Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-11, 2016 ISSN: 2454-1362, http://www.onlinejournal.in

The Effectiveness of Mobile Cataract Surgery Camps in Communities of Angiang Province-Vietnam. Duong Dieu MD, PhD.

Dean of Optical Ophthalmology Faculty-Nguyen Tat Thanh University. Add: 300A NguyenTatThanh street- Hochiminh City, Vietnam Abstract: The effectiveness of mobile cataract surgery camps (MCS) at district hospitals and commune health stations of Angiang province from 1993 to 1998 has showed: For the purpose of quantity, number of operated cataract patients have statistically increased compared to prior period. For purpose of quality, outcome of vision post operation, complications such as infection, vitreous loss did not have any difference in statistics compared to cataract surgery in Provincial Hospital, and other eye camps in or out country. For the purpose of surgical cost, our MCS had solved a great number of cataract patients in the countryside with low cost. For those purposes, MCS in communities should be continued in order to restore vision for backlog blind cataract patients. Key words: mobile cataract surgery, backlog cataract, vision and complication, effect on quantity and quality, cost efficiency Abbreviation: MCS: mobile cataract surgery camps; BPP: Blindness Prevention Program; ICCE: Intracapsular cataract extraction; ECCE: Extra-capsular cataract extraction; IOL: Intraocular lens. .

1. Introduction: The cloudy lens called cataract, which is one cause of vision loss and blindness but up to now the measures to prevent or stop its progression leads to cataract is not effective. However cataract can be removed then with intraocular lens, wearing glasses, contact lenses to restore patient’s vision. In developed countries, the eye care services with high technology is always available to the blind cataract has met the need to restore vision. In poor countries and developing countries backlog cataract remains high. So blindness prevention program (BPP) must include surgical cataract intervention to restore vision due to blind cataract as an important part of the program. In the other hand, cataract surgery in the developed countries performs it with ever increasing sophistication but those in developing countries perform it with simple instruments and a long operating list.

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From 1980-1990 in Asia: India, Nepal, Bangladesh, Africa continent: Cameroon, Transvaal ... have performed surgical team with the surgical eye camps in community for helping hundreds, thousands people suffer from cataract. In Vietnam during 10 years from 1971 to 1980 cataract surgery by district hospitals were 2306 people in north provinces. By the end of 1987 a total of 16,832 cataract people were done [1]. Angiang is an agricultural province of the Mekong Delta. With 3.424km2 area, population of 2 million of which 80% live in rural areas covering by 2,000 km roads and 3,000km waterway parallel with roads. The longevity rate of over 80 year-old is 0.6%, on 70 is 2.5%; over 60 are 6.9% and above 50 is 11% The average population growth is 2.25% yearly (Provincial statistics 1995). There are 2 ophthalmology services of the province. The 1st: Eye department with 20 eye-beds is at the Angiang Provincial Hospital’s 600 patient-beds. The 2nd: Ten eye-beds unit is at the Chaudoc Regional Hospital’s 300 patient-beds. The total number of cataract surgery is about 500 cases yearly. Since 1993, the Eye Department of Angiang Provincial Hospital has organized mobile cataract surgery camps (MCS) at the district hospitals, commune health stations in provincial BPP [1, 2]. In this paper, the effect on quantity, quality and cost efficiency of MCS (1993-1997) is evaluated.

2. Materials and methods:

Design: Clinical Trial Intervention in Communities 2.1 Subjects: All patients received cataract surgery in BPP by Ophthalmology Department of Angiang Provincial Hospital.

2.2 Methods:

* Retrospective study of cataract surgery performed at Provincial Hospital from 1982-1997. * Prospective study cataract surgery performed in communities by MCS from January 1993 to December 1997.

