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ORIGINAL ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 110-115

Cataract surgery outcomes in a Tertiary Hospital, Riyadh


1 Department of Clinical Affairs, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Department of Medical Education, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
3 Department of Ophthalmology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia

Date of Web Publication7-Apr-2016

Correspondence Address:
Bader Al-Qahtani
College of Medicine, King Saud bin Abdul-Aziz University for Health Sciences, P. O. Box: 22490, Riyadh 11426
Saudi Arabia
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DOI: 10.4103/1658-600X.179827

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  Abstract 

Background: Cataract surgery is one of the safest and most effective surgeries, but irreversible blindness may occur as a complication. Also, the visual outcome of cataract surgery can be affected by preoperative patients' comorbidities. The aim of this study was to assess the visual outcome and identify the complications of cataract surgery.
Patients and Methods: This was a retrospective cross-sectional study. It included all patients who had undergone cataract surgery at King Abdulaziz Medical City, Riyadh, from January 2014 to June 2014. All data variables were managed and analysed using SPSS software. Data security and confidentiality were ensured throughout all stages of the study process.
Results: A total number of 421 cataract surgeries were reviewed. There were 219 (52%) males and 198 (48%) females. The patients' age ranged between 34 to 94 years with an average age of 66 ± 11 years. Among 421 eyes, 187 (46%) gained a visual acuity of 20/40 or better and another 119 (29%) had 20/50 - 20/80 after the surgery. Intraoperative or postoperative complications were presented in 20 (5%) patients. The main causes for rendering the eyes from achieving the visual acuity of 20/40 or better were diabetic retinopathy, age-related macular degeneration and glaucoma.
Conclusion: Cataract removal is a safe and effective surgery which can improve the quality of life. It has some complications that can be minimised with good pre-operative evaluation and post-operative rehabilitation.

Keywords: Cataract, complications, visual acuity


How to cite this article:
Al-Qahtani B, Ahmad F, Alotaibi M, Al-Zughaibi M, Omair A, Al-Jobair K. Cataract surgery outcomes in a Tertiary Hospital, Riyadh. J Health Spec 2016;4:110-5

How to cite this URL:
Al-Qahtani B, Ahmad F, Alotaibi M, Al-Zughaibi M, Omair A, Al-Jobair K. Cataract surgery outcomes in a Tertiary Hospital, Riyadh. J Health Spec [serial online] 2016 [cited 2018 Jan 23];4:110-5. Available from: http://www.thejhs.org/text.asp?2016/4/2/110/179827


  Introduction Top


Cataract is the leading cause of blindness in the world.[1] It is considered the most common cause of blindness in North Africa and Middle East with a percentage of 29.2% in 1990 and 23.4% in 2010 among other causes of blindness.[2] The lens of the eye is made up of stratified epithelium and cytoplasmic protein which undergo degenerative changes of ageing and lead to lens opacity.[3] Lens opacity, which is known as cataract, is treated surgically by removal of that opacity. During the middle of the 20th century, Harold Ridley introduced intraocular lenses, designed from polymethylmethacrylate as a replacement of normal lens after removal of cataract.[4] Then, Charles Kelman in 1967 introduced phacoemulsification which is breaking the lens by ultrasonography, irrigation and aspiration by a hand-piece through a small incision.[5] In general, surgery is indicated if cataract interferes with the patient's needs but not visual acuity.[6]

Cataract surgery is one of the most safest and effective surgeries, but irreversible blindness may occur as a complication.[7] Complications from cataract surgery can be divided into intraoperative complications that happen during the surgery, immediate postoperative complications that happen few days after the surgery and late postoperative complications that occur weeks to months after the surgery.[8] Some of those complications are endophthalmitis, posterior capsule opacification, bullous keratopathy, intraocular lens malposition or dislocation, induced astigmatism, cystoid macular oedema, retinal detachment and toxic anterior segment syndrome.[9],[10]

Astigmatism is caused by an asymmetric shape of the cornea, which results in blurring of the vision due to the image not being focused appropriately on the retina.[11] Astigmatism is a postoperative complication of cataract surgery due to surgical incisions near the steep axis of the cornea [12] as well as due to other factors such as size of the incision and the wound construction.[13],[14]

The outcome of cataract surgery can be affected by the patients' co-morbidities existing preoperatively. This can be assessed in terms of visual acuity and postoperative complications.[15],[16] Ocular comorbidities such as optic atrophy, retinal detachment and macular changes can hinder any improvement postoperatively.[17] More than 75% of postoperative visual failure can be linked to preoperative comorbidities. Glaucoma has been linked to 17% of visual failure.[15] Climatic droplet keratopathy also known as Labrador keratopathy, spheroidal degeneration of the cornea, and desert keratopathy are associated with visual failure due to the centricity of the disease in the cornea.[15],[18] Diabetic retinopathy is associated with poor postoperative visual acuity ranging from 20/30 to 20/100.[19] Furthermore, the effects of concomitant systemic comorbidities are well established. Diabetes mellitus, hypertension, ischaemic heart disease and asthma are at the top of the list, with 20% of the overall cohort exhibiting diabetes mellitus as the most common one as revealed by the Auckland cataract study.[20]

