Visual Acuity Outcomes after Cataract Surgery: High-Volume versus Low-Volume Surgeons.

PURPOSE: The primary objective was to assess associations between annual surgeon case volume and visual acuity outcomes after cataract surgery. Secondary objectives included (1) assessing associations between other case and patient characteristics and visual acuity outcomes and (2) assessing associations between annual surgeon case volume and complication rates. DESIGN: Database study. PARTICIPANTS: All adult eyes that underwent small-incision cataract surgery (SICS) or phacoemulsification cataract extraction (PECE) with intraocular lens placement at the Aravind Eye Hospital, Madurai, India, during 2015. METHODS: Descriptive statistics were used to characterize the study population. Uncorrected visual acuity (UCVA) at follow-up was assessed relative to annual surgeon case volume and other case and demographic factors using bivariate linear regression with random effects modeling. Factors with P values of less than 0.20 on bivariate regression were included in multivariate linear regression with random effects modeling. MAIN OUTCOME MEASURES: Postoperative UCVA after cataract surgery. RESULTS: Of 91 084 surgeries, 35 880 eyes were included in this study. Cases were performed by 69 surgeons, who varied in annual case volume from 76 to 2900 cases during the study period. Increasing annual surgeon case volume was independently associated with a statistically significant but clinically modest improvement in UCVA in PECE but not in SICS. This association was most pronounced when comparing surgeons with case volumes of 350 PECE/year or fewer; surgeons with more than 350 PECE/year had similar results to one another. Similarly, increased annual case volume was associated with significantly lower complication rates, both in PECE and SICS. Younger patient age was independently associated with improved visual acuity outcomes and lower complication rates in both PECE and SICS. Greater surgeon experience was associated with lower complication rates in PECE, but not SICS, and there was no significant association with visual acuity outcomes. CONCLUSIONS: High-volume cataract surgeons showed improved visual acuity outcomes in PECE and lower complication rates in PECE and SICS. These findings further support the benefit of high-output ophthalmology clinics wherein individual surgeons perform a high number of cataract extractions annually, particularly in developing nations where there is a large backlog of untreated cataracts and the cataract patient-to-surgeon ratio is high.

The Aravind Pseudoexfoliation Study: Surgical and First-Year Postoperative Results in Eyes without Phacodonesis and Nonmiotic Pupils.

PURPOSE: To compare intraoperative complication rates, 1-year visual outcomes, and postoperative complication rates over the first postoperative year in eyes with and without pseudoexfoliation undergoing cataract surgery. DESIGN: Prospective, comparative, interventional study. PARTICIPANTS: Nine hundred thirty eyes with cataract and uncomplicated pseudoexfoliation (without phacodonesis, clinically shallow anterior chambers, or pupil size <4 mm) and 476 controls with cataract but without pseudoexfoliation recruited from 4 centers of the Aravind Eye Care System in Southern India. The 2 groups were randomized separately to receive either a single-piece acrylic intraocular lens (IOL; SA60AT; Alcon Laboratories, Fort Worth, TX) or a 3-piece acrylic IOL (MA60AS; Alcon Laboratories). The pseudoexfoliation group also was randomized to receive or not receive a capsular tension ring. METHODS: All eyes underwent phacoemulsification with IOL implantation and were followed up at 1 day, 1 month, 3 months, and 1 year after surgery. MAIN OUTCOME MEASURES: Association of pseudoexfoliation status with intraoperative complication rates, 1-year best-corrected visual acuity, and any other complications. RESULTS: Mean ages were 63.0±6.9 years and 57.9±7.3 years in the pseudoexfoliation and control groups, respectively (P < 0.001). Pseudoexfoliation patients were more likely to be men (P = 0.014), to have a nuclear opalescence grade of more than 4 (P = 0.001), and to have a pupil size of less than 6 mm (P < 0.001) when compared with controls. Intraoperative complication rates were 2.9% and 1.9% in the pseudoexfoliation and control groups, respectively (P = 0.29). One-year postoperative best-corrected visual acuity was comparable (P = 0.09). Complication rates at 1 year were 2.7% and 2.5% in the pseudoexfoliation and control groups, respectively (P = 0.82). Average endothelial cell loss was 14.7% in the pseudoexfoliation group and 12.7% in the control group at 1 year (P = 0.066) when adjusting for age and nuclear opacity. CONCLUSIONS: Pseudoexfoliation eyes without shallow anterior chamber, small pupils, or apparent zonulopathy may represent eyes with lower risks of complications. Despite smaller pupils and denser cataracts, pseudoexfoliation eyes without clinically apparent preoperative zonulopathy were not at a higher risk of intraoperative or postoperative complications or worse visual outcomes after cataract surgery.

