Screening and surgical intervention results from cataract-free-zone projects in Campinas, Brazil and Chimbote, Peru

Uptake, Barriers and Outcomes in the Follow-up of Patients Referred for Free-of-Cost Cataract Surgery in the Sao Paulo Eye Study

PURPOSE

To determine uptake, barriers and outcomes in the follow-up of patients referred for free-of-charge, expedited cataract surgery in the Sao Paulo Eye Study (SPES).

METHODS

SPES was a population-based study of urban, low-middle income residents aged ≥50 years. Presenting visual acuity (PVA), best-corrected visual acuity, refraction, and slit-lamp examination were performed in 3677 participants. For subjects with cataract as a principal cause of best-corrected visual acuity ≤20/40, surgery was offered free of charge. Two years after the baseline study, surgery uptake, barriers to surgery, and visual outcomes were analyzed.

RESULTS

Among 210 (5.71%) participants who had a cataract surgery indication at baseline, 164 (78.1%) were successfully contacted and 55 (33.5%) reported being operated on for cataract, with 51 agreeing to be re-examined. In a multiple logistic regression model, age, sex, schooling, previous cataract surgery, and PVA at baseline were not significantly associated with surgery uptake. Co-existing health conditions (20.4%), fear of surgery (12.2%) and fear of losing eyesight (11.6%) were the most frequent barriers to cataract surgery adherence. Among the 69 eyes operated on in the interval between baseline and follow-up, PVA ≥20/63 was observed in 50 (72.6%, 95% confidence interval, CI, 62.2-82.3%), PVA <20/63-20/200 in 11 (15.8%, 95% CI 8.9-22.9%) and PVA <20/200 in 8 (11.6%, 95% CI 5.3-17.9%).

CONCLUSIONS

Quality of surgery is an increasing determinant of uptake rates. Although free-of-charge and expedited cataract surgery was offered, surgical outcomes might have influenced the low uptake. Aside from cataract surgery campaigns, improvement of surgeon skills, accurate biometry, treatment of ocular comorbidities, postoperative follow-up and eye-care education are needed.

Causes of blindness and visual impairment in Latin America

We review what is known in each country of the Latin American region with regards to blindness and visual impairment and make some comparisons to Hispanic populations in the United States. Prevalence of blindness varied from 1.1% in Argentina to 4.1% in Guatemala in people 50 years of age and older, with the major cause being cataract. Diabetic retinopathy and glaucoma are starting to make serious inroads, although epidemiological data are limited, and age-related macular degeneration is now a concern in some populations. Infectious diseases such as trachoma and onchocerciasis are quickly diminishing. Although progress has been made, retinopathy of prematurity remains the major cause of childhood blindness. If VISION 2020 is to succeed, many more epidemiological studies will be needed to set priorities, although some can be of the Rapid Assessment of Avoidable Blindness design. Developing the infrastructure for screening and treatment of ophthalmic disease in Latin America continues to be a challenge.

Prevalence and causes of visual impairment in a Brazilian population: the Botucatu Eye Study

Background

This paper reports population-based data on the prevalence and causes of visual impairment among children and adults in Botucatu, Brazil.

Methods

A population-based cross-sectional study was conducted involving a random start point and then systematic sampling of an urban Brazilian population in the city of Botucatu. There were approximately 3 300 individuals aged 1 to 91 years who were eligible to participate in the study. Of this sample, 2485 (75.3%) underwent ophthalmic examination. The ophthalmic examination included uncorrected (presenting) and best corrected distance visual acuity using standardized protocols. The primary cause of decreased visual acuity was identified for all patients with visual impairment.

