Cataract surgical coverage and barriers to uptake of cataract surgery in leprosy villages of north eastern Nigeria

Assessment of cataract surgery outcomes in Nampula (Mozambique): visual acuity, visual function and quality of life

BACKGROUND

Despite advances in surgical techniques, cataract remains the leading cause of preventable blindness, and massive surgeries have been adopted as a strategy to change this situation. Monitoring the results of cataract surgeries has become imperative to ensure their quality. Therefore, this study aims to assess the cataract surgery outcomes performed at the Central Hospital of Nampula Mozambique.

METHODS

This is a prospective and longitudinal study in which translation, cultural adaptation and validation of the visual function (VF) and quality of life (QoL) questionnaire were performed. The appearance, content, construct, criterion, internal consistency and responsiveness were validated using the most common methods and indicators. Visual acuity (VA), VF and QoL were evaluated on 447 patients before and after surgery by t-test and effect sizes.

RESULTS

VF and QoL questionnaires showed one-dimension, good values of TLI (0.973, 0.951) and SRMR (0.057, 0.054), and for each item, weights > 0.7, H2 > 0.5, ranges > 5.8 and the RMSEA < 0.08. Correlations for criterion validity were high and for responsiveness were high for QoL and moderate for VF one and the ordinal Cronbach's alpha coefficients were greater than 0.97. Difference between VA, VF and QoL before and after surgery was statistically significant (p < 0.001). After surgery, 74.3% of patients had good, 23.5% had borderline and 2.2% had poor VA.

CONCLUSIONS

The cataract surgery outcomes are outside the WHO recommendations regarding VA, but they have had a great impact on improving VF and QoL. The questionnaires showed excellent psychometric properties and should be used in daily clinical practice to evaluate the results of cataract surgeries.

Effectiveness of community outreach screening for glaucoma in improving equity and access to eye care in Nigeria

PURPOSE

To determine the effectiveness of community outreach screening for glaucoma in improving equity and access to eye care in Nigeria.

METHODOLOGY

This was a prospective study in which two cohort of participants were recruited in Nigeria: 1 from 24 outreach screenings and another from consecutive patients presenting spontaneously to a tertiary eye clinic in Nigeria. Sociodemographic and clinical data were obtained from participants and compared.

RESULTS

Our sample consisted of 120 patients with glaucoma or suspected glaucoma (6.38% of 1881 screenees) recruited from the 24 outreach screenings, and another 123 patients with glaucoma who presented spontaneously at the eye clinic. Participants from the screenings were significantly older (p=0.012), less educated (p<0.001), had lower incomes (p<0.001), lower glaucoma knowledge scores and were less aware of their glaucoma (both p<0.001) and were more likely to be dependent on relations and children (p=0.002) compared with clinic participants. Of the 120 patients identified at the screenings and referred to the clinic for definitive care, 39 (32.5%) presented at the clinic within 3 months. Reasons for poor uptake of referral services were lack of a felt need and lack of money for transportation. Considering only patients who accepted referral, they were still less educated (p<0.001), poorer (p=0.001) and less knowledgeable about glaucoma (p=0.003) than spontaneous clinic presenters.

CONCLUSION

Outreach screening improved equity of access but its effects were somewhat reduced by poor uptake of referral care. Interventions such as free transportation and educational efforts may improve the uptake of referral services and maximise equity gains.

Factors associated with delayed uptake of cataract surgery among adult patients at Mulago National Referral Hospital, Uganda

BACKGROUND

Cataract is the leading cause of blindness globally. Many patients with cataract in developing countries delay to come for cataract surgery.

OBJECTIVES

This study aimed to determine the factors associated with delayed uptake of cataract surgery among adult patients seen at Mulago National Referral Hospital eye clinic in Uganda.

METHODS

Employing a hospital based cross-sectional study, adult patients with cataract and having moderate visual impairment or blindness were recruited. Patient-related factors for delayed surgery were assessed using a predetermined questionnaire. Data was analyzed using stata version 14.2. Logistic regressions were used to determine the factors associated with delayed uptake of cataract surgery among these patients.

