Socioeconomic barriers to cataract surgery in Nepal: the South Asian cataract management study

TFOS lifestyle: Impact of societal challenges on the ocular surface

Societal factors associated with ocular surface diseases were mapped using a framework to characterize the relationship between the individual, their health and environment. The impact of the COVID-19 pandemic and mitigating factors on ocular surface diseases were considered in a systematic review. Age and sex effects were generally well-characterized for inflammatory, infectious, autoimmune and trauma-related conditions. Sex and gender, through biological, socio-economic, and cultural factors impact the prevalence and severity of disease, access to, and use of, care. Genetic factors, race, smoking and co-morbidities are generally well characterized, with interdependencies with geographical, employment and socioeconomic factors. Living and working conditions include employment, education, water and sanitation, poverty and socioeconomic class. Employment type and hobbies are associated with eye trauma and burns. Regional, global socio-economic, cultural and environmental conditions, include remoteness, geography, seasonality, availability of and access to services. Violence associated with war, acid attacks and domestic violence are associated with traumatic injuries. The impacts of conflict, pandemic and climate are exacerbated by decreased food security, access to health services and workers. Digital technology can impact diseases through physical and mental health effects and access to health information and services. The COVID-19 pandemic and related mitigating strategies are mostly associated with an increased risk of developing new or worsening existing ocular surface diseases. Societal factors impact the type and severity of ocular surface diseases, although there is considerable interdependence between factors. The overlay of the digital environment, natural disasters, conflict and the pandemic have modified access to services in some regions.

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.

Effect of deprivation and ethnicity on primary macula-on retinal detachment repair success rate and clinical outcomes: A study of 568 patients

Purpose

Socio-economic deprivation and ethnic variation have been frequently linked to poorer health outcomes. We collected a large series of primary macula-on rhegmatogenous retinal detachment (RRD) cases and analysed the effect of socio-economic deprivation and ethnicity on both six-month retinal re-detachment rate and visual outcomes.

Materials and methods

Retrospective consecutive case series of 568 patients attending Birmingham and Midlands Eye Centre from January 2017–2020. Multiple Indices of Deprivation (IMD) deciles were used for deprivation status and split to two groups: IMD-A (Decile 1–5) and IMD-B (Decile 6–10). The two largest subgroups of ethnicities were compared, White and South Asians (SA).

Results

We report an overall retinal re-detachment rate of 8.5%. IMD-A re-detached significantly more than IMD-B (11.2% vs 6.0% respectively, p = 0.034). No statistical significance was found between White and SA re-detachment rate (9.1% and 5.6% respectively, p = 0.604). SA median age significantly lower at 49 years (IQR: 37–61) compared to White patients at 57 years (IQR: 50–65) (p = <0.001). IMD-A median age of 55 years (IQR: 46–64) was significantly lower to IMD-B median age of 58 years (IQR: 51–65) (p = 0.011). No differences in final visual outcomes were detected across all groups.

Conclusion

We demonstrated an increased retinal re-detachment rate in our more deprived patients according to IMD and a younger cohort of SA compared to White ethnicity. Further prospective studies are required to demonstrate the link between socio-economic deprivation and surgical success.

Barriers to Cataract Surgery Utilization Among Cataract Patients Attending Surgical Outreach Sites in Ethiopia: A Dual Center Study

BACKGROUND

Cataract is the leading cause of avoidable blindness globally and in Africa. Various barriers limit access of cataract blind individuals to cataract surgery. This study aimed to determine the barriers to cataract surgery utilization among cataract blind patients presenting to campaign sites in Ethiopia.

METHODS

An institution-based cross-sectional design study was conducted to select 209 patients. The study was conducted from July to August 2020. A structured questionnaire was used to collect socio-demographic data and barriers for not having cataract surgery. Physical examination such as visual acuity, slit lamp bio microscopy and direct ophthalmoscopy was done for all participants. Epi Info 7 was used for data entry and Statistical Package for Social Science/SPSS version 23 was used for analysis after data were exported. Descriptive methods were employed for analysis.