Results

Presenting low vision and presenting blindness were found in 5.2% (95% CI: 4.3–6.1) and 2.2% (95% CI: 1.6–2.8) of the population, respectively. Unilateral presenting low vision and unilateral presenting blindness were found in 8.3% (95% CI: 7.2–9.5) and 3.7% (95% CI: 2.9–4.4) of the population respectively. Best corrected low vision was found in 1.3% of the population (95% CI: 0.9–1.7) and best corrected blindness was discovered in 0.4% of people (95% CI: 0.2–0.7). The main cause of presenting low vision was refractive error (72.3%) and cataract was the most prevalent cause of blindness (50%).

Conclusion

The main causes of low vision and blindness in this Brazilian city were uncorrected refractive errors, cataract, and retinal diseases. Programs to further reduce the burden of visual impairment need to be targeted toward the correction of refractive error and surgery for cataracts.

Cataract remains an important cause of blindness in Campinas, Brazil

OBJECTIVE

To estimate the prevalence of blindness in the elderly population of Campinas, Brazil, and to describe the coverage and quality of cataract surgery services in the area.

METHODS

A brief assessment of cataract surgery services (using the "RACSS" (Rapid Assessment of Cataract Surgical Services Method) was conducted using random cluster sampling, with a sample composed of 60 clusters of 40 people aged 50 years or older. Visual acuity (VA) was measured and the lens status observed by direct visual ophthalmoscopy. From the selected sample of 2,400 subjects, 92.67% were examined.

RESULTS

Blindness (VA < 3/60 with available correction) was found in 1.98 % (2.03 % among male subjects, and 1.94 % among female subjects). The prevalence of blindness varied with age, from 0.2%, in the group from 50 to 54 years, to 7.2% in those above 80. Cataract was the main cause of blindness (40.2%) followed by suspected posterior segment disorders (18.2%), diabetic retinopathy (15.9%), and glaucoma (11.4%). The cataract surgical coverage was of 93% (VA < 3/60) and 82.18% when the criterion was VA 6/60 in the best eye. The main reasons the subjects did not receive surgical treatment were: fear of undergoing surgery, 11.1%; lack of awareness about the condition, 16.7%; waiting for maturity, 16.7%; and contraindication to surgery, 44.4%.

CONCLUSION

Cataract is the major cause of blindness in Campinas. Education on eye diseases, their prevention and treatment must become part of the city's public healthcare policies.

Perceptions of patients about cataract

OBJECTIVE

To identify in adult patients suffering from cataract the perceptions regarding the disease and its surgical treatment.

MATERIALS AND METHODS

An exploratory survey was conducted among adult patients suffering from cataract and participating in a large-scale cataract management program at the University of São Paulo General Hospital in 2004. The interviews were conducted by research assistants previously trained to pose questions and record answers.

RESULTS

The sample consisted of 170 men and women (43.5% and 56.5%, respectively), aged between 40 and 88 years. Of the 170 participants, 43.5% were from the State of São Paulo, 14.7% from the State of Bahia, 12.4% from the State of Minas Gerais, 5.9% from the State of Pernambuco, 1.8% from other countries, and the remaining 21.7% were from other Brazilian states. Of those who were actively working (n = 87), 43.7% had an occupational level corresponding to nonspecialized manual labor, 27.6% were in specialized manual labor jobs, 25.3% had routine nonmanual occupations, 1.1% supervised manual labor, and 2.3% had low-ranking supervision or inspection jobs over nonmanual occupations. Of those who were not actively working (n = 82), 53.6% were retired, 45.2% were housewives, and 1.2% were unemployed. Concerning conceptions about cataract, 79.0% referred to it as "a small skin fold that gradually covers the eye" and 32.4% mentioned, in addition, other conceptions. Concerning the cause, of the alternatives presented to them, 80% reported aging, 47.1% blamed "overusing the eyes in the workplace or at home", 7.1% believed they had cataract due to some kind of "spell." Of the associated answers, 94.1% referred to "blurred vision" in people suffering from cataract, 72.4% thought the person may become blind, and 66.5% believed that the patients suffering from cataract are depressed because they cannot see. Regarding surgery, 28.8% were afraid of undergoing surgery; of those, 16.3% cited with the fear of dying during surgery, 55.1% thought they might become blind, 40.8% believed the surgery would be painful, and 8.2% followed religious practices that do not permit surgery.