Residents' Learning Curve for Manual Small-Incision Cataract Surgery at Aravind Eye Hospital, India.

PURPOSE: The goal of this study was to document the resident learning curve for manual small-incision cataract surgery (MSICS) and to identify implications for the design of ophthalmology residency programs aimed to train surgeons for developing countries. DESIGN: Hospital-based retrospective cohort study. PARTICIPANTS: All 38 residents entering 2 postgraduate residency programs at Aravind Eye Hospital, Madurai, in 2012 and 2013. METHODS: Surgical complications and reoperations for all MSICSs performed by residents during the residency training period were evaluated using a computerized patient database. Multivariate logistic regression models were used to estimate the effect of the cumulative number of surgeries performed on incidence of intraoperative complications, postoperative complications, and reoperations, controlling for covariates. MAIN OUTCOME MEASURES: Incidence of intraoperative and first-day postoperative complications of Oxford Cataract Treatment and Evaluation Team (OCTET) grades II and III and the incidence of reoperations. Analyses controlled for patient-, resident-, and residency program-level covariates. RESULTS: The study evaluated 13 159 surgeries performed by the 38 residents between October 15, 2012, and August 24, 2016. The mean number of surgeries performed by a resident was 346.3 (standard deviation, 269.4). Three hundred forty-two eyes (2.60%) with at least 1 intraoperative complication, 234 eyes (1.78%) with at least 1 first-day postoperative complication, and 154 reoperations (1.17%) were observed. After controlling for baseline covariates, increasing surgical experience was associated with reduced risk of intraoperative and postoperative complications, as well as reoperations. The odds decreased by 17% (intraoperative complications), 12% (postoperative complications measured 1 day after surgery), and 7% (reoperations) per 100 additional surgeries performed. Patient-level factors such as older age, left eye surgery, and lower preoperative uncorrected visual acuity were found to be associated with higher risk of intraoperative complications (P < 0.01 for all). CONCLUSIONS: The risk of surgical complications and reoperations in MSICS decreased steadily with surgical experience gained by resident surgeons. We recommend that ophthalmology residency programs in developing nations teaching MSICS provide opportunities to perform 300 surgeries or more by residents so as to achieve rates of intraoperative and postoperative complications of less than 2%.

Prevalence and risk factors for myopia and other refractive errors in an adult population in southern India.

PURPOSE: To investigate prevalence and risk factors for myopia, hyperopia and astigmatism in southern India. METHODS: Randomly sampled villages were enumerated to identify people aged ≥40 years. Participants were interviewed for socioeconomic and lifestyle factors and attended a hospital-based ophthalmic examination including visual acuity measurement and objective and subjective measurement of refractive status. Myopia was defined as spherical equivalent (SE) worse than -0.75 dioptres (D), hyperopia as SE ≥+1D and astigmatism as cylinder <-0.5. RESULTS: The age-standardised prevalences of myopia, hyperopia and astigmatism were 35.6% (95% CI: 34.7-36.6), 17.0% (95% CI: 16.3-17.8) and 32.6 (29.3-36.1), respectively. Of those with myopia (n = 1490), 70% had advanced cataract. Of these, 79% had presenting visual acuity (VA) less than 6/18 and after best correction, 44% of these improved to 6/12 or better and 27% remained with VA less than 6/18. In multivariable analyses (excluding patients with advanced cataract), increasing nuclear opacity score, current tobacco use, and increasing height were associated with higher odds of myopia. Higher levels of education were associated with increased odds of myopia in younger people and decreased odds in older people. Increasing time outdoors was associated with myopia only in older people. Increasing age and female gender were associated with hyperopia, and nuclear opacity score, increasing time outdoors, rural residence and current tobacco use with lower odds of hyperopia. After controlling for myopia, factors associated with higher odds of astigmatism were age, rural residence, and increasing nuclear opacity score and increasing education with lower odds. CONCLUSIONS: In contrast to high-income settings and in agreement with studies from low-income settings, we found a rise in myopia with increasing age reflecting the high prevalence of advanced cataract.