RESULTS

A total of 209 subjects were recruited in the study with a mean age of 64.2 (±14.6) years, with a range of 32-99 years. From the total study subjects, 53% were males and 40.2% were over 66 years old. Upon presentation to the campaign site, 33% of study subjects had visual acuity of operable eye under blindness category and half of the study subjects (50.2%) had mature cataract. The most reported barriers were waiting until cataract becomes mature (18.7%), fear of surgery complications (16.7%), far from eye health institution (16.4%) and lack of income/cost for surgery (11.5%).

CONCLUSION

Recognizing the severity and the blindness burden of cataract in Ethiopia, creating public awareness, establishing eye health institutions, increasing the number of eye health professionals, increasing the quantity and the quality of cataract campaigns to alleviate these barriers are of paramount importance at the country level.

Pseudoexfoliation and Cataract Syndrome Associated with Genetic and Epidemiological Factors in a Mayan Cohort of Guatemala

The Mayan population of Guatemala is understudied within eye and vision research. Studying an observational homogenous, geographically isolated population of individuals seeking eye care may identify unique clinical, demographic, environmental and genetic risk factors for blinding eye disease that can inform targeted and effective screening strategies to achieve better and improved health care distribution. This study served to: (a) identify the ocular health needs within this population; and (b) identify any possible modifiable risk factors contributing to disease pathophysiology within this population. We conducted a cross-sectional study with 126 participants. Each participant completed a comprehensive eye examination, provided a blood sample for genetic analysis, and received a structured core baseline interview for a standardized epidemiological questionnaire at the Salama Lions Club Eye Hospital in Salama, Guatemala. Interpreters were available for translation to the patients’ native dialect, to assist participants during their visit. We performed a genome-wide association study for ocular disease association on the blood samples using Illumina’s HumanOmni2.5-8 chip to examine single nucleotide polymorphism SNPs in this population. After implementing quality control measures, we performed adjusted logistic regression analysis to determine which genetic and epidemiological factors were associated with eye disease. We found that the most prevalent eye conditions were cataracts (54.8%) followed by pseudoexfoliation syndrome (PXF) (24.6%). The population with both conditions was 22.2%. In our epidemiological analysis, we found that eye disease was significantly associated with advanced age. Cataracts were significantly more common among those living in the 10 districts with the least resources. Furthermore, having cataracts was associated with a greater likelihood of PXF after adjusting for both age and sex. In our genetic analysis, the SNP most nominally significantly associated with PXF lay within the gene KSR2 (p < 1 × 10⁻⁵). Several SNPs were associated with cataracts at genome-wide significance after adjusting for covariates (p < 5 × 10⁻⁸). About seventy five percent of the 33 cataract-associated SNPs lie within 13 genes, with the majority of genes having only one significant SNP (5 × 10⁻⁸). Using bioinformatic tools including PhenGenI, the Ensembl genome browser and literature review, these SNPs and genes have not previously been associated with PXF or cataracts, separately or in combination. This study can aid in understanding the prevalence of eye conditions in this population to better help inform public health planning and the delivery of quality, accessible, and relevant health and preventative care within Salama, Guatemala.

Time to recovery from cataract and its predictors among eye cataract patients treated with cataract surgery: A retrospective cohort study in Ethiopia

Background

Cataracts is the major global causes of blindness and a vision-affecting disease of the eye. Cataract surgery is a curative and cost-effective intervention. The number of people who undergo cataract surgery has increased rapidly. Hence, this study was aimed to determine predictors and the time of recovery of cataract patients after cataract surgery by using Simi parametric models of survival analysis.

Methods

A retrospective cohort study was conducted from January/01/2015 and January/30/2019. STATA version14.0 statistical software was used for analysis. The Kaplan-Meier survival method and log-rank test curves were applied. Weibull regression was used and adjusted hazard ratio 95% CI with a value of p less than 0.05 was used to identify a significant association.

