Monitoring Visual Outcomes of Cataract Surgery performed by a Non-physician Cataract Surgeon, at

New Sight Eye Center, Paynesville City, Liberia

Presentation at Unite For Sight, Global Health & Innovation Conference on April 12-13 2014, Yale University, New Haven,

Connecticut, USA

By: Robert F. Dolo

Founder & Executive Director

New Sight Eye Center

Paynesville City, Montserrado County, Liberia

Map of Liberia

Liberia Montserrado

County, Project Location

Map of Africa

Population: 3.8 million Growth rate: 2.1 % Magnitude of blindness: 0.5% (RAAB 2012) Cataract: 60.4% Glaucoma 16%. Source: RAAB Survey 2012, MOHSW

About Blindness in Liberia

The problem of cataract blindness. The size of the reservoir represents the number of people already blind

with cataract (prevalence or backlog). The water pulling into the reservoir represents the extra or new number of people going blind from cataract (incidence).

The taps out of the reservoir represent: a) the people who have

been successfully treated for cataract and now see. b) those people who die of age or disease

while still blind. Cataract is the leading cause of

blindness in Liberia accounting for 60.4%.

Incidence

Patients awaiting cataract operation

Blind due to Cataract. Liberia 60.4%

0.5% Source of blindness

Surgeons Performing Cataract Operation in Liberia Category of Eye Surgeon Available Number Routinely

performing cataract operation

Number doing small incision sutureless Cataract operation

Ophthalmologists 7 1 0

Non-Physician Cataract Surgeon 5 3 1

Background (N.S.E.C.) • N.S.E.C. Is a local nongovernmental organization (NGO). Founded 2009 and

officially launched August 2012.

• Governance & Leadership: • Board of Directors, Ophthalmologist, Cataract Surgeon, Ophthalmic Nurses, refractionist,

Professional Nurses, Accountant and support staff

• Goal: The principal goal of New Sight Eye Center is to provide affordable, accessible, available, comprehensive and quality eye health care services for all.

• Our Mission is to reduce preventable blindness and visual impairment in rural and urban communities within Liberia through community based eye health services, sight restoring surgery and eye health education

N.S.E.C. Program Components • Routine eye examination, treatment and

surgery at the center in Paynesville City, Montserrado County

• Medical (eye screening & treatment)

and surgical (perform cataract and other surgeries) outreaches in urban and rural communities

• School eye health screening and health

education program • Professional development and training

of community eye health workers

Purpose of Monitoring Cataract Surgery Outcomes: • Encourage eye surgeons to

monitor their results over time.

• Identify causes of poor outcome and help address causes to improve future outcome.

• To enhance the quality of cataract surgery.

• Monitor cataract surgical uptake based on the output of surgeon.

MCSO v2.4 software • Open-source software developed to facilitate monitoring of cataract surgery

outcomes.

• The software was supported by the Christoffel Blinden Mission, Sight Savers International, West African Health Organization and the London School of Hygiene and Tropical Medicine.

• Exclusion criteria: Age 0-19 years, Traumatic cataracts and complicated cataracts

• Outcome depends on:

• skills and knowledge of eye surgeon • surgical technique used : Small Incision Sutureless Cataract Extraction • surgical facilities, environment and post-operative care • optical correction provided • patient-related risk factors, like ocular co-morbidity (glaucoma, age-related

macula degeneration, etc.)

WHO guidelines on Visual Outcome of Cataract Surgery

POST-OPERATIVE ACUITY Presenting BEST CORRECTION

GOOD 20/20 – 20/60 ft >80% > 90%

BORDERLINE <20/60 – 20/200ft <15% <5%

POOR <20/200 <5% <5%

Presenting = Presenting VA in the operated eye with available correction Best = Best VA in operated eye, with full refraction or pinhole

Data Collection

•Surgeon: Non Physician Cataract Surgeon

•Location: New Sight Eye Center, Liberia.

•Number of eye operation performed: 937 (2012-2013)

•Number of cataract surgery performed : 695 ( age 5-80+ years)

•Total data entered into MCSO v2.4 : 377 persons with uncomplicated Cataract

296 263

643

432

TOTAL OPERATIONS CATARACT OPERATIONS

New Sight Eye Center Eye Operations 2012 and 2013.

2012 2013

Age range and gender of operated patients

20-39 40-49 50-59 60-69 70-79 80+

10 22

49 62

36

18 12 15

38

64

45

6 Resp

onde

nts

Age Range

Male Female

0

50

100

150

200

250

300

350

First Eye Second eye

328

49

Number of Operation for first and second eye

0

50

100

150

200

250

300

350

400

Admission 1-3 weeksfollow up

4-11 weeksfollow up

12+weeksfollow up

377 372 337 279

ADMISSION AND FOLLOW UP

Proportion of known ocular pathology in operated eye

Pathology in operated eye Number

% of all operations

Retinal disease 6 1.6

Glaucoma 6 1.6

Other pathology 3 0.8

Corneal Scar 2 0.5

Old Iritis 3 0.8

Total 20 5.3

Visual Acuity

20/20-20/60 ft Good

<20/60-20/200ft Borderline

<20/200 ft Poor

WHO norms on post -op Visual Outcomes

Presenting % Best %

>80 >90

<15 <5

<5 <5

Week 1 to 2years N=279

Presenting % Best %

81 93.5

19 6.5

0 0

Visual acuity in the operated eye pre-op and follow up

Pre-op % Admission

N=377

1.9 %

12.2 %

85.9 %

0102030405060708090

Discharge 1-3 weeksfollow up

4-11 weeksfollow up

12+ weeksfollow up

Good outcome Borderline outcome

Observations and comments 1. The standard posterior chamber lens

power were inserted ( 19D-22D) without doing the A/B scan biometry

2. Retrobulbar anaesthesia injection was administered 3.Duration of surgical procedure per eye is 15 minutes 5. No accommodation or inpatients admission for operated patients ( all patients are treated as OPD)

Best corrected vision after 2years

Visual Acuity

SICS+ PC IOL

Good 93.5 %

Borderline 6.5 %

Poor 0 %

0

100

200

300

400

PC IOL Inserted

AC IOL Inserted

No IOL Inserted

INTRAOCULAR LENS INSERTED IN OPERATED EYE

1. Task shifting: The shortages and misdistributions of ophthalmologists in developing countries are huge. Shift tasks from highly specialized--expensive--health workers to less specialized-- more readily available and less expensive-- workers. Please visit the link below. http://www.kcco.net/Cataractsurgeonliteraturerev2012.pdf

2. Non physician Cataract Surgeon (NPCS) help increases access to high quality cataract surgery. The cataract surgical rate ( CSR) at NSEC increase in 2013 to 432 from 263 in 2012

3. Cataract surgeons, like ophthalmologists or any other professionals, can only perform to their capacity if given adequate support within a well-functioning program.

4. 85.9% of patients came at New Sight Eye Center with poor vision and 93.5% of patients had good outcomes following cataract surgery at NSEC

Discussion

Activities / impacts

Training conducted by an American Ophthalmologist to a NPCS and Liberian

Ophthalmologist

Visual Acuity at Outreach

Health Education at outreach

Outreach Team in Grand Cape Mount County

Standing in the Middle is Mr. Sampson Norma, 41 years old blessed with 3 children….

Health Education at outreach

Departure for Outreach

Registration at Outreach Visual testing at Outreach

Eye Examination and Diagnosis Dispense Medication & glasses

Thanks

Before Cataract Operation

After Cataract operation

Website: newsighteyecenter.org Email: robertdolo@yahoo.com Contact #: 0886968316