Endophthalmitis Reduction with Intracameral Moxifloxacin Prophylaxis: Analysis of 600 000 Surgeries.

PURPOSE: To compare the postoperative endophthalmitis rate before and after initiation of intracameral (IC) moxifloxacin prophylaxis for both phacoemulsification and sutureless, manual small-incision cataract surgery (M-SICS), as well as in patients with posterior capsular rupture (PCR). DESIGN: Retrospective, clinical registry. PARTICIPANTS: All cataract surgeries (617 453) performed during the 29-month period from January 2014 to May 2016 at the 10 regional Aravind eye hospitals were included. METHODS: The electronic health record data for all study eyes were analyzed. Endophthalmitis rates before and after moxifloxaxin were statistically compared for all eyes and separately for both phacoemulsification and M-SICS, and for the eyes complicated by PCR. MAIN OUTCOME MEASURES: The postoperative endophthalmitis rates before and after initiation of IC moxifloxacin prophylaxis. RESULTS: Overall, 302 815 eyes did not receive IC moxifloxacin and 314 638 eyes did, and there was a significant decline in the endophthalmitis rate, from 0.07% (214/302 815) to 0.02% (64/314 638) (P < 0.001), with moxifloxacin. For the 194 252 phacoemulsification eyes, the endophthalmitis rate was 0.07% (75/104 894) without IC moxifloxacin prophylaxis, compared with 0.01% (11/89 358) with moxifloxacin (P < 0.001). For the 414 657 M-SICS eyes, the endophthalmitis rate was 0.07% (135/192 149) without IC moxifloxacin prophylaxis, compared with 0.02% (52/222 508) with moxifloxacin (P < 0.001). Approximately half of the 8479 eyes that had PCR received IC moxifloxacin, and half did not. Without IC moxifloxacin, PCR increased the endophthalmitis rate nearly 7-fold to 0.48% (20/4186); IC moxifloxacin reduced the endophthalmitis rate with PCR to 0.21% (9/4293) (P = 0.034). No adverse events were due to IC moxifloxacin. CONCLUSIONS: Routine IC moxifloxacin prophylaxis reduced the overall endophthalmitis rate by 3.5-fold (3-fold for M-SICS and nearly 6-fold for phacoemulsification). There was also a statistical benefit for eyes complicated by PCR, and IC antibiotic prophylaxis should be strongly considered for this high-risk population. These conclusions are strengthened by the high volume of cases analyzed at a single hospital network over a comparatively short time frame. Considering the association of hemorrhagic occlusive retinal vasculitis with vancomycin and the commercial unavailability of IC cefuroxime in many countries, moxifloxacin appears to be an effective option for surgeons electing IC antibiotic prophylaxis.

Efficacy of Intracameral Moxifloxacin Endophthalmitis Prophylaxis at Aravind Eye Hospital.

