发展中国家教学医院的白内障手术服务
【摘要】 目的：总结发展中国家教学医院的白内障手术现状，探讨怎样在减少白内障致盲率方面达到视觉2020计划的目标。方法：通过计算机化白内障手术病例表收集从2006 01/12期间在我院手术的成人白内障病例资料。不包括外伤性白内障。应用SSPS 11.0版本分析数据。结果：在研究期间，3名眼科医生对67眼实施白内障手术。囊外白内障摘除联合后房人工晶状体植入术占95.5%。12wk随访期间，74.5%患者的最好视力为6/66/18，13.7%<6/18 6/60，11.8%<6/60。结论:在尼日利亚这样的发展中国家的教学医院中，白内障手术的比率很低。这就需要提高大多数眼科医生工作的教学医院的白内障手术服务。在教学医院中实施的白内障手术应该是低成本或免费的。大量的手术是很好的锻炼，将带来好的效果。
【关键词】 白内障手术；教学医院；发展中国家
Abstract
AIM: To review the cataract surgery services in a teaching hospital in a developing country with a view to assessing how a teaching hospital can contribute to achieving the goals of the Vision 2020 programme with respect to decreasing cataract blindness.
METHODS: The computerised cataract surgery record form was used to collect data on adult cataract surgery performed at Enugu State University of Sciences and Technology (ESUT) Teaching Hospital Parklane, Enugu, Nigeria over a 12 monthperiod (from January 2006 to December 2006). Traumatic cataracts were excluded. Data was analyzed using SSPS version 11.0.
RESULTS: A total of 67 eyes had cataract operation during the study period. Three ophthalmologists did these. Majority (95.5%) had abexterno extracapsular cataract extraction with posterior chamber intraocular lens implanted (ECCE + PCIOL). At 12 weeks of follow up post operatively, 74.5% had best corrected vision of 6/66/18, 13.7% had <6/186/60 while 11.8% had <6/60.
CONCLUSION: The volume of cataract surgeries performed in a teaching hospital in a developing country like Nigeria is low. There is need for improved service delivery to improve the uptake of cataract surgery services in the teaching hospitals where majority of the ophthalmologists are working. Cataract surgery in teaching hospitals should be made free or offered at minimal cost. High volume surgery will translate to better training and better outcome.
KEYWORDS:cataract surgery; teaching hospital; developing country
INTRODUCTION
Cataract is a leading cause of blindness worldwide. It is one of the priority diseases addressed by the Vision 2020 programmea joint initiative of the World Health Organization and the International Agency for the Prevention of Blindness.
The cataract surgery rate in Africa is low[1,2]. Fear of surgery, high cost of surgery, waiting for free surgery and poor visual results are some of the documented barriers to uptake of cataract surgery[24].
The number of cataract blind persons is expected to increase over the years due to increasing longevity. If measures are not taken to improve cataract surgery uptake, the cataract backlog will continue to increase over time. Better utilisation of available resources has been advocated as the first step towards curtailing low uptake of cataract surgery services[5].
In this connection, the present study reviewed the cataract surgery services in a Nigerian teaching hospital with a view to assessing ways it can contribute to achieving the goals of the Vision 2020 programme with respect to decreasing cataract blindness.
MATERIALS AND METHODS
Enugu State University of Science and Technology (ESUT) Teaching Hospital is located in Enugu, Nigeria. It serves the people of the state and her environs.
The computerised cataract surgery record form[6] was used to collect data on adult cataract surgery performed at ESUT Teaching Hospital Parklane, Enugu, Nigeria over a 12month period (January to December 2006) prospectively. Cataract in children aged 15 years or less were excluded from the study. Traumatic cataracts were also excluded. Data were entered and frequency distribution generated using SSPS version 11.0.
Preoperative examination included assessment of visual acuity(VA), dilation of pupils and slit lamp examination. Biometry was not performed as Ascan ultrasonography and functional keratometer were not available.
