Factors associated with visual outcomes after cataract surgery: A cross-sectional or retrospective study in Liberia.

OBJECTIVE: To report the initial outcomes and associated risk factors for poor outcome of cataract surgery performed in Liberia. METHODS AND ANALYSIS: LV Prasad Eye Institute (LVPEI), Hyderabad, started providing eye care in Liberia since July 2017. Electronic Medical Records of 573 patients operated for age-related cataract from July 2017 to January 2019 were reviewed. One eye per patient was included for analysis. All patients underwent either phacoemulsification or manual small incision cataract surgery (MSICS). Pre and postoperative uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA) were recorded at one day, 1-3 weeks and 4-11 weeks. Main outcome measure was BCVA at 4-11 weeks; Intraoperative complications and preoperative ocular comorbidities (POC) were noted. BCVA less than 6/12 was classified as visual impairment (VI). Risk factor for VI was analysed using the logistic regression model.
RESULTS: Of the 573 patients, 288 were males and 285 were females (49.7%). Mean age was 65.9±10.9 years; 14.3% had POC. The surgical technique was mainly MSICS (94.59%, n = 542). At 4-11 weeks, good outcome of 6/12 or better was noted in 38.55% (UCVA) and 82.54% (BCVA). Visual acuity (VA) of 6/18 or better as UCVA and BCVA was noted in 63.5% and 88% eyes respectively. Poor outcome of less than 6/60 was noted as UCVA (11.11%) and BCVA (5.22%). Multivariable analysis showed poor visual outcomes significantly higher in patients with POC (odds ratio 3.28; 95% CI: 1.70, 6.34).
CONCLUSION: The cataract surgical outcomes in Liberia were good; with ocular comorbidities as the only risk factor.

Introduction

There are 253 million people blind or visually impaired worldwide. Of these 89% live in low and middle income countries (LMIC); and 55% are women. [1] Globally, cataract is the leading cause of blindness and second leading cause of visual impairment (VI). [2] In Sub-Saharan Africa 35–45% of blindness and 25–35% of VI is caused by cataract. [2] Liberia in West Africa has a population of approximately 5 million. [3] World Health Organization (WHO) estimates that approximately 1% of Liberians (approximately 35,000 people) suffer from blindness, of which 50% is due to cataract. [3] In terms of human resources, the sub-Saharan region has on average only one ophthalmologist per one million population. [4] This holds true even for Liberia. [4] The Cataract Surgical Rate (CSR) is one of the lowest in Liberia with 81 in 2010 and 157 in 2014. [5, 6] In terms of cataract surgical outcomes, a study by Frucht-Pery and Feldman on cataract surgery in patients with leprosy in Liberia reported that a visual acuity of 20/200 or better was achieved only in 65% of patients. [7] However, this study included only 43 eyes of 30 patients. [7] There are similar reports from other African countries with poor outcomes ranging from 10–40%. [8, 9]

The L V Prasad Eye Institute’s (LVPEI) pyramidal model of eye care delivery has a Centre of Excellence (CoE) at the top, catering to a population of 50 million population, with Tertiary Centres (TC) at the next level, each for 5 million population. [10] These are linked to Secondary Centres (SC) covering 0.5–1 million population mostly in rural locations, with Vision Centres (VC) at primary level for 50,000 population, and Vision Guardians (VG) for 5,000 population. The functions at each level of the pyramid are clearly delineated and demarcated. The SCs are run by one or two ophthalmologists who are trained at a TC or COE for a year. Patients from SCs are referred to TCs or COE only for advanced care and management of complex problems. [10] The model has shown good outcomes of cataract surgery in their rural SCs. [11] The secondary centres provide comprehensive affordable, accessible and appropriate eye care irrespective of the paying capacity of the patients, and have fully equipped surgical facilities where mainly cataract surgeries and other procedures are performed. [10]

In 2014, LVPEI launched the Liberia Eye Health Initiative (LEHI), at the John F Kennedy (JFK) Medical Centre, which is the apex centre for health care in Liberia. A formal collaborative agreement was signed between LVPEI and JFK. The Liberia Eye Centre (LEC) was formally inaugurated on 24 July 2017 in Monrovia to provide comprehensive eye care for people of Liberia. All the staff in the LEC were trained at LVPEI. Since 2018, LVPEI also started the ophthalmology residency training program in Liberia. The purpose of this study is to evaluate outcomes of cataract surgery performed at the LEC as well as associated risk factors for poor outcomes.

Materials and methods

We retrospectively analysed the records of patients who underwent cataract surgery in the LEC at JFK Memorial Medical Centre, Monrovia, Liberia from July 2017 to January 2019. The study was approved by the University of Liberia-Pacific Institute for Research & Evaluation Institution Review Board. The study was conducted in accordance to the tenets of Declaration of Helsinki.

The study included all patients 40 years of age or above. Only the first operated eye was included in the analysis. Data was collected from the Electronic Medical Records (EMR). The protocols were similar to described in our previous publication. [11] In brief, the patients underwent comprehensive eye examination, which included detailed history; uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA); intraocular pressure measurement with Goldmann applanation tonometer; slit lamp examination; dilated lens examination to assess the lens status; and stereoscopic fundus examination with +78/90 Dioptre lens as well as indirect ophthalmoscope. In case there was no view of retina, a B-scan ultrasound was done to rule out any posterior segment pathology. Pre-existing ocular comorbidities were grouped as corneal pathologies, retinal disease, glaucoma and others (non-glaucomatous optic nerve pathologies and uveitis). The systemic comorbidities included hypertension (HT), diabetes mellitus (DM), and HIV seropositive patients. When patient was advised surgery, protocols similar to L V Prasad Eye Institute protocols were followed. [12, 13] In brief, when patient was advised surgery, a designated counsellor did the counselling and explained the type of surgeries as well as associated risk and benefits. A day prior to surgery, intraocular lens (IOL) power calculation was done by measuring keratometry and A Scan biometry. Informed consent from patient and attendant was also taken along with routine blood pressure and blood sugar measurement and a physician fitness a day prior to surgery. On day of surgery, prior to entering operating room, patient dress was changed and eye were dilated with plain tropicamide (0.8% w/v) eye drop. Local anaesthesia given with 2% Xylocaine. After local anaesthesia, patient was shifted to operating room and under all aseptic precautions, eye was cleaned with betadine and draped. The surgeon decided on the surgical technique–either a phacoemulsification or manual small incision cataract surgery (MSICS) with or without intraocular lens (IOL) implantation. MSICS was performed by standard Blumenthal technique. [14] For phacoemulsification, a 5.5 mm scleral would was constructed and a routine phacoemulsification was performed. The choice of procedure was left to surgeon discretion. Anterior chamber (AC) and posterior chamber (PC) IOLs made up of polymethyl methacrylate (PMMA) were used. The intraoperative complications (posterior capsule rupture, zonular dehiscence etc) were noted. Posterior capsular rent or zonular dehiscence was managed by automated vitrectomy and placement of IOL was based on the available support of anterior and / or posterior capsule.

All the surgeries were performed by three surgeons as well as other visiting faculty. All three surgeons had experience of performing more than 1,500 cataract surgery. Post-operatively, patient was prescribed topical steroids for 4 weeks in tapering doses and topical antibiotics for a week.

The primary outcome measure was postoperative visual acuity. The visual acuity was noted preoperatively and postoperatively on day 1, between 1–3 weeks and 4–11 weeks of surgery and analysed. Visual acuity was categorized as 6/12 or better; less than 6/12 to 6/18; less than 6/18 to 6/60 and less than 6/60. Poor outcome was defined as BCVA of less than 6/12 in the operated eye.

Statistical analysis

Statistical analysis was done using Stata 13 (Statacorp, Texas).

Logistic regression model was used to evaluate the association of risk factors for poor outcomes and Fisher’s Exact test was used for categorical variable. A two tailed p value of <0.05 was considered statistically significant. Risk factors for poor outcomes were analysed using univariable and multivariable regressions, based on BCVA at 4–11 weeks follow up.

Results

Between July 2017 and January 2019, a total of 739 cataract surgeries were performed. Of these, 126 were bilateral cataract surgeries (252 eyes), and their first operated eye was included in the analysis. Those 40 patients who underwent cataract surgery at age less than 40 years were also excluded. Hence, 573 eyes of 573 patients were included in the study. Table 1 shows the baseline demographics and ocular findings of these 573 patients. The mean age of the patients was 65.9±10.9 years (ranging from 40 to 99 years); and 49.7% were females. Pre-existing ocular comorbidity was present in 82 patients (14.3%) and systemic comorbidity was noted in 20 patients (3.5%).

