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Improving our outcomes

Improving our outcomes. WHO standards. Poor outcome <20/200 best corrected <5% at two months Borderline outcome <20/60 – 20/200 Good outcome 20/60+ best corrected >90% at two months. Are poor outcomes a problem?. Maybe in your clinic! Bad news spreads

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Improving our outcomes

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  1. Improving our outcomes

  2. WHO standards • Poor outcome • <20/200 best corrected • <5% at two months • Borderline outcome • <20/60 – 20/200 • Good outcome • 20/60+ best corrected • >90% at two months

  3. Are poor outcomes a problem? • Maybe in your clinic! • Bad news spreads • Disappointed patients deter others from: • Presenting • Paying

  4. Cataractsurgery outcomes Presenting acuity <20/200Includes ICCE & +10 and ECCE & IOL • India • Hyderabad 21.4% • Best corrected vision - 16.8% <20/200 • Mysore 14.7% <20/400 • Best corrected vision – >13.1% <20/200 • Karnataka 26.4% • China • Shunyi 44.8%

  5. Cause of poor outcomes • Selection • Pre-existing eye disease • Surgery • Surgical complication • Spectacles • Failure to correct post-op refractive error

  6. What causes poor outcomes? • APEDS study in Hyderabad, S. India • Poor outcomes - <6/60 • Selection 29% • Surgery 50% • Spectacles 21% • What factors are likely to increase the risk of a poor outcome?

  7. Who has worse outcomes? • APEDS data from S. India • Worse outcome more likely if: • Illiterate • Poor • Female • Rural • ICCE • Recent surgery

  8. ICCE Prof. Allen Foster Mvumi, Tanzania March 1984

  9. Paraguay • 93 post-op eyes • Good (6/5 – 6/18) 60 65% • Poor (<6/60) 25 27% • ICCE - 37 eyes • Good 17 46% • Poor 19 51% • ECCE & IOL – 56 eyes • Good 43 77% • Poor 6 11%

  10. Sivaganga • 938 post-op eyes • 602 aphakic • 336 IOL • 6/18+ presenting vision • ICCE/ECCE 50.5% • ECCE & IOL 78.0% • <6/60 presenting vision • ICCE/ECCE 39.2% • ECCE & IOL 4.2%

  11. Sivaganga • Best corrected visions are better • 6/18+ • Aphakic 82.6% • IOL 94.5% • Risk factors for poor outcome • Rural more than urban • Female more than male

  12. Improving outcomes • Step 1 • Careful selection • Use IOL in everyone • Possibly biometry • Always refract post-op • Step 2 • Monitor outcomes

  13. Hospital studies Best corrected acuity • Much better results from trials & prospective evaluations of ECCE & IOL • Madurai • <20/200 0.6% • 20/60+ 98.1% • Kikuyu • <20/200 1.5% • 20/60+ 94.3% • Does prospective monitoring improve outcome?

  14. Outcomes project methodology • Six month trial of procedures followed by one year data collection • Involvement of all surgeons in planning • Standard pro-forma data entered into database by clerical worker • Automated analysis available to surgeons at any time

  15. Patients & Follow-up • In 1999: • Total number of eyes 1800 • Eyes with one week F/U 1671 92.8% • Eyes with two month F/U 1203 66.8% • Eyes with two month refraction 1139 63.3% • Average age at operation: • 64.0 years (S.E. = 0.33) • Gender: • Male = 895 49.7%

  16. Reducing bad outcomes Two month uncorrected acuity <20/200 c2 for trend = 13.0 , p<0.005

  17. Increasing good outcomes Two month corrected acuity 20/60+ c2 for trend = 13.0 , p<0.005

  18. Complications

  19. Surgeon performance

  20. Bad outcomes Best corrected vision <20/200 • 31 eyes had a bad outcome: • Pre-operative causes 16 51.6% • Intra-operative complications 11 35.5% • Post-operative complication 1 3.2% • Unknown 3 9.7%

  21. Risk factors • Operative complications • Odds ratio for bad outcome following vitreous loss = 9.7 95% CI 4.0-23.7 • Diabetes • Odds ratio for bad outcome in known diabetic patients = 4.6 95% CI 2.0 - 10.7 • Blindness (<3/60 in best eye) • Odds ratio for bad outcome in blind patients = 4.0 95% CI 1.8 - 8.6

  22. Age and outcome Odds ratio for bad outcome in older (>79) patients = 3.495% CI = 1.4 – 8.2

  23. Why does monitoring improve outcome? • No change in incidence of complications • No significant variation in individual surgeon performance • Availability of feedback

  24. Outcome after vitreous loss c2 = 3.9 , p<0.05

  25. Why does monitoring improve outcome? • No change in incidence of complications • No significant improvement in individual surgeon performance • Availability of feedback • Overall raised awareness of quality issues

  26. Awareness of Quality 2 for trend = 5.5, p<0.05

  27. Avoid confrontation

  28. Comparison of outcomes No! • Dr A • <6/60 9% • 6/18+ 65% • Dr B • <6/60 3% • 6/18+ 88% • Is Dr B better than Dr A?

  29. Provide food for thought

  30. Provide mentoring and guidance

  31. Improving outcomes • Step 1 • Use IOL in everyone • Possibly biometry • Always refract post-op • Step 2 • Monitor outcomes

  32. Improving outcomes • Step 1 • Use IOL in everyone • Possibly biometry • Always refract post-op • Step 2 • Monitor outcomes • Step 3 • Possibly improve techniques

  33. Cataract surgery • Phaco shown to be superior to standard ECCE in UK • BUT, phaco may not be ideal for developing countries • Complexity • Cost

  34. What can you buy for the price of a phaco?

  35. Small incision ECCE • Described by Blumenthal in 1994 • “mini-nuc” technique • Other reports from Germany, Japan & Scotland • Superseded by phaco in Europe & N. America • May be useful in Third World

  36. Lahan Eye Hospital • 4 consultant ophthalmologists, 5 residents • 45,000 cataract operations in 2003, of which 41,200 were sutureless ECCE & IOL • 14,000 cataract operations in 1997

  37. Lahan Hospital Study • 500 consecutive patients • surrounding districts • able and willing to return for F/U • no other pathology • 6/36 or less • aged 35-70 • 14,000 patients excluded!

  38. Follow-up • Follow-up • Discharge 100% • 6 weeks 88% • One year 82% of random sample of 150 patients

  39. Scleral funnel

  40. A curved incision, 6-8mm long is made 2-4 mm behind the limbus

  41. The tunnel is dissected into the cornea. Note that the internal opening extends across the full width of the anterior chamber

  42. Following staining with trypan blue, a capsulorhexis is performed

  43. A thorough hydrodissection frees the nucleus from the capsular bag, and elevates the superior pole

  44. A bent 30 gauge needle is introduced behind the nucleus, and it is extracted through the tunnel

  45. A careful hydrodissection frees the nucleus, which is then rotated to elevate the superior pole. The bent 30 gauge needle is then inserted behind the nucleus and rotated. The nucleus is then pulled out of the eye

  46. Complications • Hyphaema • 47 eyes, four needed AC washout • One capsule rupture • Retained lens matter • 2 eyes, one needed SLM removal • Corneal oedema • 2 eyes at 6 weeks

  47. Uncorrected VA Significant reduction in proportion achieving 6/18 or better between discharge and 6 weeks (p=0.03)

  48. Best corrected VA

  49. Resources required • Operating time • Median duration of surgery = 4 minutes • Cost of consumables • Approx $6.50 • Of which PMMA IOL $2.50 • No phaco machine needed

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