Letters to the editor. Cataract surgery
There is still a place for intracapsular cataract extraction (ICCE), especially in remote areas of developing countries. The main reasons are known to all who have practised in developing countries or who have experience travelling in remote areas.
John Sandford-Smith (J Comm Eye Health 2000; 13: 62) mentioned that in northern Nigeria they still practise couching rather than ICCE. That is the method they can afford. It is not unusual to find well-trained personnel in those areas but they lack essential instruments. Even those patients who have ICCE surgery lack spectacles which may not be available or be available but expensive.
I agree that IOL implant surgery has excellent results compared to the previous technique. The major problem is the unavailability of the equipment, although it may be easy to train the existing personnel who are readily available.
The DU-AL Corporation* still has much to contribute, as their equipment could be carried to the remotest areas without difficulty. I have used their cryoextractors for ICCE ever since I qualified from ICEH, London, in 1986. Post-operative results are very good.
If we want to promote IOL implant surgery in full capacity let’s follow the recommendations of Dr David Yorston in his article in this Journal (J Comm Eye Health 2000; 13: 51-52).
You, as Editor, have the means of evaluating what is written and recommended in most of our Community Eye Health Journals. Please give ICCE time — it will phase out as soon as we reach our goals of supporting the Districts and Regional Eye Workers with essential instruments.
*DU-AL Corporation now acquired by Restored Sight Projects Ltd. Singleton Court, Wonastow Road Monmouth, UK
I am now retired 11 years after 35 years practice in India, much of it in cataract work among rural communities. The letter by John Sandford-Smith and its subject captured my interest as I had prepared a similar article while I was on a working visit back to my old territory in 1992. My thesis was, and still is, akin to the subject of John Sandford-Smith’s letter (J Comm Eye Health 2000; 13: 62).
In some parts of India, the mounting backlog of cataract patients is indeed being brought under control with the use of surgery by ECCE + IOL insertion. Around Delhi is one such area. However, in many rural areas cataract surgery of any sort remains unavailable at the local level. Government eye doctors rarely ever visit such places. All my work was in the State of Bihar, the area now known as Jharkhand. Towards the end of the ’80s when ECCE-IOL was becoming available in India, a team capable of this method came our way for a week. The results were indeed good, but each operation had lasted 15-20 minutes, and some of the day’s prepared patients had to be put off until the next day. We had been used to ECCE or sometimes ICCE with no implants and no sutures. One extraction was completed in 3-5 minutes. Yet the overall incidence of cataract in the area was not being reduced. If we had all switched to the new team’s technique then, numerically, many patients would have been the losers, though some of those operated on may indeed have benefited in some ways.
My contention is that where a cataract backlog remains, those qualified to carry out cataract surgery should maintain a flexible approach in those rural areas where so many patients with mature and hypermature cataracts still exist. Most of the older, mature cataract patients in those areas are illiterate. They do not particularly want to be able to read. All they require is vision to enable them to get about their own homes again, and their local market, without the need for someone to guide them. A simple, quick operation is enough for them. For the time being, I see a place for any ‘quick’ operation which, properly applied, will help to reduce cataract waiting lists. Once cataract waiting lists are coming down and show signs of being under control, then yes, by all means, settle on a regime to restore all patients’ vision to as near 6/6 as you can get, cost problems being dealt with at the same time.
End piece: after their successes around Delhi I heard that there were so few cataracts left for the doctors to do, that they started on patients with 6/24 vision or better. It kept their hands in! Sadly, they did not consider going to those places where many mature cataracts are found.
‘Is there still a place for Intracapsular Cataract Extraction.?’ (J Comm Eye Health 2000; 13: 62)
Thank you for bringing this subject up for discussion. During most of my time at Enongal Hospital, Cameroun, we were not equipped for extracapsular cataract extraction. A Lions Club team had been past before I arrived, brought a microscope with them, and did extracapsular cataract extractions with posterior chamber lens implants; a few of their patients did very well, but most did badly. The problems we noticed with these patients were mostly ‘inflammatory’ – pupil membranes and thickly opacified capsules, sometimes with displacement of the lens implant. Our general experience was that intracapsular cataract extraction was more reliable in giving moderately good results for most people.
Our colleagues at Acha Tugi in northwestern Cameroun routinely used extracapsular cataract extraction and reckoned to get good results – but they used huge doses of steroids that were not available at Enongal. They commented too that there seems to be a change as you go westwards across equatorial Africa: east African eyes generally react mildly to being operated on, but in Cameroun at least, eyes react very briskly. David Yorston from Kikuyu in Kenya has commented on a minority of patients there who have an unusually brisk inflammatory reaction after cataract surgery (Br J Ophthalmol 2001; 85: 267-71, and Br J Ophthalmol 1999; 83: 897-901), but patients of this sort seem to be the majority in Cameroun. We also noticed that glaucoma is common and aggressive in Cameroun, and that many patients have a lot of Tenon’s capsule stuck down on the sclera. Might there be some local factor (genetic, perhaps?) which links these phenomena?
Which form of cataract surgery in developing countries?
