Prevalence and causes of blindness and visual impairment in Kogi state, Nigeria-Findings from a Rapid assessment of avoidable blindness survey.

PURPOSE: To determine the prevalence and causes of blindness and visual impairment among adults in Kogi, Nigeria. METHODS: A Rapid assessment of avoidable blindness (RAAB) protocol was used with additional tools measuring disability and household wealth to measure the prevalence of blindness and visual impairment (VI) and associations with sex, disability, wealth, cataract surgical coverage and its effectiveness. RESULTS: Age- and sex-adjusted all-cause prevalence of bilateral blindness was 3.6% (95%CI 3.0-4.2%), prevalence of blindness among people living with additional, non-visual disabilities was 38.3% (95% CI 29.0-48.6%) compared to 1.6% (95%CI 1.2-2.1%; [Formula: see text] = 771.9, p<0.001) among people without additional disabilities. Cataract was the principal cause of bilateral blindness (55.3%). Cataract surgical coverage (CSC) at visual acuity (VA) 3/60 was 48.0%, higher among men than women (53.7% vs 40.3%); 12.0% among people with non-visual disabilities; 66.9% among people without non-visual disabilities, being higher among people in the wealthiest two quintiles (41.1%) compared to the lowest three (24.3%). Effective Cataract Surgical Coverage at Visual Acuity 6/60 was 31.0%, higher among males (34.9%) than females (25.5%), low among people with additional, non-visual disabilities (1.9%) compared to people with no additional disabilities (46.2%). Effective CDC was higher among people in the wealthiest two quintiles (411%) compared to the poorest three (24.3%). Good surgical outcome (VA>6/18) was seen in 61 eyes (52.6%) increasing to 71 (61.2%) eyes with best correction. Cost was identified as the main barrier to surgery. CONCLUSION: Findings suggest there exists inequalities in eye care with women, poorer people and people with disabilities having a lower Cataract Surgical Coverage, thereby, underscoring the importance of eye care programs to address these inequalities.

Increasing access to cataract surgery in Counties Manukau by optimising the clinical pathway: a quality improvement report.

AIM: To streamline the cataract surgery pathway to improve the time from first specialist assessment (FSA) to surgery, while reducing the clinical priority assessment criteria (CPAC) score from 55 to 50. METHOD: A quality improvement project using Lean Six Sigma tools and the Model for Improvement. Most data were collected from the i.Patient Manager (iPM) system and analysed using statistical process control charts. Change interventions included combining FSA and pre-admission clinics (PAC); post-operative telephone review by non senior medical officers (SMO); and using our own surgeons in private theatres. RESULTS: The standard cataract pathway was reduced from 5 to 3 appointments. This removed 1,514 hours of appointments, released 113 SMO hours and saved patients NZ$156,000 in indirect costs over a year. The average waiting time from FSA to surgery decreased from 90 to 77 days (-13.5%). The number of overdue patients reduced from 127 to 44 (-35%). The average number of patients on the FSA waiting list dropped from 322 to 205 (-40%). There was no change to the proportions of surgeries or appointment attendance rates by ethnicity. Average monthly cataract surgeries increased from 192 to 215 (+12%), and the CPAC score threshold was decreased to 50 in February 2021. CONCLUSION: Despite significant demand pressures, and the disruptions of COVID-19, we were able to reduce the CPAC score for accessing cataract surgery by optimising the clinical pathway to better utilise staff capacity and maximise value for patients.

An epidemic of cataract surgery in Korea: the effects of private health insurance on the National Health Insurance Service.