Results

Two hundred twenty three cataract patients were recovered from cataract, 72.6% (95% CI 69.8%–75.9%). The overall median survival time was 23 weeks (IQR = 16 to 35) with (95% CI, 21%–25%). aged between 16 and 30year (AHR = 1.20 CI; 1.07–2.36), age 31 to 45 (AHR = 1.24 CI; 1.08–1.54), urban dwellers (AHR = 1.59; 95% CI, 1.18–2.14), medium visual acuity (AHR = 4.14 CI; 2.57–6.67), high visual acuity (AHR = 5.23 CI; 3.06–8.93), Secondary cataract (AHR = 2.59 CI; 1.01–3.02), traumatic cataract (AHR = 1.75 CI; 1.01–3.02), extra capsular cataract extraction surgery (AHR = 1.43 CI; 1.07–1.94),and diabetes mellitus (AHR = 0.75, CI; 0.41–0.96) were notably associated with time to recovery.

Conclusion

Time to recovery in the study area was slightly higher as compared with the global cut of time. Cataract patients with comorbidity of DM had lower recovery time.

•

A 72.6% cataract patients were recovered and 27.4% of were censored from cataract.

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The overall median survival time was 23 weeks and the mean recovery time of the patients was 23.24 weeks.

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A significant difference seen in the recovery rate among cataract patients with/out diabetes mellitus.

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Time to recovery in the study area was slightly higher.

Willingness to pay for cataract surgery and associated factors among cataract patients in Outreach Site, North West Ethiopia

Introduction

In Ethiopia, cataract surgery is mainly provided by donors free of charge through outreach programs. Assessing willingness to pay for patients for cataract surgery will help explain how the service is valued by the beneficiaries and design a domestic source of finance to sustain a program. Although knowledge concerning willingness to pay for cataract surgery is substantive for developing a cost-recovery model, the existed knowledge is limited and not well-addressed. Therefore, the study aimed to assess willingness to pay for cataract surgery and associated factors among cataract patients in Outreach Site, North West Ethiopia.

Methods

A cross-sectional outreach-based study was conducted on 827 cataract patients selected through a simple random sampling method in Tebebe Gion Specialized Hospital, North West Ethiopia, from 10/11/2018 to 14/11/2018. The data were collected using a contingent valuation elicitation approach to elicit the participants’ maximum willingness to pay through face to face questionnaire interviews. The descriptive data were organized and presented using summary statistics, frequency distribution tables, and figures accordingly. Factors assumed to be associate with a willingness to pay were identified using a Tobit regression model with a p-value of <0.05 and confidence interval (CI ≠ 0).

Results

The study involved 827 cataract patients, and their median age was 65years. About 55% of the participants were willing to pay for the surgery. The average amount of money willing to pay was 17.5USD (95% CI; 10.5, 35.00) and It was significantly associated with being still worker (β = 26.66, 95% CI: 13.03, 40.29), being educated (β = 29.16, 95% CI: 2.35, 55.97), free from ocular morbidity (β = 28.48, 95% CI: 1.08, 55.90), duration with the condition, (β = -1.69, 95% CI: -3.32, -0.07), admission laterality (β = 21.21, 95% CI: 3.65, 38.77) and remained visual ability (β = -0.29, 95% CI (-0.55, -0.04).

Conclusions

Participants’ willingness to pay for cataract surgery in outreach Sites is much lower than the surgery’s actual cost. Early intervention and developing a cost-recovery model with multi-tiered packages attributed to the neediest people as in retired, less educated, severely disabled is strategic to increase the demand for service uptake and service accessibility.

Low Vision Profile in Jordan: A Vision Rehabilitation Center-Based Study

The aim of this paper is to study the profile of persons with low vision in Jordan based on the clinical records of service users who attended the Vision Rehabilitation Center (VRC) at the German Jordanian University (GJU). A retrospective study was conducted by reviewing the archived data for persons with low vision attending the VRC over the period September 2012 to December 2017. The information collected included age, gender, referral, geographical distribution, chief functional visual problems, and ocular pathology. The records of 725 (28.9 ± 20.3 years old) persons out of 858 persons were analyzed. Almost half (50.6%) of the sample was less than 18 years old. The main cause of the low vision was retinal diseases (53.4%), followed by albinism. Gender and age showed no significant influence on ocular pathology distribution. For the referrals, ophthalmologists (37.8%) were the largest source of referral, followed by institutions for people with disabilities (14.9%). Near tasks were reported as the main functional problems for patients with low vision (74.9%), followed by distance tasks (8.3%). This study sets a precedent for determining the characteristics of persons with low vision in Jordan. Developing an efficient referral system between eye health care professionals and other health caregivers is important to ensure the best multidisciplinary services for low vision.

