Traditional couching is not an effective alternative procedure for cataract surgery in Mali

Traditional Eye Practices: Economics and Visual Status of Users in North Central Nigeria

BACKGROUND

Traditional medicine is a constellation of practices, approaches, knowledge, and beliefs, which encompass material-based medicines, spiritual therapies, and manual techniques applied individually or combined.

AIM

This study seeks to determine the cost and visual status of traditional eye treatments users among new patients at a health facility.

MATERIALS AND METHODS

This is part of the study titled "Traditional eye practices: A facility-based study in North Central Nigeria." It is a cross-sectional, facility-based study conducted between July 2013 and June 2014 on new patients seen in the eye unit of Church of Christ in the Nations Rehabilitation Center, Mangu. Interviewer-administered structured questionnaire was used to gather information on patient demographics; cost of traditional eye medication and manipulations and visual status of new patients were recorded.

RESULTS

The use of traditional eye treatment was reported by 134 (4.3%) of the 3113 new patients. Traditional operative couching of lens was more expensive than using traditional eye medications (P < 0.001). Payment modality varied, and poor visual status was significantly higher among traditional eye treatment users (P < 0.001).

CONCLUSION

Since most respondents who had their eyes couched or used traditional eye medicine were able to pay such high price with dissatisfaction and poorer visual status, they should be able to pay for modern cataract surgery with good outcome. There is a need for health education of the general public about the deleterious effects of traditional eye treatment.

The Routine Use of Intracameral Antibiotics to Prevent Endophthalmitis After Cataract Surgery: How Good is the Evidence?

Post-operative endophthalmitis (POE) following cataract surgery is an uncommon, vision-threatening complication that has been reported to occur at rates of between approximately 0.03% and 0.2%. Prompt diagnosis and treatment of endophthalmitis is critical for minimizing vision loss, but most recent efforts have focused on the prophylactic administration of antibiotics to prevent the development of endophthalmitis. Surgeons from around the world have different topical and intracameral antibiotic usage patterns to prevent endophthalmitis, and to date no general consensus regarding best practice has emerged. Several studies have reported on the routine use of intracameral cefuroxime, moxifloxacin, and vancomycin, including a single randomized clinical trial by the European Society of Cataract and Refractive Surgery (ESCRS) in 2007. These studies have notable shortcomings, but many authors suggest that intracameral cefuroxime together with topical antibiotics probably decreases the risk of endophthalmitis. However, the deleterious effects of routine prophylactic antibiotics, which include toxicity, cost, and increasing antimicrobial resistance, among others, are noteworthy. In contrast, aseptic technique with pre-operative instillation of povidone-iodine remains the only technique supported by level I evidence to reduce the incidence of endophthalmitis. Although the routine use of intracameral antibiotics continues to increase throughout the world, data from multicenter, randomized, prospective trials is needed to provide better guidance regarding the prophylactic use of antibiotics.

Exploration of indigenous knowledge systems in relation to couching in Nigeria

Background: Couching is a traditional treatment for cataracts but often has poor visual outcomes, as identified during the Nigerian National Blindness Survey.Objectives: To investigate why couching is accessed by individuals with cataracts in northern Nigeria.Methods: The ten rural clusters in Jigawa State included in the National BlindnessSurvey were revisited to trace four groups of participants: cataract blind individuals, those couched or who had undergone cataract surgery and local couchers. Additional postoperative patients were recruited from the local eye department. Semi-structured interviews were undertaken with cataract blind and cataract-operated participants, and 27 in-depth interviews were conducted with those couched and five couchers. Qualitative data were translated, transcribed and analysed after immersion and reflection using a thematic framework.Results: Half of the cataract blind attributed the cause to spiritual factors or past misdeeds, only 25% knew they had cataracts and 83% had not undergone ophthalmic examination. Cost, distance and unreliability of services were the main barriers to accessing surgery. Facilitators of couching were the responsiveness of couchers in relation to location, timing and payment, and immediate visual improvement. Couchers understood local beliefs, were itinerant and used a network of case finders.Conclusions: Couching is accepted as it is entrenched in traditional beliefs and indigenous knowledge systems, and couchers are responsive. Lack of awareness and inaccessibility were barriers to cataract surgery. Strategies to improve cataract surgery must take account of local beliefs and factors influencing health-seeking behaviour. Couchers were willing to collaborate with professional eye care providers, but this will require time, skill and mutual trust.Keywords: couching

Couching in Nigeria: prevalence, risk factors and visual acuity outcomes

PURPOSE

Couching is an ancient treatment for cataract which is still practiced in some of the poorer developing countries, particularly in sub-Saharan Africa. The purpose of this study is to describe risk factors for couching and visual acuity outcomes in a nationally representative sample of adults aged 40 years and above in Nigeria.

METHODS

Probability in proportion size methods were used to identify a representative sample. Of the 15,375 adults enumerated, 13,582 were interviewed and examined. Examination included logMar acuities, slit lamp examination and dilated fundoscopy with digital fundus imaging.

RESULTS

Almost half of the 583 eyes undergoing a procedure for cataract had been couched (249 eyes, 42.7%). Individuals living in rural areas (P = 0.033) and in the two underserved northern administrative zones (P = 0.33; P = 0.002) were more likely to have been couched. Visual outcomes were poor according to World Health Organization categories, with 55.8% of people and 73.1% of eyes having a presenting visual acuity of less than 3/60 and only 9.7% and 2.4% of people and eyes respectively having a good outcome (6/18 or better). None were wearing an aphakic correction, and with correction acuities improved but 42.6% of eyes were still blind (< 3/60).

CONCLUSIONS

Couching is still widely practiced in Nigeria and visual outcomes are very poor. The population needs to be made aware of the risks associated with the procedure, and services for high quality, affordable cataract surgery need to be expanded, particularly in rural areas and in the north of the country.

