1

1.1 Introduction
The term cataract is derived from the Greek word cataractos, which means water fall.
Cataract is opacity or clouding of the crystalline lens which prevent light rays from
reaching the retina. Cataract is the main cause of low vision and blindness in the world
Majority of cataract (85%) is regarded as senile or age related with uncertain etiology.
However, it is a preventable cause for blindness rectified by the use of appropriate surgical
services. The absence of effective utilization of such services leaves many of those affected
by it with severely impaired vision. Significantly, a majority of those living with blindness
due to cataract and poor access to services are in the developing World.1,2,3

1.2Back ground
1.2.1 World
According to WHO estimates of global data on blindness, there are an estimated 38
million blind people worldwide, and a further 110 million with low vision who are
at risk of becoming blind. Cataract is the leading cause of blindness; accounting for
about half of all blindness in the world4 and average prevalence of blindness is
about 0.7% in the world.4 Age-related cataract accounts for nearly half of these
blind individuals, and is particularly common in developing countries5. WHO
reports that there is a backlog of cataract of approximately 15.8 million people
with an annual increase of over 2 million newly cataract-blind patients6.The World
Health Organization (WHO) estimates that nearly 18 million people are bilaterally
blind from cataract in the world, representing almost half of all global cases of
blindness. Cataract remains the leading cause of blindness and an important cause
of visual impairment across the globe.5, 6

1.2.2 Pakistan
Pakistan, a developing country situated in the World Health Organizations (WHO)
Eastern Mediterranean Region (EMR-D), is bordered by India, China, Iran, and
Afghanistan is the sixth most populous country in the world. According to the
Pakistan National Blindness and Visual Impairment survey the prevalence of
blindness among individuals of all ages in Pakistan is 0.9%.Cataract accounts for
the most common cause (51.5%) of avoidable blindness in Pakistan.7
1.3 RISK FACTORS
The main non-modifiable risk factor for cataract is aging. Other frequently
associated risk factors are trauma, uveitis, diabetes, ultraviolet light exposure, and
smoking. Children are occasionally born with cataracts, mainly due to genetic
disorders. Women are at greater risk than men for developing cataracts and are less
likely to have access to services5.
1.4 Types of Cataract
Types of cataracts include:

A sub capsular cataract occurs at the back of the lens. People with diabetes
or those taking high doses of steroid medications have a greater risk of
developing a subcapsular cataract.
A nuclear cataract forms deep in the central zone (nucleus) of the lens.
Nuclear cataracts usually are associated with aging.
A cortical cataract is characterized by white, wedge-like opacities that start
in the periphery of the lens and work their way to the center in a spoke-like
3

fashion. This type of cataract occurs in the lens cortex, which is the part of
the lens that surrounds the central nucleus.8

1.6 Symptoms of Cataracts

Common symptoms of cataracts include:
blurry vision
trouble seeing at night
seeing colors as faded
increased sensitivity to glare
halos surrounding lights
double vision in the affected eye
frequent changes in glasses prescription8

1.7 Treatment of Cataracts

Non-surgical treatments for cataracts include stronger eyeglasses, magnifying
lenses, and sunglasses with an anti-glare coating. Surgery is necessary when
cataracts prevent you from going about your daily activities, such as reading or
driving. It is also performed when cataracts interfere with the treatment of other
eye problems. One surgical method, known as phacoemulsification, involves the
use of ultrasound waves to break the lens apart and remove the pieces. Extra
capsular surgery involves removing the cloudy part of the lens through a long
4

incision in the cornea. After surgery, an artificial intraocular lens is placed where
the natural lens was.8

1.8 Definition and Background of patient satisfaction

According to the English dictionary to satisfy means to supply fully with what
is desired, expected or needed. Scientists had difficulties with the translation of
this rather wide definition into objectively observable units of measurement, which
is indicated by the numerous amount of and variability in the conceptualisation of
satisfaction. Over 3,000 articles were published about satisfaction within the health
care setting only, and dozens of measurement instruments regarding patient
satisfaction were developed during the past decade. 9Patient satisfaction is a very
subjective concept which is difficult to measure. Surveying the experiences and
views of patients can provide useful information. Achievement of service provision
is a good indicator of patient satisfaction.9