PURPOSE: To compare the rate of postoperative endophthalmitis before and after initiation of intracameral (IC) moxifloxacin for endophthalmitis prophylaxis in patients undergoing cataract surgery. DESIGN: Retrospective, clinical registry. PARTICIPANTS: All charity and private patients (116 714 eyes) who underwent cataract surgery between February 15, 2014, and April 15, 2015, at the Madurai Aravind Eye Hospital were included. Group 1 consisted of 37 777 eyes of charity patients who did not receive IC moxifloxacin, group 2 consisted of 38 160 eyes of charity patients who received IC moxifloxacin prophylaxis, and group 3 consisted of 40 777 eyes of private patients who did not receive IC moxifloxacin. METHODS: The electronic health record data for each of the 3 groups were analyzed, and the postoperative endophthalmitis rates were statistically compared. The cost of endophthalmitis treatment (groups 1 and 2) and the cost of IC moxifloxacin prophylaxis (group 2) were calculated. MAIN OUTCOME MEASURES: Postoperative endophthalmitis rate before and after initiation of IC moxifloxacin endophthalmitis treatment cost. RESULTS: Manual, sutureless, small incision cataract surgery (M-SICS) accounted for approximately all of the 75 937 cataract surgeries in the charity population (97%), but only a minority of the 40 777 private surgeries (21% M-SICS; 79% phacoemulsification). Thirty eyes in group 1 (0.08%) and 6 eyes in group 2 (0.02%) were diagnosed with postoperative endophthalmitis (P < 0.0001). The group 3 endophthalmitis rate was 0.07% (29 eyes), which was also higher than the second group's rate (P < 0.0001). There were no adverse events attributed to IC moxifloxacin in group 2. The total cost of treating the 30 patients with endophthalmitis in group 1 was virtually identical to the total combined cost in group 2 of routine IC moxifloxacin prophylaxis and treatment of the 6 endophthalmitis cases. CONCLUSIONS: Routine IC moxifloxacin prophylaxis achieved a highly significant, 4-fold reduction in postoperative endophthalmitis in patients undergoing M-SICS. Compared with previous studies, having such a high volume of patients undergoing surgery during a relatively short 14-month time period strengthens the conclusion. This study provides further evidence that moxifloxacin is an effective IC prophylactic antibiotic and suggests that IC antibiotics should be considered for M-SICS and phacoemulsification.

Polymorphisms in sodium-dependent vitamin C transporter genes and plasma, aqueous humor and lens nucleus ascorbate concentrations in an ascorbate depleted setting.

We have previously reported low concentrations of plasma ascorbate and low dietary vitamin C intake in the older Indian population and a strong inverse association of these with cataract. Little is known about ascorbate levels in aqueous humor and lens in populations habitually depleted of ascorbate and no studies in any setting have investigated whether genetic polymorphisms influence ascorbate levels in ocular tissues. Our objectives were to investigate relationships between ascorbate concentrations in plasma, aqueous humor and lens and whether these relationships are influenced by Single Nucleotide Polymorphisms (SNPs) in sodium-dependent vitamin C transporter genes (SLC23A1 and SLC23A2). We enrolled sixty patients (equal numbers of men and women, mean age 63 years) undergoing small incision cataract surgery in southern India. We measured ascorbate concentrations in plasma, aqueous humor and lens nucleus using high performance liquid chromatography. SLC23A1 SNPs (rs4257763, rs6596473) and SLC23A2 SNPs (rs1279683 and rs12479919) were genotyped using a TaqMan assay. Patients were interviewed for lifestyle factors which might influence ascorbate. Plasma vitamin C was normalized by a log10 transformation. Statistical analysis used linear regression with the slope of the within-subject associations estimated using beta (ß) coefficients. The ascorbate concentrations (µmol/L) were: plasma ascorbate, median and inter-quartile range (IQR), 15.2 (7.8, 34.5), mean (SD) of aqueous humor ascorbate, 1074 (545) and lens nucleus ascorbate, 0.42 (0.16) (µmol/g lens nucleus wet weight). Minimum allele frequencies were: rs1279683 (0.28), rs12479919 (0.30), rs659647 (0.48). Decreasing concentrations of ocular ascorbate from the common to the rare genotype were observed for rs6596473 and rs12479919. The per allele difference in aqueous humor ascorbate for rs6596473 was -217 µmol/L, p < 0.04 and a per allele difference in lens nucleus ascorbate of -0.085 µmol/g, p < 0.02 for rs12479919. The ß coefficients for the regression of log10 plasma ascorbate on aqueous humor ascorbate were higher for the GG genotype of rs6596473: GG, ß = 1460 compared to carriage of the C allele, CG, ß = 1059, CC, ß = 1132, p interaction = 0.1. In conclusion we found that compared to studies in well-nourished populations, ascorbate concentrations in the plasma, aqueous humor and lens nucleus were low. We present novel findings that polymorphisms in SLC23A1/2 genes influenced ascorbate concentration in aqueous humor and lens nucleus.