CONCLUSION

Some misconceptions were identified, and the fear of blindness was the most mentioned reason for not seeking cataract surgery, which indicates the need for orientation.

Long-term visual outcomes in the Cataract-Free Zone Project in Brazil

PURPOSE

To determine the long-term visual outcomes and causes of poor vision in the cataract population in Brazil treated in the Cataract-Free Zone Project.

METHODS

Project A subjects (62 patients) were recruited in Taquaritinga, SP, 26 months after surgery. Project B subjects (34 patients) were recruited in São João da Boa Vista, SP, 43 months after surgery. All patients underwent visual screening and eye examination (examination 1). They were classified according to visual acuity in the operated eye and the causes of poor vision were diagnosed and referred for treatment. The results of these interventions were collected (examination 2) and analysed by Chi-square test.

RESULTS

At examination 1 in project A, 47 of 62 patients (75.6%) had visual acuity < or = 20/100. The main causes of poor vision were refractive error (31.9%) and posterior capsule opacification (17.0%), with or without refractive error. At examination 1 in project B, 22 of 34 patients (64.7%) had visual acuity < or = 20/100. The main causes of poor vision were again posterior capsule opacification (50.0%) and refractive error (9.0%). After posterior capsulotomy with Nd:YAG laser and prescription of new corrective eyeglasses, visual acuity = 20/80 was obtained in 64.5% of patients in project A (OR = 0.18, CI = 0.07-0.41) and 70.5% of patients in project B (OR = 0.19, CI = 0.06-0.60) at examination 2. The causes of blindness in the remaining patients were identified.

CONCLUSION

This type of project is effective in reducing blindness caused by cataracts in developing countries. However, long-term scheduled follow-up of operated patients is an effective means of avoiding consecutive blindness resulting from secondary cataracts and refractive changes.

Popular beliefs regarding the treatment of senile cataract

OBJECTIVE

To identify popular beliefs regarding the treatment of senile cataract in patients enrolled in the community health programs on eye rehabilitation.

METHODS

A cross-sectional survey was carried out using an interview questionnaire that was applied to 776 subjects drawn from a non-probabilistic sample in five cities of the state of São Paulo. The sample was made up of 47.2% males and 52.8% females, aged 50 to 96 years (average age 71.6 years).

RESULTS

Of the total of subjects studied, 41.9% had never attended school, and 78.5% were no longer in the employment market. Most (85.1%) credited the sight restoration to cataract surgery. Among those unconvinced, 47.4% asserted that sight restoration depended only on God's will. A greater proportion of women than men (p 0.0000) believed in the association of cataract and menopause, maternity, and menstrual periods and they admitted using herbal and rose teas for treating cataract.

CONCLUSIONS

Misbeliefs related to the causes and treatment of senile cataract were identified, most probably of sociocultural basis, indicating the need of education on the subject.

Eye disease and care in Latin America and the Caribbean

In the last decade, health indicators in Latin America and the Caribbean reflect advances. The per capita public expenditure on health care has increased in many countries. Despite these improvements, it is estimated that for every million population in Latin America and the Caribbean, 5,000 are blind and 20,000 are visually impaired; at least 66% of the blindness is attributable to treatable conditions such as cataract. The cataract surgery rate in the region remains low as compared to the industrialized countries, although it is higher than many other regions of the world. The availability of eye care services varies from country to country within the region, and the number of ophthalmologists per million population in the richest countries may be nine times more than in the poorest. Access, defined as the distance between the consumer and the services, is problematic in countries with isolated areas in the rainforest or high mountains, poor road systems, or lack of public transportation. Affordability is an important issue that limits utilization of services by the poorest segments of the population in nearly all countries in Latin America and the Caribbean.