RESULTS

Eighty two participants with operable cataract were evaluated. Females were 44 (54%) and the mean age of participants was 67 years. Fifty three (65%) had delayed uptake of cataract surgery. The factors associated with delayed uptake of cataract surgery among patients with cataract were financial constraint, felt no need for surgery and good unilateral vision.

CONCLUSIONS

Financial constraints, no felt need for cataract surgery and having good unilateral vision are the factors associated with delayed uptake of cataract surgery among cataract patients. We recommend cataract surgical outreach to remote areas and health education.

Utilization of Secondary Eye Care Services in Western Kenya

Background: Eye care provision is currently insufficient to meet the population's eye health needs in Kenya. Many people remain unnecessarily visually impaired or at risk of becoming so due to treatable or preventable conditions. A lack of access and awareness of services are key barriers, in large part due to their being too few eye care providers in the health system for this unmet need. Methods: A hospital-based, retrospective analysis of patients who attended Kitale eye unit, Trans Nzoia County, Kenya from 1st January 2013 to 31st December 2015. Age and sex standardized hospital attendance rates by residence, age group, and sex were calculated for Trans Nzoia county and each subcounty. The changing trends in attendance rates were estimated by calculating the difference between base year and last year. Incidence rate ratios for attendance for each age-group, sex, and residence were estimated using a multivariable regression model. Results: 20,695 patients from the county were seen in Kitale Eye Unit in 2013, 2014 and 2015. In that period, 8.3% had either uncorrected refractive error, cataracts or glaucoma, the priority VISION2020 diseases, and 61.0% had allergic or other conjunctivitis or normal eyes, which could potentially be managed at primary eye care. During the study period, overall average annual attendance rate increased from 609 to 792 per 100, 000 population, incidence rate ratio (IRR) 1.30 (95% confidence interval (CI) 1.26-1.35). Attendance rates increased more in females than males (34.7% vs. 25.1%, respectively), IRR 1.07 (1.04-1.10). Attendance rates increased with increasing age, (highest among the elderly compared to the young). We found that in extreme age groups (>75 years and <15years) females were less likely to attend than males and there was reduced utilization from those based furthest from the hospital. Conclusion: Specialist eye services are heavily utilized by people with conditions that could be managed at the primary health care level. Barriers to accessing eye services were distance and gender, especially among the most vulnerable groups (young and the elderly). Integration of primary and secondary eye care services could lower barriers to essential eye care services to the population whilst lowering pressure on the limited specialist services by ensuring more appropriate utilization.

Ciliary sulcus implantation of intraocular lens in manual small incision cataract surgery complicated by large posterior capsule rupture

The present study aimed to evaluate the safety and efficiency of ciliary sulcus implantation of intraocular lens (IOL) in patients that had undergone manual small incision cataract surgery (MSICS) complicated by large posterior capsule rupture (LPCR). A total of 11 eyes taken from 11 patients in Brazzaville, Republic of the Congo, that had experienced LPCR following MSICS were included in the current study. A rigid single-piece IOL (5.5 mm optic, 12.50 mm overall length) was implanted into the ciliary sulcus. Postoperative follow-up assessments evaluated visual acuity, anterior segment biomicroscopy, IOL centration and position, and fundus biomicroscopy. The median follow-up time was 3.7 months (range, 2-6 months). All patients experienced vision improvement: Uncorrected visual acuity 2 months following surgery was 0.3-0.5 in 9 patients and >0.5 in 2 patients. Postoperative complications included pronounced anterior segment inflammation (1 patient), mild corneal endothelium edema (3 patients), residual cortex (1 patient) and intraocular pressure elevation (1 patient). Significant IOL decentration and tilt were not observed in any patients. The results of the present study indicate that ciliary sulcus implantation of a rigid single-piece IOL may be a feasible and effective method of treating patients that have experienced LPCR complications following cataract surgery, as it provides satisfactory visual acuity outcomes. Appropriate intraoperative management may reduce the incidence of postoperative complications.

