Introduction Cataracts, real public health problem especially in developing countries, are the leading cause of blindness worldwide.
Its treatment is surgical AIM. To study the results of cataract surgery by phacoalternative procedure by small incision.
Patients and Methods He acted in a cross-sectional study with descriptive and analytical covered with a prospective collection of given
over a period of 02 months (18 May to 18 July 2015) in adults at the Ophthalmologic Hospital Saint Andre de Tinré (OHSAT). Sociodemographic,
clinical and treatment were evaluated.
Result The prevalence of cataract was 17.6%, with a male predominance (59.3%). The mean age was 61.7 ± 12.9 years with the most
represented slice of 51-65 years. 95% of patients were in a state of blindness at the entrance. Functional results indicate that 19.9% of
patients had good visual acuity without correction (≥3 / 10), 70.1% had a mean acuity (1 / 10- <3/10) and 10% poor acuity ( <1/10).
These results improve with the correction TS and pass respectively 44.8%, 49.3% and 5.9%. The main complications were intraoperative
capsular rupture (2.7%) and vitreous loss (2.3%). The postoperative complications were hyphema (3.5%) and corneal edema (1.7%).
Conclusion Cataract remains a leading cause of blindness and poses management problems in developing countries. Adequate technical
equipment would be an asset to improve business results
Cataract Surgery, Visual Acuity, Complications
Cataract defined as the opacification of the lens is a public health
problem especially in developing countries. Its management
represents one of the first priorities of the international initiative
‘Right to Sight Vision-2020’ with a current estimation of 16 to 20
million non-operated cases.
According to WHO, cataract is responsible for 60% of cases of
blindness worldwide. Cataract surgery rate in sub-Saharan area
remains among the lowest in the world, between 200 and 400
operated cases per million of inhabitants against 3500-5000 in
The vision that we can hope to recover from cataract surgery
depends both on the state of other transparent media than that of
the retina and optic nerve.
However, we must remember that any surgery carries a potential
Studies in several countries have helped to have an estimate of the
results of cataract surgery.
Thus, a multicenter study conducted in 15 European countries has
resulted in 61.3% of good results.
In local and regional literature, few studies have addressed the
results of cataract surgery. In Benin, a study conducted in Cotonou
noted that 81.3% of patients are in a state of blindness preoperative
and 69.6% had good results.
We have no recent database in
Benin in general and particularly in the northern part, allowing
us to evaluate the functional outcomes of cataract surgery. This is
what justifies the choice of our work.
Patients and Study Methods
This was a cross sectional study with descriptive and analytical
covered with a prospective data collection. The study took place
over a period of 02 months from 18 May to 18 July 2015.
Regarding the visual acuity (VA) preoperatively, we adopted the
WHO classification which is as follows:
-Blindness if AV ≤ 1/20
-Severe visual impairment if 1/20 -Moderate visual impairment if 3/10 -Normal visual function if AV> 7/10
• Regarding to postoperative AV, the classification used was that of
guidelines of WHO recommendations:
-Good results (10/10 - 3/10): postoperative uncorrected VA of at
least 80% and postoperative AV corrected at least 90%
- Average results (<3/10 - 1/10): VA postoperative uncorrected
15% and postoperative corrected VA <5%
- Poor outcome (<1/10): Postoperative VA with and without
• The corrected visual acuity: it corresponds to the VA obtained
after testing the pinhole.
• Inclusion criteria
Were included in our study patients meeting the following criteria:
-The adult subjects with unilateral or bilateral cataract,
-The adult patients operated for cataract who received an
intraocular lens during the study period and received a follow up
than a month after the operation.
• Exclusion criteria
- Local pathologies of patients: corneal opacity, glaucoma,
- Patients with whom postoperative control has been achieved and
- Patients undergoing post traumatic cataract.
• A dependent variable in our study was the operated eye for
• Independents variables were clinical, and therapeutic.
Data collection was done by the means of two techniques:
a literature review and interviews face to face interviewerinterviewee
(e) with the followed patients for an eye examination.
Each patient included after the completion of surgery received
three ophthalmologic controls: on Day 1 (eye exam and dressing),
Day 2 (measurement of visual acuity) and Day 30 (eye examination
and measurement of visual acuity).
At each control, it was done:
-an examination to collect the various complaints,
-an ophthalmic examination comprising: measuring the far visual
acuity without and with the pinhole refraction when it was not
-a review at the slit lamp with IOP measurement and FO to the
-a search for possible postoperative complications.