OBJECTIVES: In Korea, the National Health Insurance Service (NHIS) covers essential healthcare expenses, including cataract surgery. To address concerns that private health insurance (PHI) might have inflated the need for such procedures, we investigated the extent of the PHI-attributable increase in cataract surgery and its impact on NHIS-reimbursed expenses. METHODS: This retrospective, observational study uses nationwide claims data for cataract surgery from 2016 to 2020. We examined trends in utilization and cost, and we estimated the excess numbers of (1) cataract operations attributable to PHI and (2) types of intraocular lenses used for cataract surgery in 2020. RESULTS: Between 2016 and 2020, a 36.8% increase occurred in the number of cataract operations, with increases of 63.5% and 731.8% in the total healthcare costs reimbursed by NHIS and PHI, respectively. Over a 5-year period, the surgical rate per 100,000 people doubled for patients aged <65 years (from 328 in 2016 to 664 in 2020). Among the 619,771 cases in 2020 of cataract surgery reimbursed by the Korean diagnosis-related group system, more non-NHIS-covered intraocular lenses were used for patients aged <65 years than ≥65 years (68.1 vs. 14.2%). In 2020 alone, an estimated 129,311 excess operations occurred, accounting for an excess cost of US$115 million. CONCLUSIONS: A dramatic increase in the number and cost of cataract operations has occurred over the last 5 years. The PHI-related increase in operations resulted in increased costs to NHIS. Measures to curtail the non-indicated use of cataract surgery should be implemented regarding PHI.

Endophthalmitis Rates among Medicare Beneficiaries Undergoing Cataract Surgery between 2011 and 2019.

PURPOSE: To determine national incidence and risk factors associated with developing endophthalmitis after cataract surgery in the United States. DESIGN: Retrospective, cross-sectional analysis. PARTICIPANTS: Medicare beneficiaries aged ≥65 years undergoing cataract surgery between 2011 and 2019. METHODS: Medicare claims were used to identify all patients who underwent ≥1 cataract surgery between 2011 and 2019. Endophthalmitis cases within 90 days of the cataract surgery were identified using diagnostic codes. Patients with a history of endophthalmitis 12 months before their cataract surgery procedure were excluded. Annual and aggregate 9-year incidences were determined for all cataract surgeries and for stand-alone cataract procedures. A stepwise multivariable logistic regression model using generalized estimating equations was used to evaluate factors associated with occurrence of postoperative endophthalmitis. MAIN OUTCOME MEASURES: The 90-day postoperative endophthalmitis rate and patient risk factors associated with onset of endophthalmitis after cataract surgery. RESULTS: A total of 14 396 438 cataract surgeries were performed among Medicare beneficiaries between 2011 and 2019. The overall 90-day postoperative endophthalmitis rate was 1.36 per 1000 cataract surgeries for all cataract procedures and 1.30 per 1000 cataract surgeries for stand-alone cataract procedures. A decreasing trend was noted for postoperative endophthalmitis rates during the 9-year study period. On multivariable analysis, the risk of endophthalmitis after cataract surgery was increased for cases performed among those aged ≥75 years versus those aged <75 years (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.11-1.18), Blacks (OR, 1.13; 95% CI, 1.07-1.20), Native Americans (OR, 1.43; 95% CI, 1.19-1.73), and eyes with any history of invasive glaucoma surgery (OR, 1.40; 95% CI, 1.18-1.65). Cataract cases combined with retinal surgery (OR, 2.60; 95% CI, 2.15-3.16) and those performed when the Charlson Comorbidity Index (CCI) was greater than 0 also had an increased likelihood of developing endophthalmitis. The risk of endophthalmitis was lower for cases performed on women versus men (OR, 0.89; 95% CI, 0.86-0.92). CONCLUSIONS: The overall 90-day postoperative endophthalmitis rate after cataract surgery was 1.36 per 1000 cataract surgeries between 2011 and 2019. Patient age, gender, race, and CCI were associated with risk of endophthalmitis.

Keeping an eye on eye care: monitoring progress towards effective coverage.