Blindness and visual impairment in the Americas and the Caribbean

AIM

To summarise available data on the prevalence and causes of visual impairment and blindness in the Americas and the Caribbean.

METHODS

The published literature was searched in Medline and LILACS using the following key words: blindness, visual impairment, prevalence. Articles were reviewed, and the references of the articles were also searched for relevant articles, which were also reviewed.

RESULTS

Using the mortality in children under the age of 5 as an indicator, the overall prevalence of childhood blindness (in the under age 15 group) for the region was estimated at 0.45/1000, with the majority (67%) living in countries with mortality of children under age 5 above 30/1000 live births. Corneal opacities were more common in countries where the under 5 year mortality are above 30/1000 live births and retinopathy of prematurity (ROP) was an important cause in countries with intermediate death rates. For adults, overall blindness rates were not estimated because of the social, economic, and ethnic diversity in the region. The primary causes of visual loss in adults in the Americas were age related eye diseases, notably cataract and glaucoma in the African-American and Hispanic populations, and age related macular degeneration in the white population. Uncorrected refractive error was a significant cause of decreased vision across ages, ethnic groups, and countries.

CONCLUSION

More data are needed on the magnitude and causes of visual loss for the Caribbean and Latin American countries. Rates of blindness and visual loss from available data within these countries are widely disparate. Prevention and control of avoidable blindness needs to be an ongoing focus in this region.

Evaluation of barriers to surgical compliance in the treatment of trichiasis

PURPOSE

Eyelid repair surgery can prevent the effects of trichiasis leading to visual loss. Cost, transportation difficulties, and familial responsibilities have been identified as major barriers to surgical compliance. We evaluated whether offering trichiasis surgery in the village was effective in increasing the rate of surgical acceptance and in decreasing perceived barriers to surgery.

METHODS

In 1989, 205 women with trichiasis were identified in Central Tanzania and were offered free surgery along with free transport. As of 1991, only 18% of these women had undergone the surgery. We followed-up these women 7 years later after village level surgery was introduced.

RESULTS

Since 1991, an additional 12% of the women had undergone eyelid surgery. 44% were conducted in the village. Surgical cases since 1991 reported shorter travel times to the place of surgery, similar post-surgical problems, and fewer days in the hospital. While providing benefits to the patient, increased village eye services did not increase the rate of surgical acceptance. The women who declined surgery did not know surgery in the village was available and the perceived cost and transportation difficulties continued to be barriers. 50% of the non-acceptors stated that there was nothing that would enable them to accept surgical intervention despite the fact that 3/4 of them reported eye symptoms that interfered with their daily activities.

CONCLUSIONS

The cost efficacy of village level eye services needs to be evaluated and the awareness of these services increased.

[Evaluation of an educational program for patients with glaucoma]

PURPOSE

To analyze the results of an educational program applied to glaucoma patients; to serve as a guideline for a definitive educational program to be developed at the Glaucoma Service of the University of Campinas.

METHODS

Fifty glaucoma patients were given information about the disease and its treatment by an experienced nurse and answered the same questionnaire before and 2.7 months after the initial explanation. The technique of eyedrop instillation was compared before and after the educational program.

RESULTS

There was no significant improvement concerning the knowledge of the identification of the ocular disease, the side effects, the meaning of glaucoma, the importance of treatment, the purpose of medications and the normal value of intraocular pressure. There was a significant improvement in all steps of eyedrop instillation (p < 0.01) and in knowledge regarding the importance of heredity (p < 0.001) and the purpose of perimetry (p=0.033).

CONCLUSION

Although a significant improvement was observed in the technique of eyedrop instillation, the authors conclude that this plan was not complete enough for its contents fully to be understood. These findings may be secondary to the vertical teaching-learning process, which is inappropriate for the patient, and to the difficulty in comprehending the information, which is associated with low cultural and instruction levels, and to psychosocial factors related to their disease.