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

Barriers to Cataract Surgery in Africa: A Systematic Review

Cataract remains the leading cause of blindness in Africa. We performed a systematic literature search of articles reporting barriers to cataract surgery in Africa. PubMed and Google Scholar databases were searched with the terms "barriers, cataract, Africa, cataract surgery, cataract surgical coverage (CSC), and rapid assessment of avoidable blindness (RAAB)." The review covered from 1999 to 2014. In RAAB studies, barriers related to awareness and access were more commonly reported than acceptance. Other type of studies reported cost as the most common barrier. Some qualitative studies tended to report community and family dynamics as barriers to cataract surgery. CSC was lower in females in 88.2% of the studies. The variability in outcomes of studies of barriers to cataract surgery could be due to context and the type of data collection. It is likely that qualitative data will provide a deeper understanding of the complex social, family, community, financial and gender issues relating to barriers to uptake of cataract surgery in Africa.

An estimate of hernia prevalence in Nepal from a countrywide community survey

BACKGROUND

Herniorrhaphy is one of the most frequently performed general surgical operations worldwide. However, most low- and middle-income countries (LMICs) are unable to provide this essential surgery to the general public, resulting in considerable morbidity and mortality. This study aimed to estimate the prevalence, barriers to care and disability of untreated hernias in Nepal.

METHODS

Nepal is a low-income country in South Asia with rugged terrain, infrastructure deficiencies and a severely under-resourced healthcare system resulting in substantial unmet surgical need. A cluster randomized, cross-sectional household survey was performed using the validated Surgeons OverSeas Assessment of Surgical (SOSAS) tool. Fifteen randomized clusters consisting of 30 households with two randomly selected respondents each were sampled to estimate surgical need. The prevalence of and disability from groin hernias and barriers to herniorrhaphy were assessed.

RESULTS

The survey sampled 1350 households, totaling 2695 individuals (97% response rate). There were 1434 males (53%) with 1.5% having a mass or swelling in the groin at time of survey (95% CI 1.8-4.0). The age-standardized rate for inguinal hernias in men ranged from 1144 per 100,000 persons between age 5 and 49 years and 2941 per 100,000 persons age≥50 years. Extrapolating nationally, there are nearly 310,000 individuals with groin masses and 66,000 males with soft/reducible groin masses in need of evaluation in Nepal. Twenty-nine respondents were not able to have surgery due to lack of surgical services (31%), fear or mistrust of the surgical system (31%) and inability to afford care (21%). Twenty percent were unable to work as previous or perform self-care due to their hernia.

CONCLUSIONS

Despite the lower than expected prevalence of inguinal hernias, hundreds of thousands of people in Nepal are currently in need of surgical evaluation. Given that essential surgery is a necessary component in health systems, the prevalence of inguinal hernias and the cost-effectiveness of herniorrhaphy, this disease is an important target for LMICs planning surgical capacity improvements.

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.

The dangers of couching in southwest Nigeria

The need to highlight the dangers to the eye and visual status in couching has become necessary in order to discourage its patronage. This was a bi-center clinic-based prospective descriptive study about new cases of couched eyes which were seen over a two-year period. Oral interviews, eye examinations, refractions, and perimetry tests were used to obtain the information. SPSS version 16 was used for the descriptive analysis. Twenty-five patients and 30 eyes of 15 (60%) males and 10 (40%) females were studied. The age range was 34-90 years with a mean age of 67.87 years (SD 11.27). Presenting versus (vs) corrected visual acuity (VA) for normal vision was 6.7% vs 23.3%, visual impairment was 16.7% vs 26.3%, and blindness was 76.7% vs 50%. A significant number still remained blind after corrections (P = 0.014). The most common presenting complaint was "poor/blurred vision" in 24 (80.4%) and the most frequent duration of couching before presentation was 7-12 months (46.7%). Subjects with a cup:disc ratio > 0.6 had intraocular pressures (IOPs) of > 21 mmHg, and 50% of those patients had IOP > 40 mmHg (P = 0.001). Glaucoma (13.3%) and corneal opacity/retinal detachment/couching maculopathy/optic atrophy (10%) were the most common complications. Couching causes visually-disabling complications, and is therefore strongly condemned. Increasing public awareness and putting a policy in place for affordable and accessible cataract services in government hospitals would gradually phase out its patronage.

Couching techniques for cataract treatment in Osogbo, South west Nigeria

BACKGROUND

Couching is still being practised in developing countries including Nigeria despite its adverse effects on vision.