2.3 Measurements:

*Tools for diagnosis: Snellen visual acuity, Landolt visual acuity, intraocular pressure Schiotz, Maclakov-Indirect ophthalmoscopy Heine Page 1427

Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-11, 2016 ISSN: 2454-1362, http://www.onlinejournal.in *Surgical instruments: Surgical Microscope: Scanoptic Intraocular lens (IOL): Fred Hollow, Alcon. *Surgical methods:

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Intracapsular cataract extraction (ICCE) with glasses wearing. Extracapsular cataract extraction (ECCE) with IOL

. N: 1594 patients -(1993-1997) Female=876; Male=718. ICCE+Glasses 1441 patients (1993-1997)

ECCE/IOL 60 patients (1997)

N1= 200 patients F=109, M=91; Ages= 50-85

N2=60 patients F=34, M=26; Ages=25-70

1 month:190 patients, F=109, M=81 1 year :153 patients, F=88 , M=65

1 month : 56 patients F=34, M=22 1 year : 45 patients, F=30, M=15

The endothelial cells counting were excluded. We used SRK formula to calculate IOL power and used artificial mucus (viscoat) in all cases with IOL. In the case of pathological or complex cataract IOL was not inserted. Monitored patient form before and after the surgery was included: physical exam, blood pressure, routine test, blood sugar, visual acuity, intraocular pressure, complication as below: Complications according to OCTET: (Oxford Cataract Treatment and Evaluation Team) Grade I: Mild. Medical treatment but was not likely to result in marked drop in vision. Grade II: Medium. Requiring medical treatment because of vision drop if left treated. Grade III: Severe. Need surgical interventions prevent severe vision loss.

2.4 Statistical analysis:

Chi- square x2= ∑(0-E) 2 / E2 if value < 5 using Fischer’s exact T test t = (n1-n2) / √(n1+n2), t = [p1-p2] / √ (p1q1/n1) + (p2q2/n2), The statistical difference is significant with p <0.05.

3. Results and Discussions:

Our MCS are established based on 4S and 4 C as follow: [2] 1 Announcement cataract operating day (S1=Statement) is on local newspaper, on radio and television about one month before. 2 Patients’ registration (S2=Selection): Patients will register at district hospital where has selected operating patients and has done preoperative task. One-eye patients/pathologic cataract patients are excluded at MCS. 3 Cataract operating days (S3=Surgery). From 2 days to 4 days depending on the number of cataract patient. There are 100 to 150 cases of cataract surgery procedures per day which were done by cataract surgeons from central level (Hochiminh City

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hospital) coordinated with local cataract surgeons (District, Province hospital). Each surgeon conducts 2 operated tables with 2 prepared-patients. Surgeon does only extract lens and insert IOL. Assistants help him/her do all other the steps of operation. 4 Patients’ follow-up (S4=Sequelea). The patients will discharge on the same day in the case of phaco technics and one day later in case of ICCE, ECCE/PIOL. The follow up for the post-operative patients was done by local ophthalmologists. ”The plan without action is bad but the plan without evaluation is worse” we always think. Beside in 4S follow, we also coordinate and unite all surgeons are necessary, more improved instruments must be done adequately for sustainable development. There are 4C in action: Cooperate, Coordinate, Change new instruments, and Conclude. 3.1 For the quantity result: Number of cataract surgical cases increased over time as follow: 1993-1997 vs. 1982-1987 is increased 8 times; and vs.1988-1992 is increased 2 times. These increasing have statistical significance in statistics (Table 1 & 2) t = 23, p< 0.05). Especially, MCS has effective in this number of patients living in the remote-rural areas. [1] [2]. 3.2 For the quality result: * Surgical method: In 1997: The percentage of ECCE/ with IOL of MCS vs. the province hospital is 29% cases vs. 55% cases. The IOL cases in province up to 595 cases/1306 cases occupied 46%. (Table 3) * Regarding complications: For minimize complication we highlight some advantages in technical surgery included: a scleral-cornea 120 degree incision, exposed incision touching only by instrument not by hand, sutures incision with silk 8,0 -10.0 for closed anterior chamber, using viscoat in all cases with IOL. The percentage of total complication between MCS/ Province hospital: For ICCE has Page 1428

Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-11, 2016 ISSN: 2454-1362, http://www.onlinejournal.in statistical significance 24% vs. 37% (t=7 p<0.05) (Table 4); For ECCE/IOL is 25% vs. 30%. (t=9, p<0.05) (Table 5) The 17.5% of vitreous loss at our provincial hospital is higher than MCS 6% (t=4, 5, p<0.05). This can be explained at the provincial hospital the difficult, complex cases had to be done here. Our surgical complications ICCE and ECCE/IOL is the same with result of Aravind Eye Hospital / Clinical Institute of Ophthalmology and Post graduate in Madurai India.[5] (Table 4, 5 and 6). The difference in vitreous loss: In Sudan is 5.7% our MCS is 10% has statistical significance (t=4, p<0.05. [6].The percentage of infection at our MCS is 0.5% compared with Sudan 1.4% (t = 3.75, p <0.05) significantly; and compared with Bangladesh infectious percentage 1 / 2000. [7]. * The visual acuity, the complications between MCS and Provincial hospital have no statistical significance (x2 = 1.46, p> 0.02). (Table 6, 7). This may explain that some pathological, complex cases at Provincial hospital have to been performed, while the MCS has to select the available cases [2]. The patients with second eye surgery (after the 1st good operated eye by previous MCS ) has increased over the period 1994: 10% 1995: 14%, 1997 : 22%. This may be patients believed MCS as well as the backlog of cataract in community is increasing. Female is (55.5%) more than in men (45.5%) and the female patients after 1 year follow-up are more than men patients (t = 0.5, p> 0.05). 3.3 For effective cost: The operating fee of MCS is less expensive than Provincial hospital (Table 8). In India each IOL case is $ 25 US (1990), more than 3 times compared our MCS fee [8]. Saving budget, reducing operation costs as well as time of hospital beds patient’s, reducing travel costs and time for the patient and family are shown. 3.4 Some other results: * At Provincial hospital: For ophthalmologists the more they have treated at MCS, the more they have deeply understanding the patients living in remoterural area. The gap between city and countryside is wider because of urbanization. To do surgery at Provincial hospital is passive but to do surgery at MCS is active to resolve effectively the backlog cataract in community depends on high volume cataract surgery. Besides, the high tech was transferred from central hospital to provincial hospital; district hospital will help to improve

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medical staffs here. So the patients living in remote area can be used this high tech with low cost. The patients who had been operated with good vision of previous MCS are an effective propaganda in communities. Cataract surgery at commune health station was profoundly educational about the incurable blindness contributing to detect the eye diseases can be prevented. In conclusion, to maintain sustainable development of MCS (success) we have to follow 4S and 4 C that mentioned above.

4. Conclusion:

The effectiveness of the surgical cataract surgery by MCS of Angiang Provincial Hospital from 1993 to 1997 showed: 1. For the quantity result: The number patients compared with the previous period. 2. For the quality result: The vision and complications at MCS compared to Provincial Hospital, to some other places inside and outside the country. 3. For effective cost: The budget and time savings, as well as some results which are socially accepted and actively participated by people who is living in remote area. So the MCS should continue to reduce as soon as possible the high backlog cataract in the community

References:

[1]- Phan Thanh Dan, Measures to promote the prevention of blindness due to cataract, study for PhD thesis. Hanoi Medical College 1988. [2] Duong Dieu, “Some consideration on the program cataract surgery at communes, Angiang province”, Medicine and Pharmacy Journal in Hochiminh City 8/1995: 37-38 [3]. Duong Dieu, “Summary 55 cases ECCE/ IOL at ophthalmology department- Angiang provincial hospital 1993-1994”, Ophthalmology News, HCMC 8/1995 [4].Do Thu Nhan, Tran Duy Kien, Doan Trong Hau, “1000 cataract surgery campaign in districts HCMC 1988”, Ophthalmology News- Hochiminh city 1988: 83-86. [5] GN NATCHIAR, RD THULASIRA, AD NEGREL et al, “The Madurai intraocular lens Study”, American Journal of Ophthalmology Jan 1/1998: 1-35 [6] Sanjay DAHWAN, “Clinical profile of an Eye Camp in Doka, Eastern Sudan”, Community Eye Health, (3) 1993: 7-9 [7] RABIUL Husain, “Mobile eye camp in Bangladesh”, World's Major Blinding Condition 1982: 6-13 [8]. WHO. “The Use of intraocular lenses in cataract surgery in developing countries, Geneva”, 1990: 1-3

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Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-11, 2016 ISSN: 2454-1362, http://www.onlinejournal.in

