Trends in cataract surgery and healthcare system response during the COVID-19 lockdown in Malaysia: Lessons to be learned.

Background: Elective surgeries were suspended during the national lockdown in March 2020 to curb the spread of the COVID-19 pandemic in Malaysia. We sought to evaluate the impact of the lockdown on cataract surgeries and suggest lessons for future outbreaks. Study design: We conducted an interrupted time series analysis to examine rates of cataract surgery before and during the lockdown. Methods: We used national cataract surgical data between 2015 and 2021 from the Malaysian Cataract Surgery Registry. Segmented regression with a seasonally adjusted Poisson model was used for the analysis. Stratified analyses were performed to establish whether the effect of the lockdown on cataract surgeries varied by hospital designation, type of cataract service, sex, and age groups. Results: Cataract surgeries began falling in March 2020 at the onset of the lockdown, reached a trough in April 2020, and subsequently increased but never recovered to pre-lockdown levels. Cataract surgical rates in December 2021 were still 43 % below the expected surgical volume, equivalent to 2513 lost cataract surgeries. There was no evidence of a differential effect of the lockdown between COVID-19 designated and non-COVID-19 designated hospitals. The relative decrease in cataract surgical rates appears to have been greatest in outreach services and in people 40 years and older. Conclusions: The lockdown caused an immediate reduction in cataract surgical rates to nearly half of its baseline rate. Despite its gradual recovery, further delays remain to be expected should there be no redistribution or increase in resources to support backlogs and incoming new cases.

Incidence and Predictive Risk Factors for Post-Cataract Surgery Endophthalmitis in Ministry of Health Hospitals from 2012 to 2020.

PURPOSE: Postoperative endophthalmitis is a devastating complication, leading to poor visual prognosis. The purpose of this study is to determine the incidence, risk factors, and visual outcome of post-cataract surgery endophthalmitis in Malaysia over a 9-year period (2012-2020). METHODS: Data from National Eye Database (NED), involving all patients who have undergone cataract surgery from January 2012 until December 2020 were analyzed. RESULTS: Total number of patients who had undergone cataract surgery between the year 2012 till 2020 were 231,281 patients (267,781 eyes). Incidence of POE in this population was 0.08%. Patient aged 70 and above (p-value 0.047), Malay ethnicity (p-value: 0.009), presence of ischemic heart disease, renal failure, diabetic retinopathy, and poorer preoperative vision were shown to have a higher risk of POE. Cataract surgeries done in KK-KKM, duration more than 45 minutes, use of general anaesthesia, and no IOL or ACIOL implantation were significantly more in POE patients. Multivariate analysis revealed Malay ethnicity, presence of ocular comorbidity, poor preoperative vision, ACIOL, and presence of intra-operative complication were predictive factors for POE. CONCLUSIONS: Incidence of POE is low in the Malaysian population. Surgeons have to be aware that Malay ethnicity, presence of ocular comorbidity, poor preoperative visual acuity, placement of IOL and complicated cataract operation have higher risk of POE.

Demography and clinical pattern of newly diagnosed uveitis patients in Malaysia.

INTRODUCTION: Uveitis is one of the common causes of visual impairment in Malaysia. It remains a challenging entity to diagnose and manage due to variation in its clinical presentation. This study aims to observe the demographic and clinical pattern of cases from the participating ophthalmology units in Malaysia. METHODS: This study involved prospective and multicentered data collection for patients newly diagnosed with uveitis from 1st January 2018 to 31st December 2018. Variables collected and analyzed included age, gender, ethnicity, nationality, state of origin, laterality, granulomatous or non-granulomatous uveitis, and etiology of uveitis. RESULTS: A total of 1199 newly diagnosed uveitis patients were analyzed within the study period. There was a significant association between the anatomical location of uveitis with age at presentation. The percentage of patients with anterior uveitis was higher in the '40 to 60' years and 'above 60' years age groups at 52.1% (n = 210) and 61.3% (n = 114) respectively. In contrast the percentage of patients with posterior and panuveitis was higher in the 1 to 20 and 20 to 40 years age groups at 51.4% (n = 54) and 48.7% (n = 246) respectively. Sixty three percent of the patients presented with unilateral uveitis (n = 760, p < 0.001) vs bilateral. Non-granulomatous uveitis comprised 84.5% of all patients (n = 1013, p < 0.001) compared to granulomatous uveitis. Non-infectious etiology contributed to 65.7% of all patients (n = 788, p < 0.001) with the majority being unclassifiable uveitis (n = 686, 57.2%,). Specific inflammatory entities contributed to only 8.5% (n = 102) of the non-infectious causes with Vogt-Koyanagi-Harada (VKH) syndrome being the most common (n = 25, 2.1%,). Infectious uveitis comprised 34.3% (n = 411) with tubercular (TB) uveitis (n = 105, 8.8%) and viral uveitis (n = 107, 8.9%) contributing the most followed by ocular Toxoplasmosis (n = 93,7.8%).] CONCLUSION: This study has highlighted the demographic data and common causes of uveitis in Malaysia.