The eye care sector is well positioned to contribute to the advancement of universal health coverage within countries. Given the large unmet need for care associated with cataract and refractive error, coupled with the fact that highly cost-effective interventions exist, we propose that effective cataract surgery coverage (eCSC) and effective refractive error coverage (eREC) serve as ideal indicators to track progress in the uptake and quality of eye care services at the global level, and to monitor progress towards universal health coverage in general. Global targets for 2030 for these two indicators were endorsed by WHO Member States at the 74th World Health Assembly in May, 2021. To develop consensus on the data requirements and methods of calculating eCSC and eREC, WHO convened a series of expert consultations to make recommendations for standardising the definitions and measurement approaches for eCSC and eREC and to identify areas in which future work is required.

Comparing Driving Miles for Department of Veterans Affairs-delivered Versus Department of Veterans Affairs-purchased Cataract Surgery.

BACKGROUND: The Veterans Choice Act of 2014 increased the number of Veterans eligible for Department of Veterans Affairs (VA)-purchased care delivered in non-VA community care (CC) facilities. Driving >40 miles from home to a VA facility is a key eligibility criterion for CC. It remains unclear whether this policy change improved geographical access by reducing drive distance for Veterans. OBJECTIVES: Describe the driving distance for Veterans receiving cataract surgery in VA and CC facilities, and if they visited the closest-to-home facility or if they drove to farther facilities. SUBJECTS: Veterans who had cataract surgery in federal fiscal year 2015. MEASURES: We calculated driving miles to the Closest VA and CC facilities that performed cataract surgeries, and to the location where Veterans received care. RESULTS: A total of 61,746 Veterans received 83,875 cataract surgeries. More than 50% of CC surgeries occurred farther than the Closest CC facility providing cataract surgery (median Closest CC facility 8.7 miles vs. Actual CC facility, 19.7 miles). Most (57%) Veterans receiving cataract surgery at a VA facility used the Closest VA facility (median Closest VA facility 28.1 miles vs. Actual VA facility at 31.2 miles). In all, 26.1% of CC procedures occurred in facilities farther away than the Closest VA facility. CONCLUSIONS: Although many Veterans drove farther than needed to get cataract surgery in CC, this was not true for obtaining care in the VA. Our findings suggest that there may be additional reasons, besides driving distance, that affect whether Veterans choose CC and, if they do, where they seek CC.

Cataract Surgery Complexity and Surgical Complication Rates Among Medicare Beneficiaries With and Without Dementia.

PURPOSE: To evaluate cataract surgery complexity and complications among US Medicare beneficiaries with and without dementia. DESIGN: Retrospective claims-based cohort study. PARTICIPANTS: A 20% representative sample of Medicare beneficiaries, 2006-2015. METHODS: Dementia was identified from diagnosis codes on or prior to each beneficiary's first-eye cataract surgery. For each surgery, we identified setting, routine vs complex coding, anesthesia provider type, duration, and any postoperative hospitalization. We evaluated 30- and 90-day complication rates-return to operating room, endophthalmitis, suprachoroidal hemorrhage, retinal detachment, retinal tear, macular edema, glaucoma, or choroidal detachment-and used adjusted regression models to evaluate likelihood of surgical characteristics and complications. Complication analyses were stratified by second-eye cataract surgery within 90 days postoperatively. RESULTS: We identified 457,128 beneficiaries undergoing first-eye cataract surgery, 23,332 (5.1%) with dementia. None of the evaluated surgical complications were more likely in dementia-diagnosed beneficiaries. There was also no difference in likelihood of nonambulatory surgery center setting, anesthesiologist provider, or postoperative hospitalization. Dementia-diagnosed beneficiaries were more likely to have surgeries coded as complex (15.6% of cases vs 8.8%, P < .0001), and surgeries exceeding 30 minutes (OR = 1.21, 95% CI = 1.17-1.25). CONCLUSIONS: Among US Medicare beneficiaries undergoing cataract surgery, those with dementia are more likely to have "complex" surgery" lasting more than 30 minutes. However, they do not have greater likelihood of surgical complications, higher-acuity setting, advanced anesthesia care, or postoperative hospitalization. This may be influenced by case selection and may suggest missed opportunities to improve vision. Future research is needed to identify dementia patients likely to benefit from cataract surgery.

