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ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 62-66

Why is Cataract Surgery Cancelled in Eye Camps? A Prospective Evaluation


1 Department of Eye, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a, Yemen
2 Department of Eye, Faculty of Medicine and Health Sciences, Sana'a University; Cataract and Refractive Surgery Unit, Magrabi Eye Hospital, Sana'a, Yemen
3 Cataract and Refractive Surgery Unit, Magrabi Eye Hospital, Sana'a, Yemen
4 Programming Section, Al-Nibras Health Society, Sana'a, Yemen

Date of Web Publication26-Feb-2018

Correspondence Address:
Mahfouth A Bamashmus
Department of Eye, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a
Yemen
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DOI: 10.4103/sjopthal.sjopthal_25_17

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  Abstract 


Introduction: This is a prospective study to evaluate and report the reasons of cancellation of elective cataract surgeries in an eye camp, from April 5, 2017, to April 10, 2017. The proportion of elective cataract surgeries cancelled on the day of surgery was obtained from the data of the eye camp, and reasons for cancellations were recorded. Materials and Methods: The selected patients for the surgery have gone through preoperative investigations including complete blood count, random blood sugar, coagulation profile, viral serology (hepatitis B, hepatitis C, and HIV), eye examination, intraocular lens calculation, and their medical condition assessed for chronic diseases. Results: A total of 509 patients were listed for elective cataract surgery in an eye camp Hodeidah Governorate. Forty-nine cases (9.6%) were cancelled due to different reasons on the day of surgery. Main reasons for cancellation were eye infections (14), absence of general anesthesia in eye camp for some cases (9), uncontrolled diabetes (8), and late arrival of some patients when there was no time to do the operation (7). Conclusions: Postponing cataract surgery for patients scheduled for surgery in an eye camp is a stressful situation to the patients, their relatives, and the eye camp organizers. Most reasons for canceling the cataract surgery can be avoided, and efforts to reduce the number of postponed cases have to be increased. Ophthalmic examination and medical fitness should be done properly before scheduling for cataract surgery.

Keywords: Anesthesia, cancellation, cataract surgery, eye camps, Yemen


How to cite this article:
Al-Shaer MY, Al-Akily SA, Bamashmus MA, Al-Akhalee HA, Ziad NM. Why is Cataract Surgery Cancelled in Eye Camps? A Prospective Evaluation. Sudanese J Ophthalmol 2017;9:62-6

How to cite this URL:
Al-Shaer MY, Al-Akily SA, Bamashmus MA, Al-Akhalee HA, Ziad NM. Why is Cataract Surgery Cancelled in Eye Camps? A Prospective Evaluation. Sudanese J Ophthalmol [serial online] 2017 [cited 2021 Jun 19];9:62-6. Available from: https://www.sjopthal.net/text.asp?2017/9/2/62/226148




  Introduction Top


Yemen is one of the WHO Eastern Mediterranean Region Countries, the estimated prevalence of blindness in this region is 0.97,[1] and Yemen is regarded as one of the countries with a high prevalence rate of blindness.[2],[3],[4] However, 75% of blindness is avoidable; defined as blindness that can be either treated or prevented by a cataract surgery which is a successful, cost-effective intervention.[1]

Cataract-related blindness treatment is one of the priorities of the WHO and the International Agency for the Prevention of Blindness, especially after the presentation of the VISION 2020: the right to sight initiative in 1999.[5],[6] Cataract blindness is a public health problem of major proportions in developing countries. The most common cause of blindness in Yemen is cataract and accounts for 49%–70% of the causes of blindness,[2],[3],[4] and cataract surgery is the most common procedure done in ophthalmic units in Yemen.[7]

Eye camps that are organized by Al-Nibras Health Society in Yemen have been launched in 1999.[8] These eye camps provide free eye services to the poor and needy people in Yemen. Usually, eye camps are done in the main medical center of major cities in the governorate. Al-Nibras Health Society has visited almost all governorates over the past 18 years.[8] This eye camp was done in Hodeidah governorate which is situated the West Coast of Yemen. In 2012, 62,577 cataract surgeries were done in Yemen, 16.6% were done by charity societies, and majorities are done in eye camps.[7]

We noticed that a number of patients had their cataract surgery postponed on the day of surgery in our eye camps. On-the-day cancellation of cataract surgery causes much distress for the patient and increases the burden on the organizers of the eye camp in addition to significant financial implications. When a cataract patient surgery is canceled in an eye camp, there is usually a waste in the time, effort and resources of these eye camps, especially if it is sponsored by a local or international charity society. The problem of cancelling cataract surgery has got important economical and family issues. It is distressing for the health society, surgeons, patients, relatives, and the sponsoring body of the eye camp.

The worldwide studies have shown that there are some preventable and nonpreventable causes of cancellation [9],[10] although all studies were done in hospitals and not eye camps. Planned operations that are cancelled reflect inefficiency in management.[11],[12],[13] In the literature, surgical cancellation causes have been classified by factors such as surgeon, anesthesia, and patient factors.[11],[13],[14]

We did this prospective study of same day cataract surgery cancellations in Hodeidah eye camp, collecting data from eye camp records and documentation of the reason for the cancellation.


