Causes of Suboptimal Cataract Surgical Outcomes at Nkhoma Hospital, Malawi: A Retrospective Analysis

Background: Cataract remains the leading cause of blindness worldwide, particularly in low- and middle-income countries. Cataract surgery is an effective intervention, but poor or borderline outcomes reduce its impact in eliminating avoidable blindness. Assessing cataract surgical outcomes is essential for improving surgical quality. This study aimed to identify reasons for poor or borderline cataract surgical outcomes at NkhomaHospital, Malawi, focusing on ocular comorbidities, surgical complications, refractive errors, and demographic factors, including gender.Methods This was a retrospective analysis of 828 patients with a post-operative visual acuity of 6/18 or worse in at least one eye following cataract surgery. Data were extracted from theatre records, including demographics, referral source, preoperative examination, intraoperative findings, and post-operative assessment. Reasons for poor or borderline outcomes were classified based on ocular comorbidities, refractive error, surgical complications, and screening errors.Results Among patients with poor or borderline surgical outcomes, 52.2% had ocular comorbidities (e.g., glaucoma, diabetic retinopathy, corneal scarring), which adversely affected vision post-surgery. Uncorrected refractive error accounted for 25.8% of cases, indicating gaps in post-operative optical correction services. In 13.5% of cases, records lacked sufficient data to determine a cause.A significant gender disparity was observed (p = 0.027), with women more likely than men to present as blind at the time of surgery. These findings highlight potential barriers to timely cataract surgery for women, including financial constraints, caregiving responsibilities, and delayed health-seeking behavior. Conclusion The causes of poor cataract surgery outcomes at Nkhoma Hospital are multifactorial, mainly driven by pre-existing ocular conditions, inadequate screening, and post-operative refractive care. Strengthening pre-operative screening, post-operative optical correction services, and gender-targeted outreach programs can improve surgical success. Targeted capacity building for cataract surgeons, outreach teams, and post-op follow-up staff is essential to ensuring equitable access to cataract surgery and reducing avoidable blindness in Malawi and other countries.