Factors Influencing Visual Improvement after Phacoemulsification Surgery among Malaysian Cataract Patients.

Blindness and visual impairment are part of the global burden of eye disease, with cataract being one of the leading causes of blindness. This study aimed to determine the factors affecting visual acuity (VA) improvement among cataract patients after phacoemulsification surgery in Malaysia. Cataract patients aged over 18 who underwent phacoemulsification surgery between January 2014 and December 2018 were included in this retrospective cohort study. Patients' sociodemographic, comorbidities, surgical, and related complication factors were extracted from the National Eye Database. The outcome was measured by the difference in visual acuity before and after the operation and was categorized as "improved", "no change", and "worse". A total of 180,776 patients were included in the final analysis. Multinomial logistic regression analysis showed "no changes in VA" was significantly higher in patients aged less than 40 years old (OR: 1.66; 95% CI: 1.22, 2.26), patients with ocular comorbidities (OR: 1.65; 95% CI: 1.53, 1.77), patients who had undergone surgery lasting more than 60 min (OR: 1.39; 95% CI: 1.14, 1.69), patients who had surgery without an intraocular lens (IOL) (OR: 1.64; 95% CI: 1.20, 2.26), and patients with postoperative complications (OR: 8.76; 95% CI: 8.13, 9.45). Worsening VA was significantly higher among male patients (OR: 1.11; 95% CI: 1.01, 1.22), patients who had ocular comorbidities (OR: 1.76; 95% CI: 1.59, 1.96), patients who had undergone surgery lasting more than 60 min (OR: 1.94; 95% CI: 1.57, 2.41), patients who had surgery without an IOL (OR: 2.03; 95% CI: 1.48, 2.80), and patients with postoperative complications (OR: 21.46; 95% CI: 19.35, 23.80). The factors impacting "no changes" in and "worsening" of VA after cataract surgery were the following: older age, male gender, ethnicity, ocular comorbidities, surgeon grade, absence of IOL, intraoperative complication, and postoperative problems.

Risk factors affecting cataract surgery outcome: The Malaysian cataract surgery registry.

This is a 5 years multicentre database study that recruited subjects from the Malaysian Ministry of Health Cataract Surgery Registry (MOH CSR), aimed to determine risk factors that affect cataract surgery visual outcome and evaluates post-cataract surgery vision. All age-related cataract surgeries with primary intraocular lens (IOL) implantation were included. Cases with secondary cataract, previous ocular surgeries and incomplete data were excluded. A total of 131425 cases were included in the study. Amongst all types of cataract surgery, 92.9% attained post-operative best-corrected visual acuity better than 6/18 and the outcome improved to 97.1% when ocular comorbidities were excluded. Factors with Odds Ratio (OR) >1.5 associated with an impaired visual outcome included: elderly patients of 80 years old and above; systemic disease such as renal failure; ocular co-morbidities; pre-operative vision worse than 6/60; general anaesthesia, retrobulbar anaesthesia or subconjunctival anaesthesia; extracapsular cataract extraction (ECCE), intracapsular cataract extraction (ICCE), anterior chamber intraocular lens (ACIOL) implantation or combined cataract surgery; the presence of intra- and post-operative complications. In conclusion, a good visual outcome was achieved after cataract surgery in most cases. This large multicentre study provides information about risk factors for poor visual outcome post-cataract surgery and may serve as a basis for evidence-based guidelines.

Prevalence of cataract and factors associated with cataract surgery uptake among older persons in Malaysia: A cross-sectional study from the National Eye Survey II.

Nationally-representative evidence is limited on factors affecting uptake of cataract surgery in Malaysia. We found the prevalence of cataract among older persons to be 26.8%. The two most common barriers were 'need not felt' (43.5%) and 'fear of surgery or poor result' (16.2%). Reluctance for surgical intervention was greater outside the Central zone.

Estimates of visual impairment and its causes from the National Eye Survey in Malaysia (NESII).

