|Year : 2017 | Volume
| Issue : 2 | Page : 81-84
Socioeconomic impact of simultaneous bilateral rhegmatogenous retinal detachment: A single center analysis
Kalpana Badami Nagaraj, Roopashree Kamisetty
Department of Vitreo-Retina, Minto Ophthalmic Hospital, Bengaluru, Karnataka, India
|Date of Submission||15-Jul-2015|
|Date of Acceptance||08-Jun-2016|
|Date of Web Publication||25-Apr-2017|
Kalpana Badami Nagaraj
Department of Vitreo-Retina, Minto Ophthalmic Hospital, AV Road, Chamrajpet, Opp. Central Police Station, Bengaluru - 560 002, Karnataka
Source of Support: None, Conflict of Interest: None
Purpose: To evaluate the reasons for poor visual outcome and the socioeconomic impact of the consequent blindness in patients with simultaneous bilateral rhegmatogenous retinal detachment (SRD). Materials and Methods: A retrospective cohort study was done at a tertiary eye center including patients seen between 2012 and 2014 where 46 eyes in 23 patients with SRD were studied. The postoperative visual outcome and its socioeconomic impact including mean change in annual income, change in occupation before and after blindness, direct costs incurred, and mean years of productivity loss were analyzed. Results: Among the total 190 operated cases of retinal detachment during the study period, 23 (12%) patients had SRD at presentation. Their mean age was 31.9 years, and 57% were males among them. Delayed presentation (average 26 months) and complex detachments (39% Grade C proliferative vitreo-retinopathy) were the prominent features. Thirty-eight of 46 (82%) eyes were operated. Best-corrected acuity of 20/200 was achieved in 62% of eyes. Change of occupation in 78% (18) and >70% decrement in income was noted in 74% (17) of patients. Mean years of productivity loss was 27.6 years. Conclusion: Delayed presentation and complex detachments at diagnosis correlate to poor visual outcomes and social blindness in SRD. This is likely to impart a negative effect on their family and social life, occupation, and income.
Keywords: Bilateral retinal detachment, simultaneous rhegmatogenous retinal detachment, socioeconomic impact, visual outcomes
|How to cite this article:|
Nagaraj KB, Kamisetty R. Socioeconomic impact of simultaneous bilateral rhegmatogenous retinal detachment: A single center analysis. J Clin Ophthalmol Res 2017;5:81-4
|How to cite this URL:|
Nagaraj KB, Kamisetty R. Socioeconomic impact of simultaneous bilateral rhegmatogenous retinal detachment: A single center analysis. J Clin Ophthalmol Res [serial online] 2017 [cited 2017 Dec 14];5:81-4. Available from: http://www.jcor.in/text.asp?2017/5/2/81/205177
Rhegmatogenous retinal detachment (RRD) is a potentially blinding condition  and the presence of simultaneous RRD (SRD) of both eyes is a rare finding.
Treatment of retinal detachment (RD) has been a low priority in developing countries and the lack of facilities for treatment means that the risk of blindness due to RD is relatively greater. A population-based survey in our country found that retinal disease was the primary cause of blindness in 12.7%. The socioeconomic consequences of blindness are known to have an adverse impact on the society.
In our study, we intended to understand the reasons for poor visual outcomes and the socio-economic impact of the resulting blindness in patients presenting with SRD.
| Materials and Methods|| |
The relevant data of the patients treated for RRD at a tertiary ophthalmic hospital from June 2012 to June 2014 were collected from the hospital database. A retrospective cohort study was done to study patients with RD. All cases with SRD at presentation to us were included in the study. Cases with exudative and tractional RD with secondary breaks were excluded from the study. SRD was defined as the presence of RD in both eyes, observed by indirect ophthalmoscopy at the initial examination.
The family history of RD and systemic associations were noted. Retinal drawings were analyzed to study the configuration of RD. B-scan was done in cases with hazy media. Pre- and post-operative visual acuity and the surgical procedure done were noted. Postoperative results were analyzed.
Ocular morbidity was quantified as social and economic blindness as per the World Health Organization (WHO) and National Programme for Control of Blindness (NPCB) definitions. WHO defines blindness (analogous with social blindness according to NPCB) as visual acuity of 20/400 or less with the best possible spectacle correction. Economic blindness (NPCB) is expressed as visual acuity less than 20/200 in the better eye with spectacle correction.
The patients were finally evaluated at 6 months postoperative during which the data regarding the patients occupation, monthly income before treatment and the change in occupation, and income at 6 months following treatment were noted. Details regarding the surgical costs and insurance if any were also noted.
