cases, and (3) > 1000 cases.

Persons with cataracts were categorized according to the following scoring system [Table A].

Table A: Patient characteristics used in the scoring protocol

     Category 1                        Category 2 (1 point each)               Category 3 (3 points each)

No additional risk factors        Previous vitrectomy                                         Dense/total/brunescent/black cataract

Corneal scarring                                               Pseudoexfoliation

Small pupil (<3 mm)                                          Phacodonesis

Shallow anterior chamber (depth<2.4 mm)

Age>75 years

High ametropia (>6D myopia or hypermetropia)

Posterior capsule plaque

All records retrieved from medical record department; data were entered in pretested forms.

Cases that were not followed up to the appointment for spectacles were not included in the study.

Patients were followed up on the 1st day, the 3rd day, and after the 1st and 2nd week, and for the appointment for spectacles after 4 weeks in the postoperative proformas.

Visual acuity testing using a Snellen chart, slit lamp examination of the anterior segment, and fundus examination with an indirect ophthalmoscope was performed at each visit.

All data were collected from electronic medical records, exported to Microsoft Excel, and analyzed using SPSS (ver. 22.0; IBM SPSS Statistics 22.0.1, Chicago, IL, USA).

RESULTS

We have operated 68680 cases of cataract, of which we have 809 cases of capsular complications (1.18%).

We have operated 904 cases of aphakia with a mean age of 60.9 (+/- 9.5)  years.

Surgical intervention significantly improved post‑operative visual acuity following corrective surgery (P<0.000) [Table 2].

The association between lens position and final visual acuity was investigated, and data revealed a signifi cant association ( P<0.001) [Table 3].

Of all 904 cases of aphakia, JR 236(26.1%), SR 137(15.2%), Indian trainees 140(15.5%),international trainees 129(14.26%), fellows  83(9.1%) consultant 84(9%) were responsible [Table 1]. When compared final visual outcome was >6/18 in 494(55%) (P<0.03) which was significant [Table 4], not the primary surgery (P<0.80) [Table 5].

Secondary glaucoma, pseudophakic bullous keratopathy, and cystoid macular edema were common causes for the diminution of vision following corrective surgery [Table 6]. 

  Table [1]  Surgeon’s Category with respective number of Aphakia

Surgeon Category		No. of Aphakia
	FELLOWS		83 (9.1%)
	CONSULTANTS		84 (9%)
	INTERNATIONAL TRAINEES		129 (14.26%)
	INDIAN TRAINEES		140 (15.5%)
	OUTSIDE		95 (10.95%)
	JUNIOR RESIDENTS		236 (26.1%)
	SENIOR RESIDENTS		137 (15.2%)
	TOTAL		904

Table [2] Comparison of visual acuity before and 

                after surgical treatment 

POST OPERATIVE VISION	PRE-OPERATIVE VISION
	1/60	1/60-3/60	6/60-6/36	6/24-6/18	6/12-6/9	TOTAL
<1/60	45	26	15	6	0	92
1/60-3/60	68	59	20	6	0	153
6/60-6/36	45	76	34	9	1	165
6/24-6/18	45	97	38	27	3	210
6/12-6/9	47	104	65	44	6	266
6/6-6/5	1	12	3	2	0	18
TOTAL	251	374	175	94	10	904

(P<0.000)

Table [3] Visual outcome with different lens positions

POST OPERATIVE VISION	IOL PUT IN				TOTAL
	AC	BAG	SF IOL	SULCUS
<1/60	5	5	15	67	92
1/60-3/60	7	4	10	132	153
6/60 TO 6/36	22	4	10	129	165
6/24 TO 6/18	11	2	11	186	210
6/12  TO 6/9	17	9	30	210	266
6/6 TO 6/5	2	0	0	16	18
TOTAL	64	24	76	740	904

AC- Anterior Chamber; SFIOL- Scleral Fixated Intraocular Lens.

