Cataract in children attending schools for the blind and resource centers in eastern Africa

Causes of severe visual impairment and blindness in students in schools for the blind in Northwest Ethiopia

Objectives

To determine the causes of severe visual impairment and blindness (SVI/BL) among students in schools for the blind in Northwest Ethiopia and to identify preventable and treatable causes.

Method

Students attending nine schools for the blind in Northwest Ethiopia were examined and causes assigned using the standard WHO record form for children with blindness and low vision in May and June 2015.

Results

383 students were examined, 357 (93%) of whom were severely visually impaired or blind (<6/60 in their better eye). 253 (70.9%) were aged 16 years or above and 228 (63.9%) were males. 100 students aged <16 years were blind and four were SVI, total 104. The major anatomical site of visual loss among those 0-15 years was cornea/phthisis (47.1%), usually due to measles and vitamin A deficiency, followed by whole globe (22.1%), lens (9.6%) and uvea (8.7%). Among students aged 16 years and above, corneal/phthisis (76.3%) was the major anatomical cause, followed by lens (6.3%), whole globe (4.7%), uvea (3.6%) and optic nerve (3.2%). The leading underlying aetiology among students aged <16 years was childhood factors (39.4%) (13.5% measles, 10.6% vitamin A deficiency), followed by unknown aetiology (54.8%), perinatal (2.9%) and hereditary factors (2.9%). In the older group, childhood factors (72.3%) (25% measles, 15% vitamin A deficiency) were major causes, followed by unknown aetiology (24.1%), perinatal (2.4%) and hereditary factors (0.8%). Over 80% of the causes were avoidable with majority being potentially preventable (65%).

Conclusion

Corneal blindness, mainly as the result of measles and vitamin A deficiency, is still a public health problem in Northwest Ethiopia, and this has not changed as observed in other low-income countries. More than three-fourth of causes of SVI/BL in students in schools for the blind are potentially avoidable, with measles/vitamin A deficiency and cataract being the leading causes.

The Use of Key Informant Method for Identifying Children with Blindness and Severe Visual Impairment in Developing Countries

PURPOSE

An estimated 19 million children are visually impaired; of these, 1.4 million are irreversibly blind. A key challenge is to identify them early in life to benefit maximally from visual rehabilitation, and/or treatment. This aggregative review and structured literature analysis summarizes evidence of what it is about the key informant (KI) approach that works to identify children with blindness or severe visual impairment (B/SVI) in the community (for whom, to what extent, in what circumstances, in what respect, how and why).

METHODS

Peer-reviewed (PubMed, hand search) and grey literature (Google, World Health Organization website, academic theses, direct requests) were included, and methods and criteria used for identification, productivity (number of children referred per KI), accuracy of referrals (positive predictive value, PPV), age of children with B/SVI, KI definition, sex, information about cost and comparisons aggregated.

RESULTS

We included 31 documents describing 22 unique KI programs. Mostly KIs identified children with B/SVI in 1-3 weeks, i.e. "campaign mode." In 60%, KIs were community volunteers, others formal health sector workers (FHSW). Around 0.02-1.56 children per KI (median = 0.25) were successfully recruited. PPV ranged from 12 to 66%. In two studies comparing FHSWs and community KIs, the latter were 8 and 10 times more productive.

CONCLUSION

KIs working in campaign mode may provide an effective approach to identifying children with B/SVI in communities. Including identification of ocular problems and/or other impairments has been recommended. Research on factors that influence effectiveness and on whether KIs continue to contribute could inform programs.

Outcomes of Pediatric Cataract Surgery in the Copperbelt Province of Zambia

PURPOSE

To study the outcomes of pediatric cataract surgeries in children operated on in the Copperbelt Province of Zambia and the barriers to accessing surgery.

METHODS

All children who had congenital, developmental, and traumatic cataracts operated on by lens aspiration, primary posterior capsulotomy, and anterior vitrectomy with posterior chamber intraocular lens implantation from 2012 to 2013 and followed up beyond 6 months were studied. Each child underwent a comprehensive preoperative evaluation. An active, assisted follow-up was done and parents were asked about reasons for delay between presentation and surgery.