In economic terms, the cost of blindness was inferred based on the direct costs incurred by the blind person and the loss of productivity. Direct costs are defined as the actual expenses related to an illness and contain medical costs, nonmedical costs, and other direct costs. We have included only the surgical cost for analysis.
The loss of productivity was calculated as follows: assuming the age at retirement as 60 years in our country, the mean number of years of loss of productive work following blindness in both eyes were calculated.
Statistical analysis was done using Chi-square test by SPSS software (version 16.0, IBM Corporation, USA).
| Results|| |
During the 2-year study period between June 2012 and June 2014, 190 new cases of RRD were treated at our center. Among them, in 23 patients (12%), SRD was noted. The mean age at the time of diagnosis was 31.9 years (range: 12–50 years). Of the 23 patients, 57% were males and 43% females. The predominance in males was not statistically significant (P = 0.16). There was no family history of RRD in any of our study patients. The average duration between the onset of symptoms of RD and presentation to us was 26 months (4 days to 48 months).
Preoperative visual acuity ranged from hand motion to <20/500. The mean axial length noted was 24.5 mm (range: 17.6–27.8 mm). The configurations of RRD noted in our patients are as shown in Graph 1. Of the group with both eyes total RRDs, 5(10%) had funnel RDs in other eye and were inoperable. Grade C proliferative vitreo-retinopathy (PVR) was noted in 18 (39%) eyes. No vitreous anomalies were noted in any of the study patients. One patient had Marfan's syndrome, and two of them had retinochoroidal coloboma with developmental cataract.
Thirty-eight of 46 (82%) eyes were operated. Five eyes were inoperable. Both eyes were operated on an average duration of 2 months, eyes with less extensive detachment were preferred to operate first. Scleral buckling with encirclage band was done in 24 eyes (62%), Pars plana vitrectomy in 13(31%), and pneumoretinopexy in 2(5%). Silicone oil tamponade was needed in 8% of eyes, the fellow eyes of whom underwent scleral buckling. Anatomical retinal reattachment was achieved in 84% (32 of the 38) of the operated eyes at 6 months. The remaining six patients had redetachment, and further surgical intervention was deferred.
Mean best-corrected visual acuity at 6 months was 20/200 in buckle group (62%), 20/80 in pneumoretinopexy (5%) cases, 20/400 in the vitrectomy group (33%) (range: Hand movements-counting fingers 2 m) despite anatomical success. Economic blindness was seen in 11 out of 23 cases (47%) and social blindness in 4 out of 23 cases (17%) in anatomically attached retina.
Most of our patients were daily wage laborers. Nearly, 74% (17 of 23) were breadwinners of the family, 13% (3) were housewives, and 13% (3) were students. Mean annual income of the study population before the onset of RD was INR 30516 (USD 488.6). Over a period of 6 months and after treatment, mean annual income reduced to INR 9384 (USD 150.2). The mean decrement in annual income of the family was INR 21132 (USD 338.3). This means that they lost about 69% of their income during the period of 6 months. Nearly, 74% of patients had gross decrease in their earnings. Seventy-eight percent of them had to change their occupation owing to visual disability. Mean change in annual income before the onset of RD and at 6 months after treatment has been represented in Graph 2. Only three of the male patients were supported by their working wives.
Direct cost incurred by the patients including surgery in both eyes was mean INR 7869 (USD 126.2). These amounts to almost 25% of their annual income before illness. Mean years of loss of productivity were 27.6 years (10–48 years). All our patients were from low socioeconomic status, many of them were unaware about medical insurance.
| Discussion|| |
SRD is uncommon, accounting for 1.18–2.5% of all RD.,, There are no population-based surveys of the incidence of RD in any developing country. In 1998, Dandona et al. concluded that 0.5% of blindness in a subpopulation of our country is caused by RD. During our retrospective analysis over a period of 2 years, we found 23 out of 190 patients (12%) with SRD. In a similar analysis, Bodanowitz et al. found 1.2% with SRD, El Matri et al. 1.5%, Krohn and Seland  2.3% over a period of 8 years. Indeed, we found a higher number of patients with SRD over a shorter period compared to other authors, probably because ours is a referral eye hospital.
The disease mainly affects the younger population  and predominantly in males. The average age in our series was 31.9 years, in El Matri et al. is 35 years, in Krohnand Seland  40 years, Yorston and Jalali  38 years (in our population). These factors are probably a reflection of a very different and alarming demography of RRD patients in our country. We found a slight predominance in males (57%) as also found by Bodanowitz et al. in 73%. However, other authors , agreed that men and women were equally affected.