  Materials and Methods Top


A prospective review of cataract surgery done in an eye camp in Hodeidah Governorate from April 5, 2017, to April 10, 2017, was conducted to identify the reasons of cataract surgery cancellations. Al-Nibras Health Society is one of the leading charity societies in Yemen in doing eye camps in Yemen.

The stages of an eye camp go through six steps. First step concerned with advertisement for the eye camp in the main city and the villages in the same governorate. Patients are registered for an eye examination in the second step. Patients are listed for cataract surgery in the third step. Registered patients are prepared for cataract surgery, and those patients are examined by an eye specialist and medical doctor in the fourth step. In the fifth step, the selected patients for the surgery go through preoperative investigations including complete blood count, random blood sugar, coagulation profile, viral serology (hepatitis B, hepatitis C, and HIV), intraocular lens (IOL) calculation, and their medical condition assessed for chronic diseases. In the final step, patients are given a date and time for their cataract surgery which is usually done in the same week.

All patients who were scheduled for cataract surgery and their surgeries were cancelled due to any reason were included in this study. The data of patients fulfilling the above criteria were collected from the form prepared for this study.

Surgeries are done for 3–5 days from 8:00 AM to 6:00 PM using three to four operating tables. The patients are assessed by junior ophthalmologist just before the operation and giving the local anesthesia. The nurse in charge prepares the patient for cataract surgery which is usually done by the senior ophthalmologist. Case cancellation is defined as those procedures that were cancelled either on the day on which surgery was scheduled, or the previous day, or cases that appeared in the definitive schedule list that ultimately were not performed. During the day of surgery, the eye camp staff fills a list of cancellations and records reasons for the cancellation.

Cancellation reasons were entered into a database using an Excel 2010 program. Details of the patient age, sex, and reason for cancellation were noted. The data recorded included the total number of operation performed in the study period, the number of operations cancelled, and the reasons for cancellation were recorded and classified by who decided to cancel the operation. Cancellation decision was taken by the junior ophthalmologist who examined the patient and gave the local anesthesia, the senior ophthalmologist who will do the surgery, and cancellation could be due to factors relevant to patients.

Research Ethics Committee of Al-Nibras Health Society gave the ethical approval.


  Results Top


A total of 509 patients (353 male and 156 female) were planned and listed for cataract surgery in the scheduled eye camp. Forty-nine cases were cancelled on the day of their operation due to different reasons (40 were adults and 9 were children). All patients were scheduled for cataract surgery with IOL implantation.

The mean age of the cancelled cases was 53.45 ± 24.40 standard deviation (SD) years old with a range between 1 and 75 years. According to the age, the patients were divided into either children (9 [18.4%]) and adults (40 [81.6%]). The mean age of children group (9 patients) was 6.22 ± 5.83 SD years old with range between 1 and 17 years. The mean age of adult group (40 patients) was 64.08 ± 9.75 SD years old with a range between 42 and 75 years.

From 49 patients of the study, 31 patients were males (63.3%) and 18 patients were females (36.7%). From children age group, 9 patients of the study, 4 patients were male (44.4%) and 5 patients were female with 55.6%. From adult age group, 40 patients of the study, 27 patients were male with 67.5% and 13 patients were female with 32.5%.

All cases that were postponed and cancelled were studied, and the reason for surgery cancellation was analyzed and is shown in [Table 1].
Table 1: Reasons of cancellation of cataract surgery in Hodeidah eye camp

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  Discussion Top


Cataract surgery is the most common elective surgical procedure performed in eye clinics and hospitals.[15] We estimated that 9.6% of cataract surgeries in eye camps that were cancelled on the day of surgery were potentially avoidable. Case cancellation is defined as those procedures that were cancelled either on the day on which surgery was scheduled, or the previous day, or cases that appeared in the definitive schedule list that ultimately were not performed.[16],[17] In the UK, the National Health Service defined case cancellation as those that occur after the patient has been notified of operation date.[18]

An efficient ophthalmic camp should have a low rate of cancellation of cataract surgery. This study of an eye camp in Yemen that was done by Al-Nibras Health Society demonstrates that most causes of cancellation of cataract surgery in an eye camp were potentially avoidable, and proper preoperative evaluation and assessment may decrease the cancellation of cases before surgery or on the day of surgery.

In a study done in Yemen in an ophthalmic unit that is managed by the government and that provides cataract surgery to the poor at low cost, the cancellation rate was 12%.[13] An ophthalmic center in Saudi Arabia had a higher rate of cancellations (19%).[19] In a study in the United States, 5.3% of ambulatory ophthalmic surgeries were cancelled within 24 h of the scheduled start time.[20] In a study in Portugal, there were 2965 scheduled cataract surgeries, with 650 cancellations (21.92%), and this is the highest reported in the literature.[10]

The reasons of cancellation can be grouped into different factors. In this study, they were grouped into those who were cancelled by the junior ophthalmologist who gave the local anesthesia, the senior ophthalmologist who did the surgery, and patient-related factors.