Table 1

Demographics and baseline characteristics of the patients who underwent cataract surgery.

Variable		Number of patients (Percentage)
Age group	40 to 49 years	38 (6.6)
	50 to 59 years	122 (21.3)
	60 to 69 years	202 (35.3)
	70 years or above	211 (36.8)
Gender	Male	288 (50.3)
	Female	285 (49.7)
Economic status	Paying (Paid surgeries)	306 (53.4)
	Non-paying (Free surgeries)	267 (46.6)
Eye	Right eye	329 (57.4)
	Left eye	244 (42.6)
Preoperative BCVA*	Less than 6/60	289 (50.4)
	Less than 6/18 to 6/60	94 (16.4)
	Less than 6/12 to 6/18	75 (13.1)
	6/12 or better	115 (20.1)
Systemic comorbidities	Diabetes Mellitus	4 (0.7)
	Hypertension	12 (2.1)
	HIV seropositive	4 (0.7)
Ocular comorbidities	None	491 (85.7)
	Cornea	16 (2.8)
	Glaucoma	39 (6.8)
	Retina	9 (1.6)
	Others#	18 (3.1)

*BCVA Best corrected visual acuity

#Nonglaucomatous optic nerve disease and Uveitis

Of the 573 eyes, the MSICS technique was used in 542 (94.6%) eyes and phacoemulsification was done in 31 (5.4%) eyes. Five hundred and sixty two (98.1%) eyes underwent PCIOL, 11 (1.9%) eyes were either left aphakic or had an ACIOL. Major intraoperative complications such as posterior capsular rest and zonular dehiscence were noted in 3.3% of eyes. Other complications (0.9%) such as Descemet’s membrane detachment (one eye), iridodialysis (two eyes) and would leak (two eyes) were also noted.

Table 2 shows the preoperative and post-operative (uncorrected and best corrected) visual acuity on the first day; 1 to 3 weeks and 4–11 weeks follow up. At last follow up, UCVA of 6/12 or better was seen in 38.6% patients and BCVA of 6/12 or better was seen in 82.5% patients. Similarly, UCVA of 6/18 or better was seen in 63.5% patients and BCVA of 6/18 or better was seen in 88% patients. UCVA and BCVA of less than 6/60 were seen in 11.11% and 5.22% patients respectively.

Table 2

Uncorrected and best corrected visual acuity at different follow-up intervals.

	Preoperative		Post-operative
			Day 1		1–3 weeks		4–11 weeks
	n = 573 (100%)		n = 573 (100%)		n = 509 (88.83%)		n = 441 (76.96%)
VA	UCVA#	BCVA*	UCVA#	BCVA*	UCVA#	BCVA*	UCVA#	BCVA*
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
6/12 or better	44 (7.7)	115 (20.1)	249 (43.5)	419 (73.1)	224 (44.0)	402 (79.0)	170 (38.5)	364 (82.5)
Less than 6/12 to 6/18	48 (8.4)	75 (13.1)	150 (26.2)	50 (8.7)	118 (23.2)	33 (6.5)	110 (24.9)	24 (5.4)
Less than 6/18 to 6/60	132 (23.0)	94 (16.4)	114 (19.9)	53 (9.2)	109 (21.4)	35 (6.9)	112 (25.4)	30 (6.8)
Less than 6/60	349 (60.9)	289 (50.4)	60 (10.5)	51 (8.9)	58 (11.4)	39 (7.7)	49 (11.1)	23 (5.2)

#UCVA Uncorrected visual acuity

*BCVA Best corrected visual acuity

At 4–11 weeks, there were 441 (77%) patients available for follow-up. Table 3 shows the demographics and ocular findings of those who reported for follow up and those who did not, between 4–11 weeks. There was no difference between those lost to follow up and those who were available for follow up, in terms of gender, paying and non-paying status, eye operated, type of surgery, use of intraocular lens, choice on intracameral antibiotics, and intraoperative complications. However, there was a difference in terms of age group, operating surgeon and presence of ocular comorbidity.

Table 3

Demographics and ocular findings of those who followed up and who did not follow up between 4–11 weeks of follow up.

Variables	Sub-group	Available	Not available	P value
		n = 441	n = 132
Age group	40–49 years	34 (89.5%)	4 (10.5%)
	50–59 years	90 (73.8%)	32 (26.2%)
	60–69 years	146 (72.3%)	56 (27.7%)
	> = 70 years	171 (81%)	40 (19%)
				0.04
Gender	Male	219 (76%)	69 (24%)
	Female	222 (77.9%)	63 (22.1%)
				0.60
Economic status	Paying(Paid surgeries)	227 (74.2%)	79 (25.8%)
	Non-paying (Free surgeries)	214 (80.1%)	53 (19.9%)
				0.09
Eye	Right eye	255 (77.5%)	74 (22.5%)
	Left eye	186 (76.2%)	58 (23.8%)
				0.72
Type of surgery	Phacoemulsification	26 (83.9%)	5 (16.1%)
	MSICS#	415 (76.6%)	127 (23.4%)
				0.35
Type of IOL	PC IOL^	430 (76.5%)	132 (23.5%)
	No IOL* or AC IOL&	11 (100%)	0 (0.0%)
				0.07
Intracameral antibiotics	Cefuroxime	49 (83.1%)	10 (16.9%)
	Moxifloxacin	334 (74.1%)	117 (25.9%)
				0.21
Intraoperative Complications	No or minor complications	427 (77.1%)	127 (22.9%)
	Major complications	14 (73.7%)	5 (26.3%)
				0.73
Surgeon category	Faculty 1	140 (82.8%)	29 (17.2%)
	Faculty 2	249 (82.5%)	53 (17.5%)
	Faculty 3	46 (75.4%)	15 (24.6%)
	Visiting Faculty	6 (14.6%)	35 (85.4%)
				<0.001
Systemic comorbidities	Absent	425 (76.9%)	128 (23.1%)
	Present	16 (80%)	4 (20%)
				0.74
Ocular comorbidities	Absent	370 (75.4%)	121 (24.6%)
	Present	71 (86.6%)	11 (13.4%)
				0.03

#MSICS–Manual small incision cataract surgery

*IOL–Intraocular lens

^PCIOL–Posterior chamber intraocular lens

&AC IOL–Anterior chamber intraocular lens

Table 4 shows the differences between the demographics and ocular characteristics of patients who had good versus poor outcomes. Those with poor outcomes were older (p = 0.04); had higher intraoperative complications (p<0.001) as well as associated ocular comorbidity (<0.001); and had either an AC IOL or were left aphakic (p = 0.001).

Table 4

Difference between demographics and ocular characteristic of good versus poor outcome.

Variables	Sub-group	BCVA 6/12 or better	BCVA less than 6/12	Total	P value
		n = 364	n = 77	n = 441
Age group	40–49 years	29 (85.3%)	5 (14.7%)	34
	50–59 years	79 (87.8%)	11 (12.2%)	90
	60–69 years	126 (86.3%)	20 (13.7%)	146
	> = 70 years	130 (76%)	41 (24%)	171
					0.04
Gender	Male	178 (81.3%)	41 (18.7%)	219
	Female	186 (83.8%)	36 (16.2%)	222
					0.49
Economic status	Paying(Paid surgeries)	190 (83.7%)	37 (16.3%)	227
	Non-paying (Free surgeries)	174 (81.3%)	40 (18.7%)	214
					0.51
Eye	Right eye	207 (81.2%)	48 (18.8%)	255
	Left eye	157 (84.4%)	29 (15.6%)	186
					0.38
Type of surgery	Phacoemulsification	22 (84.6%)	4 (15.4%)	26
	MSICS#	342 (82.4%)	73 (17.6%)	415
					0.77
Type of IOL	PC IOL^	359 (83.5%)	71 (16.5%)
	No IOL* or AC IOL&	5 (45.5%)	6 (54.5%)
					0.001
Intracameral antibiotics	Cefuroxime	36 (73.5%)	13 (26.5%)	49
	Moxifloxacin	281 (84.1%)	53 (15.9%)	334
					0.07
Intraoperative complications	Absent	357 (83.6%)	70 (16.4%)	427
	Present	7 (50%)	7 (50%)	14
					<0.001
Surgeon category	Faculty 1	119 (85%)	21 (15%)	140
	Faculty 2	197 (79.1%)	52 (20.9%)	249
	Faculty 3	43 (93.5%)	3 (6.5%)	46
	Visiting Faculty	5 (83.3%)	1 (16.7%)	6
					0.09
Systemic comorbidities	Absent	351 (82.6%)	74 (17.4%)	425
	Present	13 (81.3%)	3 (18.7%)	16
					0.89
Ocular comorbidities	Absent	319 (86.2%)	51 (13.8%)	370
	Present	45 (63.4%)	26 (36.6%)	71
					<0.001

#MSICS–Manual small incision cataract surgery

*IOL–Intraocular lens

^PCIOL–Posterior chamber intraocular lens

&AC IOL–Anterior chamber intraocular lens

Table 5 shows univariable and multivariable association of demographic and ocular surgical factors with poor outcomes (BCVA of less than 6/12 at 4–11 weeks follow-up). In univariable analysis, poor outcomes were associated with presence of ACIOL/No IOL (OR 6.07; 95% CI:1.80, 20.43); intraoperative complications (OR 5.10; 95% CI: 1.73, 15.00); and associated ocular comorbidities (OR 3.61; 95% CI: 2.05, 6.37). However in multivariable analysis, the only significant factor was presence of ocular comorbidities (OR 3.28; 95% CI: 1.70, 6.34).