BACKGROUND: Population-based data on prevalence, causes of blindness and extent of ophthalmological coverage is required for efficient implementation and evaluation of ocular health programs. In view of the scarcity of prevalence data for visual impairment and blindness in Malaysia, this study aims to estimate the prevalence and causes of visual impairment (VI) in the elderly, using Rapid Assessment of Avoidable Blindness (RAAB) survey technique. METHODS: Malaysia was divided into six regions, with each region consisting of 50 clusters. Multistage cluster sampling method was used and each cluster contained 50 residents aged 50 years and above. Eligible subjects were interviewed and pertinent demographic details, barriers to cataract surgery, medical and ocular history was noted. Subjects had visual acuity assessment with tumbling 'E' Snellen optotypes and ocular examination with direct ophthalmoscope. The primary cause of VI was documented. Results were calculated for individual zones and weighted average was used to obtain overall prevalence for the country. Inter-regional and overall prevalence for blindness, severe VI and moderate VI were determined. Causes of VI, cataract surgical coverage and barriers to cataract surgery were assessed. RESULTS: A total of 15,000 subjects were examined with a response rate of 95.3%. The age and gender-adjusted prevalence of blindness, severe visual impairment and moderate visual impairment were 1.2% (95% Confidence Interval: 1.0-1.4%), 1.0% (95%CI: 0.8-1.2%) and 5.9% (5.3-6.5%) respectively. Untreated cataract (58.6%), diabetic retinopathy (10.4%) and glaucoma (6.6%) were the commonest causes of blindness. Overall, 86.3% of the causes of blindness were avoidable. Cataract surgical coverage (CSC) in persons for blindness, severe visual impairment and moderate visual impairment was 90%, 86% and 66% respectively. CONCLUSION: Increased patient education and further expansion of ophthalmological services are required to reduce avoidable blindness even further in Malaysia.

Catquest-9SF questionnaire: validation of Malay and Chinese-language versions using Rasch analysis.

BACKGROUND: Catquest questionnaire was originally developed in Swedish to measure patients' self-assessed visual function to evaluate the benefit of cataract surgery. The result of the Rasch analysis leading to the creation of the nine-item short form of Catquest, (Catquest-9SF), and it had been translated and validated in English. The aim is therefore to evaluate the translated Catquest-9SF questionnaire in Malay and Chinese (Mandarin) language version for measuring patient-reported visual function among cataract population in Malaysia. METHODS: The English version of Catquest-9SF questionnaire was translated and back translated into Malay and Chinese languages. The Malay and Chinese translated versions were self-administered by 236 and 202 pre-operative patients drawn from a cataract surgery waiting list, respectively. The translated Catquest-9SF data and its four response options were assessed for fit to the Rasch model. RESULTS: The Catquest-9SF performed well in the Malay and Chinese translated versions fulfilling all criteria for valid measurement, as demonstrated by Rasch analysis. Both versions of questionnaire had ordered response thresholds, with a good person separation (Malay 2.84; and Chinese 2.59) and patient separation reliability (Malay 0.89; Chinese 0.87). Targeting was 0.30 and -0.11 logits in Malay and Chinese versions respectively, indicating that the item difficulty was well suited to the visual abilities of the patients. All items fit a single overall construct (Malay infit range 0.85-1.26, outfit range 0.73-1.13; Chinese infit range 0.80-1.51, outfit range 0.71-1.36), unidimensional by principal components analysis, and was free of Differential Item Functioning (DIF). CONCLUSIONS: These results support the good overall functioning of the Catquest-9SF in patients with cataract. The translated questionnaire to Malay and Chinese-language versions are reliable and valid in measuring visual disability outcomes in the Malaysian cataract population.

The Effect of Eye Patching on Clear Corneal Incision Architecture in Phacoemulsification: A Randomized Controlled Trial.

PURPOSE: To investigate the effects of postoperative eye patching on clear corneal incision architecture in phacoemulsification. DESIGN: A single-center, randomized controlled trial. METHODS: A total of 132 patients with uncomplicated phacoemulsification were randomly allocated to the intervention or control group. The intervention group received postoperative eye patching for approximately 18 hours, whereas the control group received eye shield. The clear corneal incision architecture was examined postoperatively at 2 hours, 1 day, and 7 days after surgery using optical coherence tomography. RESULTS: Epithelial gaping was significantly reduced on postoperative day 1 in the intervention group (52.4%) compared with control (74.2%) (P = 0.01). No differences were found for other architectural defects. Descemet membrane detachment was associated with lower intraocular pressure on postoperative day 7 (P = 0.02). Presence of underlying diabetes mellitus did not seem to influence architectural defects. CONCLUSIONS: Postoperative eye patching facilitated epithelial healing and reduced the occurrence of epithelial gaping on postoperative day 1. It may play a role in protecting and improving corneal wounds during the critical immediate postoperative period.