RESULTS

One hundred two eyes of 70 children met the inclusion criteria of the study. Preoperatively, 76 of 77 (98.7%) eyes in the congenital and developmental cataract group had presenting visual acuity of worse than 6/60. This improved postoperatively, with 19 (29.7%) eyes having best corrected visual acuity (BCVA) of better than 6/18, 23 (35.9%) having BCVA of 6/24 to 6/60, and 22 (34.4%) having BCVA of worse than 6/60. Older age (P = .005), better preoperative vision (P = .045) at presentation, unilaterality (P = .012), and delay between presentation and surgery (P = .004) were predictors of a better postoperative outcome. On multivariate analysis, only age was significant (P = .025). Distance and cost of travel and surgery were the causes of delay in presentation. In the patients with traumatic cataracts, 17 of 25 (68%) had BCVA of better than 6/18, 6 (24%) had BCVA between 6/24 and 6/60, and 2 (8%) had BCVA of worse than 6/60 at the 6-month follow-up. The most common causes of injury were being struck by sticks and stones (10 children, 25%).

CONCLUSIONS

Visual outcomes after pediatric cataract surgery in Zambia were comparable and satisfactory. Cost of treatment was a barrier, but delay did not adversely affect outcome. [J Pediatr Ophthalmol Strabismus. 2016;53(5):311-317.].

Strategies to improve follow-up of children after surgery for cataract: findings from Child Eye Health Tertiary Facilities in sub-Saharan Africa and South Asia

PurposeWe sought to conduct a systematic literature review on follow-up of children with ocular surgical management (primarily childhood cataract) in developing countries. Second, we sought to determine the current practices regarding follow-up for clinical, optical, low vision, rehabilitation, and educational placement among children receiving surgical services at Child Eye Health Tertiary Facilities (CEHTF) in sub-Saharan Africa (SSA) and South Asia.MethodsA systematic literature review was conducted. Separately, we conducted a cross-sectional study among CEHTF in SSA and South Asia (India, Nepal, and Bangladesh) to assess current capacities and practices related to follow-up and educational placement.ResultsThe articles that met the systematic review eligibility criteria could be grouped into two areas: factors and strategies to improve post-operative follow-up and educational placement of children after surgery. Among the 106 CEHTF in SSA and South Asia, responses were provided by 75 CEHTF. Only 59% of CEHTF reported having a Childhood Blindness and Low Vision Coordinator; having a coordinator was associated with having appropriate follow-up mechanisms in place. Educational referral practices were associated with having a low-vision technician, having low-vision devices, and having donor support for these services.ConclusionsThe systematic literature review revealed evidence of poor follow-up after surgical interventions for cataract and other conditions, but also showed that follow-up could be improved significantly if specific strategies were adopted. Approaches to follow-up are generally inadequate at most facilities and there is little external support for follow-up. Findings suggest that funding and supporting a coordinator would assist in ensuring that good practices for follow-up (cell phone reminders, patient tracking, and reimbursement of transport) were followed.

Surgery for sight: outcomes of congenital and developmental cataracts operated in Durban, South Africa

PURPOSE

To study the visual outcomes of congenital and developmental cataract surgery and determine variables for presentation for pediatric cataract surgery in KwaZulu Natal province of South Africa.

METHODS

Care-givers of children presenting with cataract to a quaternary centre were asked when they first detected the condition. The reasons for delay between detection and surgery were studied. The children underwent a comprehensive eye examination and then appropriate surgery. They were prospectively followed up for 3 months and visual acuity and stereopsis were noted. Delay in presentation for surgery and visual outcomes were co-related with demographic and clinical factors.

RESULTS

Eighty-three non-traumatic cataract surgeries in 50 children were studied. Twenty-six (52%) were males, mean age was 3 years 10 months (SD 3yrs 4 months). The mean delay between identification and surgery was 20.7 months (SD 18 months). Twenty-six (52%) children had >15 months interval between diagnosis and surgery. Only mother's occupation was significantly associated with delay (P=0.017). Post-surgery 17/69 (24.7%) had visual acuity ≥6/18, 20/69 (29.0%) had vision between 6/24-6/60, whereas 32/69 (46.3%) had visual acuity ≤6/60. The final vision was associated with age (P=0.031), delay between diagnosis and surgery (P<0.001), type of surgery (P=0.046) and preoperative vision (P<0.001).

CONCLUSION

Although the children's vision improved substantially, a longer follow-up and amblyopia treatment would be necessary to optimize the visual outcome, which depended on age and preoperative vision. Health promotion activities aimed at mothers are important in improving visual outcomes.

Long term outcomes of bilateral congenital and developmental cataracts operated in Maharashtra, India. Miraj pediatric cataract study III

AIM

To study long term outcome of bilateral congenital and developmental cataract surgery.