Rapid assessment of avoidable blindness and cataract surgery coverage among forcibly displaced Myanmar Nationals (Rohingya refugees) in Cox's Bazar, Bangladesh.

AIM: To determine the prevalence and causes of blindness, vision impairment and cataract surgery coverage among Rohingya refugees aged ≥ 50 years residing in camps in Cox's Bazar, Bangladesh. METHODS: We used the Rapid Assessment of Avoidable Blindness (RAAB) methodology to select 76 clusters of 50 participants aged ≥ 50 years with probability proportionate to size. Demographic and cataract surgery data were collected using questionnaires, visual acuity was assessed per World Health Organization criteria and examinations were conducted by torch, and with direct ophthalmoscopy in eyes with pinhole-corrected vision <6/12. RAAB software was used for data entry and analysis. RESULTS: We examined 3,629 of 3800 selected persons (95.5%). Age and sex adjusted prevalence of blindness (<3/60), severe visual impairment (SVI; >3/60 to ≤6/60), moderate visual impairment (MVI; >6/60 to ≤6/18), and early visual impairment (EVI; >6/18 to ≤6/12) were 2.14%, 2.35%, 9.68% and 14.7% respectively. Cataract was responsible for 75.0% of blindness and 75.8% of SVI, while refractive error caused 47.9% and 90.9% of MVI and EVI respectively. Most vision loss (95.9%) was avoidable. Cataract surgical coverage among the blind was 81.2%. Refractive error was detected in 17.1% (n = 622) of participants and 95.2% (n = 592) of these did not have spectacles. In the full Rohingya cohort of 76,692, approximately 10,000 surgeries are needed to correct all eyes impaired (<6/18) by cataract, 12,000 need distance glasses and 73,000 require presbyopic correction. CONCLUSION: The prevalence of blindness was lower than expected for a displaced population, in part due to few Rohingya being ≥60 years and the camp's good access to cataract surgery. We suggest the United Nations High Commissioner for Refugees include eye care among recommended health services for all refugees with long-term displacement.

Cataract surgery in New Zealand: access to surgery, surgical intervention rates and visual acuity.

AIMS: To analyse the surgical intervention rate (SIR), best spectacle-corrected visual acuity (BSCVA) and disparities in access to public-funded cataract surgery in New Zealand. The New Zealand Ministry of Health uses the National Prioritisation Web Service (NPWS) to prioritise all patients for public-funded cataract surgery. BSCVA at prioritisation, ethnic, demographic and geographic disparities have not previously been assessed. METHODS: A retrospective cohort study. Between November 2014 and March 2019, 61,095 prioritisation events for 44,403 unique patients were identified. Cataract prioritisation events extracted from the NPWS were merged with date of birth and ethnicity extracted from the National Health Index database. All data were de-identified prior to statistical analysis. RESULTS: Mean age at prioritisation was 74.4 years, with female preponderance (56%). Overall ethnicity was 'European' in 69.8% and 'New Zealand Maori' in 9.6%. Mean Snellen BSCVA was 6/30-2 (prioritised eye), and 6/12-1 (binocular). Maori and Pasifika presented on average 10 years earlier than other ethnic groups with significantly worse BSCVA. Surgery was approved in 74.4% of prioritisation events with mean Snellen BSCVA of 6/38-2. Only 34.9% of New Zealand patients had Snellen BSCVA of 6/12 or better in the prioritised eye, compared to 58.4% in the European Union. Cataract SIR varied by region. CONCLUSIONS: New Zealand's cataract SIR is lower than most Organisation for Economic Co-operation and Development countries and patients have significantly worse BSCVA at prioritisation. Access to cataract surgery in New Zealand varies according to region. Maori and Pasifika present younger with worse BSCVA, suggesting potential barriers in accessing timely referral and prioritisation.