The patients were offered abexterno extracapsular cataract extraction with posterior chamber intraocular lens implant (ECCE+PCIOL). Those who had posterior capsule rent received anterior chamber intraocular lens (ACIOL) implant or no IOL implant as deemed appropriate by the surgeon.
RESULTS
Sixtyseven patients had cataract surgery in our centre during the study period. There were 34 males (50.7%) and 33 females (49.3%). The mean age was 59.99±12.79SD, while the range was 2687 years.
The preoperative VA was as follows: 60 eyes (89.6%) had VA of <3/60, 6(8.9%) had 3/60 and 1(1.5%) had 6/60. The coexisting ocular morbidity noted preoperatively were glaucoma 3(4.5%) and maculopathy 2(3.0%). Others were old iritis, advanced pterygium crossing the visual axis, divergent squint, leprosy and diabetic retinopathy 1(1.5%) each.
There were 26 operations (38.8%) on the right eye and 41(61.2%) on the left eye. Sixtyfour eyes (95.5%) had ECCE/PCIOL, 2 eyes (3.0%) had ECCE/ACIOL and 1 eye (1.5%) had ECCE only.
Three ophthalmologists did the operations. The complications included posterior capsule rent/vitreous loss 3(4.5%) and corneal decompensation 3(4.5%).
The visual acuities at 13 weeks, 411 weeks and 12 weeks post operatively are shown in Tables 13.
DISCUSSION
The total number of cataract surgeries performed in this study in one year was low (although traumatic cataract and paediatric cataract were excluded). This is in keeping with low cataract surgery rate documented in literature in Africa[1,2]. In contrast, one hundred cataract operations were performed by 2 ophthalmologists in a Nigerian mission hospital in less than 2 months[7]. The teaching hospital which serves as a centre for manpower development for different cadres of ophthalmic staff has lower productivity. The staff work at below capacity. In east Africa[8], it was noted that cataract surgeons based at Ministry of Health Hospitals had lower productivity than those based at mission or private hospitals, although they received similar training and sponsorship.
One of the emphases of the Vision 2020 programme on human resource development in Africa is the training of more ophthalmologists. While this objective should be pursued, there is equally a great need to utilise the services of the current ophthalmologist maximally. Most ophthalmologists in Nigeria due to remuneration and better job stability work in government hospitals (mainly teaching hospitals). The mission hospitals where high volume cataract surgery is practised lack the capability to employ many ophthalmologists. The government can employ ophthalmologists and deploy them to work in mission hospitals.
Cost has been documented as a barrier to uptake of cataract surgery both in Africa[2] and Asia[9]. Cataract surgery in teaching hospitals in Africa should be made free or offered at cost. When the teaching hospitals achieve high volume of cataract surgery, better utilization of available human resources would have been achieved and the overall cataract surgical rate in the country will increase. Increasing efficiency and productivity of the teaching hospitals should be the long term goal. High volume surgery would translate to better training and better outcome. It is only then that the teaching hospitals would have been playing their proper role in the Vision 2020 initiative.
At 12 weeks postoperative period, only 13 eyes (out of 51), 25.5% achieved presenting VA of 6/6 6/18. With refraction this improved to 38 eyes (74.5%). This is lower than 96% obtained from a centre in China[9] after intensive training of the surgeons on sutureless large incision manual cataract extraction. Facilities for biometry are not available in our centre. There is a need to make biometry services widely available and to have more centres offering training in manual small incision cataract surgery in Africa. Many patients may not eventually wear prescribed glasses due to cost constraint or other reasons. Procedures that offer maximum presenting visual acuity are desirable, as good outcome increases uptake of services.
Table 1Post operative visual acuity at 13 weeksn（略）
Table 2Postoperative visual acuity at 411 weeksn（略）
Table 3Postoperative visual acuity at 12 weeksn（略）
Acknowledgements:The author wishes to thank Dr Chukwurah G immensely for keeping the cataract surgery records.
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