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OUTCOME OF AGERELATED CATARACT SURGERY IN JUBA MEDICAL COMPLEX

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Tiêu đề Outcome of Age-Related Cataract Surgery in Juba Medical Complex
Tác giả Dr. Aja Paul Kuol
Người hướng dẫn Dr. Sheila Marco MB.CHB, M.Med (Nairobi), FEACO, Ophthalmologist (Glaucoma Specialist), Prof. Jefitha Karimurio, MB.CHB, M.MED (Nairobi), MSC-CEH (London), FEACO, PhD (Melbourne), Dr. Wani Gindalang Mena, MBChB, MMED (Harari) Msc, ClinEpi Consultant Ophthalmologist, Head of Eye Unit, Juba Teaching Hospital-S.Sudan
Trường học University of Nairobi
Chuyên ngành Ophthalmology
Thể loại Thesis Proposal
Năm xuất bản 2014
Thành phố Nairobi
Định dạng
Số trang 35
Dung lượng 370,5 KB
File đính kèm RESEARCH PROPOSAL AJA September 8 SM.zip (22 B)

Cấu trúc

  • 1.0 INTRODUCTION (7)
  • 1.1 Overview of cataract (7)
  • 1.2 Epidemiology (8)
  • 1.3 Cataract Surgery in South Sudan (9)
  • 2.0 LITERATURE REVIEW (11)
  • 2.1 Outcome of cataract surgery (11)
  • 3.0 JUSTIFICATION (17)
  • 4.0 OBJECTIVES OF THE STUDY (18)
  • 4.1 Main Objective (18)
  • 4.2 Specific Objectives (18)
  • 5.0 MATERIAL AND METHODS (19)
  • 5.1 Study Area (19)
  • 5.2 Study Design (20)
  • 5.3 Study Population (20)
  • 5.4 Case Definition (20)
  • 5.5 Target population (20)
  • 5.6 Sample Size (21)
  • 5.7 Study Period (21)
  • 5.8 Inclusion Criteria (22)
  • 5.9 Exclusion Criteria (22)
  • 5.10 Data Collection (22)
  • 5.12 Data Management and Analysis (23)
  • 5.12 Ethical Considerations (24)
  • 5.13 Study Limitations (24)
  • 6.0 REFERENCES (25)
  • 7.0 APPENDICES (29)
  • 7.1 APPENDIX I: QUESTIONNAIRE (29)
  • 7.2 APPENDIX II: W.H.O. CLASSIFICATION OF BLINDNESS (32)
  • 7.3 APPENDIX III: DEFINITION OF TERMS (33)
  • 7.4 APPENDIX IV: WORK PLAN (34)
  • 7.5 APPENDIX V: BUDGET (35)

Nội dung

According to World Health Organization (WHO), cataract is the leading cause of blindness and visual impairment throughout the world with approximately 50% of the worlds blind suffer from cataract.1 Most cases of blindness in the world are avoidable and preventable. WHO VISION 2020 targets elimination of cataract as one of blinding diseases by 2020 since its preventable.2 Most age related cataract surgery outcomes are poor in subSaharan Africa due to a number of factors such as poor patient selection, poor surgical techniques among others.3 The number of people undergoing cataract surgery of the past years has been increasing rapidly hence the need to investigate the outcomes of the cataract surgeries being performed. It’s therefore necessary to conduct a study on the outcome of agerelated cataract.

INTRODUCTION

Cataracts are the world's leading cause of blindness, affecting approximately 50% of the globally blind population (WHO) While most blindness is preventable, achieving the WHO VISION 2020 goal of cataract elimination by 2020 remains a challenge, particularly in sub-Saharan Africa where surgical outcomes are often poor The rising number of cataract surgeries necessitates research into improving surgical outcomes for age-related cataracts.

Overview of cataract

Cataracts, cloudy patches on the eye's lens, cause blurred vision and affect one or both eyes independently Most cataracts are age-related and common in older adults, but other types exist, including traumatic, congenital, and radiation-induced cataracts.

Cataracts are diagnosed through eye exams including visual acuity tests and dilated exams Early symptoms may improve with glasses, brighter lighting, or magnification; however, surgery—removing the cloudy lens and replacing it with an intraocular lens (IOL)—is the only effective treatment for advanced cataracts, preventing blindness.

Cataract surgery techniques include phacoemulsification, extracapsular cataract extraction (ECCE), intracapsular cataract extraction (ICCE), and small incision cataract surgery (SICS) Risk factors for age-related cataracts are diabetes, sun exposure, tobacco use, and alcohol consumption.

Epidemiology

Globally, approximately 39 million people are blind, with 82% aged 50 and over, and 285 million are visually impaired, predominantly (90%) in developing nations Cataract accounts for 33% of global visual impairment, impacting 65% of those aged 50+, or 20% of the world's population Developed countries see blindness and vision loss increase each decade after age 40, while in regions like South Sudan, lower life expectancy (54/55 years) contributes to earlier cataract onset, around age 40 Surgical removal remains the effective treatment for cataracts.