Cefuroxime (Aprokam®) in the Prophylaxis of Postoperative Endophthalmitis After Cataract Surgery Versus Absence of Antibiotic Prophylaxis: A Cost-Effectiveness Analysis in Poland.

OBJECTIVE: The analysis aims to assess the cost-effectiveness of cefuroxime (Aprokam®) in the prophylaxis of postoperative endophthalmitis (POE) after cataract surgery compared with the absence of antibiotic prophylaxis from the National Health Fund perspective in Poland. METHODS: We performed a cost-effectiveness and cost-utility analysis using the decision tree and Markov model, respectively, for patients after cataract surgery. The efficacy of Aprokam was 0.21 (95% confidence interval [CI], 0.08-0.55) and is based on the results of the European Society of Cataract and Refractive Surgery study. According to the epidemiological data from Poland, the risk of POE is 0.377%. The costs associated with the Aprokam administration and POE treatment costs were included. We determined the utilities of the health states in the model depending on visual loss due to POE. To determine the uncertainty of estimates parameters, a one-way deterministic and probabilistic sensitivity analysis were performed. RESULTS: Using Aprokam allows avoiding 0.003 POEs per patient. The benefit from the intervention is 0.0007 quality-adjusted life years per patient in the lifetime horizon. The total costs of prophylaxis are higher at about €1.70. The cost of avoiding one POE (incremental cost-effectiveness ratio) is about €569.85. The estimated incremental cost-effectiveness utility ratio is equal to €2427.72/quality-adjusted life-years, and it is significantly lower than the cost-effectiveness threshold in Poland in 2019 (about 7.5% of the threshold). In all scenarios of performed one-way sensitivity analyses, Aprokam is cost-effective. CONCLUSIONS: In Poland, the use of Aprokam is cost-effective, with the estimated incremental cost-utility ratio significantly lower than the cost-effectiveness threshold.

COVID-19 and cataract surgery backlog in Medicare beneficiaries.

PURPOSE: To forecast the volume of cataract surgery in Medicare beneficiaries in the United States in 2020 and to estimate the surgical backlog that may be created due to COVID-19. SETTING: Medicare Beneficiaries, United States. DESIGN: Epidemiologic modeling. METHODS: Baseline trends in cataract surgery among Medicare beneficiaries were assessed by querying the Medicare Part B Provider Utilization National Summary data. It was assumed that once the surgical deferment is over, there will be a ramp-up period; this was modeled using a stochastic Monte Carlo simulation. Total surgical backlog 2 years postsuspension was estimated. Sensitivity analyses were used to test model assumptions. RESULTS: Assuming cataract surgeries were to resume in May 2020, it would take 4 months under an optimistic scenario to revert to 90% of the expected pre-COVID forecasted volume. At 2-year postsuspension, the resulting backlog would be between 1.1 and 1.6 million cases. Sensitivity analyses revealed that a substantial surgical backlog would remain despite potentially lower surgical demand in the future. CONCLUSIONS: Suspension of elective cataract surgical care during the COVID-19 surge might have a lasting impact on ophthalmology and will likely result in a cataract surgical patient backlog. These data may aid physicians, payers, and policymakers in planning for postpandemic recovery.

Factors associated with the uptake of cataract surgery and interventions to improve uptake in low- and middle-income countries: A systematic review.

Despite significant evidence around barriers hindering timely access to cataract surgery in low- and middle-income countries (LMICs), little is known about the strategies necessary to overcome them and the factors associated with improved access. Despite significant evidence that certain groups, women for example, experience disproportionate difficulties in access, little is known about how to improve the situation for them. Two reviews were conducted recently: Ramke et al., 2018 reported experimental and quasi-experimental evaluations of interventions to improve access of cataract surgical services, and Mercer et al., 2019 investigated interventions to improve gender equity. The aim of this systematic review was to collate, appraise and synthesise evidence from studies on factors associated with uptake of cataract surgery and strategies to improve the uptake in LMICs. We performed a literature search of five electronic databases, google scholar and a detailed reference review. The review identified several strategies that have been suggested to improve uptake of cataract surgery including surgical awareness campaigns; use of successfully operated persons as champions; removal of patient direct and indirect costs; regular community outreach; and ensuring high quality surgeries. Our findings provide the basis for the development of a targeted combination of interventions to improve access and ensure interventions which address barriers are included in planning cataract surgical services. Future research should seek to examine the effectiveness of these strategies and identify other relevant factors associated with intervention effects.

