Comparison of cataract surgery in a base hospital and in peripheral eye camps
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The Base Hospital approach (reach in) and Peripheral Eye Camp approach (reach out) are both community-orientated approaches to tackle the backlog of cataract blindness under the National Programme for the Control of Blindness. Both have proved effective and each has its merits and demerits. Both rely on community articipation, intersectorial coordination and appropriate technology at an affordable cost.
We studied 3130 patients operated on for cataract by the Lions NAB Eye Hospital, Miraj (Base Hospital) between 1st January and 31st December 1996 and 1135 patients operated on at 58 Peripheral Eye Camps by the Sangli District, Mobile Ophthalmic Unit and The National Association for the Blind, in the same period. Follow-up was done one week, 3 weeks and 6 weeks after surgery.
The Base Hospital conducted diagnostic camps in the periphery and patients were moved to the Hospital, accounting for 80% of the patients, with the rest being ‘walk-ins’. Patients were evaluated using the slit-lamp biomicroscope, keratometry and A-scan where necessary. They underwent planned extracapsular cataract extraction with a posterior chamber intraocular lens implant (58.2%) under a microscope with use of viscoelastics. They were re-transported after dressing the next day.
The Peripheral Eye Camps were conducted in Rural Hospitals or Primary Health Centres in permanent operation theatres, using sterile procedures. Diagnostic camps were conducted at the same site and the patients operated on the next day with intracapsular cataract extraction under an incandescent lamp. Dressing was done on the first and third day by the operating surgeon, followed by discharge.
More women were operated on in Peripheral Eye Camps (59.1%) as compared to the Base Hospital (48%) as their carers were reluctant to transport them far. The very young and very aged were predominantly operated on in the Base Hospital because of the presumed quality of surgery and better management of complications.
Table 1. Post-operative corrected visual acuities in peripheral eye camps and base hospital.
Aphakic correction with + 10 D given to 99.1% patients (1125 out of 1135) and retinoscopic refraction given to 63.9% (2000 out of 3130); six weeks after surgery
| Vision | Total | % at Eye Camps | Total | % at Base Hospital |
|---|---|---|---|---|
| 6/6-6/9 | 58 | 5.2% | 685 | 34.3% |
| 6-12/6/18 | 434 | 38.6% | 966 | 48.3% |
| 6/24-6/36 | 575 | 51.1% | 227 | 11.4% |
| 6/60 | 44 | 3.9% | 92 | 4.6% |
| <6/60 | 14 | 1.2% | 30 | 1.5% |
Even in the periphery, 92% of patients or their carers were aware of IOL implantation surgery. Only 8% were unaware. Inability to pay was the chief reason (80%) for operating without lens implantation. Only 12% had fear or misconception about something put in their eyes. This means that a larger demand for surgery exists in the periphery for which we must prepare.
Final corrected visual acuity was much better in the Base Hospital (82.7% > 6/18) as compared to Peripheral Eye Camps (43.7%>6/18). There is a significant difference between post-operative visual acuity in these groups. Microsurgery, visco-elastics and retinoscopic refraction gave a statistically significant rualititative improvement in vision. Base Hospital surgery resulted in better and earlier visual rehabilitation.
The Professor had significantly better results than all other categories. It should be noted that more experienced surgeons operated on more difficult, ‘guarded prognosis’ cases. (Professor: 95.2% > 6/18; Medical Officers/Registrars: 82.6%> 6/18; Senior Residents 86.5% > 6/18; Junior Residents : 76.3% > 6/18).
However, post-operative follow-up in the Base Hospital was very poor; only 52.7% patients turned up regularly on their own. For the rest, we had to do active follow-up in rural areas. Peripheral Eye Camps boasted 99.1% follow-up as they were conducted near to the patients’ homes with the help of ophthalmic assistants who had close community contacts. The Base Hospital should have satellite outposts to ensure better patient follow-up and compliance. This will strengthen its network in the community.