Table 5

Univariable and multivariable association of demographics, surgical factors with visual outcome of 6/12 or better at 4–11 weeks follow-up.

	Univariable analysis		Multivariable analysis
Variables	Odds Ratio (95% CI$)	P value	Odds Ratio (95% CI$)	P value
Age group
40–49 years	Reference		Reference
50–59 years	0.81(0.26, 2.52)	0.71	1.16 (0.27, 4.96)	0.84
60–69 years	0.92 (0.32, 2.66)	0.88	1.29 (0.33, 5.06)	0.71
> = 70 years	1.83 (0.66, 5.03)	0.24	3.02 (0.81, 11.28)	0.1
Gender
Male	Reference		Reference
Female	0.84 (0.51, 1.38)	0.49	0.81(0.45, 1.47)	0.49
Economic status
Paying(Paid surgeries)	Reference		Reference
Non-paying (Free surgeries)	1.18 (0.72, 1.93)	0.51	1.00 (0.55, 1.81)	0.99
Eye
Right eye	Reference		Reference
Left eye	0.80 (0.48, 1.32)	0.38	0.82 (0.46, 1.49)	0.52
Type of surgery
Phacoemulsification	Reference		Reference
MSICS#	1.17 (0.39, 3.51)	0.77	0.65 (0.19, 2.20)	0.49
Type of IOL
PC IOL^	Reference		Reference
No IOL* or AC IOL&	6.07 (1.80, 20.43)	0	3.97 (0.50, 31.66)	0.19
Intracameral antibiotics
Cefuroxime	Reference		Reference
Moxifloxacin	0.52 (0.26, 1.05)	0.07	0.59 (0.27, 1.30)	0.19
Intraoperative Complications
Absent	Reference		Reference
Present	5.10 (1.73, 15.00)	<0.001	4.30 (0.68, 27.01)	0.12
Surgeon category
Faculty 1	Reference		Reference
Faculty 2	1.50 (0.86, 2.61)	0.16	1.67 (0.79, 3.54)	0.18
Faculty 3	0.40 (0.11, 1.39)	0.15	0.68 (0.17, 2.73)	0.59
Visiting Faculty	1.13 (0.13, 10.19)	0.91	0.96 (0.09, 10.67)	0.97
Systemic comorbidities
Absent	Reference		Reference
Present	1.09 (0.30, 3.94)	0.89	0.93 (0.23, 3.81)	0.92
Ocular comorbidities
Absent	Reference		Reference
Present	3.61 (2.05, 6.37)	<0.001	3.28 (1.70, 6.34)	<0.001

#MSICS–Manual small incision cataract surgery

*IOL–Intraocular lens

^PCIOL–Posterior chamber intraocular lens

&AC IOL–Anterior chamber intraocular lens

$CI–Confidence interval

Discussion

One of the indicators for quality of cataract surgery is the outcome of surgery. Hence, periodic monitoring of outcomes should be an essential component of any hospital quality audit. We reported here the outcomes of cataract surgeries performed in a present facility built in Liberia. There is very little data on outcomes of cataract surgery from Liberia, due to limited number of surgeries. We started this new facility in July 2017, and installed the Electronic Medical Records (EMR) system to collect and store patient data on a daily basis. This is a good source for monitoring the outcomes of cataract surgery.

The only report from Liberia, by Frucht-Pery and Feldman, on cataract surgical outcomes in patients with leprosy, showed that a visual acuity of 20/200 or better was achieved in 65% of patients. [7] However, this study was published more than 25 years ago, included only 43 eyes and the surgical technique used was intracapsular or extracapsular cataract extraction. [7] In our setting, a majority of the surgeries were MSICS with IOL implantation, and had better outcomes. UCVA of 6/18 or better was seen in 63.5% patients and BCVA of 6/18 or better was seen in 88% patients at last follow up. With further cut-off in visual acuity value to 6/12 or better, UCVA of 6/12 or better was seen in 38.6% patients and BCVA of 6/12 or better was seen in 82.5% patient. Similar outcomes were reported in many other countries in Asia and India. [15-18] MSICS was the primary surgical technique in all these studies also. [15-18] There are very few reports on outcomes of cataract surgery from Africa, and outcomes reported by some of these are not encouraging. [19-21] One of the reasons for improved outcome in some centres may be the availability of well-trained surgeons performing high volume work in these centres. However, outcomes of this study was better than many other studies from Africa, including PRECOG study. [22-25] This could be due to availability of well-trained surgeons, accurate biometry in all cases, availability of equipment and consumables, and well trained staff. [26] Another possible reason for poor outcomes reported in Africa could be because the earlier outcome studies in Africa were based on extracapsular cataract extraction (ECCE). In our study, surgeries were performed using MSICS technique. The outcomes of MSICS have been reported to be better than ECCE. [15–18, 22] WHO has recommended a good visual outcome as 90% having BCVA of 6/18 or better and 80% having UCVA of 6/18 or better. The outcomes were also similar to the recommended rates of WHO for BCVA, but were less than what is recommended for UCVA. [27] There were a significant number of patients blind or with severe visual impairment (SVI) (VA less than 6/60) preoperatively; whereas only 5% had VA of less than 6/60 postoperatively at 4–11 weeks. This implies better quality of life for those blind or with SVI before cataract surgery. This also suggests that there are a significant number of blind and SVI in the population who need intervention on a priority basis.

Major intraoperative complications were found in 3.3% eyes, and these are within acceptable standard stated by WHO (less than 5%). These were mainly due to posterior capsular rent or zonular dehiscence. This was slightly higher than other studies from India and Nepal [15-18] but less than most studies from Africa. [23-25] Mavrakanas et al reported an overall complication rate of 8.2% with less in MSICS surgeries (5.3%) as compared to ECCE (10.2%). [23] However, these surgeries were carried out by cataract surgeons undergoing training. [23] Complication rate was also much lower than what was reported on PRECOG and other studies. [25] However, complications were higher compared to Matta et al (1.4%) and Sherwin et al (2.5%). [11, 28] Unlike other studies, we did not find age or presence of a complication to be risk factor for poor outcomes. [20, 29] This could be due to lesser number of complications as well as adequate management of these complications. [29] No devastating complications like expulsive choroidal haemorrhage or endophthalmitis were reported, though the number of surgeries was less.

In univariable analysis, poor outcomes were associated with presence of ACIOL/No IOL (OR 6.07; 95% CI:1.80, 20.43), intraoperative complications (OR 5.10; 95% CI: 1.73, 15.00), and associated ocular comorbidities (OR 3.61; 95% CI: 2.05, 6.37). However in multivariable analysis, the only significant factor was presence of ocular comorbidities (OR3.28; 95% CI: 1.70, 6.34). This was similar to the reports from other studies. [15, 20, 22] This suggests that a good preoperative comprehensive eye examination by a trained ophthalmologist would be necessary to identify ocular comorbidities that are likely to affect outcomes. Patients with ocular comorbidities can then be counselled with a clear explanation on the outcomes of surgery.

One of the limitations of the study could be the patients who were lost to last follow up (132 patients, 23%). However, on comparing those available and those lost to follow up, there was a statistically significant difference between the two groups only in terms of age group, operating surgeon, and presence of ocular comorbidity. Those available for follow up had a higher prevalence of ocular comorbidity. Hence, this could underestimate the good outcomes at last follow up. PRECOG study showed good correlation between early outcome (3 or fewer days) and 40 days or more post operatively. It also showed that eyes with borderline or poor outcome at discharge tend to improve and achieve better vision at 4–6 months. Hence, the results obtained from those available for follow up may underestimate the good outcomes.

This is the first study to report on the outcomes of cataract surgeries in Liberia. We believe that there are multiple factors which might have played a role—availability of full time well-trained surgeons, accurate biometry, availability of equipment and consumables, and well trained staff. However, further studies are needed to support this hypothesis. A Residency program has been started in Liberia recently and this article is one of the first articles from Liberia and cataract surgery outcomes of residents will be compared and reported in future.

