Audit of cataract surgical outcomes: The cataract surgery learning curve of a trainee Ophthalmologist, Pacific Eye Institute.

Blindness is defined by the World Health Organization (WHO) as a visual acuity of less than 3/60, or corresponding visual field loss to less than 10 degrees, in the better eye with best possible correction. In other words, seeing at 3 meters what a person with normal vision sees at 60 meters. Low vision is defined as a visual acuity less than 6/18 but better than 3/60 with best possible correction. [1, 2] An estimated 246 million people have low vision and 39 million are blind worldwide. Of those, 10 million blind people and 79 million with poor vision live in the Western Pacific Region. Ninety percent (90%) of all blindness is found in developing countries including the islands of the South Pacific. Eighty percent (80%) of visual impairment can be prevented or treated. [3, 4]
Cataract is the leading cause of treatable blindness worldwide, which is also true for the Western Pacific Region. A cataract is the clouding of the crystalline lens which causes gradual visual loss. Cataracts can be associated with ocular and systemic diseases, congenital abnormalities, trauma and certain medications though the most common cause is a natural process that is age related. Cataract surgery is relatively simple operation which replaces the clouded lens with a plastic one. The surgery is highly effective, restoring visual function, improving quality of life for patients, yet many people in the low and middle-income countries do not have access to the surgery.
Uncorrected refractive errors, diabetic retinopathy and glaucoma are other main causes of blindness in the Western Pacific Region. For these diseases, early diagnosis and appropriate management is crucial to avoid irreversible vision loss. All patients accessing their community health system should have access to important information on how to avoid blindness and to a quality referral system that can detect people with potentially blinding eye disease.
Estimated rates of blindness in Pacific Island countries range from 5000 per million in Papua New
Guinea to 16,220 per million in the Cook Islands. Low vision may be as high as 18,000 per million in Tonga. Cataract and diabetic retinopathy have been listed as the main causes of vision impairment in the Pacific. Other causes of visual impairment include trauma, corneal disease, age related macular degeneration (AMD), trachoma and glaucoma.
There are different techniques of performing cataract surgery. In the developed world phacoemulsification through a 2-3mm wound, with the insertion of a foldable intraocular lens (IOL) is the standard. Prior to this, an extracapsular cataract surgery (ECCE), through an 8-10mm wound requiring sutures and insertion of an intraocular lens was the standard. ECCE's are still performed in many parts of the developing world. [7, 8] Sutureless manual small incision cataract surgery (MSICS) was a modification of ECCE, developed for the developing world especially with high volume surgery as a cheaper alternative to phacoemulsification with comparable surgical outcomes. It is done through a 6 — 8mm self-sealing scleral wound. Intracapsular cataract surgery (ICCE) is when the lens with an intact capsular bag is extracted. This is no longer routinely practiced being replaced by

ECCEs. But it is conducted on a few patients, such as those with an anteriorly dislocated crystalline lens as may happen in trauma, through an ECCE or SICS wound.
VISION 2020 is a joint program of the World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB) with an international membership of NGOs, professional associations, eye care institutions and corporations. This global initiative aims to eliminate avoidable blindness; blindness which could be either treated or prevented by known, cost effective means, including cataracts, which is treated with cataract surgery.
The Pacific Eye Institute (PEI), situated in Suva, Fiji is an initiative of the Fred Hollows Foundation New Zealand (FHFNZ) whose mission is "to overcome avoidable blindness in the Pacific. To achieve this, we will collaborate with like-minded partners." One of the PEI's goals is "To meet the eye health needs in Fiji and the region, the Pacific Eye Institute (PEl) will train appropriate numbers of Fijian and Pacific people to be eye health specialists." [14] As a training institute it encourages the reporting of the surgical outcomes especially of trainees as a means of monitoring and improving the quality of surgery conducted, thus ensuring the highest quality of eye care services.
Prospective monitoring of cataract surgical outcomes has demonstrated an improvement in visual outcomes and appears to be associated with a change in the surgeons' attitudes, appropriately addressing factors found to cause poor visual outcomes.