This letter is in response to the letter by John Sandford-Smith on the desirability or otherwise of intracapsular cataract extraction (ICCE) surgery in many developing countries (J Comm Eye Health 2000; 13: 62). It is indeed true that in some developing countries (like northern Nigeria) the practice of couching has increased in relation to cataract surgery, especially in rural areas. This is of course a cause for concern for eye care personnel in this part of the world. A recent study in a rural community of northern Nigeria revealed that couching of the eye is being practised 5 times more than cataract surgery. What are the factors that tend to make people have couching rather than cataract surgery? There are 3 main reasons for this attitude in most parts of northern Nigeria.
- Couching is more readily available to the people than cataract surgery. Many couching practitioners now move from village to village to solicit clients (people with cataract or at times any eye problem) on whom they will practise their trade. They conduct their services often within the premises of their patients/clients without any delay. Thus, couching is mostly done on the first visit. Cataract surgery often requires the poor villager to travel long distances several times before having the surgery. In some instances the service (i.e., cataract surgery) is just not available.
- Couching is often more affordable to these poor people. Some couching practitioners are paid in kind (e.g., by receiving agricultural products), instead of money. Sometimes services are paid only after the patient is satisfied with the outcome of the couching. This is in contrast to surgery where the patient is required not only to pay in money, but to pay before surgery. Even if the surgery is free the indirect cost involved (travel cost, lost wages, etc.) in accessing the surgery is an enough hindrance to the surgery.
- The visual outcome of couched eyes may be better than some cataract surgery eyes, especially eyes after intracapsular surgery (ICCE) which is basically the form of operation done in outreach activities and many peripheral hospitals in Nigeria. Indeed we have encountered several couched eyes with much better vision than ICCE post-operative eyes. Even ICCE eyes with good visual outcome may not be better than a well performed couched eye, as the couching practitioners have learnt to issue +10 aphakic spectacles to their clients.
So the poor villager with cataract can have his eyesight restored instantly by a few minutes couching procedure in his own house without having to travel, without leaving his family, without leaving his village, without several visits and at an affordable rate or agreeable terms. More importantly, the sight of the couched eye is restored with the same aphakic spectacles which the ICCE eyes will require post-operatively.
The point here is that a well performed couched eye may be equal in visual outcome to well performed cataract surgery (ICCE) in our environments. As such, my opinion is that apart from attempts at overcoming barriers relating to unaffordability and inaccessibility of cataract surgery in our part of the world , we necessarily have to provide a cataract service that is competitively better in outcome than the best couched eye – a cataract service that will inspire confidence in the people. This requires that the visual outcome of the post-operative surgical eye will be obviously better than the best couched eye with aphakic spectacles. That procedure, I believe, is extracapsular cataract extraction with posterior chamber IOL (ECCE+PCIOL) or possibly ICCE with anterior chamber IOL (if its safety is assured).
With low-cost IOLs, portable low price operating microscopes, I believe cost may not be a problem. Furthermore, more ophthalmologists in developing countries are abandoning ICCE and getting well acquainted with the IOL surgery. Governments, eye care personnel and NGOs in developing countries should face this challenge. Cataract outreach programmes, as well as the routine form of cataract surgery in hospitals should be ECCE+PCIOL as much as possible, rather than the lower quality ICCE.
I write in response to Dr John Sandford-Smith’s letter on intra capsular cataract extraction (J Comm Eye Health 2000; 13: 62). In my experience, most ophthalmologists prefer ECCE with PC IOL to ICCE, because ICCE, the traditional method, has the potential complication of cystoid macular oedema. This is much less common in ECCE. However, there are a number of problems associated with ECCE plus IOLs.
- IOLs remain expensive for most of the population of poor countries, especially when we consider that food is the first priority, even for the blind.
- There is limited access to operating microscopes and laser equipment in many developing countries. When available, they are based in urban centres where most ophthalmologists also live. The bus fares necessary to reach the service are a big burden for the poor.
- Difficult access to YAG lasers is the biggest problem. People may have to be referred to other countries to get this service.
- As many people are aware, in developing countries patients do not follow the service, but services should follow them. This means giving priority to social and economic factors, local beliefs, religious taboos or fear of witchcraft, and making every effort to provide health education. Charging for IOLs in this kind of society will be a further barrier to stop people seeking surgery.
- I have to say that it is not true that in a developing country an aphakic patient without an aphakic correction is good for nothing. He or she can improve from light perception to counting fingers, which enables the patient to walk around, and this is a significant gain amongst poor blind people in developing countries.
Therefore, if we are to abolish ICCE in developing countries, various facilities need to be provided and maintained, remembering that electricity and reliable water supplies are still the exception rather than the norm in many countries.
It is necessary to have:
- Cheap portable microscopes with good co-axial illumination
- Very cheap IOLs, viscous fluid and BSS solutions
- YAG lasers which can be afforded and operated in third world countries.
More consideration needs to be given to ICCE with A/C IOL which does not need access to microscopes and YAG laser facilities. I think this may be preferable in many developing countries. However, I remain in a dilemma because most ophthalmologists give much less priority to this method.