Primary eye care in India - The vision center model

The World Health Organization (WHO) Global Action Plan (GAP) 2014-19 emphasize providing Comprehensive Eye Care (CEC) using the health system approach to achieve Universal Eye Health Coverage (UEHC). An important aspect of CEC is Primary Eye Care (PEC). The scope of PEC varies significantly with primary health workers providing PEC in most parts of the developing world, whereas in developed nations PEC is provided by specialized personnel such as optometrists. This article focuses on delivery of PEC models in India, specifically through the vision center (VC) approach. VCs are part of a larger eye care network and provide PEC in remote rural areas of the country. The authors describe the how PEC is delivered in more than 300 VCs operated by six mentor hospitals in India under the Global Sight Initiative (GSI). Key factors compared include: The role of leadership; human resource planning, including recruitment and retention; service delivery; leveraging technology for planning and reaching key populations; financial sustainability; supply chain management; and quality and monitoring. It also discusses issues to be considered to strengthen VCs as we move ahead towards our collective goal of achieving UEHC and eliminating avoidable blindness.

Factors associated with the uptake of cataract surgery and interventions to improve uptake in low- and middle-income countries: A systematic review

Despite significant evidence around barriers hindering timely access to cataract surgery in low- and middle-income countries (LMICs), little is known about the strategies necessary to overcome them and the factors associated with improved access. Despite significant evidence that certain groups, women for example, experience disproportionate difficulties in access, little is known about how to improve the situation for them. Two reviews were conducted recently: Ramke et al., 2018 reported experimental and quasi-experimental evaluations of interventions to improve access of cataract surgical services, and Mercer et al., 2019 investigated interventions to improve gender equity. The aim of this systematic review was to collate, appraise and synthesise evidence from studies on factors associated with uptake of cataract surgery and strategies to improve the uptake in LMICs. We performed a literature search of five electronic databases, google scholar and a detailed reference review. The review identified several strategies that have been suggested to improve uptake of cataract surgery including surgical awareness campaigns; use of successfully operated persons as champions; removal of patient direct and indirect costs; regular community outreach; and ensuring high quality surgeries. Our findings provide the basis for the development of a targeted combination of interventions to improve access and ensure interventions which address barriers are included in planning cataract surgical services. Future research should seek to examine the effectiveness of these strategies and identify other relevant factors associated with intervention effects.

The association between socioeconomic status and visual disability among older adults in China

AIM

To investigate the association between socioeconomic status (SES) and visual disability (VD) among older Chinese adults.

METHODS

We obtained data from the Second National Sample Survey on Disability, conducted in China in 2006. A total number of 192 375 older adults (aged≥65y) were screened for suspected VD via interviews with trained examiners. Those who screened positively for VD were referred to ophthalmologists to obtain a final diagnosis.

RESULTS

VD was prevalent among 7.29% of Chinese adults aged 65 and older, and was higher in rural areas (8.71%) than in urban areas (4.82%). After adjusting for SES indicators and covariates, we found that less-educated older adults were more likely to suffer from VD, with an odds ratio (OR) of 2.50 (95%CI: 2.26-2.82) for illiterates, compared with those who graduated from senior high school or above. Older adults who were in the lowest income quintile were more at risk of VD, with an OR of 1.81 (95%CI: 1.68-2.95), compared with adults in the highest income quintile. In urban areas, when compared with adults who graduated from senior high school or above, those who did not continue their education after junior high school, primary school, or those who were illiterate, were more likely to suffer from VD, with an OR of 1.35 (95%CI: 1.51-1.59), 1.84 (95%CI: 1.60-2.12), and 2.63 (95%CI: 2.27-3.04), respectively. Lower levels of income were statistically significant when associated with VD. In rural areas, adults who were illiterate had an OR of 2.21 (95%CI: 1.75-2.79) when compared to adults with senior high school or above education level. Per capita, household income remained significantly associated with VD. Older adults who were ≥85, female, single, and residing in rural areas were associated with higher risks of VD.

CONCLUSION

Individual-level SES among the elderly, in the form of education and income, is associated with VD among elderly Chinese adults in both urban and rural areas; however, the association is stronger in rural areas. Further studies are still required to explore the mechanism behind the relationships.