Table 2. Experience of surgeon and post – operative vision in base hospital
| Vision | Junior Residents <50 ops. |
Senior Residents 50-200 ops. |
Registrar or Medical Officer >200 ops |
Professor >4000ops |
|---|---|---|---|---|
| 6/6-6/9 | 33% | 30.4% | 33.9% | 57.1% |
| 6-12/6/18 | 43.3% | 56.1% | 48.7% | 38.1% |
| 6/24-6/36 | 16% | 8.5% | 10.7% | |
| 6/60 | 5.6% | 3.1% | 6.7% | |
| <6/60 | 2.6% | 1.9% | 1.8% | 4.8% |
Complications with both approaches were equally found, though the Base Hospital operated on all the difficult cases. Also, all Peripheral Eye Camps were conducted in permanent operation theatres. Vitreous loss was the chief cause of low post-operative vision (1.8% in the periphery and 3.3% at the Base Hospital). Posterior segment pathology was responsible for most others (3.7%).
The surgery in Peripheral Eye Camps was marginally more economical as compared to the Base Hospital (recurring expenses per patient being Rs. 390.5 and Rs. 408.77 respectively). But considering the quality of surgery, early and better visual rehabilitation, the Base Hospital approach has much to recommend it.
Satellite Centres could be set up to improve follow-up. This shift to Base Hospital and Satellite Centres would ensure quality eye care to all patients, while still keeping community orientation.
There is no significant difference comparing Junior Residents (<50 ops.), Senior Residents (50-200 ops.) and Registrars/
Medical Officers (200-4000 ops.). There is, however, a significant difference between the results of the Professor (> 4000 ops.) and all other categories.
Table 3. Cost of surgery per patient
(All figures are in rupees)
| Expense | Peripheral Eye Camp | Base Hospital |
|---|---|---|
| Vehicle | 23.0 | 17.25 |
| Expense | 47.0 | 76.49 * |
| Consumables # for Surgery | 75.0 | 79.91 |
| Medicines for Patients | 80.0 | 78.66 |
| Salary and Wages of Surgical Team | 152.5 | 142.76 |
| Goggles | 13.0 | 13.00 |
| 390.50 | 408.07 | |
| Office Expense | 29.91 | |
| Hospital | 44.10 | |
| Maintenance | ||
| Depreciation | 15.02 | |
| Total | 390.50 | 497.10 |
| IOL expense | 233.66** |
* Includes food provided for patient over three days
# Includes suture material, viscoelastic substance etc
** The cost of IOLs is now almost half the price 5 years ago
Sources
1. Annual audit report for 1996-97 of Lions NAB Eye Hospital.
2. Personal communication with the District Ophthalmic Surgeon (Class-1), Sangli District, for Peripheral Eye Camps.
References
1 Das T, Venkataswamy G. Surgical results – Comparison of Patients Operated in Eye Camp with Patients Operated in Hospital. Indian J Ophthalmol 1983; 31 : 924-927.
2 Murthy G V, Sharma P. Cost Analysis of Eye Camps and Camp-based Cataract Surgery. Medical Journal, India 1994; 7 : 111-114.
3 Nag Subhasish. Comparative Analysis of Camp Surgery at Base Hospital versus Satellite Center versus Rural Eye Set Up. Paper presented at 53rd AIDS Annual Conference, Mumbai, Feb. 1996.
4 Natchiar G, Robin A D, Thulasiraj R D, Krishnaswamy S. Attacking the Backlog of India’s Curable Blind-The Aravind Eye Hospital Model. Arch Ophthalmol 1994; 112 : 987-993.
5 Prajna N V, Rahamatullah R. Changing Trends in the IOL Acceptance in Rural Tamilnadu. Indian J Ophthalmol 1995; 43 : 177-178.
6 Ravindra M S, Rekha Gyanchand. Rural Eyecamps versus Base Hospital Eyecamps. Paper presented at 54th AIDS Annual Conference, Chandigarh, Feb. 1997.