The Malaysian Cataract Surgery Registry: risk Indicators for posterior capsular rupture.

AIM: To identify the risk indicators for posterior capsular rupture (PCR) in the Malaysian Cataract Surgery Registry (CSR). METHODS: Data from the web-based CSR were collected for cataract surgery performed from 2008 to 2013. Data was contributed by 36 Malaysian Ministry of Health public hospitals. Information on patient's age, ethnicity, cause of cataract, ocular and systemic comorbidity, type of cataract surgery performed, local anaesthesia and surgeon's status was noted. Combined procedures and type of hospital admission were recorded. PCR risk indicators were identified using logistic regression analysis to produce adjusted OR for the variables of interest. RESULTS: A total of 150 213 cataract operations were registered with an overall PCR rate of 3.2%. Risk indicators for PCR from multiple logistic regression were advancing age, male gender (95% CI 1.04 to 1.17; OR 1.11), pseudoexfoliation (95% CI 1.02 to 1.82; OR 1.36), phacomorphic lens (95% CI 1.25 to 3.06; OR 1.96), diabetes mellitus (95% CI 1.13 to 1.29; OR 1.20) and renal failure (95% CI 1.09 to 1.55; OR 1.30). Surgical PCR risk factors were combined vitreoretinal surgery (95% CI 2.29 to 3.63; OR 2.88) and less experienced cataract surgeons. Extracapsular cataract extraction (95% CI 0.76 to 0.91; OR 0.83) and kinetic anaesthesia were associated with lower PCR rates. CONCLUSIONS: This study was agreed with other studies for the risk factors of PCR with the exception of local anaesthesia given and type of cataract surgery. Better identification of high-risk patients for PCR decreases intraoperative complications and improves cataract surgical outcomes.

The Malaysian Cataract Surgery Registry: Profile of Patients Presenting for Cataract Surgery.

PURPOSE: To investigate the change in the profile of patients who had cataract surgery at Ministry of Health (MOH) hospitals in Malaysia. DESIGN: Secondary analysis on Malaysian Cataract Surgery Registry data. METHODS: The Malaysian Cataract Surgery Registry, a MOH-initiated registry, collects data on patients who had cataract surgery at the 36 MOH ophthalmology departments including demography, causes of cataract, systemic and ocular comorbidity, preoperative visual acuity (VA), operative details, and postoperative outcomes. This article reviews data on patient profiles from 2002 to 2004 and 2007 to 2011. RESULTS: The coverage of cataract surgery was 91.5% (171,482/185,388). Mean patient age was 64.5 years, and 51.6% were women. A high proportion of patients had hypertension (48.9%), diabetes mellitus (37.1%), and diabetic retinopathy (10.7%). Most had senile cataract (93.4%) and one third had second eye surgery. Most patients (82.0%) had preoperative unaided VA of worse than 6/12. Eyes presenting with unaided VA of worse than 3/60 decreased from 62.6% in 2002 to 47.7% in 2011, whereas those with 6/18 to 3/60 increased from 35.2% to 48.5% (P < 0.001). Patients who had extracapsular cataract extraction had worse preoperative VA than those who had phacoemulsification (81.3% vs 40% had vision worse than 3/60). CONCLUSIONS: The obvious change in patient profiles was the decreasing number of eyes presenting with worse than 3/60 vision. Compared with developed countries, patients who had cataract surgery at MOH hospitals in Malaysia were younger and had higher associations with diabetes mellitus and diabetic retinopathy.

Risk Factors and Prediction Models for Retinopathy of Prematurity.

OBJECTIVES: To develop a simple prediction model for the pre-screening of Retinopathy of Prematurity (ROP) among preterm babies. METHODS: This was a prospective study. The test dataset (January 2007 until December 2010) was used to construct risk prediction models, and the validation dataset (January 2011 until March 2012) was used to validate the models developed from the test dataset. Two prediction models were produced using the test dataset based on logistic regression equations in which the development of ROP was used as the outcome. RESULTS: The sensitivity and specificity for model 1 [gestational age (GA), birth weight (BW), intraventricular haemorrhage (IVH) and respiratory distress syndrome (RDS)] was 82 % and 81.7%, respectively; for model 2, (GA and BW) the sensitivity and specificity were 80.5% and 80.3%, respectively. CONCLUSION: Model 2 was preferable, as it only required two predictors (GA and BW). Our prediction model can be used for early detection of ROP to avoid poor outcomes.