SUBJECTS

258 pediatric cataract operated eyes of 129 children.

MATERIALS AND METHODS

Children who underwent pediatric cataract surgery in 2004-8 were traced and examined prospectively in 2010-11. Demographic and clinical factors were noted from retrospective chart readings. All children underwent visual acuity estimation and comprehensive ocular examination in a standardized manner. L. V. Prasad Child Vision Function scores (LVP-CVF) were noted for before and after surgery.

STATISTICS

Statistical analysis was done with SPSS version 16 including multi-variate analysis.

RESULTS

Children aged 9.1 years (std dev 4.6, range 7 weeks-15 years) at the time of surgery. 74/129 (57.4%) were boys. The average duration of follow-up was 4.4 years (stddev 1.6, range 3-8 years). 177 (68.6%) eyes had vision <3/60 before surgery, while 109 (42.2%) had best corrected visual acuity (BCVA) >6/18 and 157 (60.9%) had BCVA >6/60 3-8 years after surgery. 48 (37.2%) had binocular stereoacuity <480 sec of arc by TNO test. Visual outcome depended on type of cataract (P = 0.004), type of cataract surgery (P < 0.001), type of intra-ocular lens (P = 0.05), age at surgery (P = 0.004), absence of post-operative uveitis (P = 0.01) and pre-operative vision (P < 0.001), but did not depend on delay (0.612) between diagnosis and surgery. There was a statistically significant improvement for all the 20 questions of the LVP-CVF scale (P < 0.001).

CONCLUSION

Pediatric cataract surgery improved the children's visual acuity, stereo acuity and vision function. Developmental cataract, use of phacoemulsification, older children and those with better pre-operative vision had betterlong-termoutcomes.

Childhood cataract in sub-Saharan Africa

Investment by organizations and agencies has led to a growing body of evidence and information to assist ophthalmologists and others to meet the needs of children with cataract in Africa. The geographic distribution of research, training, and programme development across Africa has been uneven; investment has been greatest in eastern and southern Africa. Population based surveys (using key informants) suggest that 15-35% of childhood blindness is due to congenital or developmental cataract. There may be up to 82,000 children with non-traumatic cataract in Africa, with approximately 19,000 new cases each year. Effective strategies to find and refer children are those that engage the community in case detection. Identification and referral does not automatically mean surgical intervention with distance to the surgical facility being the most common reason for failure to seek care. Surgical management has become more specialized and a team based approach has been adopted by many paediatric ophthalmologists and their programmes. Although many children still present late for surgery, outcomes of surgery are much improved from previous experiences. Research suggests that post-operative follow up, still a challenge, can be improved through adoption of specific strategies. There has been limited success in ensuring that children are placed in appropriate educational settings. While eye care professionals may feel their responsibility ends with clinical care, it is important for the paediatric eye care team to be engaged with educational and rehabilitation services.

Visual outcome of cataract in pediatric age group: does etiology have a role

PURPOSE

To compare visual outcome results among traumatic and nontraumatic groups of eyes with cataract in the pediatric age group.

METHOD

This is a retrospective cohort study. This study comprised a consecutive series of pediatric patients under 5 years of age with unilateral congenital, developing, or traumatic cataract who underwent surgery between January 1999 and April 2012 at Drashti Netralaya, Dahod. Records were retrieved from the medical record department. Patients were grouped as traumatic or nontraumatic and their demographics, cataract type, presenting symptoms, surgical intervention, and postoperative visual acuity follow-up refractive changes were recorded and compared.

RESULTS

A total of 128 eyes of 128 children under 5 years of age were included with unilateral cataract. A total of 85 (66.4%) were traumatic and 43 (33.3%) nontraumatic. The age at surgery ranged from 1 to 60 months. Eyes were grouped by etiology: group 1- traumatic 85 (66.4%) eyes that had traumatic cataracts. Group 2 non-traumatic 43 (33.3%) eyes that had congenital, developmental or complicated cataracts. The mean follow-up time was 117 days. Finally, 22 (51.1%) group 1 patients and 40 (47.1%) group 2 patients achieved visual acuity better than 20/200 (p = 0.000).

CONCLUSIONS

Surgical treatment with intraocular lens implantation for children with congenital, developmental, or traumatic cataract is an effective treatment for visual rehabilitation. Visual outcome is significantly better (p = 0.005) in case of nontraumatic cataracts than traumatic cataracts.