OBJECTIVES

To find out the different techniques of couching, highlight the unacceptable poor visual sequelae and assess knowledge, attitudes, and practices of subjects.

SETTINGS AND DESIGN

Clinic based and prospective observational study.

METHODS AND MATERIAL

Structured interview and clinical examination of consecutive patients was used to obtain information.

RESULTS

Fifteen subjects and 20 eyes of 9(60%) males and 6(40%) females were studied. Age range 60 -90 years and mean 72.4±8.0. Commonest presenting complaints were "I cannot see properly/clearly" 4(26.7%) and "I want to do my second eye so I can see better" 3(20%). Presenting Versus (vs.) Corrected visual acuity (VA) was75% vs 60% blind, 55% vs 45% low vision, and 0% vs 10% normal vision, p= 0.032. Friends and neighbours mostly introduced subjects to couching (26.7% each). Commonest methods involved using sharp objects/needling 45% and blunt/grooving/rocking methods (30%). Subjects assumed "supine" position 75% of time. Eighty five percent of eyes were done at the coucher's. Procedure was painful in 73.3%. Only 5 eyes (25%) maintained vision for >10years. Thirteen (86.7%) said "no" to a repeat procedure and 93.4% would advice against couching.

CONCLUSIONS

Couching methods used were very crude and archaic with attendant poor quality of vision and dissatisfaction. Public education, affordable and accessible cataract surgical services taken to the rural communities could gradually phase out couching.

Cataract blindness, surgical coverage, outcome, and barriers to uptake of cataract services in Plateau State, Nigeria

PURPOSE

The purpose was to estimate the prevalence of blindness due to cataract, assess visual outcomes of cataract surgery, and determine the cataract surgical coverage rate and barriers to uptake of services among individuals aged 50 years or older in Plateau State, Nigeria.

MATERIALS AND METHODS

A population-based, cross-sectional survey of 4200 adults 50 years or older was performed. Multistage stratified random sampling, with probability proportional to size was used to select a representative sample. The Rapid Assessment of Cataract Surgical Services protocol was used. Statistical significance was indicated by (P < 0.05).

RESULTS

The cohort comprised 4115 subjects (coverage: 98%). The prevalence of bilateral blindness due to cataract was 2.1%, [95% confidence intervals (CI): 1.7-2.5%] in the entire cohort, 2.4% in females (95% CI: 1.8-3.8%); and 1.8% in males (95% CI: 1.2-2.4%) (χ(2) = 0.85, P > 0.05). The prevalence of monocular blindness due to cataract was 5.9% (95% CI: 5.2-6.6%). The cataract surgical coverage for subjects with visual acuity (VA) less 3/60 was 53.8% in the entire cohort; 60.5% for males and 48% for females (χ(2) = 2.49, P > 0.05). The couching coverage for subjects who were blind was 12%. A total of 180 eyes underwent surgical intervention (surgery or couching) for cataract, of which, 48 (26.7%) eyes underwent couching. The prevalence of bilateral (pseudo) aphakia was 1.5%, (95% CI: 1.2-1.9%) and 2.7% (95% CI: 2.2-3.2%) for unilateral (pseudo) aphakia. Visual outcomes of the 180 eyes that underwent surgical intervention were good (VA ≥ 6/18) in 46 (25.6%) eyes and poor (VA < 6/60) in 105 (58.3%) eyes. Uncorrected aphakia was the most common cause of poor outcome (65.1%). Most subjects who underwent cataract surgery were not using spectacles 74 (71.2%). Cost and lack of awareness were the main barriers to uptake of cataract surgery services.

CONCLUSION

Couching remains a significant challenge in Nigeria. The outcomes of cataract surgery are poor with the lack of aphakic correction being the main cause of the poor outcomes.

Assessment of barriers to surgical ophthalmic care in South-Western Nigeria

BACKGROUND

The prevalence of blindness and visual impairment are still of public health importance worldwide and yet underutilisation of available eyecare services are still rampant. Therefore, there is continuing need to study the barriers to eyecare uptake.

AIM

To identify barriers to eye surgical uptake in the only teaching hospital in Sagamu, Ogun State, in South-Western Nigeria.