Traditional Arabic technique of couching for cataract treatment in Yemen

PURPOSE

In Yemen, a number of cataract patients still receive sight-restoring surgery using a traditional Arabic couching procedure. In order to evaluate the relative effectiveness and outcomes of the traditional couching procedure, patients attending a teaching center in Sana'a who had the procedure were studied.

METHODS

Fifty-five eyes of 50 patients treated by traditional couching were evaluated. All individuals were checked for best-corrected visual acuity, intraocular pressure, slit-lamp biomicroscopy and fundal examination. All were questioned regarding their clinical history, cost of the surgery, and their satisfaction with the procedure immediately following the operation and presently.

RESULTS

There were 55 eyes of 50 patients treated by a traditional couching procedure by a local healer. A total of 32 (64%) were men and 18 (36%) were women. The traditional healer was often paid partially in kind and the price paid varied according to patientís ability and was on average 62 USD plus accommodation and meals in the village the healer visited. After aphakic correction of eyes, 1.8% (1/55) had good vision (VA > or = 6/18), 21.8% (12/55) had low vision (> or =3/60), and 76.4% (42/55) were still blind (<3/60). Complications noted were glaucoma (21), corneal opacity (14), uveitis (6), posterior capsule opacity (8), retinal detachment (7), and severe pain (14).

CONCLUSIONS

In Yemen, cataract-blind persons are still treated by traditional healers. This study suggests that the couching method used is relatively expensive, ineffective, and dangerous, and most patients are not satisfied with the results.

Willingness to Pay for Cataract Surgery in Rural Southern China

PURPOSE

To study willingness to pay for cataract surgery, and its associations, in Southern China.

DESIGN

Cross-sectional willingness-to-pay interview incorporating elements of the open-ended and bidding formats.

PARTICIPANTS

Three-hundred thirty-nine persons presenting for cataract screening in Yangjiang, China, with presenting visual acuity (VA) < or = 6/60 in either eye due to cataract.

METHODS

Subjects underwent measurement of their VA and a willingness-to-pay interview. Age, gender, literacy, education, and annual income also were recorded.

MAIN OUTCOME MEASURES

Maximum amount that the subjects would be willing to pay for cataract surgery.

RESULTS

Among 325 (95.9%) subjects completing the interview, 169 (52.0%) were 70 years or older, 213 (65.5%) were women, and 217 (66.8%) had an annual income of <5000 renminbi (5000 = US 625 dollars). Eighty percent (n = 257) of participants were willing to pay something for surgery (mean, 442+/-444 renminbi [US 55 dollars+/-55]). In regression models, older subjects were willing to pay less (8 renminbi [US 1 dollar] per year of age; P = 0.01). Blind subjects were significantly more likely (odds ratio, 5.7; 95% confidence interval, 1.7-19.3) to pay anything for surgery, but would pay on average 255 renminbi (US 32 dollars) less (P = 0.004). Persons at the highest annual income level (>10,000 renminbi [US 1250 dollars]) would pay 50 dollars more for surgery than those at the lowest level (<5000 renminbi) (P = 0.0003). The current cost of surgery in this program is 500 renminbi (US 63 dollars).

CONCLUSIONS

Sustainable programs will need to attract younger, more well-to-do persons with better vision, while still providing access to the neediest patients.

Couching for cataract and Sino-Indian medical exchange from the sixth to the twelfth century AD

This paper investigates the processes of interpretation and integration of the Indian ophthalmic technique known as 'couching for cataract' into Chinese medicine from the sixth to the twelfth century ad. The Indian medical knowledge of this procedure was eventually accepted because it could be reconstructed following Chinese medical concepts.

Outcome and number of cataract surgeries in India: policy issues for blindness control

PURPOSE

To assess what impact attention to quality of cataract surgery and postoperative follow up can have on cataract blindness in India, and to estimate the number of surgeries needed to eliminate cataract blindness in India.

METHODS

In a population-based sample of 5268 persons in two rural areas in the state of Andhra Pradesh, India, data on the visual outcome of cataract surgery were obtained on 129 eyes of 106 persons operated previously. These were compared with the visual outcome of cataract surgery performed during 1999 in 2394 eyes of 2213 persons at two new rural eye centres set up in these areas that pay particular attention to the quality of eye care. Blindness in an eye was defined as presenting distance visual acuity less than 6/60, and in a person as this acuity level in the better eye. These data were extrapolated to India.

RESULTS

In the population-based sample, of the 129 operated eyes, 51 (39.5%) were blind after surgery, which included 41 (31.8%) from cataract surgery-related causes. Of the 106 persons in the population sample who had had cataract surgery in one or both eyes, 26 (24.5%) were still blind. In contrast, for the cataract surgery at the two rural eye centres paying attention to quality, 3.1% of the eyes and 1.8% of the persons were blind soon after surgery, but these figures could increase 2.6 times over the lifetime of these persons. The 3.5 million cataract surgeries in India in 2000 are estimated to result in 0.32 million persons having blindness averted over their lifetime. To eliminate cataract blindness in India, an estimated 9 million good-quality cataract surgeries are needed every year during 2001-2005, increasing to over 14 million surgeries needed every year during 2016-2020 on persons most likely to go blind from cataract.

CONCLUSIONS

The number of persons in whom blindness is being averted due to cataract surgery in India is currently a very small fraction of the number blind from cataract. If adequate attention is given to the quality of eye care, for the current number of cataract surgeries in India it should be possible to increase by threefold the number in whom blindness can be averted with cataract surgery. In addition to improving quality, the annual number of cataract surgeries has to be at least threefold the current number during 2006-2010 if cataract blindness in India is to be eliminated.