Cataracts cause over 50% of blindness in sub-Saharan Africa, where 7.1 million of the world's 38 million blind people reside, impacting women disproportionately (60%) This region has a 0.5% prevalence of blinding cataracts, representing a significant global health challenge given that cataracts are the leading cause of blindness worldwide.

Cataracts affect 100 million eyes globally, resulting in visual acuity below 6/60 While 30 million cataract surgeries are needed annually, only 10 million are performed, leaving 20 million people blind due to the condition.

Cataract Surgery in South Sudan

Cataract surgery access in South Sudan remains limited due to insufficient awareness, funding, and specialized ophthalmologists The Juba Medical Complex (JMC), currently the sole private provider performing extracapsular cataract extraction (ECCE), is overwhelmed by the substantial population need, operating with only one ophthalmologist and minimal support staff.

Juba Medical Complex, a leading eye hospital in South Sudan with limited ophthalmologists, performs a significant number of cataract surgeries, though affordability remains a major barrier This study analyzes the outcomes of age-related cataract surgery (patients 40+) at Juba Medical Complex from March [Insert Year] to [Insert Year], revealing the impact of cost on access to care Between 2011 and 2014, approximately 350 cataract surgeries were conducted.

This first-of-its-kind study at the hospital (2011-March 2014) on age-related cataract surgery will establish a baseline for future research, inform best practices, and guide ophthalmologist training.

Outcome of cataract surgery

Cataract surgery outcomes are crucial due to potential complications like infection, bleeding, inflammation, vision loss, and altered eye pressure While these are usually treatable with prompt care, South Sudan lacks reported studies on age-related cataract surgery outcomes Existing research highlights complications, and the WHO emphasizes the need to address poor post-operative visual acuity.

6/12 pre-correction, while post-correction, 79.5% attained VA >6/18 Refractive errors and retinal disorders were the leading causes of vision impairment or blindness in operated eyes.

Lai et al investigated clinical outcomes of cataract surgery in very elderly adults aged

Cataract surgery in patients aged 90 and above yielded common complications including vitreous loss (8.2%), posterior capsular rupture (7.2%), and zonular rupture (4.8%) Age-related macular degeneration (AMD) and vitreous loss correlated with reduced postoperative visual improvement Despite significant comorbidities, favorable surgical outcomes were achieved in this elderly population A subsequent Juba-based study will further investigate these clinical outcomes.

A 2002 Malik et al study in Pakistan examined visual outcomes in 181 cataract surgery patients (ages 45-82) undergoing ECCE, phacoemulsification, or these procedures with IOLs Functional vision was good in 77% of ECCE+IOL and 71.8% of phaco+IOL cases, with uncorrected refractive error (75.5%) the most common cause of poor vision The study highlighted the need for postoperative monitoring but lacked preoperative visual acuity data; this limitation will be addressed in our study assessing the impact of surgical techniques and incorporating preoperative data.

Bastawrous and Sherwin's systematic reviews examined age-related cataract as a cause of blindness and visual impairment in sub-Saharan Africa, analyzing population-based studies published between 2000 and October 2012.

A study of over 50-year-olds across 15 countries revealed cataracts as the leading cause of blindness and visual impairment, demonstrating a strong correlation between successful visual outcomes and intraocular lens (IOL) implantation This research further assessed the link between surgical techniques and visual outcomes, noting a data gap for countries like South Sudan in a 2013 sub-Saharan African age-related cataract surgery evaluation.

Chirambo's 2000 Malawi study revealed a 19.5% poor visual outcome rate post-cataract surgery, primarily due to post-operative corneal edema This study will assess age-related cataract surgery outcomes in Juba, South Sudan.

A study in Goro District, Central Ethiopia, evaluated cataract surgery coverage and outcomes, revealing that only 23.7% of operated eyes achieved a presenting visual acuity of 6/18 or better, rising to 47.4% after correction Surgery-related complications accounted for 61.1% of poor visual outcomes, falling below WHO recommended standards.

A Kenyan Lions Sight First Eye Hospital study by Trivedy found no significant correlation between preoperative visual acuity, surgeon, surgery time, and postoperative uncorrected visual acuity (UCVA) of 6/18 or better in high-volume cataract surgeries Thirty-day postoperative examinations revealed no anterior segment complications The study concluded that high-quality cataract surgery is achievable in high-volume settings.

JUSTIFICATION

Continuous auditing of eye hospitals is crucial for assessing visual and surgical outcomes of cataract surgeries, particularly in regions like South Sudan This study establishes age-related cataract surgery outcomes, addressing the common poor outcomes observed in developing countries The findings will help monitor hospital performance and provide baseline data for future research.

