What are the priorities for improving cataract surgical outcomes in Africa? Results of a Delphi exercise.

PURPOSE: The quality of cataract surgery delivered in sub-Saharan Africa (SSA) is a significant constraint to achieving the elimination of avoidable blindness. No published reports from routine SSA cataract services attain the WHO benchmarks for visual outcomes; poor outcomes (<6/60) often comprise 20% in published case series. This Delphi exercise aimed to identify and prioritise potential interventions for improving the quality of cataract surgery in SSA to guide research and eye health programme development. METHODS: An initial email open-question survey created a ranked list of priorities for improving quality of surgical services. A second-round face-to-face discussion facilitated at a Vision 2020 Research Mentorship Workshop in Tanzania created a refined list for repeated ranking. RESULTS: Seventeen factors were agreed that might form target interventions to promote quality of cataract services. Improved training of surgeons was the top-ranked item, followed by utilisation of biometry, surgical equipment availability, effective monitoring of outcomes of cataract surgery by the surgeon, and well-trained support staff for the cataract pathway (including nurses seeing post-operative cases). CONCLUSION: Improving the quality of cataract surgery in SSA is a clinical, programmatic and public health priority. In the absence of other evidence, the collective expert opinion of those involved in ophthalmic services regarding the ranking of factors to promote quality improvement, refined through this Delphi exercise, provides us with candidate intervention areas to be evaluated.

Causes of blindness at Nkhoma Eye Hospital, Malawi.

PURPOSE: The majority of blindness in Sub-Saharan Africa is treatable. This hospital-based study was undertaken in order to investigate the etiology of blindness at Nkhoma Eye Hospital, Malawi. METHODS: One ophthalmologist examined 2082 consecutive new patients who presented to the outpatient department at Nkhoma Eye Hospital, Malawi in 2006. Data recorded included age, sex, visual acuity and diagnosis. Patients were classified as blind if their best corrected visual acuity was <3/60 in one eye (unilateral) or two eyes (bilateral). RESULTS: The most common diagnosis in new outpatients was cataract (52.8%), followed by glaucoma (8.1%), corneal pathology (7.2%), uveitis (4.5%) and maculopathy (3.2%). There were 742 (35.6%) patients with unilateral blindness and 331 (15.9%) patients with bilateral blindness. Unilateral blindness was present in 37.4% of males and 26.5% of females. The most common causes of unilateral blindness were lens pathology (57.8%), followed by glaucoma (12.1%), corneal pathology (10.0%) and uveitis (6.1%). Bilateral blindness was present in 12.5% of males and 16.8% of females respectively. The most common causes of bilateral blindness were lens pathology (54.4%), followed by glaucoma (19.9%), retinopathy (3.6%), maculopathy (3.6%), uveitis (3.6%) and corneal pathology (3.3%). CONCLUSIONS: Cataract is the most common cause of blindness in Nkhoma. Resultantly, cataract management is preferentially targeted in the Nkhoma VISION2020 Programme. Training of auxiliary eye personnel in cataract diagnosis and surgery may assist in this approach.