In conclusion, overall the outcomes of cataract surgery in Liberia was good as compared to many studies done in Africa. Apart from this, the complications rates were also comparable to WHO standards and only risk factor for poor outcome was presence of ocular comorbidities.

‘liberia0402019_age40_and_above.dta’ attached.

(DTA)

Click here for additional data file.

3 Mar 2020

PONE-D-19-34050

Cataract Surgery Visual Outcomes and Associated Risk Factors in Liberia

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This study presents the cataract surgery outcomes of the Liberia Eye Health Initiative by the LVPEI and highlights risk factors for poor outcome. The study is simple and the results clearly presented, but some grammar editing and proofreading is required to facilitate readability. Recalculation of some figures in the tables would also be helpful. I have included some suggestions below.

Line 28: ‘Since July 2017, LV’

Putting this at end of sentence would improve flow

Line 44: recommendation, not ‘recommended’

Line 51: of, not ‘for’

Line 54: from blindness of which 50% is due to cataract.

Add comma after blindness

Line 54-56: In terms of human resources, there is only one ophthalmologist for one million population on an average in the sub-Saharan region.

Rephrase:

In terms of human resources, the sub-Saharan region has on average only one ophthalmologist per one million population.

Line 56: This holds true even for Liberia [4]

Add full stop at end of sentence

Line 63-65 : The L V Prasad Eye Institute’s (LVPEI) pyramidal model of eye care delivery has a Centre of Excellence (CoE) at the top catering to a population of 50 million population with Tertiary Centres (TC) at the next level, each for 5 million population.[10]

add commas after 'top' and '50 million' to improve clarity

Line 80: The Liberia Eye Centre (LEC)

80 was formally inaugurated on 24 July 2017 in Monrovia, to provide comprehensive eye care

81 for people of Liberia.

Delete comma

Line 81-82

Since 2018, LVPEI also started the ophthalmology residency training program in Liberia.

Suggest delete this line: irrelevant and disrupts the flow (unless this study involves this program?)

Line 82-84

The purpose of this study is to evaluate outcomes of cataract surgery performed, at the LEC as well as associated risk factors for poor outcomes.

Delete comma

Line 132: While 562 (98.1%) eyes underwent PCIOL, 11 (1.9 %) eyes were either left aphakic or had an ACIOL.

Rephrase; try not to start sentence with 'while'

Line 133-136: Major intraoperative complications such as posterior capsular rest and zonular dehiscence were noted in 3.3% eyes. Other complications (0.9%) such as Descemet’s membrane detachment (1eye), iridodialysis (2 eyes) and would leak (2 eyes) were also noted.

-33% 'of' eyes

- Note spacing between ‘1’ and ‘eye’

- Generally, when quoting figures below ten, they should be spelt in full (eg. one eye)

Line 138-139: Table 2 shows the preoperative and post-operative (uncorrected and best corrected) visual acuity first day; 1 to 3 weeks and 4-11 weeks follow up.

…visual acuity ‘on the’ first day

Line 162: Those with poor outcomes were older (p=0.04); had higher intraoperative complications (p<0.001) as well as associated ocular comorbidity (<0.001); and had no IOL and AC IOL (p=0.001).

It would be clearer to say ‘and had either an ACIOL or were left aphakic’

Line 183: We reported here the outcomes of cataract surgeries performed by in a new facility

184 built in Liberia.

Replace with 'present'

Line 185: ‘We started this new facility in July 2017, and installed the Electronic Medical Records (EMR) system to collect and store patient data on a daily basis. This is a good source for monitoring the outcomes of cataract surgery.’

Comment: This part is not relevant in discussion. Please delete. Any discussion of methods eg EMR should be in Methods.

Line 189: The only report from Liberia by Frucht-Pery and Feldman, on cataract surgical outcomes in 190 patients with leprosy, showed that a visual acuity of 20/200 or better was achieved in 65% of 191 patients.

Add comma after Liberia

Line 191: However, this study published more than 25 years ago, included only 43 eyes and

192 the surgical technique used was intracapsular or extracapsular cataract extraction.

-grammar: ‘…this study, which was published ...’

Line 198-202: There are very few reports on outcomes of cataract surgery from Africa, and outcomes reported by these are not encouraging, except a few centres. One of the reasons for this was the availability of well-trained surgeons performing high volume work in these centres. However, outcomes were better than many other studies from Africa, including PRECOG study. This could be due to availability 203 of well-trained surgeons, accurate biometry in all cases, availability of equipment and

consumables, and well trained staff.

Please rephrase for clarity and readability. For example, by 'one of the reasons for this', it is unclear if you mean the reason for the poor outcome or the exceptions. and when you say' outcomes were better than many other studies', to which outcomes do you refer?

Line 208: The outcomes were also similar to the recommended rates of WHO for BCVA (BCVA of 90% having 6/18 or better), but were less than what is recommended for UCVA.

Rephrase sentence…

Line 212: This implies better quality of life for those blind or SVI before cataract surgery.

Use either 'severely visually impaired' or 'with SVI'

Line 224: Unlike other studies, we did not find age or presence of a complication as a risk factor for poor outcomes

Replace ‘as’ with ‘to be’

Line 226: No devastating complications like expulsive choroidal haemorrhage or endophthalmitis were report, though the number of surgeries was less.

Reported, not ‘report’

Line 236: Patients with ocular comorbidities, can then be counselled with a clear explanation on the outcomes of surgery.

Delete comma

Line 239: However, when we compared those available and those lost to follow up, we found that they differed in terms of age group, operating surgeon, and presence of ocular comorbidity.

Suggest rephrase… there was a statistically significant difference between the two groups only in terms of age group, operating surgeon, and presence of ocular comorbidity.

Line 241: Those available for follow up had higher prevalence of ocular comorbidity.

‘had a higher’

Line 242: PRECOG study also showed good correlation between early outcome (3 or fewer days) and 40 days or more post operatively.

Delete ‘also’ (you have it in the next sentence too)

Line 245: Hence, the results obtained from those available for follow up can underestimate the good outcomes.

‘may’, instead of ‘can’

Conclusion: Rephrase to link the thoughts/clarify your recommendations. Eg. you might suggest, after your sentence re well trained staff, that the planned residency program is a move in such a direction. Whether regular monitoring would improve the catarat outcomes in patients with ocular comorbidities is doubtful- in this case, screening and prevention (where possible) of primary disease may be more relevant.

Tables:

Table 1: Please check formatting of table. ? no line between ‘HIV seropositive’ and ‘none’...?

Table 3: Since you are comparing between those whose follow up was available vs not, the percentages should be by column (eg gender: Female 222/285 = 77.9%). Likewise for table 4 (good vs poor outcome)

Reviewer #2: While commending the efforts of the authors , i will wish to state that this manuscript has significant flaws.

First is the title. A change ought to be considered to reflect the fact that the "risk factor" considered was for poor outcome. The title as it is "Cataract Surgery Visual Outcomes and Associated Risk Factors in Liberia" does not reflect this point.

The authors only considered visual acuity using distant snellen acuity and there was no information on near vision. It would have been of benefit to give an idea of the post operative refractive outcome ie myopia, hyperopia or astigmatism within a specified range of diopters.

A significant concern is a lack of description of the process. There is need to inform the readers of what process the patient has to go through. A step wise description of the process from the point of patient contact and diagnosis, through the preoperative workup and surgical technique should be included in the manuscript.

What was the basis for selection to perform MSICs or Phacoemulsification?

No information on biometry was given ie was biometry done and at what point?

There is no information on if there was a patient counseling, and by whom.

Was there a patient participation in decision to surgery? Patient consent was not mentioned, let alone discussed.

Can an explanation for the high number of failure to attend 4 to11 week follow up clinic visit be given.

There are other significant points requiring attention in the attached manuscript. This has been included as comments in the manuscript. Click on the comments icon at each point to view the question.

Reviewer #3: Why were most patients operated using MSICS and not phacoemulsification?

Only a total of 86.8% received intracameral antibiotics, what informed this decision and did this information affect any of the measured outcomes?

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Reviewer #1: Yes: Evelyn Tai

Reviewer #2: Yes: OGUGUA, N. OKONKWO

Reviewer #3: No

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Submitted filename: PONE-D-19-34050_reviewer (1).pdf

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11 Apr 2020

Response to Editor comments

1. Should not the title be more reflective if it was: Factors associated with Visual Outcomes after Cataract Surgery: A cross-sectional or retrospective study in Liberia

Our response: Thanks for this suggestion. Title has been modified accordingly. (Page1; Line 1-2)

2. Abstract: The objective seems to be good as a Title.

Our response: Thanks for this feedback.