1.8.1 Patient satisfaction after cataract surgery

From a societal perspective, cataractis especially considered to be a medical and
economic problem. Because of the high prevalence, age-related cataract constitutes
the main surgical workload of ophthalmic services. With the global ageing of
populations and the post Second World War baby-boom, which turned out to a
cohort of people who are now at risk for developing cataract, the demand for
5

cataract surgery is expanding rapidly. These medical and economic problems

caused by cataract are reflected by the numerous clinical and cost-effectiveness
studies, which mainly describe the benefits of cataract surgery. However, it is
important to also examine the psychosocial aspects of cataract surgery to how
much the patient satisfied from surgery. Especially, when modern indications for
cataract surgery are based on daily interference of visual function of the patient.9
Although cataract surgery is routine surgery, one should never forget the
uniqueness of the surgical experience for the patient. The eye is an important
organ, both from a physiological and a psychological point of view. With respect to
an outcome-related quality of care, point of view is that cataract surgery has
proximal and distal goals: to improve vision, which results in better vision related
functioning that will subsequently enhance the generic quality of life (Figure 1.8).1

Figure 1.8.1: Proximal and distal goals of cataract surgery

Visual functioning and quality of life have been recognized as important measures
of treatment effectiveness in addition to the more traditional outcome parameter
visual acuity. The difference between the more traditional definition of success of
cataract surgery from the doctors perspective and the patients defined success is
demonstrated by the following quotations. Citing an ophthalmologist: My patient
has 20/20 Snellen vision and reads Jaeger 1. A patient may translate this medical
outcome into Subtitles on the television are not blurred anymore, and I have taken
up my needlework. This patient translation shows satisfaction levels are clearly
related to clinical outcome10.Quality of vision is the patients ability to see well in
6

the context of his or her own individual visual requirements, that is, patients
satisfaction with the surgery

PATIENT OUTCOME CRITERIA

Outcome criteria can vary for each patient, depending on the patients needs, lifestyle, and
medical condition. In general, outcome criteria include the following:

Reduction of visual symptoms

Improvement in visual function

Achievement of desired refractive outcome

Improvement in physical function, mental health, and quality of life8

According to World Health Organization (W.H.O) the standard category for Visual outcome is
good vision is 6/6 to 6/18, borderline vision is less than 6/18 to 6/60 and poor vision is less than
6/60.12

Rationale
Cataract is one of the most frequently occurring causes of visual impairments among the ocular
disorders

in

the

world

and

is

the

most

important

cause

of

reversible

visual

impairment.13,14Cataract in elderly patients can cause progressive painless vision loss 13, Because
of the demographic shift in developed countries toward older age, the prevalence over the whole
population has increased. In Pakistan approximately 570,000 adults are estimated to be blind as a
result of cataract 14. The major indication for cataract surgery is to improve as many aspects of
the visual function as possible, such as contrast sensitivity, disability glare and even visual fields.
The goal is not only to improve functional vision, but also to improve performance in daily
living activities. Despite this, controversy remains regarding the effectiveness of surgery in
improving visual acuity (VA) in the elderly15,16. In cataract patient's 40 years old, there is a
relationship between postoperative VA and the ability to enjoy activities of daily life.

17,18

Previous reports
have focused primarily on the patients VA, while the effect of surgery on the patients quality of
life with respect to vision-dependent activities (visual function) or satisfaction with the final
outcome of surgery has received less evaluative attention. The decision to perform cataract
surgery should not be based solely on VA results.20
A growing body of research indicates that visual acuity (VA) alone is an inadequate measure of
visual impairment. The impact on visual function (VF) is closely related to patient-perceived
outcomes and has become a significant factor in the evaluation of the outcome of surgical
interventions. Although patients may benefit from an increase in VA and VF after cataract
surgery, their satisfaction may be limited. Assessment of patient satisfaction gives additional
9

information on the result of surgery and is therefore of further importance in evaluating surgical
outcome.13
There have been a number of previous studies to find out only VA after cataract surgery with
intraocular lens implants,19 but no study is done on a combination of all these criteria in
Peshawar region, that is, VA and satisfaction regarding the effect of VA on the patients ability to
participate in their daily living activities after cataract surgery. So the present study planned with
the objectives of assessing the visual outcomes of patients after cataract surgery with intraocular
lens implants and to assess the patient satisfaction with surgical outcome. This work is also
required for the partial fulfillment of BVS (Hons) course at Pakistan Institute of Community
Ophthalmology (PICO) HMC Peshawar.