The majority of our patients presented late due to various reasons including long travel distance, lack of financial means, nonawareness about the curability of the disease, late diagnosis, negligence, and the lower socioeconomic status of the patients. Most of the subjects cited personal reasons for not seeking treatment even after having noticed decreased vision followed by economic and social reasons. This in turn was also the reason for greater number of total RDs and advanced (Grade C) preoperative PVR at diagnosis. It imparts a significantly negative effect on the final visual outcome and adds to the burden of ocular morbidity in our country. It is noteworthy that most of them presented with symptoms in only one eye, in spite of RD causing poor vision in both eyes as also noted by El Matri et al. and Krohn and Seland. In addition, symptoms from one eye could have been ignored by some due to more severe symptoms from the eye with the most extensive RD as found in our patients.
There was no difference in preferred surgical procedure in treating bilateral detachments. Anatomical success was achieved in 84% of eyes. According to other studies, anatomical success in these cases varies from 90% to 97%.,, In spite of reasonable anatomical success in the operated eyes, the ocular morbidity and blindness were high owing to the bilaterality of the condition and complex detachments at presentation. Seventeen percent (17%) of our patients were socially blind (<20/400) and 47% of them were economically blind (<20/200) despite the best treatment efforts.
The consequences of blindness range from depression ,, loss of jobs or change to low-income jobs  jeopardized relationships , to meager economic conditions. Blindness forced them to forego their wage earnings thereby leading to a decline in overall income. Faced by challenges, people with blindness become a burden to themselves, the family, and society. Most eyes had visual recovery that was insufficient for them to pursue the skills involved in their previous occupation, postoperative visual outcomes corresponding to the complexity of the detachment. The decrement in income is also attributable to the number of working days missed out due to hospital admission, duration of recovery following surgery in one or both their eyes, in addition to the direct costs of the treatment. Furthermore, there are significant burdens imposed due to the decrease in productivity, loss of quality of life, and independence among those affected that translates to a major health, and socioeconomic burden for the society. About (75%) of our patients were breadwinners of their family. The resulting bilateral socioeconomic blindness in one or in both their eyes forced them to adopt low-income jobs, barely enough for their subsistence. They spent a sizeable amount (25%) of their annual income for treatment and had no medical insurance to support them. Nearly, 27 years of loss of productivity in a breadwinner's family was noted which translates to poverty, poor education to their children, and low living standards. The lack of social security or health insurance schemes further added to the plight of the blind persons. People who provide care to the blind and look after them also earn less income due to fewer hours available to them to participate in the labor market.
The presentation of RD in developing countries like ours is different. Lack of both primary eye care and specialist retina centers in peripheral areas means that presentation is often delayed, and complex detachments are common at diagnosis. This further demands for the need of sophisticated and costly surgery to re-attach the retina in them. Most of our patients suffer due to lack of affordability (economic) and lack of awareness (social reasons). Therefore, it is imperative that we use approaches that combine the strategies of prevention and treatment to address these barriers.
Perhaps what we need is novel approaches such as setting up permanent eye care facilities closer to people like Satellite Eye Centres, to provide affordable secondary level eye care, and the more recent innovation of establishing “Vision Centres” linked vertically to secondary eye care centers. Each Vision Center is run by a trained vision technician who can screen patients and detect blinding conditions that are referred for further medical and surgical management while addressing issues of accessibility and affordability of eye care at the grassroots. However, to overcome social barriers, we may need to have long-term strategies of community development.
Despite these problems, the majority of eyes undergoing surgery for RD in suitably equipped centers will regain useful vision, and anatomical success rates approach 90%. Cataract surgery remains the priority for ophthalmologists in developing countries, but RD is an equally important treatable cause of blindness. While rare in comparison to blinding cataract, it is second, specialist centers capable of treating all types of RD should be developed so that future generations will have better access to skilled personnel, and adequate facilities.
We noted SRD predominantly in younger subjects. Despite maximal efforts to salvage their eyes, most of them had only navigational vision following surgery. To tackle this, government, nongovernment development agencies, and ophthalmologists must collaborate to train ophthalmologists and other health care workers in the early detection of RD as well as its management.
The limitations of our study were inclusion of only referral patients who presented at the tertiary care center and possibility of most patients presenting at a later stage. Therefore, our observations may not be generalized to all population sub-groups.
| Conclusion|| |
SRD is noted in younger population. Delayed presentation, with complex detachments at diagnosis, contributes to higher social, and economic blindness. This negative effect of blindness not only affects vision but also affects their family and social life, occupation, and income.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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