3. Conclusion: Conclusions do not support the results. How do we know if these are similar to the WHO outcomes? Either it could be said “very high or give the data from WHO”.

Our response: Thanks for this feedback. The conclusion is modified accordingly. It says The cataract surgical outcomes in Liberia were good; with ocular comorbidities as the only risk factor.” (Page2; Line 20-21)

4. Results: Lines 119-122 should go under Materials and Methods. Also, same information is repeated twice.

Our response: Thanks for the suggestion. However as the lines 119-122 are part of results, we would request to retain it in results.

5. Table 2: While UCVA is better than 6/12 for 44 for UCVA 115 (20%), did they need any surgery? If they were referred in future, could have been saved resources and extend the facilities who need urgent treatment. Please explain the rationale behind it.

Our response: Thanks for the comment. We agree with the editor that these group may have not needed surgery. However, as per our protocol, we leave the decision of surgery to patient and suggest them to undergo surgery if there is any visual disability. It’s well known that individual disability level cannot be confidently predicted from his / her visual acuity alone.

Enclosed related reference: https://www.ncbi.nlm.nih.gov/books/NBK207559/

6. Table is very difficult to understand its meaning. How the outcome sustains in different VA categories would be appropriate. For example, of 115 (20%) had VA 6/12 at baseline compared to 82.5% after week 4. This is a fascinating improvement.

Our response: Outcome is given as per WHO categories which makes it simple to understand.

7. Then, 289 (50.4%) had worse than 6/60 at baseline compared to 5.2% at week 4. This means, approximately 289-23= 266 improved their vision from 6/60, i.e. 92% got improvement. Is it correct? In case of 6/12 or better, 364-115 = 249 i.e., 68% got improvement. Worse the VA, more the improvement after surgery. Is it not the message?

Our response: Thanks for the comment. However unfortunately, this is not the correct way of interpreting. The table signifies only change in categories. It’s likely that the 115 who were 6/12 or better remained in same category i.e. 100% improvement. Post-operative 6/12 or better means that are patients in lower categories pre-operatively and have moved to 6/12 or better post-operatively.

8. Table 2: Please remove the % to fit and make the Table better.

Our response: We would like to keep the ‘n’ and % as this gives better idea of the % who have improved /post-operatively. However, if you insist, we can remove it.

9. Surgeon category: Did Faculty 2 performed worse? Is there any explanation of this significant finding?

Our response: There was no difference in outcomes of the surgeons as shown in table 4. The p values for surgeon category in 0.9.

10. Please combine Table 4 and 5 together. When the univariate analysis shows non-significant association, no need to go for multi-variate adjustment. In fact, all are non-significant except the last one which could be presented in the text.

Our response: Table 4 has the ‘n’ in each group as well as uses the chi-square test. Table 5 is univariable and multivariable analysis. Both tables have different information and we would request to leave them for better understanding of readers.

For multivariable analysis, selection does not depend on the results of univariable analysis. If one thinks that the independent variable will have an effect of dependent variable, the variable can be used in both analysis. We have accordingly considered all variable for univariable and multivariable analysis. For more details on how to select variable for univariable and multivariable analysis, please refer the following: http://www.biostathandbook.com/multiplelogistic.html

11. Conclusion: “In conclusion, this is the first study to report on the outcomes of cataract surgeries in Liberia. This is not a conclusion. It could be said “this first study conducted in Liberia reported……………….”.

Permanent infrastructure, uniform protocols, and well-trained staff in all cadres can improve uptake of cataract surgeries in future. It is not clear with which results this conclusion is linked.

Regular monitoring and follow-up will improve the outcomes further.

A Residency program has been started in Liberia recently and this article is one of the first articles from Liberia and outcomes of residents will be compared and reported in future. Is it a conclusion or strength? Alternatively, are we interest to see what we have instead of potential outcome?

I would consider the conclusion should be better reflected of the findings.

Our response: Thanks for your valuable inputs. The text is modified as: ‘This is the first study to report on the outcomes of cataract surgeries in Liberia. We believe that there are multiple factors which might have played a role - availability of full time well-trained surgeons, accurate biometry, availability of equipment and consumables, and well trained staff. However, further studies are needed to support this hypothesis. A Residency program has been started in Liberia recently and this article is one of the first articles from Liberia and outcomes of residents will be compared and reported in future.’

‘In conclusion, overall the outcomes of cataract surgery in Liberia was good as compared to many studies done in Africa. Apart from this, the complications rates were also comparable to WHO standards and only risk factor for poor outcome was presence of ocular comorbidities.’ (Page 16; Line 10-19)

Response to reviewer 1

1. This study presents the cataract surgery outcomes of the Liberia Eye Health Initiative by the LVPEI and highlights risk factors for poor outcome. The study is simple and the results clearly presented, but some grammar editing and proofreading is required to facilitate readability. Recalculation of some figures in the tables would also be helpful. I have included some suggestions below.

Our response: Thanks for your constructive criticism.

2. Line 28: ‘Since July 2017, LV’ Putting this at end of sentence would improve flow

Our response: Thanks for this comment. Suggestion incorporated. It reads as ‘LV Prasad Eye Institute (LVPEI), Hyderabad, started providing eye care in Liberia since July 2017.’ (Page2; Line 4-5)

3. Line 44: recommendation, not ‘recommended’

Our response: Thanks for comment. However, based on editor comments the conclusion is changed and it reads as ‘The cataract surgical outcomes in Liberia were good; with ocular comorbidities as the only risk factor.’ (Page2; Line 20-21)

4. Line 51: of, not ‘for’

Our response: Thanks for pointing this out. Suggestion incorporated. It reads as “In Sub-Saharan Africa 35-45% of blindness and 25-35% of VI is caused by cataract” (Page3; Line 5)

5. Line 54: from blindness of which 50% is due to cataract. Add comma after blindness

Our response: Thanks for the suggestion. This is done. (Page3; Line 8)

6. Line 54-56: In terms of human resources, there is only one ophthalmologist for one million population on an average in the sub-Saharan region. Rephrase: In terms of human resources, the sub-Saharan region has on average only one ophthalmologist per one million population.

Our response: Thanks for the suggestion. This is rephrased. It reads as ‘In terms of human resources, the sub-Saharan region has on average only one ophthalmologist per one million population’ (Page3; Line 8-9)

7. Line 56: This holds true even for Liberia [4] Add full stop at end of sentence.

Our response: This is done and a full stop has been added. (Page3; Line 10)

8. Line 63-65 : The L V Prasad Eye Institute’s (LVPEI) pyramidal model of eye care delivery has a Centre of Excellence (CoE) at the top catering to a population of 50 million population with Tertiary Centres (TC) at the next level, each for 5 million population.[10] add commas after 'top' and '50 million' to improve clarity

Our response: this is done and the sentence now reads as “..delivery has a Centre of Excellence (CoE) at the top, catering to a population of 50 million population,…” (Page3; Line 18)

9. Line 80: The Liberia Eye Centre (LEC) was formally inaugurated on 24 July 2017 in Monrovia, to provide comprehensive eye care for people of Liberia.

10. Our response: Thanks for pointing this out. The comma is deleted. The sentence now reads as “The Liberia Eye Centre (LEC) was formally inaugurated on 24 July 2017 in Monrovia to provide comprehensive eye care for people of Liberia” (Page4; Line 9)

11. Line 81-82: Since 2018, LVPEI also started the ophthalmology residency training program in Liberia. Suggest delete this line: irrelevant and disrupts the flow (unless this study involves this program?)

Our response: While point is well taken, the idea of introducing the residency program is to build a case for resident outcomes for our next paper which is on their outcomes. Hence we would request to retain it.