A South Sudanese study of ocular morbidity in patients aged 40 and over revealed cataract as the second leading cause of eye disease, although the specific cataract type remained unspecified.

Main Objective

To assess the outcome of age related cataract surgery in patients aged 40 years and above performed at Juba Medical Center between March 2011 and March 2014.

Specific Objectives

1 To assess the visual outcomes of age-related cataract surgery

2 To determine the complications of age-related cataract surgery

3 To determine the factors associated with poor surgical outcome.

Study Area

Fig 1: A map showing Juba Medical Centre, Juba

This study will be conducted at Juba Medical Complex in Juba, South Sudan, serving a population of approximately 350,000 within a 150 km radius (Sudan 2008 census) The complex is located in Central Equatorial State.

The JMC eye unit, operating weekly, sees 10-20 patients daily (3,600-7,000 annually), encompassing all age groups Cataract surgeries, however, comprise 2-10 daily cases (700-3,600 yearly).

Juba Medical Complex (JMC) is a 60-bed hospital in Juba, South Sudan, providing high-quality secondary and tertiary healthcare Its five blocks include pharmacy, operating theater, maternity ward, inpatient wards, and administration.

At JMC there is only one ophthalmologist consultant who does all the eye surgeries and only one ophthalmic nurse.

Study Design

This will be a retrospective hospital based case series.

Study Population

Records of all persons age 40 and above went for cataract surgery at JMC.

Case Definition

Any patient aged 40 years and above who had under gone cataract surgery for age related cataract between March 2011 to March 2014 at Juba Medical Center.

Target population

An estimated number of 350 patients have undergone age-related cataract surgery atJuba Medical Complex between March 2011 and March 2014 (from the Juba MedicalComplex records).

Sample Size

The following sample size determination formula for finite population correction (Lwanga & Lameshow, 1991) 31 was used to estimate the proportion of population study size.

Where n' = sample size with finite population correction,

N = size of the target population = 350 (estimated number of patients who have undergone age-related cataract surgery according to the Juba Medical Centre theatre registry book between March 2011 to March 2014)

Z = statistic for 95% level of confidence

P = estimated proportion of patients with poor age-related surgical outcome – 4.2% 3 d = margin of error = 2.1%

Study Period

The study will be conducted from December 2013 to December 2014.

Inclusion Criteria

All the records of persons 40 years and older who had age related cataract surgery at the centre will be eligible to be included in the study.

Exclusion Criteria

Missing or incomplete records (age ,VA)

Record of all persons less than 40 years at the time of surgery

Data Collection

Patient data for this retrospective cohort study (March 2011-March 2014) will be collected using structured questionnaires (Appendix I) from hospital records of cataract surgery patients over 40 Data includes demographics, preoperative (visual acuity, refraction, complaints), surgical details (date, surgeon, technique, complications), and postoperative examinations (visual acuity, complications, follow-up at 1, 2, 3, and 4).

Data collection period will be between December 2014 and January 2015

Data Management and Analysis

Data analysis will utilize STATA 13 for cleaning, validation, and coding, with rigorous error checks and backup procedures ensuring data integrity Confidentiality is maintained through coded data, password protection, and secure storage under the principal investigator's control.

Study data will be securely destroyed after completion, encompassing both hard copies (shredded) and digital files (deleted from computers, flash drives, and hard disks).

This study utilizes STATA version 13 for data analysis, employing descriptive statistics (means, frequencies, proportions) visualized through graphs and tables Proportionate tests will compare categorical and continuous variables across demographics, preoperative, surgical, and postoperative phases Chi-square tests will identify factors associated with poor outcomes, using a 95% confidence level.

Ethical Considerations

Patient anonymity will be strictly maintained throughout data collection No identifying information, including names or medical record numbers, will be recorded Questionnaires will be accessible only to the biostatistician and investigator for analysis.

Ethical approval for this study will be obtained from the University of Nairobi and Kenyatta National Hospital's Ethics and Research Committee, as well as Juba Medical Complex and the South Sudan Ministry of Health.

Raw data confidentiality is maintained until thesis acceptance, publication, and one year post-ethical approval Following this, questionnaires and materials will be destroyed.

Study Limitations

The retrieved information from the private health facility (JMC) may not be sufficient for the study to make inference about the whole of south Sudan.

APPENDIX I: QUESTIONNAIRE

TITLE OF STUDY: OUTCOME OF AGE-RELATED CATARACT SURGERY

This questionnaire is for collecting information for the patients aged 40 years and above

Questionnaire code _ Data collection date

Home district/ region _ Age (years)

Type of cataract: Nuclear Cataract Hypermature

Retrobulbar haemorrhage during aneasthesea _ Other _

Day of follow up Findings

Main cause of poor Outcome at last visit

APPENDIX II: W.H.O CLASSIFICATION OF BLINDNESS

Category Degree of visual impairment Best corrected visual acuity in the better eye

2 Severe visual impairment 6/60 -

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