The collected data were entered using Epi data software. Then
they were treated with EPI INFO software (Version 7).
EXCEL software was used for organizing data in tables and graphs.
Comparing the proportions and percentages was performed
with the chi2 test (or Fisher’s exact test (test Karl Pearson) as
appropriate). For these comparisons probability p <0.05 was
considered statistically significant.
During the study period from 18 May to 18 July 2015 (2 months),
2126 patients were registered in Ophthalmologic Hospital Saint
Andre de Tinré (OHSAT). Out of these, 375 (17.6%) had a cataract.
Our sample consisted of 221 (58.9%) patients with postoperative
controls carried out for all of them. The turnout was 79.8%. Each
patient was operated on one eye.
Laterality of the cataract
In our series (442 eyes of 221 patients), 322 were diagnosed
cataracts. 101 patients (45.7%) had bilateral cataract and 120
patients had unilateral cataract. The right eye was affected in 24%
of cases and the left in 30.3% of cases.
Laterality of the operated eye
In our series, the 322 cataracts, 221 (68.6%) were made (one eye
The left eye has represented the eye mainly operated with a number
of 117 (53.2%) against 104 (46.8%) for the right eye.
Preoperative visual acuity
95% of patients were in a state of blindness at the admission.
Distribution of patients according to visual acuity
before surgery (Tinré, 2015).
Patients operated by ophthalmologists physicians represented a workforce of 123 (55.7%) against 98 patients (44, 3%) for the superior technician in ophthalmology cataract operator.
The phacoalternative was the technique performed in all cases
with posterior chamber Intra ocular lens in 218 cases (98.64%)
and anterior chamber Intra ocular lens in 3 cases (1.36%). All Intra
ocular lens were standard power of 21 diopters.
Uncorrected visual acuity
Figure 2 shows the distribution of patients according to the VA
without correction preoperatively, at postoperative Day 2 then Day 30.
Distribution of patients according to the visual acuity
without correction in preoperatory, at Day 2 and at Day 30 postoperatory
Corrected visual acuity
In our study patients with visual acuity between 1/20 and 3/10 after
testing the pinhole were the most represented with 101 patients
(45.7%) to D 2 and 109 patients (49.3%) to Day 30.
Day 30 visual acuity between 3/10-7/10 represented 90 patients
Distribution of patients according to the visual
acuity with correction in preoperatory, at Day 2 and at Day 30
postoperatory (Tinré, 2015).
Figure 3 shows the distribution of patients according to the VA
with the pinhole at D 0 and D 2 and postoperative Day 30.
Gain obtained by visual acuity class
The functional gain in visual acuity at D 2 and D 30 postoperative
is shown in Table II.
Visual acuity depending on the quality of the operator Day 2 and
Day 30 postoperative
The quality of the operator influences the improvement in visual
acuity (p = 0.011) at Day 2 and Day 30 postoperative (p = 0.031)
depending on whether a doctor or a STO. Visual acuity ≥3 / 10
was observed in 77.3% of cases in patients operated on by doctors.
Figures 4 and 5 establish the distribution of visual acuity depending
on the quality of the operator respectively J2 and postoperative
Distribution of patients according to the quality of
operator and visual acuity at Day 2 post-surgery (Tinré, 2015).
Distribution of patients according to the quality of
operator and visual acuity at Day 2 post-surgery (Tinré, 2015).
Postoperative complications and visual acuity
The majority of patients had corneal edema with a staff of 55
(73.3%) for visual acuity between 1/20 and 3/10.
The table I shows that the corneal complications including corneal edema, those of the pupil and those related to the implant interfere
statistically significant on improving visual acuity
Table I: Post surgery distribution of patients according to the complications and visual acuity (without correction and with
correction) (Tinré, 2015).
*OCP= Posterior capsular opacification
**Iritis = 5 ; reliquat de masse= 5
Out of the 375 cases of cataract, 277 (89.1%) patients met the
inclusion criteria. Of these, 211 (79.8%) have met the postoperative
controls to Day 2 and Day 30 (participation rate).
Our results were similar to those of Barañano et al. in 2008 in
California, which reported 82% participation rate.
In opposite, Addisu and Solomon in 2011 in the southwest
of Ethiopia reported a rate of 90% participation, higher than our
results for a postoperative check carried out 5 weeks after surgery.
An improvement of visual acuity in some patients may lead them
to judge useless to return, especially those who live outside of the
city where is located the hospital.