12. Line 82-84: The purpose of this study is to evaluate outcomes of cataract surgery performed, at the LEC as well as associated risk factors for poor outcomes. Delete comma

Our response: Thanks for pointing this out. The comma is deleted. Sentence reads as ‘The purpose of this study is to evaluate outcomes of cataract surgery performed at the LEC as well as associated risk factors for poor outcomes. (Page4; Line 12)

13. Line 132: While 562 (98.1%) eyes underwent PCIOL, 11 (1.9 %) eyes were either left aphakic or had an ACIOL. Rephrase; try not to start sentence with 'while'

Our response: Thanks for pointing this out. Sentence changed and it reads as “Five hundred and sixty two (98.1%) eyes underwent PCIOL, 11 (1.9 %) eyes were either left aphakic or had an ACIOL” (Page 7; Line 6-7)

14. Line 133-136: Major intraoperative complications such as posterior capsular rest and zonular dehiscence were noted in 3.3% eyes. Other complications (0.9%) such as Descemet’s membrane detachment (1eye), iridodialysis (2 eyes) and would leak (2 eyes) were also noted. 3.3% 'of' eyes. Note spacing between ‘1’ and ‘eye’. Generally, when quoting figures below ten, they should be spelt in full (eg. one eye)

Our response: Thanks for pointing this out. Suggestion incorporated. Sentence reads as ‘Major intraoperative complications such as posterior capsular rest and zonular dehiscence were noted in 3.3% of eyes. Other complications (0.9%) such as Descemet’s membrane detachment (one eye), iridodialysis (two eyes) and would leak (two eyes) were also noted.’ (Page 7; Line 7-10)

15. Line 138-139: Table 2 shows the preoperative and post-operative (uncorrected and best corrected) visual acuity first day; 1 to 3 weeks and 4-11 weeks follow up. …visual acuity ‘on the’ first day

Our response: Thanks for your suggestion. It reads as ‘Table 2 shows the preoperative and post-operative (uncorrected and best corrected) visual acuity on the first day; 1 to 3 weeks and 4-11 weeks follow up.’ (Page 8; Line 2)

16. Line 162: Those with poor outcomes were older (p=0.04); had higher intraoperative complications (p<0.001) as well as associated ocular comorbidity (<0.001); and had no IOL and AC IOL (p=0.001). It would be clearer to say ‘and had either an ACIOL or were left aphakic’

Our response: Suggestion incorporated. It reads as ‘Those with poor outcomes were older (p=0.04); had higher intraoperative complications (p<0.001) as well as associated ocular comorbidity (<0.001); and had either an AC IOL or were left aphakic (p=0.001).’ (Page 10; Line 6)

17. Line 183: We reported here the outcomes of cataract surgeries performed by in a new facility built in Liberia. Replace with 'present'

Our response: Suggestion incorporated. It reads as ‘We reported here the outcomes of cataract surgeries performed by in a present facility built in Liberia.’ (Page 13; Line 7)

18. Line 185: ‘We started this new facility in July 2017, and installed the Electronic Medical Records (EMR) system to collect and store patient data on a daily basis. This is a good source for monitoring the outcomes of cataract surgery.’ Comment: This part is not relevant in discussion. Please delete. Any discussion of methods eg EMR should be in Methods.

Our response: Comments well taken, however, as EMR is relevant for prospective data collection, we feel its relevant to discuss its importance. It has been mentioned in methods as well as discussion. If all hospitals in Africa get EMR, routine monitoring of cataract outcome would become easy.

19. Line 189: The only report from Liberia by Frucht-Pery and Feldman, on cataract surgical outcomes in patients with leprosy, showed that a visual acuity of 20/200 or better was achieved in 65% of 191 patients. Add comma after Liberia

Suggestion incorporated. It reads as ‘The only report from Liberia, by Frucht-Pery and Feldman, on cataract surgical outcomes in patients with leprosy, showed that a visual acuity of 20/200 or better was achieved in 65% of patients’ (Page 13; Line 13)

20. Line 191: However, this study published more than 25 years ago, included only 43 eyes and the surgical technique used was intracapsular or extracapsular cataract extraction. -grammar: ‘…this study, which was published ...’

Suggestion incorporated. It reads as ‘However, this study was published more than 25 years ago, included only 43 eyes and the surgical technique used was intracapsular or extracapsular cataract extraction’ (Page 13; ;Line 15)

21. Line 198-202: There are very few reports on outcomes of cataract surgery from Africa, and outcomes reported by these are not encouraging, except a few centres. One of the reasons for this was the availability of well-trained surgeons performing high volume work in these centres. However, outcomes were better than many other studies from Africa, including PRECOG study. This could be due to availability of well-trained surgeons, accurate biometry in all cases, availability of equipment and consumables, and well trained staff. Please rephrase for clarity and readability. For example, by 'one of the reasons for this', it is unclear if you mean the reason for the poor outcome or the exceptions. and when you say' outcomes were better than many other studies', to which outcomes do you refer?

Our response: Comment well taken and changes done. The sentence now reads as “One of the reasons for improved outcome may be the -availability of well-trained surgeons performing high volume work in these centres.” (Page 14; Line 9-11)

22. Line 208: The outcomes were also similar to the recommended rates of WHO for BCVA (BCVA of 90% having 6/18 or better), but were less than what is recommended for UCVA. Rephrase sentence…

Our response: Comment well taken and changes done. The sentence now reads as “WHO has recommended a good visual outcome as 90% having BCVA of 6/18 or better and 80% having UCVA of 6/18 or better. The outcomes were also similar to the recommended rates of WHO for BCVA, but were less than what is recommended for UCVA. (Page 14; Line 17-19)

23. Line 212: This implies better quality of life for those blind or SVI before cataract surgery. Use either 'severely visually impaired' or 'with SVI'

Our response: Comment well taken and changes done. The sentence now reads as ‘This implies better quality of life for those blind or with SVI before cataract surgery.’ (Page 14; Line 23)

24. Line 224: Unlike other studies, we did not find age or presence of a complication as a risk factor for poor outcomes. Replace ‘as’ with ‘to be’

Our response: Comment well taken and changes done. The sentence now reads as ‘Unlike other studies, we did not find age or presence of a complication to be risk factor for poor outcomes’ (Page 15; Line 11)

25. Line 226: No devastating complications like expulsive choroidal haemorrhage or endophthalmitis were report, though the number of surgeries was less. Reported, not ‘report’

Our response: Comment well taken and changes done. The sentence now reads as ‘No devastating complications like expulsive choroidal haemorrhage or endophthalmitis were reported, though the number of surgeries was less.’ (Page 15; Line 13)

26. Line 236: Patients with ocular comorbidities, can then be counselled with a clear explanation on the outcomes of surgery. Delete comma

Our response: Comment well taken and changes done. The sentence now reads as ‘Patients with ocular comorbidities can then be counselled with a clear explanation on the outcomes of surgery.’ (Page 15; Line 22)

27. Line 239: However, when we compared those available and those lost to follow up, we found that they differed in terms of age group, operating surgeon, and presence of ocular comorbidity. Suggest rephrase… there was a statistically significant difference between the two groups only in terms of age group, operating surgeon, and presence of ocular comorbidity.

Our response: Comment well taken and changes done The sentence now is rephrased as “However, on comparing those available and those lost to follow up, there was a statistically significant difference between the two groups only in terms of age group, operating surgeon, and presence of ocular comorbidity.” (Page 15; Line 25 and Page 16; Line 1-2)

28. Line 241: Those available for follow up had higher prevalence of ocular comorbidity. ‘had a higher’

Our response: Comment well taken and changes done. The sentence now reads as ‘Those available for follow up had a higher prevalence of ocular comorbidity’ (Page 16; Line 2)

29. Line 242: PRECOG study also showed good correlation between early outcome (3 or fewer days) and 40 days or more post operatively. Delete ‘also’ (you have it in the next sentence too)

Our response: Comment well taken and changes done. The sentence now reads as ‘PRECOG study showed good correlation between early outcome (3 or fewer days) and 40 days or more post operatively.’ (Page 16; Line 4)

30. Line 245: Hence, the results obtained from those available for follow up can underestimate the good outcomes. ‘may’, instead of ‘can’

Our response: Comment well taken and changes done. The sentence now reads as ‘Hence, the results obtained from those available for follow up may underestimate the good outcomes.’ (Page 16; Line 7)

31. Conclusion: Rephrase to link the thoughts/clarify your recommendations. Eg. you might suggest, after your sentence re well trained staff, that the planned residency program is a move in such a direction. Whether regular monitoring would improve the catarat outcomes in patients with ocular comorbidities is doubtful- in this case, screening and prevention (where possible) of primary disease may be more relevant.

Our response: Comment well taken, however based on editor comment, the conclusion has been changed. It reads as “In conclusion, overall the outcomes of cataract surgery in Liberia was good as compared to many studies done in Africa. Apart from this, the complications rates were also comparable to WHO standards and only risk factor for poor outcome was presence of ocular comorbidities. (Page 16; Line 16-19)

32. Tables:Table 1: Please check formatting of table. ? no line between ‘HIV seropositive’ and ‘none’...?

Our response: Comment well taken and a line has been added

33. Table 3: Since you are comparing between those whose follow up was available vs not, the percentages should be by column (eg gender: Female 222/285 = 77.9%). Likewise for table 4 (good vs poor outcome)

Our response: Comment well taken and is done for table 3 and 4

Response to reviewer 2

1. While commending the efforts of the authors , i will wish to state that this manuscript has significant flaws. First is the title. A change ought to be considered to reflect the fact that the "risk factor" considered was for poor outcome. The title as it is "Cataract Surgery Visual Outcomes and Associated Risk Factors in Liberia" does not reflect this point.