SETTING

The study was done at the eye clinic of Olabisi Onabanjo University Teaching Hospital [OOUTH], Sagamu, Nigeria. This is the only state-owned tertiary eye centre in Ogun State. It serves an approximate population of 3 million.

MATERIALS AND METHOD

All patients who had attended at least 2 follow-up clinics between February and June 2010, and consented to be included in the study were interviewed, and additional information from their case notes were coded and recorded in the software SPSS version 16. This was then analysed for frequencies of variables.

RESULTS

One hundred and sixty-seven (167) respondents were interviewed, comprising 92 males and 75 females, with an age range between 1 and 90 years. 106(63.9%) indicated encountering one form of barrier or the other since attending the eye clinic, out of which 64 were females and 42 males. The types of barriers encountered were: Cost of hospital services [28.3%], fear of surgery [24.1%], long waiting time to see the doctor [23.5%], accessibility to the hospital [16.9%], lack of electricity in the hospital [10.8%], and frequent strikes by health workers [7.2%].

CONCLUSIONS

The commonest barriers to eye surgical care in this study are comparable to those in previous studies but in different proportions and calls for an urgent need to ensure affordable and sustainable surgical care, so as to achieve the goals of vision 2020.

Why do people not attend for treatment for trachomatous trichiasis in Ethiopia? A study of barriers to surgery

BACKGROUND

Trachomatous trichiasis (TT) surgery is provided free or subsidised in most trachoma endemic settings. However, only 18-66% of TT patients attend for surgery. This study analyses barriers to attendance among TT patients in Ethiopia, the country with the highest prevalence of TT in the world.

METHODOLOGY/PRINCIPAL FINDINGS

Participants with previously un-operated TT were recruited at 17 surgical outreach campaigns in Amhara Region, Ethiopia. An interview was conducted to ascertain why they had not attended for surgery previously. A trachoma eye examination was performed by an ophthalmologist. 2591 consecutive individuals were interviewed. The most frequently cited barriers to previous attendance for surgery were lack of time (45.3%), financial constraints (42.9%) and lack of an escort (35.5% in females, 19.6% in males). Women were more likely to report a fear of surgery (7.7% vs 3.2%, p<0.001) or be unaware of how to access services (4.5% vs 1.0% p<0.001); men were more frequently asymptomatic (19.6% vs 10.1%, p<0.001). Women were also less likely to have been previously offered TT surgery than men (OR = 0.70, 95%CI 0.53-0.94).

CONCLUSIONS/SIGNIFICANCE

The major barriers to accessing surgery from the patients' perspective are the direct and indirect costs of surgery. These can to a large extent be reduced or overcome through the provision of free or low cost surgery at the community level.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00522860 and NCT00522912.

Follow-up survey of cataract surgical coverage and barriers to cataract surgery at Nkhoma, Malawi

PURPOSE

Nkhoma Eye Hospital, Malawi provides high volume, high quality free cataract surgery to people in its catchment region of Central-Malawi. However, a previous survey in 2000 indicated that only 1 in 7 people with bilateral blindness from cataract had received surgery in a 10-mile radius of Nkhoma.

METHODS

We conducted a population-based survey in 2006 in the 32 villages within a 10-mile radius of Nkhoma Hospital in people aged ≥ 40 years in order to investigate the cataract surgical coverage (CSC) and barriers to cataract surgery.

RESULTS

The prevalence of blindness (visual acuity [VA] <3/60 in better eye) in 835 people aged ≥ 40 was 1.3% (95% CI 0.5-2.1), of which 36.4% was due to cataract. Overall, the CSC was 83.3%, and for eyes (VA<3/60) was 66.0%. The CSC was lower in females compared to males (73.3% vs. 100.0%. P < 0.001). The most common barrier to surgery was cost (58%).

CONCLUSION

Our results demonstrate a 5-fold increase in coverage in the 6 years, primarily by increasing efficiency of the service provider and providing a community screening and referral service. Supporting the ophthalmic personnel with appropriate infrastructure and management has been central to this shift. Implementing an active case finding and referral mechanism has enabled this unit to provide regular high volume cataract surgery. There is a need to understand the factors influencing perceptions about cost as a barrier in this community and the disparity between need and access to services for women.