(P<0.001) 

Table [4] Visual outcome compared according trainee category 

SURCAT	POST OPERATIVE VISION
	<1/60	1/60-3/60	6/60-6/36	6/24-6/18	6/12-6/9	6/6-6/5	TOTAL
FELLOWS	7	19	8	18	30	1	83
CONSULTANTS	7	20	15	16	22	4	84
INTERNATIONAL TRAINEES	4	16	38	35	33	3	129
INDIAN TRANIEES	23	22	16	35	41	3	140
OUTSIDE	11	13	14	21	33	3	95
JUNIOR RESIDENTS	23	38	46	58	70	1	236
SENIOR RESIDENTS	17	25	28	27	37	3	137
TOTAL	92	153	165	210	266	18	904

(P<0.03)

Table [5] Primary surgery and final visual outcome

	POST OPERATIVE VISION
PRIMARY SURGERY	<1/60	1/60-3/60	6/60-6/36	6/24-6/18	6/12-6/9	6/6-6/5	TOTAL
ECCE	1	0	1	1	1	0	4
LENS+VIT	0	0	0	1	0	0	1
OUTSIDE	8	11	7	14	19	1	60
PKE	19	24	36	54	65	5	203
SICS	64	118	121	140	180	12	635
VIT MAJOR ND	0	0	0	0	1	0	1

(P<0.8)

ECCE-Extra Capsular Cataract Extraction; LENS+VIT- Lensectomy with Vitrectomy; PKE-Phacoemulsification; SICS- Small Incission Cataract Surgery; VIT MAJOR ND- Vitrectomy with Nucleus Drop.

Table [6] Causes of Diminision of Vision

Causes	Frequency
CYSTOID MACULAR EDEMA	62
CORNEAL EDEMA	7
ENDOPHTHALMITIS	1
INFLAMMATION	20
IOL DROP	40
LENS MALPOSITION	12
LOST TO FOLLOW UP	152
NO ABNORMALITY	367
CORNEAL OPACITY	18
OPTIC ATROPHY	12
PREEXISTING CORNEAL OPACITY	1
PROLIFERATIVE VITREO RETINOPATHY	1
PSEUDOPHAKIC BULLOUS K PTHY	118
RETINAL DETACHMENT	8
SECONDARY GLAUCOMA.	82
VIT. HEMORRHAGE	3
Total	904

DISCUSSION

We retrospectively studied secondary intraocular lens (IOL) implantation in 904 aphakic eyes from 2003 to 2015.

We studied the primary surgeon who did the surgery leading to aphakia including consultant, fellows, trainees from India /abroad & residents (JR/SR) of our institute.

We found that the level of training is directly affecting the surgical outcome (number of aphakia)and the final post operative visual acuity after secondary intraocular lens implantation.

Chan et al.  reported that capsular rupture is one of the most common complications of cataract surgery and that surgical complications have an impact on the final visual outcome.³

In our study, a significant effect on visual outcome after corrective procedures was shown for surgeonsin the category of “undertrained”.

Buchan and Cassels-Brown⁴ reported similar findings.

Surgical complications were more common among doctors who are undertrained, as indicated in earlier reports.Similar findings have been reported from training centers that have trainees with different skill levels ^5,6.

Visual rehabilitation is difficult in cases of aphakia. Long‑term contact lens use may be attempted, but this is not a practical solution, as it is associated with numerous problems. Several groups have reported difficulties in the rehabilitation of aphakia either with spectacles or contact lenses^7,8.9.10,11. We attempted such rehabilitation with a corrective surgical procedure.

David et al¹²reported that long‑term results of anterior chamber implants were also not very positive. There have been many reports of pathological effects associated with the use of various types of anterior chamber implant. In contrast, in our study we found no significant difference in visual outcome between posterior chamber and anterior chamber implants.

We also investigated the use of vitrectomy and the implantation of a posterior chamber lens in the remaining part of the capsular support, which was also reported by Dick and Augustin¹³, Hayward et al.¹⁴, and Slade¹⁵. The secondary implant results reported by Hayward et al. and Slade were encouraging, with both studies showing similar results with these implants. As previously reported by Woodhams and Lester¹⁶, we found that pigmentary glaucoma was a common complication.

CONCLUSION

The category of surgeon training had a significant effect on secondary IOL implantation & final visual acuity. 

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