Our response: Thanks for your constructive criticism. We will try our best to address all the issues raised. As far as title is concerned, based on editor suggestion, the title has been modified. Please see response to editor comment 1.

2. The authors only considered visual acuity using distant snellen acuity and there was no information on near vision. It would have been of benefit to give an idea of the post operative refractive outcome ie myopia, hyperopia or astigmatism within a specified range of diopters.

Our response: Thanks for your valuable suggestion. Pre and post-operative refractive error change as well as presbyopia are part of a different manuscript.

3. A significant concern is a lack of description of the process. There is need to inform the readers of what process the patient has to go through. A step wise description of the process from the point of patient contact and diagnosis, through the preoperative workup and surgical technique should be included in the manuscript.

Our response: As suggested, a detail description is included. It reads as ‘The protocols were similar to described in our previous publication.[11] In brief, the patients underwent comprehensive eye examination, which included detailed history; uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA); intraocular pressure measurement with Goldmann applanation tonometer; slit lamp examination; dilated lens examination to assess the lens status; and stereoscopic fundus examination with +78/90 Dioptre lens as well as indirect ophthalmoscope. In case there was no view of retina, a B-scan ultrasound was done to rule out any posterior segment pathology. Pre-existing ocular comorbidities were grouped as corneal pathologies, retinal disease, glaucoma and others (non-glaucomatous optic nerve pathologies and uveitis). The systemic comorbidities included hypertension (HT), diabetes mellitus (DM), and HIV seropositive patients. When patient was advised surgery, protocol similar to L V Prasad Eye Institute protocols were followed.[12, 13] In brief, when patient was advised surgery, a designated counsellor did the counselling and explained the type of surgeries as well as associated risk and benefits. A day prior to surgery, intraocular lens (IOL) power calculation was done by measuring keratometry and A Scan biometry. Informed consent from patient and attendant was also taken along with routine blood pressure and blood sugar measurement and a physician fitness a day prior to surgery. On day of surgery, prior to entering operating room, patient dress was changed and eye were dilated with plain tropicamide (0.8% w/v) eye drop. Local anaesthesia given with 2% Xylocaine. After local anaesthesia, patient was shifted to operating room and under all aseptic precautions, eye was cleaned with betadine and draped. The surgeon decided on the surgical technique – either a phacoemulsification or manual small incision cataract surgery (MSICS) with or without intraocular lens (IOL) implantation. MSICS was performed by standard Blumenthal technique.[14] For phacoemulsification, a 5.5 mm scleral would was constructed and a routine phacoemulsification was performed. The choice of procedure was left to surgeon discretion. Anterior chamber (AC) and posterior chamber (PC) IOLs made up of polymethyl methacrylate (PMMA) were used. The intraoperative complications (posterior capsule rupture, zonular dehiscence etc) were noted. Posterior capsular rent or zonular dehiscence was managed by automated vitrectomy and placement of IOL was based on the available support of anterior and / or posterior capsule.

All the surgeries were performed by three surgeons as well as other visiting faculty. All three surgeons had experience of performing more than 1,500 cataract surgery. Post-operatively, patient was prescribed topical steroids for 4 weeks in tapering doses and topical antibiotics for a week. (Page 4; Line 22-25; Page 5; Line 1-25 and Page 6; Line 1-4 )

4. What was the basis for selection to perform MSICs or Phacoemulsification?

Our response: As described in the manuscript, the choice of procedure was left to surgeon discretion. (See response to comment 3)

5. No information on biometry was given ie was biometry done and at what point?

Our response: Thanks for the comment. This is added to the manuscript and the sentence reads as ‘A day prior to surgery, intraocular lens (IOL) power calculation was done by measuring keratometry and A Scan biometry.’ (See response to comment 3)

6. There is no information on if there was a patient counseling, and by whom.

Our response: Thanks for the comment. This is added to the manuscript and it reads as ‘In brief, when patient was advised surgery, a designated counsellor did the counselling and explained the type of surgeries as well as associated risk and benefits.’ (See response to comment 3)

7. Was there a patient participation in decision to surgery? Patient consent was not mentioned, let alone discussed.

Our response: Thanks for the comment. This is added to the manuscript and it reads as ‘Informed consent from patient and attendant was also taken along with routine blood pressure and blood sugar measurement and a physician fitness a day prior to surgery.’ (See response to comment 3)

8. Can an explanation for the high number of failure to attend 4 to11 week follow up clinic visit be given

Our response: The follow-up rate was nearly 77% which is much better than most of the studies done in Africa. We are separately collecting data on barriers which is part of different manuscript.

9. There are other significant points requiring attention in the attached manuscript. This has been included as comments in the manuscript. Click on the comments icon at each point to view the question.

Our response: Thanks for this information.

10. In my opinion , this title does not read well and is not clear. It may be preferable to say "Outcome of Cataract Surgery and Risk Factors for Poor Visual Outcome Amongst Liberians / or In Liberians. I am very aware of your short title.

Our response: Thanks for this suggestion. As far as title is concerned, based on editor suggestion, the title has been modified. Please see response to editor comment 1. The short title now is changed to “Visual outcomes of cataract surgery in Liberians” (Page1; Line 21)

11. Risk factors for what? If it is for poor visual outcome, then please say so and add it to the sentence.

Our response: Thanks for this suggestion. It is changed to ‘To report the initial outcomes and associated risk factors for poor outcome of cataract surgery performed in Liberia’ (Page2; Line 2-3)

12. In my mind this should read "Majority of the patients underwent MSICS, while a few had phacoemulsification" . This is because only 5.4% of the eyes had a phaco. according to your results, which is far fewer than the number than had MSICS.

Our response: Thanks for this suggestion. This has already been mentioned in results.

13. Was this finding also at 4 -11 weeks ?

Our response: Yes, this was at 4-11 weeks also

14. What factors influenced the decision on choice of technique, IOL use ?

Our response: It was the surgeon who decided on the surgical technique. Anterior chamber (AC) and posterior chamber (PC) IOLs made up of polymethyl methacrylate (PMMA) were used. (See response to comment 3)

15. Please provide details of the experience and expertise of the three surgeons and the visiting faculty. Were cases done my ophthalmology residents +/- with supervision

Our response: The three surgeons have performed more than 1500 cataract surgeries in India. No surgeries were performed by the residents. (See response to comment 3)

16. Also provide more details of the entire pre operative process. Was a biometry done and at what point?

Our response: (See response to comment 3)

17. Was there a need for B scan ultrasonography in some cases?

Our response: Yes, five patients underwent ultrasonography

18. What of blood works etc?

Our response: Yes, routine blood pressure measurement and blood sugar was checked and physician fitness was taken a day prior to surgery. (See response to comment 3)

19. Describe in detail the process each patient is expected to have gone through until he or she gets to the OR. I would also expect a description of the technique of MSICS including wound size etc.

Our response: A day prior to surgery, intraocular lens (IOL) power calculation was done by measuring keratometry and A Scan biometry. Informed consent from patient and attendant was also taken along with routine blood pressure and blood sugar measurement and a physician fitness a day prior to surgery. On day of surgery, prior to entering operating room, patient dress was changed and eye were dilated with plain tropicamide (0.8% w/v) eye drop. Local anaesthesia given with 2% Xylocaine. After local anaesthesia, patient was shifted to operating room and under all aseptic precautions, eye was cleaned with betadine and draped. The surgeon decided on the surgical technique – either a phacoemulsification or manual small incision cataract surgery (MSICS) with or without intraocular lens (IOL) implantation. MSICS was performed by standard Blumenthal technique.[14] For phacoemulsification, a 5.5 mm scleral would was constructed and a routine phacoemulsification was performed. The choice of procedure was left to surgeon discretion. Anterior chamber (AC) and posterior chamber (PC) IOLs made up of polymethyl methacrylate (PMMA) were used. The intraoperative complications (posterior capsule rupture, zonular dehiscence etc) were noted. Posterior capsular rent or zonular dehiscence was managed by automated vitrectomy and placement of IOL was based on the available support of anterior and / or posterior capsule. Reference for the details of the tehnnique aand protocols has been added.

a. Thomas R, Kuriakose T, George R. Towards achieving small-incision cataract surgery 99.8% of the time. Indian J Ophthalmol. 2000 Jun;48(2):145-51. Review. PubMed PMID: 11116514.

b. https://www.lvpei.org/patient-care/surgeries-inpatient

c. https://www.lvpei.org/sub-speciality/cataract

(See response to comment 3)