The frequency of the cataract at OHSAT was 17.6%. At Cotonou in
Benin Republic, Doutetien et al. observed a higher frequency of
52% for a study period of about 4 years. This frequency obtained
in our study was greater than that of Bejiga and Tadesse in
Ethiopia in 2008 which recorded a prevalence of cataract of 3.2%,
as well as that of Balo et al. in Togo who reported a prevalence
Patient compliance to appointments for postoperative monitoring
has been decreased during the study period from 100% at Day 1 to
79.8% (20.2% lost to follow) at Day 30.
The sample size is 221 patients (221 eyes) and the duration of the
study period was 2 months probably explain this loss of one in
Patients with a history of surgery for cataract of the contralateral
side accounted for 41 cases (18.5%) in our study.
Our results are lower than those of Nangia et al. in 2011 in
India, which reported that 64% had received unilateral surgery.
Bilateral cataract represented a workforce of 101 cases (45.7%).
Ko et al. in 2012 in China noted a unilateral cataract in 20.0%
and bilateral in 80% of cases.
Preoperative visual acuity
In our series, 95% of patients were in state of blindness and
2.7% had visual acuity between 1/20 and 3/10 at admission. Our
findings were identical to those of Mpyet et al. in Nigeria
in 2007 and Doutetien et al. at Cotonou, in Benin Republic
who respectively reported that all patients were in blind condition
before surgery with 100% and 81.3%.
Diallo et al. in Burkina Faso reported a preoperative visual
acuity less than 1/20 (blindness) in 70.7% of cases and 24.7% had
visual acuity between 1/20 and 3/10.
Limburg et al. in a multicenter study in India reported that
83.4% of patients had visual acuity less than 1/20 before the
These high rates of blindness could be explained by the later
consultations for patients in developing countries, unlike developed
countries where visual impairment caused by cataract impacting
the socio-professional activities leads patients to consult earlier.
The eye diseases associated
In our series, 56.5% of patients had an inaccessible fundus, 43%
normal fundus and 0.5% a dull macula.
The results reported by Diallo et al. in Burkina Faso showed
that the fundus was inaccessible in 81%. These results are superior
Blur or inaccessible aspect of the fundus could be explained by the
absence of additional tests such as ultrasound B-mode, what did
not have our hospital.
Laterality of the operated eye
Our results allowed us to see that the left eye represented mainly
operated with a number of 117 (53.20%) in opposite to 104
(46.80%) for the right eye.
Our results corroborate those of Mpyet et al. in Nigeria in
2007 and Jing et al. China that reported a predominance of
left eyes respectively operated 44 (62%) in opposite to 27 (38%)
for the right eye in Nigeria and 40 cases (48.8%) for the left eye in
opposite to 42 (51.2%) for the right eye in China. In Benin Republic
in 2006 Doutetien et al. also reported that the operated eye was
left in 4.6% of cases in opposite to 37.6% for the right eye and both
eyes in 57.8%.
These results are different from those of Diallo et al. in
Burkina Faso who reported that the operated eye was right in 170
Surgical procedure :
• The quality of the operator
In our series, patients operated by ophthalmologists physicians
represented a workforce of 123 (55.7%) against 98 patients
(44.3%) for the superior technician in ophthalmology (STO)
Patients operated by ophthalmologists at postoperative Day 30,
had good results in 75% of cases unlike to those operated by the
superior technician in ophthalmology cataract operator in 25%.
This difference was statistically significant (p = 0.031). Addisu
and Solomon Ethiopia reported 71.5% of patients operated by
ophthalmologists, 6% by residents and 22.5% of trainees under the supervision of surgeons ophthalmologists.
Other authors like Guirou et al. reported that the good results
(51.2%) without correction were observed in the group of patients
operated by ophthalmic surgeons and with correction (69.3%)
compared to those operated by the DES with 34, 9% of good
results without correction and 51.3% with correction.
• Per operatories complications
In total we reported a percentage of 8.7% per operative
The most reported complication was posterior capsular rupture in
2.7%, followed by the lens exit in 2.3% of cases.
Our results were higher than those of Maneh et al. in 2015 in
Togo, who reported 1.89% of intraoperative incidents.
Addisu and Solomon in 2011 in the southwest of Ethiopia
mentioned that the most frequent operative complications are,
posterior capsular rupture in 5% of cases with vitreous loss
occurred in 3.9% of which 2 5% received an implant in the anterior
Daboué et al in Burkina Faso, Borzeix et al in Senegal
and Ouhadj and Nourim in Algeria noted that the capsular
rupture rate is respectively, 3%, 2% and 1.4%.