Findings from a Rapid Assessment of Avoidable Blindness (RAAB) in the Southwest Region of Kyrgyzstan.

Purpose: Reliable data on eye care needs in Kyrgyzstan are not readily available. The purpose of this study was to determine the prevalence and causes of blindness and visual impairment in persons aged 50 and above in the southwest of Kyrgyzstan and to support the Ministry of Health (MoH) in the planning of eye care in the region.Methods: A population-based survey was conducted in three states (Oblast) in the southwest region of Kyrgyzstan. Sixty clusters of 50 people aged 50 years and older were selected by probability proportionate to size sampling. Ethical approval was obtained from the MoH, consent was obtained from each participant.Results: A total number of 3,000 persons aged 50 and older were sampled. Among these 2,897 (95.9%) were examined. The prevalence of bilateral blindness was 1.7% [95%CI: 1.1-2.4]. Cataract (43.3%) was the main cause of blindness, followed by glaucoma (30%), age-related macular degeneration (ARMD) (8.3%), other posterior segment diseases (6.7%) and non-trachomatous corneal opacities (5%). The prevalence of blindness and visual impairment increased strongly with age. The cataract surgical coverage in blind persons was 59%.Conclusion: Cataract and glaucoma were the major causes of blindness and visual impairment in persons 50 and above. The majority of the causes (85%) were avoidable, with 45% (cataract and uncorrected aphakia) treatable, 6.7% (corneal opacity and phthisis) preventable by primary health care/eye care services and 33.3% (cataract surgical complications, glaucoma) preventable by specialized ophthalmic services. The data suggest that an expansion of eye care services to reduce avoidable blindness is needed, as ageing will lead to an increase in older people at risk and a higher demand for eye care in the future.

Inequity in Access: Cataract Surgery Throughput of Chinese Ophthalmologists from the China National Eye Care Capacity and Resource Survey.

Purpose: To investigate the distribution of cataract surgery performed by ophthalmologists in China.Methods: A cross-sectional study was designed to investigate nationwide ophthalmological resources and capacity for cataract surgery in China⁠-The 2014 China National Eye Care Capacity and Resource Survey. Data analyzed in this report included regional distribution, urban-rural comparison, levels and types of medical institutions, and cataract surgery types and volume per surgeon. In China, only ophthalmologists at or above the level of attending are eligible to perform cataract surgery independently, so the ability of cataract surgery for ophthalmologists at or above the level of attending is analyzed in the current study. Descriptive statistics were used.Results: 36,333 ophthalmologists were included in this survey, which is an average of 1.33 ophthalmologists to every 50,000 population. Of the surgeons in this survey, 23,412 (50.22%) were attending or more senior ophthalmologists and were mainly distributed in eastern urban areas. Annual average cataract surgeries per ophthalmologist in China were 259 in 2017, less than 300 cases.Conclusion: The average number of ophthalmologists per population in China has achieved the goal of WHO's Vision 2020; however, these surgeons are concentrated in urban areas. Further, the ability of cataract surgery among ophthalmologists is unbalanced. The annual average cataract surgeries performed by ophthalmologists are insufficient, which is an important factor resulting in the current situation in China that ophthalmic service capacity has not met the requirements for eliminating cataract blindness.

Prevalence and service assessment of cataract in Tibetan areas of Sichuan Province, China: population-based study.