Predicting surgical compliance in a cohort of women with trichiasis

Trichiasis/Entropion are the severe consequences of chronic trachoma during early life. Blindness and vision loss is preventable with timely lid surgery to correct trichiasis. In a trachoma hyperendemic region of Central Tanzania, a two year follow-up survey was conducted among 205 women with trichiasis to determine the proportion who had had surgery and the barriers to having surgery. Only 18% of the women had undergone surgery by the 2 year follow-up. Those who had surgery tended to report more eye problems at baseline and have more corneal opacities at baseline. Barriers preventing women from going to surgery were costs, problem of children left at home alone, and difficulties in identifying someone to accompany them to the health center. Over 2/3 of those who had surgery reported a significant decrease in pain, improvement of vision, and improved ability to carry out activities of daily life. Ways to improve compliance with recommendations for trichiasis surgery need to be developed.

Cataract surgery at district hospital level

Cataract remains the leading cause of blindness worldwide, curable though, by a simple procedure. The backlog of cataract patients in developing countries is mounting despite sustainable and downright efforts by health ministries, international voluntary and non-governmental organisations [1]. The current situation has put many developing countries in a difficult dilemma. The authors present a review of a pilot-project in decentralised eye-care in Mutasa District, Zimbabwe. Cataract surgery is performed by a district general doctor as an alternative to clearing the cataract back-log in developing countries, as suggested in several studies [2-5]. It is important to persuade the health ministries to adopt this simple and cheap policy [6,7].

Results and evaluation of high volume intracapsular cataract surgery in Nepal

One thousand intracapsular cataract extractions were performed by two ophthalmologists over a 57-day period at Lahan Eye Hospital in Nepal. Ninety-nine per cent of eyes had a visual acuity of less than 3/60 at surgery. Ninety-eight per cent of eyes achieved a visual acuity of 3/60 or better with aphakic spherical correction at discharge, of which 69% had a visual acuity of 6/36 or better. In 314 eyes seen at 1-month follow-up, 88% achieved 6/18 or better with full aphakic correction. The surgical time averaged less than 10 min and the cost of disposables less than pounds 1 per operation.

The cost effectiveness of strategies to reduce barriers to cataract surgery. The Operations Research Group

The cost and effectiveness of eight approaches to reducing barriers to cataract surgery were evaluated in a rural area of South India during 1987-1989. The approaches were based on four intervention alternatives--aphakic motivator (AM), basic eye health worker (BW), screening van (SV), and mass media (MM). Each intervention was offered at two levels of economic incentive: partial, which provides free surgery and hospital stay, and full, which also provides transport from the recipient's village to the hospital and free food during the hospital stay. Evaluations took place in a probability selection of 90 villages, including ten control villages not subjected to either of the interventions. Only costs unique to patients from the intervention villages were considered: Health education and screening costs were included, surgery costs were not. Percentage reductions in the cataract blind backlog and increases in surgical coverage were used as effectiveness measures. Analyses suggest that the SV and AM interventions, both with full economic incentive, offer the greatest advantage. The AM intervention is the more effective of the two, but also the more costly.

Points of action in the campaign against blindness in developing countries

This article provides a survey of the problems of prevention of blindness in developing countries. The World Health Organization estimates that 31 million people are blind and 15 million people partially-sighted. The main cause of blindness is cataract. Other causes are trachoma, glaucoma, xerophthalmia, river blindness, corneal scars and leprosy. Prevention or treatment of these causes is possible in more than 80% of cases. The number of blind persons, however, is still increasing due to the increase in population and the immense shortage of all kinds of ophthalmological equipment and personnel. An effective strategy for the prevention of blindness in developing countries should focus on: more cheap cataract operations, increasing teaching facilities for ophthalmic personnel, integration of ophthalmic care into the general health system and the promotion of blindness prevention in political organizations.