Diallo et al. reported that in their series the most common
intraoperative complication was secondary chemosis following
anesthesia with 4.67% of cases. The outcome of glazed and subconjunctival
hemorrhages was observed in 1.33% of cases.
All patients in our series received a posterior chamber implant
standard power (21 diopters) with the exception of 3 patients
(1.36%) that received an implant in the anterior chamber following
the capsular rupture with vitreous loss.
• Postoperative complications at Day 1 and Day 30
On postoperative day 1, the most frequent complications was
corneal edema in 34.3% followed by 7.7% in hyphema, iris pigment
and lens mass balances in 3.2%. The implant was decentered in
2.3% of cases, descemetics folds were observed in 1.8% and the
pupil was asymmetric in 1.7%.
At postoperative Day 30, we noticed a decline to 1.8% of the
corneal edema, 3.5% for hyphema. The posterior capsular
opacification was present in 1.4% of cases.
Our results were lower than those of Addisu and Solomon
who reported that in south-western Ethiopia the most common
complication encountered postoperatively was corneal edema in
71.5% followed by the pupil asymmetric (11 , 7%), the posterior
capsular opacification (5%). The implant was biased in 1.1% of
Tuskarr et al. obtained in a retrospective study of two (2) years
with phacoemulsification as surgical technic; the most common
postoperative complication was ocular hypertension (34.5%).
Other authors such as Guzek and Ching in Ghana and Yorston
and Foste respectively indicated that the main complication
of small incision surgery was corneal edema, which persisted at
least until the visit of one week in 7% of cases and the loss of the
vitreous in 3% of cases against 4.6%.
Maneh et al. in 2015 in Togo and Addisu and Solomon
in the South West Ethiopia respectively reported a percentage
of opacification of the posterior capsule in 3.76% after
phacoalternative in Togo and hyphema rate of 4 5% in Ethiopia.
Diallo et al. in 2015 in Burkina Faso reported meanwhile
that early postoperative complications were dominated by corneal
edema with 26.33% of cases at Day 1. Other complications were
superficial punctate keratitis with 7.7% and hyphema in 4.3% of
cases. At postoperative Day 30 only 2 cases of corneal edema
persisted. The pupil was irregular in 8% of eyes at Day 60, and
a secondary cataract was observed in 5.33% of cases. In 3.5% of
cases there is a fibrosis of the posterior capsule were noticed at
No cases of endophthalmitis were noted in our series, as well as
that of Diallo et al. in opposite to Daboué et al. in 2002
who reported an endophthalmitis rate of 0.3%.
A case of endophthalmitis was reported by Doutetien et al. in
southern part of Benin.
These various complications have significantly decreased during
checking carried out at Day 30 postoperative in our series.
The differences in these rates with ours might be explained by the
earlier examination (after 4 weeks in our case). In addition, the
relative inexperience of the operators, and lack of adequate and
appropriate surgical instruments may have also played a significant
role in the incidence of these complications.
In our series, at Day 2 postoperative there were 68 patients (30.8%)
with visual acuity <1/10 (bad results) uncorrected and corrected
19%. The proportion of patients in the category of average results
(AV between 1/10 and 3/10) was 60.2% and 45.7% without
correction and with correction. Visual acuity without correction
greater than 3/10 (good results) occurred in 9% of patients and
35.3% with correction.
At postoperative Day 30, 155 (70.1%) patients had a visual acuity
between 1/10 and 3/10 (average results) uncorrected and corrected
49.3% (pinhole). Patients with visual acuity greater or equal to 3/10
without correction were 19.9% and those corrected represented
44.8%. There were 10% of bad results without correction, and
5.9% with correction.
This could mean a significant number of patients were visually
impaired by cataract before undergone to surgery.
Our visual uncorrected and corrected results are below to the WHO
guidelines and recommendations rate. The functional results are
classified as good postoperative uncorrected if visual acuity is
greater than or equal to 3/10 in 80% of cases or less in at least
90% and are corrected bad result in less than 5% of cases. Our results could be better with a good patch of aphakia by the use
of implants fitting after calculating their power by biometry. The
sutureless technic used in our study is more difficulty to learn than
extra capsular cataract extraction with suture and implant posterior
chamber (ECCE / IPC).
Our results were also lower than those of Diallo et al. who
reported that at day 30 after surgery, no good visual corrective
result had been noted for 67.83% of and 31.47% had limited
results according to the WHO recommendations. These results are
respectively 94.4% and 4.9% with best correction.