20. Did all the surgeon employ the same technique and were there modifications.

Our response: Yes: All surgeons followed the same technique (mentioned above). For MSICS, standard Blumenthal technique was used. For phacoemulsification, a 5.5 mm scleral would was constructed and a routine phacoemulsification was performed. (See response to comment 3)

21. What was done in cases of PC rent or zonular dialysis i.e how was this complication managed? Please give details.

Our response: Posterior capsular rent or zonular dehiscence was managed by automated vitrectomy and placement of IOL was based on the available support of anterior and / or posterior capsule. (See response to comment 3)

22. At what point was patient consent for surgery taken?

Our response: Informed consent from patient and attendant was also taken along with routine blood pressure and blood sugar measurement and a physician fitness a day prior to surgery. (See response to comment 3)

23. Was any form of preoperative counselling done?

Our response: In brief, when patient was advised surgery, a designated counsellor did the counselling and explained the type of surgeries as well as associated risk and benefits. (See response to comment 3)

24. Did the patient participate in the decision of for surgery and what type of surgery to be done?

Our response: In brief, when patient was advised surgery, a designated counsellor did the counselling and explained the type of surgeries as well as associated risk and benefits. (See response to comment 3)

25. There is no mention of a consent for surgery from the patient or relations.

Our response: Informed consent from patient and attendant was also taken along with routine blood pressure and blood sugar measurement and a physician fitness a day prior to surgery. (See response to comment 3)

26. What is the pre operative counselling like and at what stage is consent for surgery taken?

Our response: In brief, when patient was advised surgery, a designated counsellor did the counselling and explained the type of surgeries as well as associated risk and benefits. (See response to comment 3)

27. can any explanation or discussion be given for the relatively higher amount / percentage or ratio of failure to attend follow up visits compared to attending follow up visits, amongst the "visiting faculty" . The ratio is very large and not seen in the other faculty.

Our response: This is a good observation. Visiting faculty were two local surgeons and two who came from India. It’s likely that as the visiting surgeon (their operating surgeon) was not available during the subsequent visit of the patient, the patients might have not turned up.

28. poor outcome cannot be defined as BCVA of less than 6/12 . That means the 6/18 will fall into the category of poor vision. This truly is not the case.

Our response: This is as per WHO definitions. Also in most of the countries would have 6/12 vision mandatory for driving licence so that too was considered separately.

29. Was any consideration given to the presence of posterior capsular opacity formation? Was YAG laser capsulotomy attempted in any of the eyes ?

Our response: As the follow up period was only 4-11 weeks, there was no YAG laser attempted.

30. Please reconstruct this sentence. it is faulty and does not read well.

Our response: The sentence is reconstructed. It reads as ‘We reported here the outcomes of cataract surgeries performed in a present facility built in Liberia’ (Page 13; Line 7-8)

31. This is a repetition of information already given in the results section. It should do better if re phrased.

Our response: Sentence changed to ‘UCVA of 6/18 or better was seen in 63.5% patients and BCVA of 6/18 or better was seen in 88% patients at last follow up. With further cut-off in visual acuity value to 6/12 or better, UCVA of 6/12 or better was seen in 38.6% patients and BCVA of 6/12 or better was seen in 82.5% patient’. (Page 14; Line 3-6)

32. This statement is likely not the case .I recommend you visit the African Journal on Line (AJOL) to conduct your search on this topic. You will find a large amount of reports.

Our response: Thanks for the suggestion. New reference has been added and sentence changed to ‘There are very few reports on outcomes of cataract surgery from Africa, and outcomes reported by some of these are not encouraging’ (Page 14; Line 8-9)

33. These references are old . Over a decade old. Can there be more recent information. You may find this ref useful

Our response: Thanks for the suggestion. New reference added.

Oderinlo, Olufemi & Hassan, Adekunle et al. (2016). Refractive aim and visual outcome after phacoemulsification: A 2-year review from a Tertiary Private Eye Hospital in Sub-Saharan Africa. Nigerian Journal of Clinical Practice. 20. 10.4103/1119-3077.183249.

34. Which centers are you referring to ? Please clarify .

Our response: These refer to centres in Africa. Sentence changed and reads as ‘One of the reasons for improved outcome in some centres may be the availability of well-trained surgeons performing high volume work in these centres.’ (Page 14; Line 9-11)

35. which outcomes is being referred to here? Is it outcome from this study ? Please state clearly and make your sentences clear and easy to understand.

Our response: Yes, we are referring to outcomes of our study. Sentence changed and it reads as ‘However, outcomes of this study was better than many other studies from Africa, including PRECOG study’. (Page 14; Line 11-12)

36. No mention was made about the training of the surgeons either in the methods section or hear. Faculty 3 appeared to perform far less surgery as well as the visiting faculty . Any comments on this ?

Our response: The three surgeons have performed more than 1500 cataract surgeries in India. It has been added in methods section. It reads as ‘All three surgeons had experience of performing more than 1,500 cataract surgery.’ The surgeries of faculty 3 is less as the surgeon joined at a later date. The visiting faculty were four in number and they came only for a week period. Hence, their numbers are less. (See response to comment 3)

37. No mention was made of biometry throughout the manuscript until now. How and when was this done. This has been previously mentioned in the methods section.

Our response: This has been previously mentioned in the methods section. It reads as ‘A day prior to surgery, intraocular lens (IOL) power calculation was done by measuring keratometry and A Scan biometry.’ (See response to comment 3)

38. Please reconstruct this sentence to provide clarity and meaning to it.

Our response: Its reconstructed. Reads as ‘This implies better quality of life for those blind or with SVI before cataract surgery.’ (page 14; Line 23)

39. This truly shows why a description of your process is essential, to understand what exactly the patient goes through from the point of initial patient contact in the clinic to after surgery care .

Our response: Thanks for the comments. It has been mentioned in methods section. (See response to comment 3)

40. A significant proportion of your patients did not complete the followup or dropped out. What will you do to reverse this trend?

Our response: The follow-up rate was nearly 77% which is much better than most of the studies done in Africa. We are separately collecting data on barriers which is part of different manuscript.

41. What outcomes of residents ? Please clarify.

Our response: Thanks for the comment. Sentence changed ‘A Residency program has been started in Liberia recently and this article is one of the first articles from Liberia and cataract surgery outcomes of residents will be compared and reported in future.’ (Page 16; Line 13-16)

Response to reviewer 3

1. Why were most patients operated using MSICS and not phacoemulsification?

Our response: As described in the manuscript, the choice of procedure was left to surgeon discretion. (See response to comment 3 of reviewer 2)

2. Only a total of 86.8% received intracameral antibiotics, what informed this decision and did this information affect any of the measured outcomes?

Our response: This is a routine protocol of cataract surgery that is followed based on our previous experience of using intracameral antibiotics as a prophylaxis for prevention of endophthalmitis. However, in some cases, the surgeon missed to give it.

Submitted filename: Response to reviewers comments_Final.doc

Click here for additional data file.

29 Apr 2020

Factors associated with Visual Outcomes after Cataract Surgery: A cross-sectional or retrospective study in Liberia

PONE-D-19-34050R1

Dear Professor Khanna,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Authors,

Congratulations on your work. It is accepted. However, I would suggest to fix the formatting issues before it publishes. I have not liked the formatting of the Tables which do not look fantastic. For example,

Table 1: Number of Patients (percentage). If it gives 38 (6.6%) and so on. Does it not using the percentage twice? Either it should be removed from the title line or from the numbers. Removing from the numbers (inside of the tables) is preferred because it will give extra space to accommodate not for Table 1 but for other tables.

Table 2 is taking two rows due to keeping the percentage. It could be looked better. Still OK

Table 3: There is no title in the first two columns (characteristics and labels of characteristics). These two columns could be presented in one column bringing the labels of characteristics under the characteristics. This would give ample space to fit everything in Tables 3 & 4. I WOULD NOT KEEP THIS SILLY MISTAKES AND FORMATTING ISSUES LEFT FOR THE REVIEWERS/EDITOR. P values are mainly with two decimal places but one is with one decimal place. Sometimes, there are spaces between parenthesis and words and sometimes not. Should be very consistent throughout.

There are some footnotes in Table 3. However, the symbol choice seems random. *, plus sign (+), cross sign...........comes before these. These are formatting issue which is just a matter of last-minute work to fix after a long time work.

Reviewers' comments:

5 May 2020

PONE-D-19-34050R1

Factors associated with Visual Outcomes after Cataract Surgery: A cross-sectional or retrospective study in Liberia

Dear Dr. Khanna:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

Dr Fakir M Amirul Islam

Academic Editor

PLOS ONE