Evaluation and model to achieve sex parity in cataract surgical coverage in Theni district, India.

BACKGROUND/AIMS: To propose an approach to determine the target ratio of cataract surgical rates (CSRs) of female to male subpopulations to increase sex parity in cataract surgical coverage (CSC), based on the sex gap in cataract burden and incidence, and demonstrate its application to Theni district, India. METHODS: A population-based longitudinal study between January 2016 and April 2018. We recruited 24 327 participants using random cluster sampling. We conducted detailed eye examinations of 7087 participants aged ≥40 years (4098 females, 2989 males). We fit exponential models to the age-specific and sex-specific cataract burden and estimated annual incidence rates. We developed a spreadsheet-based planning tool to compute the target CSR ratio of female to male subpopulations. RESULTS: Among those aged ≥40 years, cataract burden was 21.4% for females and 17.5% for males (p<0.05). CSC was 73.9% for females versus 78.6% for males (p<0.05), with an effective CSC of 52.6% for females versus 57.6% for males (p<0.05). Treating only incident cataracts each year requires a target CSR ratio of female to male subpopulations of 1.30, while addressing in addition 10% of the coverage backlog for females and 5% for males requires a target CSR ratio of 1.48. CONCLUSIONS: The female population in Theni district, as in many low-income and middle-income countries, bears a higher cataract burden and lower CSC. To enhance sex parity in coverage, both the higher number of annual incident cataracts and the larger backlog in females will need to be addressed.

Comparison of cataract surgery outcomes between a secondary and a tertiary eye hospital in Tamil Nadu, India.

PURPOSE: To examine the difference in post-operative visual outcomes of cataract surgeries between a tertiary and secondary centre at Aravind Eye Hospitals in Tamil Nadu, India. METHODS: Our retrospective cross-sectional study analysed cataract surgeries at a secondary centre and its associated tertiary centre in 2021. Our main outcome measures were postoperative best corrected visual acuity (BCVA), spherical equivalent, and intraoperative and postoperative complications. Two-sample proportion tests and logistic regression analyses were performed. RESULTS: The analysis of 32,302 cataract surgeries in 2021 of which 4357 were performed at the secondary centre and 27,945 were performed at the tertiary centre showed that the tertiary centre operated on more advanced cataract condition (p < 0.001). Intraoperative (p < 0.001) and post-operative complication rates (p < 0.001) were higher in the tertiary centre. The odds of effective outcomes (BCVA > = 6/12) controlling for all covariates are poorer (p < 0.0001) in the tertiary centre for both phacoemulsification (phaco) and manual small incision cataract surgeries (MSICS). CONCLUSION: World Health Organization recommendations for the effective outcome of cataract surgery are met by both the tertiary and secondary centres, but the odds of effective outcomes in the tertiary centre was lower after adjusting for all known factors. Further investigations of the causes of poor vision in both phaco and MSICS in the tertiary centre are needed to improve the situation.

Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery.

PURPOSE: To determine whether four new operating room (OR) protocols instituted because of COVID-19 reduced the cataract surgical postoperative endophthalmitis rate (POE). DESIGN: Retrospective, sequential, clinical registry study. METHODS: 85 552 sequential patients undergoing cataract surgery at the Aravind Eye Hospitals between 1 January 2020 and 25 March 2020 (56 551 in group 1) and 3 May 2020 and 31 August 2020 (29 011 in group 2). In group 1, patients were not gowned, surgical gloves were disinfected but not changed between cases, OR floors were not cleaned between every case, and multiple patients underwent preparation and surgery in the same OR. In group 2, each patient was gowned, surgical gloves were changed between each case, OR floors and counters were cleaned between patients, and only one patient at a time underwent preparation and surgery in the OR. RESULTS: Group 1 was older, had slightly more females, and better preoperative vision. More eyes in group 2 underwent phacoemulsification (p=0.18). Three eyes (0.005%) in group 1 and 2 eyes (0.006%) in group 2 developed POE (p=0.77). Only one eye that underwent phacoemulsification developed POE; this was in group 1. There was no difference in posterior capsule rupture rate between the two groups. CONCLUSIONS: Adopting a set of four temporary OR protocols that are often mandatory in the Western world did not reduce the POE rate. Along with previously published studies, these results challenge the necessity of these common practices which may be needlessly costly and wasteful, arguing for the reevaluation of empiric and potentially unnecessary guidelines that govern ophthalmic surgeries.

