EBO technical review of the validity of Recommendation #14 of the Clinical Practice Guidelines for the Management of Cataract among Adults

Methodological quality of the review: Low confidence

Author: The Evidence-Based Ophthalmology Group.

Region: The Philippines

Sector: Cataract

Sub-sector: Clinical Practice Guidelines for the Management of Cataract among Adults

Type of cataract: Age-related cataract

Equity focus: None specified

Review type: Technical review/effectiveness review.

Quantitative synthesis method: Narrative analysis

Qualitative synthesis methods: Not applicable

Background

Growing numbers of ophthalmologists are adopting phacoemulsification (Phaco) over extracapsular cataract extraction (ECCE) because of the immediate visual rehabilitation and improved visual outcomes achieved with Phaco. In the Philippines, the two most common cataract-extraction procedures being used are Phaco and ECCE. In 2005, The Philippine Academy’s Clinical Practice Guidelines for the Management of Cataract among Adults recommended that both Phaco and ECCE are acceptable surgical techniques.

Research objectives

To assess the current validity of recommendation #14 which states that both Phaco and ECCE are acceptable techniques among patients undergoing cataract surgery.

Main findings

Eight studies were cited in the ‘summary of evidence’ in the review, including one-year prospective study and randomized controlled trials, all comparing ECCE to Phaco from January 2001 to May 2005. Two trials comparing the cost and benefits of ECCE with those of manual small-incision cataract (MSICS) were also included to introduce MSICS as another potential treatment option.

The comparison between Phaco and ECCE was reported in eight studies in the review; one study reported that complications of intraocular lens (IOL) malposition or dislocation and retinal detachment were no different for Phaco versus ECCE. One study concluded that Phaco had improved rate of immediate post-operative complications, although after four months the two techniques were comparable. Two studies evaluated the higher occurrence of endophthalmitis in patients who had ECCE. Two studies reported better visual outcome with Phaco and excellent and immediate visual rehabilitation.

Based on the data reviewed the panel agreed that recommendation #14 of the Clinical Practice Guidelines for the Management of Cataract among Adults should be retained. Authors noted that ‘more local data is needed to compare the value and applicability of these different techniques in the Philippines where cataract is still the leading cause of blindness. The use of MSICS needs to be further explored as a viable treatment option in the Philippines.’

Methodology

Updating the guideline recommendation was done in two stages: (1) identifying significant new evidence by conducting a systematic review of the literature, and (2) assessing whether the new evidence warrants updating or withdrawal by using the Delphi method in soliciting the opinion of experts from the original panel that developed the guidelines.

Authors reran the search for primary studies comparing ECCE to Phaco from January 2001 to May 2005. Trials were identified from the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) on The Cochrane Library and Medline. Based on the results of the identified evidence, Recommendation #14 was classified as “Retain, append new evidence.” The proposed revision was sent to all members of the original panel for approval.

Using the conceptual model developed by the US Agency for Healthcare Research and Quality, the group evaluated Recommendation #14 to determine whether it should be updated or withdrawn. Accordingly, an update was warranted under any of the following circumstances:

1. ‘New preventive, diagnostic, or treatment interventions may have emerged to complement or supersede other interventions.
2. New evidence may require updating of the estimates of benefits and harm for existing interventions.
3. New evidence may identify as important outcomes that were previously unappreciated or wholly unrecognized.
4. Evidence that current practice is optimal may change.
5. The values that individuals or society place on different outcomes may change over time.
6. The resources available for health care may change significantly.’

Applicability/external validity

The authors do not discuss the applicability/external validity of the results.

Geographic focus

The review was not clear in regards to the location of the included studies and applies its results to the Philippine context alone. However, the results may potentially be applicable to low- to middle-income settings since recommendations to come out of the review recognizes the need to continue the use of ECCE as an acceptable and cost effective alternative to Phaco in low- to middle-income settings.

Quality assessment

Authors did not fully report the search strategy conducted to identify relevant studies to be included in the review. As such, we cannot be confident that relevant studies were not omitted in the review. There was a lack of detail in regards to methods used to screen studies and extract data of included studies. Therefore, low confidence in the conclusions about the effects was attributed to this study.