Case-control studies and risk factors for cataract in two population studies in Nigeria

PURPOSE

The aim of this study was to determine and investigate the risks associated with cataract in South Western and North Central Nigeria.

MATERIALS AND METHODS

A hospital-based, case-control study was conducted in Lagos (Lagos group), South Western Nigeria, and Kano (Kano group), North Central Nigeria. In this study, 530 subjects with visually impairing cataracts (study group) and 530 age(-) and sex-matched controls (control group) were recruited from patients aged 40 to 89 years attending the ophthalmology clinics at the same hospital. All subjects were examined for the presence/absence of cataract and interviewed about their educational achievements, diarrhea/dehydration crises, urban/rural residence, and ophthalmological conditions. A standardized questionnaire was administered to all subjects. Logistic regression analysis with age adjustment, literacy, outdoor work, body mass index, crowding, regular vegetable intake, heavy alcohol, and cigarette intake was performed. P < 0.05 was considered statistically significant.

RESULTS

Using multivariate regression analysis, after adjustment for age and other demographics factors, low education and no education [adjusted odds ratios (OR) = 2.42 for the Lagos group and 4.10 for Kano group] and a positive history of diarrhea or dehydration crises (adjusted OR = 1.31 for the Lagos group and 2.12 for Kano group) were associated with an increased risk for cataract. Senile cataracts were more common among the Fulani ethnic group (adjusted OR = 2.21) of North Central Nigeria. However, rural or urban residence did not reveal any positive risk for cataract.

CONCLUSION

The risk of cataract in North Central Nigeria is similar to that in South Western Nigeria. Cataracts were strongly associated with increasing age, with peak age of 55 years and were more common in those with lower education, severe diarrhea and among the members of Fulani in North Central Nigeria.

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.

Non-Invasive Couching Technique to Treat a Morgagnian Cataract Causing Bullous Keratopathy

A case is described in which a non-invasive couching technique was used to relieve bullous keratopathy caused by a dislocated Morgagnian cataract. This technique involved applying digital pressure to the inferior cornea to push the dislocated nucleus through the pupil and into the posterior segment. This technique may be useful in cases where relief or prevention of eye pain is the primary goal.

Cost-effectiveness of interventions to prevent disability in leprosy: a systematic review

BACKGROUND

Prevention of disability (POD) is one of the key objectives of leprosy programmes. Recently, coverage and access have been identified as the priority issues in POD. Assessing the cost-effectiveness of POD interventions is highly relevant to understanding the barriers and opportunities to achieving universal coverage and access with limited resources. The purpose of this study was to systematically review the quality of existing cost-effectiveness evidence and discuss implications for future research and strategies to prevent disability in leprosy and other disabling conditions.

METHODOLOGY/PRINCIPAL FINDINGS

We searched electronic databases (NHS EED, MEDLINE, EMBASE, and LILACS) and databases of ongoing trials (www.controlled-trials.com/mrct/, www.who.int/trialsearch). We checked reference lists and contacted experts for further relevant studies. We included studies that reported both cost and effectiveness outcomes of two or more alternative interventions to prevent disability in leprosy. We assessed the quality of the identified studies using a standard checklist for critical appraisal of economic evaluations of health care programmes. We found 66 citations to potentially relevant studies and three met our criteria. Two were randomised controlled trials (footwear, management of neuritis) and one was a generic model-based study (cost per DALY). Generally, the studies were small in size, reported inadequately all relevant costs, uncertainties in estimates, and issues of concern and were based on limited data sources. No cost-effectiveness data on self-care, which is a key strategy in POD, was found.

CONCLUSION/SIGNIFICANCE

Evidence for cost-effectiveness of POD interventions for leprosy is scarce. High quality research is needed to identify POD interventions that offer value for money where resources are very scarce, and to develop strategies aimed at available, affordable and sustainable quality POD services for leprosy. The findings are relevant for other chronically disabling conditions, such as lymphatic filariasis, Buruli ulcer and diabetes in developing countries.