OBJECTIVES: To assess the prevalence of visual impairment (VI) and blindness (BL) due to cataract and cataract surgical outcomes in remote dispersed and high-altitude Tibetan areas of China. DESIGN AND SETTING: A cross-sectional study was conducted among people aged 50 and above in Tibetan Autonomous Prefecture of Kandze (TAPK), China, in 2017. The Rapid Assessment of Avoidable Blindness protocol was followed. PARTICIPANTS: Of 5000 eligible participants, 4764 were examined (response rate 95.3%). PRIMARY AND SECONDARY OUTCOME MEASURES: Cataract VI was defined as lens opacity at visual acuity (VA) levels of <3/60 (Blindness (BL)), ≥3/60 and <6/60 (severe visual impairment (SVI)), ≥6/60 and <6/18 (moderate visual impairment (MVI)), ≥6/18 and <6/12 (early visual impairment (EVI)). RESULTS: The estimated prevalence of cataract BL was 0.61% (95% CI 0.42 to 0.87). With best corrected VA, the estimated prevalence of SVI from cataract was 0.86% (95% CI 0.63 to 1.17); MVI was 2.39% (95% CI 2.00 to 2.87) and EVI was 5.21% (95% CI 4.61 to 5.87). Women in TAPK had a significantly higher prevalence of cataract BL (0.82%, 95% CI 0.54 to 2.15) than men (0.34%, 95% CI 0.16 to 0.70). Women had lower cataract surgical coverage (CSC) by eyes (60.8%, 95% CI 55.5 to 65.8) compared with men (70.1%; 95% CI 63.7 to 75.7). The prevalence of cataract BL was higher among Tibetan (2.28%; 95% CI 1.98 to 2.62) than Han Chinese (1.01%%; 95% CI 0.54% to 1.87%). Overall CSC by person with BL (by better eye) was 82.0% (95% CI 75.2 to 87.6). Among cataract-operated participants, 71.2% had VA equal to or better than 6/18. CONCLUSIONS: The study detected a low prevalence of VI and BL due to cataract with high CSC in the study area compared with many other places in China. Further actions should be taken to improve cataract surgical outcome.

Establishing a Pediatric Ophthalmology Service in Malawi: Developments in Childhood Cataract Surgery.

PURPOSE: The purpose of this study is to report on the establishment of a Pediatric Ophthalmology Service for Malawi using childhood cataract surgery as a surrogate measure of its effectiveness. MATERIALS AND METHODS: A retrospective review of pediatric cataract surgery at Lions Sight First Eye Hospital, Blantyre, between 2011 and 2016. The paucity of comprehensive records allowed for the sampling of a maximum of 25 cases/year (n = 150) for comparison. Theatre records and population statistics were used to calculate childhood cataract surgical rates (CCSR). RESULTS: A total of 949 cataract operations were performed during the six years studied - 55.8% of these were boys. The number of operations per year remained generally stable. Of the 150 cases reviewed, the mean age at presentation was 6.01 years, with a trend toward a slightly younger age over the period. Over the years studied, the geographical distribution of referrals became more reflective of the population's distribution. Where the logarithm of the minimum angle of resolution (LogMAR) visions were available, these demonstrated a mean improvement from 2.008 (n = 43) preoperatively to 0.613 (n = 51) postoperatively. The mean follow-up was 106 days (0 days-3.25 years). Complication rates were low. The CCSR was 9.2/million population. CONCLUSIONS: A Pediatric Ophthalmology Service has been established in Malawi delivering safe, effective surgery on a country-wide scale for childhood cataract. Over the period studied, the age at presentation reduced, and there was an improvement in the geographical distribution of patients, likely due to an improvement in referral systems throughout Malawi.

Expediting cataract surgery in New Zealand is cost-effective for falls prevention and improving vision-so what might be the next steps?