Accuracy of an artificial intelligence-based mobile application for detecting cataracts: Results from a field study.

Purpose: To assess the accuracy of e-Paarvai, an artificial intelligence-based smartphone application (app) that detects and grades cataracts using images taken with a smartphone by comparing with slit lamp-based diagnoses by trained ophthalmologists. Methods: In this prospective diagnostic study conducted between January and April 2022 at a large tertiary-care eye hospital in South India, two screeners were trained to use the app. Patients aged >40 years and with a best-corrected visual acuity <20/40 were recruited for the study. The app is intended to determine whether the eye has immature cataract, mature cataract, posterior chamber intra-ocular lens, or no cataract. The diagnosis of the app was compared with that of trained ophthalmologists based on slit-lamp examinations, the gold standard, and a receiver operating characteristic (ROC) curve was estimated. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were computed. Results: The two screeners used the app to screen 2,619 eyes of 1,407 patients. In detecting cataracts, the app showed high sensitivity (96%) but low specificity (25%), an overall accuracy of 88%, a PPV of 92.3%, and an NPV of 57.8%. In terms of cataract grading, the accuracy of the app was high in detecting immature cataracts (1,875 eyes, 94.2%), but its accuracy was poor in detecting mature cataracts (73 eyes, 22%), posterior chamber intra-ocular lenses (55 eyes, 29.3%), and clear lenses (2 eyes, 2%). We found that the area under the curve in predicting ophthalmologists' cataract diagnosis could potentially be improved beyond the app's diagnosis based on using images only by incorporating information about patient sex and age (P < 0.0001) and best-corrected visual acuity (P < 0.0001). Conclusions: Although there is room for improvement, e-Paarvai app is a promising approach for diagnosing cataracts in difficult-to-reach populations. Integrating this with existing outreach programs can enhance the case detection rate.

Chronic diseases and injuries in India.

Chronic diseases (eg, cardiovascular diseases, mental health disorders, diabetes, and cancer) and injuries are the leading causes of death and disability in India, and we project pronounced increases in their contribution to the burden of disease during the next 25 years. Most chronic diseases are equally prevalent in poor and rural populations and often occur together. Although a wide range of cost-effective primary and secondary prevention strategies are available, their coverage is generally low, especially in poor and rural populations. Much of the care for chronic diseases and injuries is provided in the private sector and can be very expensive. Sufficient evidence exists to warrant immediate action to scale up interventions for chronic diseases and injuries through private and public sectors; improved public health and primary health-care systems are essential for the implementation of cost-effective interventions. We strongly advocate the need to strengthen social and policy frameworks to enable the implementation of interventions such as taxation on bidis (small hand-rolled cigarettes), smokeless tobacco, and locally brewed alcohols. We also advocate the integration of national programmes for various chronic diseases and injuries with one another and with national health agendas. India has already passed the early stages of a chronic disease and injury epidemic; in view of the implications for future disease burden and the demographic transition that is in progress in India, the rate at which effective prevention and control is implemented should be substantially increased. The emerging agenda of chronic diseases and injuries should be a political priority and central to national consciousness, if universal health care is to be achieved.

Embracing technology in cataract surgical training - The way forward.

While ophthalmology as a surgical branch itself has evolved technologically with newer instruments, techniques and procedures; ophthalmic surgical training appears to have stagnated in terms of how it is delivered and how trainees' learning and performance are assessed. This collaborative editorial attempts to identify the lacunae in ophthalmic residency training and highlight how technological tools such as surgical simulators can be incorporated into ophthalmic training even in limited-resource settings with good results.

Prevalence of cataract in an older population in India: the India study of age-related eye disease.