I II III

Table 1 Number of operated cataract patients at provincial hospital[2] Year Periods Patient number Percentage % 1982-1987 532 8,1 1988-1992 2.143 32,3 1993-1997 3.955 59,6 Total 6.630 100%

Table 2 Number of operated cataract patients at MCS, provincial hospital and cooperated with Hochiminh eye hospital in Angiang province 1993-1997[3] Year MCS Provincial hospital MCS cooperated with Hochiminh eye hospital 1993 297 397 220 1994 352 490 250 1995 404 499(IOL:60) 250 1996 280 480(IOL:100) 450 (IOL:200) 1997 261(IOL:75) 495(IOL:270) 550 (IOL:250) Total 1594 2361 1720 Table 3 MCS, provincial hospital: Distribution patients with surgical technics 1997[3] Surgery MCS Provincial hospital Cooperated HCM eye hospital Patient number Patient number Patient number (Percentage %) (Percentage %) (Percentage %) ICCE 186 (71,26) 225 (45,45) 300 54,54 ECCE/IOL 75 (28,74) 270 (54,55) 250 45.46 Total 261 100% 495 100% 550 100% Table 4 MCS and Provincial hospital: Intraoperative and postoperative complications of ICCE MCS Provincial hospital (N=200) (N=202) Patient number Patient number Intraoperative complication: (Percentage %) (Percentage % ) Hyphema anterior chamber 4 2 8 4 Hemmorhage post globe 1 0,5 0 0 Capsule tear 10 5 6 3 Vitreous loss in anterior chamber/ 10 6 35 17.3 out anterior chamber 8 4 10 4.9 Total Postoperative complication: Iris prolapse Uveitis Glaucoma Infection

33

17,5% 59

2 8 1 1

1 4 0,5 0,5

10 4 1 0

5 2 0,5 0

Total Total complication

12 45

6% 15 23,5% 64

7,5% 36,7%

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29,2%

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Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-11, 2016 ISSN: 2454-1362, http://www.onlinejournal.in Table 5 : MCS and Provincial hospital: Intra operative and post operative complications of EECE/IOL [3] Complications: (1997)MCS (1994) Provincial hospital Patients Patients number (%) number (%) (N=60) (N=55) Intra operation 1 Vitreous prolapse 4 6 2 Iris tear 1 1 5 7 Total Post operation 1 month 1. Pupil dilated, cortex+ 6 6 2. Glaucoma 0 1 3. Uveitis 3 4 4. Luxation of IOL 1 0 Total 10 11 Total complication 15(25%) 18(30%) Table 6: MCS complications according to OCTET[7] Intra-operation 1 month 1 year N (%) post-operation/ post-operation/ N (%) N (%) ICCE/ Grade III 6(3,0) 6(4,8) 5(3,4) GII 10(5,0) 10(6,2) 12(7,8) GI 1(0,5) 0(0,0) 0(0,0) 0 183(91,5) 144(90,0) 136(88,8) Total 200(100,0) 160(100,0) 153(100,0) ECCE/IOL/Grade III 4(6,6) 4(7,1) 4(8,9) G II 9(15,0) 10(17,8) 11(24,4) GI 2(3,4) 1(1,8) 0(0,0) 0 45(75,0) 41(73,3) 30(66,7) Total 60(100,0) 56(100,0) 45(100,0) Table 7 MCS and Provincial hospital: Visual acuity 1 month post operation (1995)[2] VA increased VA no change Total N(%) N(%) N(%) Provincial hospital 197(97, 6%) 5(2, 4%) 202 MCS 196(98%) 4(2%) 200 Total 393(97, 8%) 9(2, 2%) 402(100%)

MCS

Provincial hospital

Table 8: MCS and Provincial hospital: Cost for each case of ICCE and ECCE/IOL (1995) ICCE ECCE/IOL Preop: Lab+Drugs:50.000VND Same + Intraop: silk 1/4 :70.000 VND (IOL+ Viscoat 1/6 tube: 250.000 VND) Postop : Glasses :80.000 VND Total 200.000VND 450.000VND Same MCS plus Same MCS+(IOL+1 tube viscoat: hospital bed fee :100.000 VND 500.000VND) + hospital bed fee : 100.000 VND Total 300.000VND 800.000VND

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