Multifactorial individual assessment with interventions tailored to the individual's risk factors can reduce the rate of falls and risk of fractures. Assessment of vision is one key aspect of multifactorial assessment and first eye cataract surgery reduces the rate of falls. We recently modelled the impact of expediting first eye cataract surgery in New Zealand for falls prevention (Boyd et al Injury Prevention). The model used was the same model used for previous modelling of home safety assessment and modification and community exercise programmes. This study found that expedited cataract surgery was highly cost-effective by generating a quality-adjusted life-year (QALY) for NZ$10,600 (95%UI: NZ$6,030-15,700). Routine cataract surgery itself (relative to no such surgery being available) was even more cost-effective at $4,380 per QALY gained, when considering vision benefits and falls prevention benefits. In this viewpoint article, we discuss the potential next steps for expediting cataract surgery and further improving its cost-effectiveness in the New Zealand setting.

Assessing the Progress towards Achieving "VISION 2020: The Right to Sight" Initiative in Ghana.

Purpose: The aim of this study was to analyse eye health delivery in Ghana and examine the progress towards achieving VISION 2020 indicator targets. Methods: This descriptive cross-sectional study was conducted between October 2017 and May 2018. It used a mixed method approach including desk-based reviews, a questionnaire-based survey of eye facilities in Ghana, and interviews with eye health system stakeholders to collect information on eye health delivery in facilities owned by the Ghana Health Service (GHS), quasigovernmental bodies (security agencies), and Christian Association of Ghana (CHAG). The information was benchmarked against the World Health Organization (WHO) targets for achieving the goals of VISION 2020. Results: The magnitude of blindness and moderate to severe visual impairment (without pinhole) was 0.9% and 3.0%, respectively. The number of ophthalmologists available at the country level was 80.6% of the VISION 2020 target with optometrists and ophthalmic nurses exceeding targets for VISION 2020. The distribution of human resources was heavily skewed towards two out of the 10 regions in Ghana. Cataract surgical rate was low and met 25% of the WHO target. Basic equipment for refraction was available in the majority of facilities; however, there was a general lack of specialised eye care equipment across the country. Comparatively, CHAG facilities were better equipped than GHS facilities at the same level. Conclusion: The Government of Ghana should revitalize the goals of VISION 2020 beyond the year 2020 and spearhead a concerted effort to ensure equitable distribution of human and infrastructural resources across the country.

Shortened cataract surgery by standardisation of the perioperative protocol according to the Joint Commission International accreditation: a retrospective observational study.

OBJECTIVES: To investigate the impact of standardisation of the perioperative protocol based on the Joint Commission International (JCI) accreditation guidelines for operating time in cataract surgery. DESIGN: Retrospective observational study. SETTING: Single centre in Japan. PARTICIPANTS: Between March 2014 and June 2016, 3127 patients underwent cataract surgery under topical anaesthesia including 2581 and 546 patients before and after JCI accreditation, respectively. PRIMARY AND SECONDARY OUTCOMES: We compared three time periods, comprising the preprocedure/surgery time (pre-PT), PT and post-PT, and total PT (TPT) of cataract surgery between patients before and after JCI accreditation, by regression analysis adjusted for age, sex and cataract surgery-associated confounders. RESULTS: The main outcomes were pre-PT, PT, post-PT and TPT. Pre-PT (19.8±10.5 vs 13.9±8.5 min, p<0.001) and post-PT (3.5±4.6 vs 2.6±2.1 min, p<0.001) significantly decreased after JCI accreditation, while PT did not significantly change (16.8±6.7 vs 16.2±6.3 min, p=0.065). Consequently, TPT decreased on average by 7.3 min per person after JCI accreditation (40.1±13.4 vs 32.8±10.9 min, p<0.001). After adjusting for confounders, pre-PT (ß=-5.82 min, 95% CI -6.75 to -4.88), PT (ß=-0.76 min, 95% CI -1.34 to -1.71), post-PT (ß=-0.85 min, 95% CI -1.24 to -0.45) and TPT (ß=-7.43 min, 95% CI -8.61 to -6.24) were significantly shortened after JCI accreditation. CONCLUSION: Perioperative protocol standardisation, based on JCI accreditation, shortened TPT in cataract surgery under local anaesthesia.