The Malaysian Cataract Surgery Registry: Cataract Surgery Practice Pattern.

PURPOSE: To present the cataract surgery practice pattern among the ophthalmic surgeons in hospitals managed by the Ministry of Health (MOH) in Malaysia. DESIGN: Secondary data analysis on Malaysian Cataract Surgery Registry (CSR). METHODS: The Malaysian CSR collected data on cataract surgeries done at all the ophthalmology departments in MOH from year 2002 to 2004 (paper-based) and 2007 to 2011 (web-based). Data collected include type of admission, surgical techniques, type of anesthesia, and intraocular lens (IOL). Descriptive and inferential analysis was performed. RESULTS: Of the 185,388 cataract surgeries done over 8 years, 171,482 (91.5%) were captured in CSR. There was a steep rise in phacoemulsification cataract surgery from 39.7% in 2002 to 78.0% in 2011 with a corresponding fall in extracapsular cataract extraction from 54.0% to 17.3% in the respective years. This explained the surge in the use of foldable IOL from 26.5% in 2002 to 88.3% in 2011. The proportion of cataract surgery with IOL implantation was 97.5% in 2012 and 98.2% in 2011. The proportion of day-care cataract surgery was low, with 39.3% in 2002 to 52.3% in 2011. Vitreoretinal surgery was the commonest type of combined surgery performed. CONCLUSIONS: Although phacoemulsification was performed in two thirds of the patients who presented to MOH hospitals in Malaysia, extracapsular cataract extraction was still being performed because of a significant proportion of cataract that were brunescent and limited access to phacoemulsification machines and consumables. There is a need to increase day-care cataract surgery as it will eventually save cost.

Spontaneous malignant glaucoma in a patient with patent peripheral iridotomy.

BACKGROUND: To report a case of spontaneous malignant glaucoma in an Asian female. To propose the term "positive vitreous pressure glaucoma" to reflect the pathophysiology, treatment and prognosis of the condition. CASE PRESENTATION: A 56-year old Chinese female was diagnosed of primary angle closure glaucoma and had bilateral laser peripheral iridotomy one year ago. She presented with spontaneous onset of malignant glaucoma involving the left eye. The condition was treated successfully; the final best corrected visual acuity was 0.67 (decimal notation). CONCLUSION: This case highlights that acute angle closure attack can occur in an eye with patent peripheral iridotomy. Early recognition and treatment is essential for good visual prognosis.

CUSUM: a dynamic tool for monitoring competency in cataract surgery performance.

AIMS: To apply cumulative sum (CUSUM) in monitoring performance of surgeons in cataract surgery and to evaluate the response of performance to intervention. METHOD: A CUSUM analysis was applied to 80 phacoemulsification performed by three ophthalmic trainees and one consultant, for the occurrence of posterior capsular rupture and postoperative refracted vision of worse than 6/12 among patients without pre-existing ocular comorbidity. The CUSUM score of each consecutive procedure performed by an individual surgeon was calculated and charted on CUSUM chart. When trainees' CUSUM charts showed an unacceptable level of performance, their supervisors would give feedback and impose closer monitoring of subsequent surgeries. RESULTS: CUSUM charts of the trainees demonstrated an initial upward followed by flattening trend. This reflects learning curves in their process of acquiring competency in phacoemulsification. In contrast, the consultant showed a flat curve indicating an ongoing maintenance of competence. CONCLUSION: The CUSUM analysis is able to monitor and promptly detect adverse events and trends of unacceptable outcomes in cataract surgery. This objective and dynamic monitoring makes CUSUM a useful audit tool for individual surgeons, but more so for busy consultants who need to supervise trainees.

Occult open globe injury in a patient with corneal foreign body: a case report.

PURPOSE: To demonstrate the role of ultrasonographic biomicroscopy in diagnosing occult open globe injury. METHOD: A 50-year old man presented with a 2-day history of a corneal foreign body caused by a missile injury. Slit lamp biomicroscopy showed an intrastromal corneal foreign body measuring 0.7 x 0.7 mm, situated at the visual axis. Seidel test was negative. Full thickness corneal penetration could not be ruled out and an ultrasonographic biomicroscopy examination was subsequently performed. RESULTS: Ultrasonographic biomicroscopy revealed a probable full thickness corneal penetration. The patient was diagnosed with penetrating corneal injury. CONCLUSION: Ultrasonographic biomicroscopy has an important role in the diagnosis of occult open globe injury.