10

11

AIM:
Assessment of patient satisfaction level after cataract surgery in population
having age 40 years.

OBJECTIVES:
To evaluate the patient satisfaction level amongst patients operated for
cataract in HMC.

To evaluate the effect of cataract surgery on VA in patients having age 40

years.

12

13

Patient satisfaction with surgery is an important outcome measure to include in the assessment of
surgical outcomes.
The retrospective study carried out using operation theater records at the Rural Health Training
Centre (RHTC), Paithan, during 2007. Out of 819 cataract surgery patients operated in 2007 a
total of 50 were selected randomly.post-operative VA was 6/18 or better in n=9(19.6%), while 21
(45.7%)patients had

vision (<6/18-6/60) and 16 (34.7%) had vision < 6/60 in total

46

patients.According to score 24 (52.1%) good, 14 (30.4%) normal and 8 (17.3%) were poor
satisfied with their visual outcome.21
According to a study conducted in the Level II hospital UN mission, Feb 2006 to Nov 2006 , A
total of 141 eyes of 136 patients who completed the minimum 6 weeks. A vision of 6/18 or
better was obtained in 102 eyes (72.3%), 6/24-6/60 in 23(16.3%) and >6/60 in 16 (10.3%) at
their last follow up visit.122 (86.5%) good, 14 (9.9%) normal and 5 (3.5%) were poor satisfied
with their visual outcome.
A study conducted at Department of Ophthalmology, Medical University of Vienna, Vienna,
Austria Improvements in visual outcomes were significantly higher Three months
postoperatively, 94.2% of the patients reported improved VA and 92.5% reported improvements
in visual function.
Heritage Medical Research published a study through BJ Ophthalmology found that out of 166
patients

62.4%

were

Very

satisfied,19.5%,Somewhat

satisfied

13.4%Neutral,4.7%Dissatisfied`with cataract extraction .

According to a study which was conducted at Eye department Lady Reading Hospital,
Peshawar by Mubashir Rehman,Asim Ali Shah et al post-operative VA 6/18 or better in
14

n=74(49%), while 60 (39%)patients had vision (<6/18-6/60) and 17 (12%) had vision < 6/60in
151 patients.The questionnaire also indicated good patients satisfaction with the results
achieved.22
According to study conducted in in tribal region of Surat district of Gujaratstate, India,There
were 62.3% cataract operated people having good visual outcome (PVA 6/6-6/18), 24.5% had
(PVA <6/18-6/60) and 13% had <6/60 and The satisfaction level was high among operated in
the sample (79%),15.5 % were in normal level and Only 5.5% were dissatisfied with respect to
surgery.23

At Kikuyu Eye Unit, to assess the visual outcome of patient undergoing cataract surgery and the
result were: BCVA of 6/18 or better was obtained in 94.3% of eyes and an uncorrected vision of
6/18 or better in 78.2% of eyes. Six eyes (1.5%) had BCVA of < 6/60 and almost patients were
satisfied.
Significance of the study
Calculates the visual outcome and assesses the quality of cataract surgery.
Encouraging eye surgeons to monitor their own results, over time, in itself will lead to
better outcomes of cataract surgery.
Provide base line data for the eye unit to design appropriate strategies in order to provide
the highest level of satisfaction and improve results of cataract surgery as improved
outcome will motivate more patients to come forward for surgery.

15

16

METHODS AND MATHRIALS:

Pre survey & Survey Methodology:

Pre survey planning

Development of Performa
Training on IBM SPSS Statistics 20 and Excel.
Prior communication
Sample size estimation
Pilot Study
Study Design Selection
Inclusion and exclusion criteria
Data collection
Budgeting

Post Survey Methodology:

Data entry
Data analyzing
Final report Writing

I.

METHODOLOGY

1. Pre Survey Planning:

In this important phase of study, I discussed the proposed methodology with
me respected supervisor

and colleagues, and the decisions regarding the

17

future fieldwork and data analysis and interpretation was made through
supervisor guidance.
2. Training on IBM SPSS Statistics 20 and Ms Excel:

One week module was attended and creating Questionnaire, Data Entry and
Data Analysis was learnt. Mr. Zia, I.T. Expert, PICO, was the supervisor.

