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    • In the context of cataract surgery Nathan Congdon and

    2019-05-22

    In the context of cataract surgery, Nathan Congdon and colleagues (August, p e37) propose the possibility of using early postoperative assessment of all patients or late assessment only of those who return for follow-up without additional prompting as practicable methods to improve long-term patient outcomes in settings where barriers to adequate post-operative follow-up exist. Such approaches would be feasible in many resource-limited settings, and where appropriate should be extended to postoperative follow-up of other surgical procedures. However, a potential exists for many patients to slip through the net by not returning for follow-up assessment despite developing harmful postoperative complications. Paternalistic medicine persists in many developing countries. Yousuf and colleagues reported that most patients in Srinigar, India, avoid the responsibility of decision making and defer this responsibility to the doctor. Where self-reporting contradicts socially and culturally mediated beliefs, systems that rely on this mechanism might not be able to ensure continuity in patient care. We therefore recommend a protocol wherein the doctor explicitly advises the patient to return should they tropisetron experience predefined complications. Furthermore, the health-care provider should attempt to facilitate travel and rebooking where possible.
    We thank Rele Ologunde and Sohaib Rufai for their interest in our study. Their conclusions echo those of the Comment by Yuzhen Jiang and Paul Foster that accompanied our report, in accepting the usefulness of early assessment of cataract surgery, while also stressing that good follow-up is crucial to “detect and treat postoperative complications in a timely manner”. Ologunde and Rufai suggest that doctors should actively advise patients when to return in order to promote compliance. Although our study methods required all patients to be instructed to return for examination 40 days after surgery, only half returned to the clinic without additional prompting, and only a quarter did so from the 18 Chinese hospitals. Jiang and Foster cite evidence that failure to correct refractive error often leads to poor outcomes in low-resource settings, and recommend interventions to improve follow-up, as do Ologunde and Rufai. Despite the clinical benefits of postoperative care after cataract surgery, little evidence exists for its cost effectiveness in settings with poor follow-up. The cost of improving follow-up might be substantial for facilities, and present a financial burden to patients. Balanced against vagina issue could be a low acceptance and effectiveness of postoperative care: although 87% of patients in a Chinese study could obtain improved vision with refraction after cataract surgery, only a third would accept prescriptions, the most common reason being a perceived lack of need. Although uptake of free yttrium aluminium garnet (YAG) capsulotomy in the same setting was substantially higher, such procedures improved visual acuity in less than 10% of patients from the surgical cohort who presented with poor postoperative vision. Research is needed to establish the cost effectiveness of interventions to improve follow-up after cataract surgery before we can assert that such interventions are warranted. In PRECOG, we collected information about follow-up costs from both patients and facilities. We identified patients whose visual acuity could improve by two or more lines with refraction or other treatment, and the proportion who would accept and pay for glasses or treatment. We will soon report on the average cost of identifying a single patient whose vision could be improved by refraction or other treatment. We very much agree with the correspondents and the Comment authors that all patients deserve the best care that we as providers can give. However, in settings where postoperative compliance is challenging and acceptance and effectiveness of postoperative interventions can be low, we feel that cost-effectiveness data can be helpful for deciding how much we are prepared to ask patients and facilities to spend on additional follow-up.