PURPOSE: To describe the prevalence of cataract in older people in 2 areas of north and south India. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: Randomly sampled villages were enumerated to identify people aged ≥ 60 years. Of 7518 enumerated people, 78% participated in a hospital-based ophthalmic examination. METHODS: The examination included visual acuity measurement, dilatation, and anterior and posterior segment examination. Digital images of the lens were taken and graded by type and severity of opacity using the Lens Opacity Classification System III (LOCS III). MAIN OUTCOME MEASURES: Age- and gender-standardized prevalence of cataract and 95% confidence intervals (CIs). We defined type of cataract based on the LOCS III grade in the worse eye of: ≥ 4 for nuclear cataract, ≥ 3 for cortical cataract, and ≥ 2 for posterior subcapsular cataract (PSC). Any unoperated cataract was based on these criteria or ungradable dense opacities. Any cataract was defined as any unoperated or operated cataract. RESULTS: The prevalence of unoperated cataract in people aged ≥ 60 was 58% in north India (95% CI, 56-60) and 53% (95% CI, 51-55) in south India (P = 0.01). Nuclear cataract was the most common type: 48% (95% CI, 46-50) in north India and 38% (95% CI, 37-40) in south India (P<0.0001); corresponding figures for PSC were 21% (95% CI, 20-23) and 17% (95% CI, 16-19; P = 0.003), respectively, and for cortical cataract 7.6% (95% CI, 7-9) and 10.2% (95% CI, 9-11; P<0.004). Bilateral aphakia/pseudophakia was slightly higher in the south (15.5%) than in the north (13.2%; P<0.03). The prevalence of any cataracts was similar in north (73.8%) and south India (71.8%). The prevalence of unoperated cataract increased with age and was higher in women than men (odds ratio [OR], 1.8). Aphakia/pseudophakia was also more common in women, either unilateral (OR, 1.2; P<0.02) or bilateral (OR, 1.3; P<0.002). CONCLUSIONS: We found high rates of unoperated cataract in older people in north and south India. Posterior subcapsular cataract was more common than in western studies. Women had higher rates of cataract, which was not explained by differential access to surgery.

Inverse association of vitamin C with cataract in older people in India.

OBJECTIVE: To examine the association between vitamin C and cataract in the Indian setting. DESIGN: Population-based cross-sectional analytic study. PARTICIPANTS: A total of 5638 people aged ≥60 years. METHODS: Enumeration of randomly sampled villages in 2 areas of north and south India to identify people aged ≥60 years. Participants were interviewed for socioeconomic and lifestyle factors (tobacco, alcohol, household cooking fuel, work, and diet); attended a clinical examination, including lens photography; and provided a blood sample for antioxidant analysis. Plasma vitamin C was measured using an enzyme-based assay in plasma stabilized with metaphosphoric acid, and other antioxidants were measured by reverse-phase high-pressure liquid chromatography. MAIN OUTCOME MEASURES: Cataract and type of cataract were graded from digital lens images using the Lens Opacity Classification System III (LOCS III), and cataract was classified from the grade in the worse eye of ≥4 for nuclear cataract, ≥3 for cortical cataract, and ≥2 for posterior subcapsular cataract (PSC). Any cataract was defined as any unoperated or operated cataract. RESULTS: Of 7518 enumerated people, 5638 (75%) provided data on vitamin C, antioxidants, and potential confounders. Vitamin C was inversely associated with cataract (adjusted odds ratio [OR] for highest to lowest quartile = 0.61; 95% confidence interval (CI), 0.51-0.74; P=1.1×10(-6)). Inclusion of other antioxidants in the model (lutein, zeaxanthin, retinol, ß-carotene, and α-tocopherol) made only a small attenuation to the result (OR 0.68; 95% CI, 0.57-0.82; P < 0.0001). Similar results were seen with vitamin C by type of cataract: nuclear cataract (adjusted OR 0.66; CI, 0.54-0.80; P < 0.0001), cortical cataract (adjusted OR 0.70; CI, 0.54-0.90; P < 0.002), and PSC (adjusted OR 0.58; CI, 0.45-0.74; P < 0.00003). Lutein, zeaxanthin, and retinol were significantly inversely associated with cataract, but the associations were weaker and not consistently observed by type of cataract. Inverse associations were also observed for dietary vitamin C and cataract. CONCLUSIONS: We found a strong association with vitamin C and cataract in a vitamin C-depleted population. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.