3. Prior Communication:
Through communication with the concerned authority prior approval and
cooperation was sought.

4.

Performa development/ Designing:

Variables in the Performa were selected according to the aims and objectives of
the study and was tested in eye O.P.D at Hayatabad Medial Complex, Peshawar
in one day pilot survey and then finalized for survey.
5. Pilot Study:
A one day pilot was conducted to get an idea of the number of patients of the
required age group in O.P.D, for making arrangements.

6. Sample size:

18

All patients aged 40 years who are operated for cataract and visiting eye OPD
for follow up during 2

weeks i.e. from 13 th October 2014 till 25th October

2014.
7. Study design:
Descriptive Cross-Sectional
8. Study Location:

This study was conducted in eye O.P.D at Hayatabad Medical Complex,

Peshawar. The second largest Hospital in Peshawar, a postgraduate training
center, equipped with all the medical/surgical specialties, serves not only the
western part of the city but also caters of patients coming from across the
border.

9.

Staff Training & Selection of Team:

I myself performed and recorded Visual Acuity, and filled the Performas at
lower O.P.D, while performas were also given and fellow students, working at
other stations.
10. Budgeting
As this was a hospital-based research, so there was no amount needed for
transport. Estimated amount needed for stationary, printing of data and report
assembling of final report extra was approximately RS 10,000/II.

SURVEY METHODOLOGY

19

This cross-sectional study was conducted for patient aged 40 years who
operated for cataract and visiting for follow up.
1. Data Collection Methodology:
This hospital-based, descriptive cross-sectional study was conducted at Eye
department;HMC

Peshawar

for

three

months,

from

sep2014

to

Dec2014.Approval from hospital ethical committee was obtained. Patients aged

40 years underwent cataract surgery was included in the study. Pre-Operative
Visual acuity recorded fromocular examination record and post-Operative VA
with Snellens VA Chart at 6 meters. Data on visual outcome was grouped using
WHO's classification A specially designed questionnaire was used to assess the
patient satisfaction level with outcomes. A Satisfaction level was categorized
into good, satisfactory, and poor on basis of score categorized in
questionnaire. Patients who have no preoperative ocular examination record
were excluded from thestudy. Glare was assessed by trouble seeing street signs
during daylight and problems with oncoming headlights at night. Color
perception was assessed by asking for trouble recognizing specific colors.
Depth perception was assessed by trouble pouring liquids or going downstairs.
Haloes were assessed by asking for rings around light during night. Quality of
vision was assessed during TV watching, playing or working outdoor, reading
time on watch and wall clock, driving at night and during rain, and using
computer and cell phone. After asking all the above questions the patients were
asked to give an overall satisfaction level.

Study tools were required:

VA Chart (snellens).
20

 Trail frame with occluder.

Self-madePerforma.

2. Inclusion Criteria:
All patients aged 40 years who are operated for cataract and visiting eye
O.P.D H.M.C after 1st follow up.
3. Exclusion Criteria:
Mentally retarded patients.
Cataract survey is done for other purpose than visual.
Patients who have no preoperative ocular examination record.
Patients who are not willing to participate in study.
4. Fieldwork Duration:
Fieldwork was from 13th October to 25th October 2014.
5. Ethical Consideration:
The proposal was submitted to Research Supervisor, Mr. Faheem
Marwat.
Before including in the study, verbal Consent was taken from each and
every subject.
The patients were not delayed for undue tests to save the time of patients
as well as the examiner.
Confidentiality was maintained in record keeping.
Performas were distributed to other stations.
21

III. POST SURVY METHODOLOGY

1. Data Entry:
Collected data was then entered in the pre created questionnaire in IBM SPSS
Statistics 20 and then was finally analyzed to get the results.
2. Final Report Writing:

Finally the report is written and submitted to the Research Supervisor, Mr.
Azmat Jahan.