Measuring the visual acuity before and after the operation can be considered as an objective mean to determine the success of the surgery.[21] There are some factors that could be blamed for not achieving the intended visual acuity after the cataract surgery which is 20/40 or better. Errors of refraction, associated ocular or systemic diseases and complications of surgery are the main responsible factors.[22],[23] To the best of our knowledge, this is the first study conducted in King Abdul-Aziz Medical City (Riyadh) (KAMC-R) to assess the outcome of cataract surgery, the causes of not reaching the intended visual acuity for patients who underwent cataract surgery and the effects of comorbidity on the outcome. The findings of this study are a good update to local studies and will help in planning better approaches to improve the management of cataract patients.

The overall aim of this research project was to evaluate the epidemiologic and the clinical aspects of the cataract surgery outcome in those patients admitted to King Abdul-Aziz Medical City between January 1st and June 30th of 2014. Also, we aimed to identify the complications of the cataract surgery among the study population.


  Patients and Methods Top


This was a retrospective cross-sectional, hospital-based, clinically oriented data review study. The study was conducted in KAMC-R, a 1000-bedded specialised health care institution that covers a wide range of secondary and tertiary care specialities. It provides a full range of medical and surgical ophthalmological care for paediatric and adult patients among society members through promoting tertiary care facilities, to develop new knowledge and treatment for eye diseases through clinical and basic research and promoting the continuous education and expertise of its members in the practice of ophthalmology.

Saudi and non-Saudi consecutive male and female patients above the age of 35 years who underwent a surgery of cataract extraction at KAMC-R between January 1st and June 30th of 2014 were eligible for the study. Surgeries of more than one ophthalmologic consultant were included. Moreover, we included only those who had phacoemulsification. Those who gave a history of ocular trauma or who showed a preoperative retinal detachment by ultrasonography were excluded. Demographic and clinical variables were collected from medical records and relevant hospital databases. All data had been collected, sorted, filtered, cleaned and merged together with special reference to the index admission date by the co-investigators.

All data variables were managed and analysed by IBM SPSS statistics version 16.0 software from International Business Machines Corporation, New York. Proportions, confidence intervals (CIs), means and standard deviations were calculated for relevant variables. Continuous variables such as the age and visual acuity were expressed as mean ± standard deviation. Categorical variables such as the gender and the comorbidities were presented as frequencies (%). To evaluate the risk factors, 95% CI for proportion and Chi-square test or Fisher's exact test had been applied. P < 0.05 is considered significant. Data confidentiality was ensured at all times and throughout all stages of the study process.


  Results Top


A total number of 421 patients underwent cataract extraction surgery between January and June of 2014. There were 219 (52.5%) males and 198 (47.5%) females. Their ages ranged between 35 to 94 years with the mean age of 66 ± 11 years. Age and sex distribution was as shown in [Table 1]. There were 177 (42%) surgeries in the right eye and 195 (46%) in the left eye, whereas 49 (12%) had surgery in both eyes. Cataract types were mostly nuclear while some of them cortical and others subcapsular. All patients had been followed up 1 week and 1 month post surgery.
Table 1: Age and sex distribution

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Preoperative and postoperative visual acuities and percentages are shown in [Figure 1]. The postoperative visual acuities were assessed at least 3 months after surgery. About 187 patients had a visual acuity of 20/40 or better and 119 had a visual acuity between 20/50 and 20/80 after the surgery. About 10 patients had a poor visual acuity between 20/300 and 20/400 and 15 patients had a visual acuity between counting fingers (CF) and light perception (LP).
Figure 1: Visual acuity before and after cataract extraction. VA: Visual acuity, CF: Counting fingers, LP: Light perception

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There were 348 (83%) patients who had at least one systemic comorbidity. There were 178 (81%) out of 219 males who had at least one systemic comorbidity as compared to 167 (84%) of 198 females. The most common comorbidity was hypertension with 140 (64%) from the male patients and 130 (66%) from the females. The second most common comorbidity was diabetes mellitus, which affects 137 (63%) of male and 120 (61%) of female patients. [Table 2] lists the frequent systemic comorbidities found in those patients.
Table 2: Systemic co-morbidities among cataract patients

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About 65 (15%) had at least one concurrent ocular disease. There were 34 (16%) out of 219 males with at least one ocular comorbidity as compared to 31 (16%) females. While pseudo-exfoliation (5.6%), diabetic retinopathy (5.1%) and open angle glaucoma (4.6%) were the most common, all ocular diseases are listed in [Table 3].
Table 3: Ocular co-morbidities among cataract patients

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There were 20 (4.8%) patients who had complications during or after surgery. There were three patients whose eyes had two complications. Complications were present in 15 (7%) of 219 males as compared to 5 (2.5%) of 198 females (P = 0.04). Also, complications were found to be more in patients aged above 70 years (9%) than those ≤70 years of age (3%) (P = 0.04). More details regarding the demographic parameters versus complications are listed in [Table 4]. The most common complications are rupture of the posterior capsule, endophthalmitis and retinal detachment. All these and other ocular complications and their frequencies are shown in [Table 5]. Systemic and ocular comorbidities versus complications are listed in [Table 6] with P > 0.05 for any co-morbidity.
Table 4: Demographic parameters versus complications

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Table 5: Intra- and post-operative ocular complications

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Table 6: Systemic and ocular comorbidities versus complicati

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  Discussion Top


Cataract is recognised as the most common cause of reversible blindness in Saudi Arabia according to a study done in 1986.[24] As a matter of fact, cataract extraction is a very effective and safe surgery. This study assessed the visual outcome after cataract removal along with the factors preventing patients from gaining the desired postoperative visual acuity. Although the complications of cataract surgery are considered unusual events, some of them have been documented during this study period.