The junior ophthalmic surgeon, who gave local anesthesia and assessed the patients on the day of surgery, cancelled the cataract surgeries in some patients because of uncontrolled diabetes (8 [16.3%]), uncontrolled hypertension (1 [2.0%]), uncontrolled diabetes and hypertension (2 [4.1%]), and local anesthesia given to the wrong eye and vasovagal attack after local anesthesia (1 [2.0%]). In children, the cancellation was because of lack of general anesthesia (9 [18.4%]) and patients were referred to an eye center in the major cities where general anesthesia is available.

Senior ophthalmologist who did the surgery cancelled the surgeries because of eye infections, namely, conjunctivitis and severe blepharitis (14 [28.6%]), uncooperative patient before the start of cataract surgery (1 [2.0%]), and the degree of cataract was in the early stages (2 [4.1%]). Maturity of cataract is very important in eye camps because the selection usually should be for those cases who are blind from cataract rather than those who are mild to moderate visually impaired.

Blepharitis was the most common ocular reason for the cancellation of cataract surgery in eye camps, and it is recorded in the literature as one of the main reasons of cataract surgery cancellation.[21] Most ophthalmologists fear from postoperative endophthalmitis, and blepharitis is thought to be a major risk factor.[15] A primary risk factor for endophthalmitis is thought to be local eyelid disease, with the majority of cases attributable to the patients' own flora.[22] Current guidelines, therefore, suggest that surgery is postponed pending disease control, usually with a lid hygiene regimen.[15] Unfortunately, diagnosis of significant blepharitis is based on a subjective assessment, and this is why a form of blepharitis can be seen by another doctor as not important finding. A policy has to be applied regarding lid hygiene to all preoperative cataract patients with a view to reducing the number of cancellations due to blepharitis.

Patient-related factors included patients came late for surgery or the time of the eye camp were not enough to do these late cases (7 [14.3]), surgery cancelled by the patient (1 [2.0%]), and no documentation of the reason why the patient cancelled the patient (1 [2.0%]). Our data suggest strongly that proper preoperative evaluation by a medical doctor or experienced junior ophthalmologist plays a significant role in reducing cancellation rates and case delays in eye camps. This study also shows that patients with more medical comorbidities should visit their physician preoperatively.

The civil war in Yemen and the hard socioeconomic situation have affected a large number of the Yemeni population.[23],[24] The cancellation creates psychological and financial hardships for the patients and relatives who plan to have the cataract surgery done in an eye camp. In addition to the negative impact that a case cancellation has on patient, relatives, and staff satisfaction, cancellations in eye camps also have potentially financial implications for donors who support the eye camps in Yemen. In eye camps that are organized by Al-Nibras Health Society, there is usually a target number in each eye camp, and if a case is cancelled, there is usually a waiting list for those who are not on the primary list of the eye camp and are told that they will be contacted by telephoning them if cases are cancelled.

Eye camps organized by Al-Nibras Health Society are usually sponsored by local or international charity organizations. It usually covers all costs related to the surgery, namely, eye camp staff transportation and accommodation, theater staff expenses, instrumentation, microscopes, sterilization, and all intra- and postoperative medications are given to the patients for free. Senior ophthalmic surgeons provide their services in eye camps as volunteer work. Patients only have to cover their own transportation, food, and housing.

Two studies in 2003 and 2012 were done to describe the cataract surgical rate in Yemen.[7],[25] Eye camps accounted for 9% of total cataract surgery done in 2003 and for 16.6% of total cataract surgery done in 2012. The increase in the role of eye camps is mainly due to the war and financial problems in Yemen.[22] Al-Nibras Health Society was one of the main providers of cataract surgery eye camps in Yemen.[7],[25]

Disruptions in the power supply have been an issue in Yemen because of the civil war and other third world countries,[24] Al-Nibras Health Society has overcome this problem by having its own electrical generators, and this has helped in no cancellation related to problems with power supply.

To avoid these situations, a new concept has evolved, especially in day case surgeries such as cataract surgery, i.e., anesthesia preoperative medicine clinic (APMC). The use of APMC has not only decreased the number of cancellation but also undue tension on patients and surgeons.[26] This concept is now to be studied by the board of Al-Nibras Health Society.


  Conclusions Top


Cataract surgery is an expensive procedure in Yemen, and all over the world, its cost is increasing, so eye camps help those who are in need, especially in the war period where a good number of the population is affected financially and psychologically. Ensuring efficiency in reducing postponing cases in eye camps helps the patient, his relative, the health society staff, and the sponsoring charity organizations. Improving the medical evaluation and ophthalmic examination preoperatively definitely will reduce postponing cases during an eye camp.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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This article has been cited by
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[Pubmed] | [DOI]



 

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