22

23

Preoperative VA
Visual Acuity
6/6-6/18

Frequency Percent
Nil

<6/18-6/60

12.5

<6/60

49

87.5

Total

56

100.0

Pre-Operative VA
50
40
30
20
10
0
6/6-6/18
<6/18-6/60
<6/60

24

Post-Operative VA
Visual Acuity

Frequency Percent

6/6-6/18

36

64.3

<6/18-6/60

12

21.4

<6/60 8

14.3

Total

56

100.0

Post-Operative VA
40
35
30
25
20
15
10
5
0
6/6-6/18

<6/18-6/60

<6/60

25

Gender Distribution
Gender

Frequency Percent

Female

18

32.1

Male

38

67.9

Total

56

100.0

Gender Distribution
40
35
30
25
32.10%

20
15
10
5
0

Females

Males

26

Comparison of Pre and Post-Operative VA

Visual acuity
6/6-6/18
<6/186/60
<6/60
Total

Preoperative
Nil
7(12.5)
49 (87.5)
56 (100.0)

Postoperative
36 (64.3)
12 (21.4)
8 (14.3)
56 (100)

Figures in parenthesis denote percentages

Comparison of Pre and Post-Operative VA

49

36
Pre-Operative

Post-Operative

12
8

06/6-6/18

<6/186/60

<6/60

27

Distribution of Satisfaction scores of cataract surgery patients

Score Satisfaction level

Number(%age)

60 80

Good

27 (48.2%)

30 50

Normal

18 (32.1%)

10 20

Poor

11 (19.6%)

Satisfaction level with Score

30
25
20
15
10
5
0
60-80 Good

30-50 Normal

10-20 Poor

28

The study was conducted for three months from Sep2014 to Sep2014,data
collection period was 2 weeks. Total 56 patients studied in this study which
conducted at Eye OPD Hayatabad Medical Complex, Peshawar. Mean age was
61 years. Gender distribution was analyzed as n=38(67.9%) of 56 patients were
males and n=18(32%) were females.
Visual outcome after cataract surgery
There were 36 (64.4%) cataract operated people having good visual outcome (PVA
6/6-6/18), 12 (36.4%) had (PVA <6/18-6/60) and 8 (14.3%) had PVA <6/60.

Visual acuity
6/6-6/18
<6/186/60
<6/60

Preoperative
Nil
7(12.5%)
49 (87.5%)

Postoperative
36(64.3%)
12 (21.4%)
8(14.3%)

Total

56 (100%)

56 (100%)

Satisfaction with surgery

The satisfaction level was high among operated in the sample 27 (48.2%), normal
level studied 18 (32%), while 11 19.6% were poor satisfied.
29

Score

Number

(%age)

10 - 20

Good

27

48.20%

30 - 50

Normal

18

32.10%

60 - 80

Poor

11

19.60%

30

The WHO suggests that 85% of eyes undergoing cataract surgery should have
good outcome (6/66/18), 10% have borderline outcome (6/186/60), while less
than 5% havepoor outcome (6/60).24The visual results are similar to other
studies.This study showed that visual outcome in most of the operated eyes was
good (PVA 6/18) in (36) 64.4% cases,12(21.4%) was at Borderline, while in some
8(14.3%) respectively after cataract extraction. However our study was no similar
to WHOs standard but revealed good outcome results than population based
studies in Lower Dir, Pakistan (37.3%), Chakwal, Pakistan (32.2%), Nepal (21%),
China (39%)24
According to Mubashir R, Asim A S et al studies post-operative VA 6/18 or better
in n=74(49%), while 60 (39%)patients had vision (<6/18-6/60) and 17 (12%) had
vision < 6/60in 151 patients. which is comparable to our results that was 64.4%,
21.4% and 14.3%.
Proportionately high number of people who had undergone cataract surgery and
were satisfied 48.2% which can associated with

study of*Vijay K. Domple,

Arvind V. Gaikwad,et al 52.1%,However our results about visual outcomes are

much better than mentioned study. Out of 819 cataract surgery patients operated in
2007 a total of 50 were selected randomly. Post-operative VA was 6/18 or better in
n=9(19.6%), while 21 (45.7%)patients had vision (<6/18-6/60) and 16 (34.7%) had