Among the study population, the proportion of males and females who underwent cataract surgery in the study period was considered statistically insignificant. This is different from a study that had been done in New Zealand with the results revealing female predominance.[20] We found that most of the people diagnosed with cataract were above 60 years of age. The average age group in this study was so close when we compared it with another study done in Nigeria.[25] Some patients were as young as 34 and some patients were above 90 years of age.

About 75% of the patients in this study had a 20/80 or better visual acuity which supports that cataract surgery is effective as stated in the literature. These results are relatively better than what have been found in a study done by al Faran in 1990 (Riyadh, Saudi Arabia) wherein about 57% of the patients gain a visual acuity of 20/80 or better.[23] Some of the patients had no improvement and ended up with a visual acuity ranging from CF to LP while the same outcome had been found in 10% of the patients in the previous study done by al Faran (10%).[23] We found that these poor visual acuities were due to a high number of comorbidities in this group of patients as they had diabetic retinopathy, glaucoma and age-related macular degeneration. We also believe that the advances that have taken place in the last decade in cataract surgery and in the field of ophthalmology in general have had major effects on the outcomes.[26] These advances in the techniques and equipments are the main factors of improved visual outcome when comparing our study results with those done by al Faran.[23]

The identification of systemic comorbidities before surgery is recommended in the literature because stratifying patients depending on complication risk(s) would help in avoiding those complications as much as possible. Most of our study individuals had at least one systemic comorbidity while it was found to be 80% in the Auckland Cataract Study.[20] The percentage difference between males and females regarding the systemic comorbidities is statistically insignificant. The most common systemic comorbidities we found were hypertension followed by diabetes mellitus. While the order of systemic co-morbidities remain the same as the Auckland Cataract Study with hypertension first then followed by diabetes mellitus, there is still a difference in percentages for these diseases between the two studies.[20]

The complication rate difference has been noticed to be significant with more occurrences in males than females and more prominent with people above the age of 70 years. The most common complications were rupture of the posterior capsule, endophthalmitis and retinal detachment. The rupture of the posterior capsule has been reported in many studies to be the most common intraoperative complication.[23],[20],[27] In one of the previous studies, they also found that the rupture of the posterior capsule could lead to lower-than-expected ultimate visual outcome.[27] It has been noted that endophthalmitis incidence in this study was higher than documented figures in other published articles.[28] Unfortunately, until this point in time, we could not assert a clear reason for this high incidence of post-cataract endophthalmitis in our hospital. This should raise the attention of policy makers to address this issue and discuss it with the department's head and staff. Furthermore, another study concentrating mainly on post-cataract endophthalmitis and its risk factors is highly recommended.

In addition, it has been noted that posterior capsular opacification has a very low incidence and this might be due to multiple factors. Some of the factors were patient-related and others were surgery-related. While our study population was limited to patients aged 35 years and above, the young age group including paediatrics, were considered one of the major risk factor group for posterior capsular opacification as documented in the literature.[29] In our study, in almost all of the patients we used the phacoemulsification surgical technique with no lens epithelial cells left behind which in turn helped in decreasing the percentage of posterior capsular opacification as a complication. On the other hand, the other surgical technique (extracapsular cataract surgery), could have lead to more opacification because more lens epithelial cells would be left behind in the capsular bag.[30] In addition, yttrium aluminium garnet (YAG) laser capsulotomy has been known as one of the treatment options for posterior capsule opacification. We had only one patient who left with opacification post-cataract surgery; this patient was advised to do YAG laser capsulotomy, but for unknown and undocumented reasons, the patient was not interested in this procedure and refused it. None of the systemic or ocular comorbidities were found to increase complication rates among these patients.

Finally, we believe that our study had some avoidable limitations. Firstly, this was a retrospective study with all the known limitations of such a study design. Secondly, all the patients were from one hospital, which could lead to biased results based on the caliber of the equipment utilised in that hospital and how skilful the ophthalmologists over there were.


  Conclusion Top


Cataract surgery is an effective surgery and yields satisfying results. Although different complications of cataract surgery have been reported, it is still considered as one of the safest surgeries. A meticulous preoperative examination and postoperative follow-up might lead to better results and improved quality-of-life for cataract patients in the future.

A future multicentre study with longer study period is highly recommended. A prospective study design is also recommended to control the confounding factors and other potential biases as much as possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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