Guirou et al. in 2013 at Bamako indicated that 45.5% of
patients had good visual acuity (well) with the correct range, 33%
had visual acuity limited and 21.6% had poor visual acuity. With
best correction through Pinhole, the proportion of patients with
good results increases to 63% and 22.9% of visual acuity limited
and 14.1% poor results.
Addisu and Solomon reported in five weeks postoperative, 57%
good results uncorrected and corrected 70.4% through Pinhole.
Their results were limited without correction in 30.7% and 21.8%
with correction. The poor results without correction were 12.3%
and 7.8% with Pinhole.
Maneh et al. in 2015 in a study conducted in two centers in
Togo noted that the poor results were 3.76% after-phacoalternative
These results could also due to the presence of suckers who
trainees need extended operating time with excessive preoperative
manipulation; this could result in the loss of endothelial cells and
Causes of poor results have not been investigated in this study and
are one of the limits. Guirou et al. reported that causes of poor
results were mainly related to surgical complications (42.1%) and
refractive error (34.8%).
Other studies conducted in Nepal by Hennig et al. showed that
their results were bad for 5.5% and of them 0.6% had a preexisting
eye disease, 3.2% a refractive defect that can be corrected and
1.7% of complications in surgery.
Our results show the improvement in visual acuity with
phacoalternative that could be potentiated by the echo preoperative
biometry and auto refractometer that were not available at OHSAT.
Their presence would have improved visual acuity by calculating
the power of implant to use and postoperative optical correcting
for each patient. An improvement of visual acuity in some patients
may lead to unnecessary judge to return, especially those residing
outside the municipality of Parakou and N’Dali.
Some authors performed biometrics examination, this is the
case of Diallo et al. who noticed that in 59.67% of cases the
implant matched the power calculated by biometrics, and in 40.3%
the implant was inadequate with a difference ranging from - 5 to
+ 4 diopters.
Guirou et al. reported that calculated implant was unavailable
in 1% of cases.
Our results are certainly bad but we noticed a high rate of
illiteracy in our series. They do not really need a sharp vision to
go about their occupation. Therefore patients who improved the
performance of their daily tasks after-cataract surgery maintained
a relatively stable slightly improved visual acuity. So they drift
overall benefit of cataract surgery in their daily lives. Thus Rohart
et al. demonstrated in a study conduct in France in patients
with cataract and AMD that there was a benefit both in terms of
visual acuity and quality of life to operate cataract.
Insufficient results (according to WHO standards) were noted in
many studies in developing countries. However, in many developed
countries the WHO standards were met. This is explained by the
fact of surgical techniques.
Phacoemulsification is the technology
preferred for cataract surgery in developed countries, as several
studies have shown that phacoemulsification gives better visual
results. This is due in-part to low postoperative astigmatism
because of the lack of stitches and a smaller incision size.
The manual phacoalternative sutureless surgery is an alternative
to phacoémulsification, and is used increasingly in developing
countries such as Mali, Burkina Faso and Benin.
Visual acuity and sociodemographic data and postoperative at Day
2 and Day 30
The good results in our series mainly were observed in the age
group of 21-35 years old with 70%. The worst results were recorded
in the age group over 65 years old. We noticed no statistical link of
age on the improvement of visual acuity (p = 0.151).
Guirou et al. reported that the worst results are observed
beyond 60 years old with and without corrections, the best
results being observed in less than 50 years old with and without
In our series, at Day2 postoperative, we observed a rate of 63.3%
of average results in the group of women and a rate of 11.1% good
results in the men group. In opposite men who have average results
were with a rate of 58% and good with 7.6%.
At postoperative Day 30, we noted a similarity in the results with
22.2% good results in women in opposite to 18.3% for men.
Our results differed from those of Guirou et al. who reported
that results were good among men with and without correcting
respectively with 49.1% and 65% of cases.
• Level ‘ of instruction
Good results were observed especially in the group of patients
with primary level while poor results were observed in the group
However the level of education does not interfere any way
statistically significantly in improving on visual acuity (p = 0.157).
Cataract remains a leading cause of blindness and brings
management problems in developing countries. It surgery by small
incision allows an increased fight against reversible blindness due
to cataract in developing countries like Benin. It makes it possible
to offer quality care to a larger population while reducing the costs
of their care. Therefore, an adequate technical support center would be an asset to improved surgical results.
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