31

vision < 6/60 in total 46 patients and our results were (PVA 6/18) in (36) 64.4%
cases,12 (21.4%) was at Borderline, while in some 8(14.3%) respectively.
Patient satisfaction with surgery is an important outcome measure to include in the
assessment of surgical outcomes The satisfaction level was high among operated in
the sample 27 (48.2%), normal level studied 18 (32%), while 11 19.6% were poor
satisfied.
According to study conducted in the Level II hospital UN mission , vision of 6/18
or better was obtained in 102 eyes (72.3%), 6/24-6/60 in 23(16.3%) and >6/60 in
16 (10.3%) at their last follow up visit, which were comparable to our study,
The presenting visual acuity was similar and comparable to those in other reviewed
studies. It showed that most of our patients only seek medical attention when they
are blind or almost blind in the two eyes, or at least one eye. This is slightly
different from what obtains in developed countries, where patients seek medical
attention earlier and therefore present with better visual acuity.25

The present study revealed that cataract surgery is an effective treatment in terms
of improvement of visual acuity, postoperative functioning, and patients opinion
about the quality of life. Around 50% of the operated patients showed their score in
the range of 60-80 for visual satisfaction, more than 2/3 patients found to be
satisfied after cataract surgery.

32

33

This study clearly shows the beneficial and favorable outcomes. The patients who
are operated for cataract were fully satisfied from their surgery because they
having better visual acuity after cataract surgery and were able to perform their
daily life activities.

34

35

RECOMMENDATION:

Post-operative pseudophakic correction is necessary for better visual outcomes. Therefore

vision centers with good and affordable RE services needs to be established in the rural
area.

There is need to focus more on quality of the cataract surgery which in turn may help in
sustaining the surgical services at base hospital. Training of surgeons, good instruments
and equipments and regular clinical audits in the hospital must be in place to ensure the
quality.

There is a need to provide effective cataract surgical services in the rural areas at country
level.

There is a need to have outreach programs (screening at village and surgery at base
hospital or satellite Centers with free transportation facility or paying them for the cost of
their return travels.

36

Awareness regarding cataract surgery is not enough in the community. Peoples may
educate and advertise in their villages about eye care and facility available and refer
them. The local print and electronic media, handbills-flyers and health talks by health
workers may help.

37

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40

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25.

O.O. Olawoye1, A.O. Ashaye1,et al, VISUAL OUTCOME AFTER CATARACT

SURGERY AT THE UNIVERSITYCOLLEGE HOSPITAL, IBADAN Ann Ibd. Pg. Med 2011.
Vol.9, No.1 8-13.

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DATA ENTRY FORM FOR ASSESSMENT OF SATISFACTION LEVEL AFTER CATARACT

SURGERY IN PATIENTS HAVING AGE 40 YEARS ATTENDING EYE UNIT HMC
PESHAWAR.
Date ______________

OPD Reg No _____________

Name______________

Gender
1): Teacher
8: Driver

Age______________

Area

[1] Male [2] Female

2: Clerk

3: doctor

9: Computer Operator

VA Before Surgery:

4: Engineer

_____________

Occupation
5 : Mechanic

10: Wood Worker

OD

6: Housewife

11: Businessman

7: Farmer

12: Other

OS

[1] 6/6 [2] 6/9 [3] 6/12 [4] 6/18 [5] 6/24 [6] 6/36 [7] 6/60 [8] < 6/60
Surgery Done in
VA After Surgery:

[1] Right Eye

OD

[2]

Left Eye

[3] Both Eyes

OS

[1] 6/6 [2] 6/9 [3] 6/12 [4] 6/18 [5] 6/24 [6] 6/36 [7] 6/60 [8] <6/60

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1. Do you feel difference in vision? Yes/No

2. Is your VA according to your expectations after surgery? Yes/No
3. Is there a trouble seeing street signs during daylight and problems with oncoming headlights at
4.
5.
6.
7.

night?
Yes/No
Do you have any trouble in recognizing specific colors? Yes/No
Is there any trouble pouring liquid or going downstairs? Yes/No
Do you see rings around light during night?
Yes/No
Any problem during TV watching, playing or working outdoor, reading time on watch and wall

clock, driving at night and during rain, and using computer and cell phone? Yes/No
8. Will you persuade other patients to come for surgery?

Satisfaction Score:
(1) 60-80 Good

(2)30-50 Satisfactory(3) 10-20 Poor

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