The Nigerian national blindness and visual impairment survey: Rationale, objectives and detailed methodology

Background

Despite having the largest population in Africa, Nigeria has no accurate population based data to plan and evaluate eye care services. A national survey was undertaken to estimate the prevalence and determine the major causes of blindness and low vision. This paper presents the detailed methodology used during the survey.

Methods

A nationally representative sample of persons aged 40 years and above was selected. Children aged 10–15 years and individuals aged <10 or 16–39 years with visual impairment were also included if they lived in households with an eligible adult. All participants had their height, weight, and blood pressure measured followed by assessment of presenting visual acuity, refractokeratomery, A-scan ultrasonography, visual fields and best corrected visual acuity. Anterior and posterior segments of each eye were examined with a torch and direct ophthalmoscope. Participants with visual acuity of < = 6/12 in one or both eyes underwent detailed examination including applanation tonometry, dilated slit lamp biomicroscopy, lens grading and fundus photography. All those who had undergone cataract surgery were refracted and best corrected vision recorded. Causes of visual impairment by eye and for the individual were determined using a clinical algorithm recommended by the World Health Organization. In addition, 1 in 7 adults also underwent a complete work up as described for those with vision < = 6/12 for constructing a normative data base for Nigerians.

Discussion

The field work for the study was completed in 30 months over the period 2005–2007 and covered 305 clusters across the entire country. Concurrently persons 40+ years were examined to form a normative data base. Analysis of the data is currently underway.

Conclusion

The methodology used was robust and adequate to provide estimates on the prevalence and causes of blindness in Nigeria. The survey would also provide information on barriers to accessing services, quality of life of visually impaired individuals and also provide normative data for Nigerian eyes.

Control of blinding eye diseases in leprosy: strategies for India

Over half of the people affected by leprosy worldwide are in India, many of whom are severely disabled when they present for care. Changes in policy and the integration of the leprosy programme with general health services has given rise to new challenges for the control of blinding eye disease in leprosy patients. This paper looks at the challenges posed: management, materials, manpower, money, and mobility--all of which are common barriers to the availability, access, and utilization of services--and to monitoring existing programmes. We consider strategies to overcome these challenges and fulfill the goal of VISION 2020--eliminating avoidable blindness--through the provision of comprehensive eye care and strengthening the existing infrastructure. Formal cooperation between national governments, non-governmental organisations, and International Development Agencies will need to continue, although possibly, in different roles and with plans modified to be relevant to the local needs of leprosy patients.

Cataract prevalence, cataract surgical coverage and barriers to uptake of cataract surgical services in Pakistan: the Pakistan National Blindness and Visual Impairment Survey

AIM

To estimate the prevalence of visual impairment and blindness caused by cataract, the prevalence of aphakia/pseudophakia, cataract surgical coverage (CSC) and to identify barriers to the uptake of cataract services among adults aged >or=30 years in Pakistan.

METHODS

Probability proportional-to-size procedures were used to select a nationally representative sample of adults. Each subject underwent interview, visual acuity measurement, autorefraction, biometry and ophthalmic examination. Those that saw <6/12 in either eye underwent a more intensive examination procedure including corrected visual acuity, slit lamp and dilated fundus examination. CSC was calculated for different levels of visual loss by person and by eye. Individuals with <6/60 in the better eye as a result of cataract were interviewed regarding barriers.

RESULTS

16 507 Adults were examined (95.5% response rate). The crude prevalence of blindness (presenting <3/60 in the better eye) caused by bilateral cataract was 1.75% (95% CI 1.55%, 1.96%). 1317 Participants (633 men; 684 women) had undergone cataract surgery in one or both eyes, giving a crude prevalence of 8.0% (95% CI 7.6%, 8.4%). The CSC (persons) at <3/60, <6/60 and <6/18 were 77.1%, 69.3% and 43.7%, respectively. The CSC (eyes) at <3/60, <6/60 and <6/18 were 61.4%, 52.2% and 40.7%, respectively. Cost of surgery (76.1%) was the main barrier to surgery.

CONCLUSION

Approximately 570 000 adults are estimated to be blind (<3/60) as a result of cataract in Pakistan, and 3,560000 eyes have a visual acuity of <6/60 because of cataract. Overall, the national surgical coverage is good but underserved populations have been identified.