Barriers to uptake of referral services from secondary care to tertiary care and its associated factors in L V Prasad Eye Institute network in Southern India: a cross-sectional study

OBJECTIVE

To examine barriers to the uptake of referral services from secondary care centres to higher level tertiary care centres.

DESIGN

Cross-sectional study.

SETTING

Secondary care hospital in Khammam District in the Telangana state of India.

PARTICIPANTS

Nine hundred and three patients who were referred from a secondary care centre to tertiary care centres between June 2011 and December 2012, were over the age of 18 and lived within 50 km of the secondary care centre were identified. Six hundred and sixteen (68.2%) of these patients were successfully contacted, and 611 (99%) of those contacted consented to participation in the study.

INTERVENTIONS

Those who attended at higher centres after referral (compliant) and those who failed to attend (non-compliant) were interviewed with a standard questionnaire designed for the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcome measures were barriers to the uptake of eye care services for the non-compliant participants and the associated risk factors for non-compliance.

RESULTS

Of the contacted patients, 418 (68.4%) were compliant and 193 (31.6%) were non-compliant. The mean age of interviewed patients was 48.4 years (SD: 17.9 years) and 365 (59.7%) were male. Of those who did not comply with their referral, the major identified barriers were 'cannot afford treatment cost' (30%) and 'able to see adequately' (20.7%). Multivariable analysis showed that participants in the non-compliant group were more likely to have had only one prior visit to the centre (OR: 2.5, 95% CI 1.6 to 3.9), be referred for oculoplastic services (OR: 3.0, 95% CI 1.0 to 8.8) and to be the main earning member of the family (OR: 1.9, 95% CI 1.2 to 2.8).

CONCLUSIONS

Non-compliance with referrals in this population is largely attributable to economic and attitudinal reasons. Focusing on these specific barriers and targeting groups at higher risk of non-compliance could potentially improve uptake of referral services.

Multiple deprivation, vision loss, and ophthalmic disease in adults: global perspectives

The association between socioeconomic position and morbidity and mortality has long been recognized. We evaluate the evidence for an association between multiple aspects of deprivation and ocular health in a global context. This is a systematic review of studies that evaluated deprivation in the adult population in the context of the major acquired causes of visual loss such as cataract, diabetic eye disease, glaucoma, age-related macular degeneration, and ocular trauma. The search strategy identified relevant studies reported between 1946 and August 2016, with randomized control trials, case-control, cohort, and cross-sectional study designs being selected for inclusion. The studies identified in this review from across the world demonstrate the extent to which the common themes such as low educational attainment and low income may be associated with increased incidence of various sight-threatening conditions and may adversely affect access to specialist assessment and delivery of treatment. Health inequality may always persist, but an increased recognition of the importance of the various impacts of deprivation may empower policy makers to target limited resources to the most vulnerable groups in order to deliver the greatest benefit.

Economic and social factors that influence households not willing to undergo cataract surgery

Purpose:

Literature investigating barriers to cataract surgery is mostly done from the patient's point of view. However, many medical decisions are jointly taken by household members, especially in developing countries such as India. We investigated from the household head's (or representative's) perspective, households’ view on those not willing to undergo cataract surgery along with the economic and social factors associated with it.

Materials and Methods:

A cross-sectional survey of four randomly selected village clusters in rural areas of Theni district, Tamil Nadu, India, was conducted to elicit the willingness to pay for cataract surgery by presenting “scenarios” that included having or not having free surgery available. The presentation of scenarios allowed the identification of respondents who were unwilling to undergo surgery. Logistic regression was used to estimate relationships between economic and social factors and unwillingness to undergo cataract surgery.

Results:

Of the 1271 respondents, 49 (3.85%) were not willing to undergo surgery if they or their family members have cataract even if free surgery were available. In the regression results, those with good understanding of cataract and its treatment were less likely to be unwilling to undergo cataract surgery. Those not reporting household income were more likely to be unwilling to undergo cataract surgery.

Conclusions:

As a good understanding of cataract was an important predictor of willingness to undergo cataract surgery, health education on cataract and its intervention can improve uptake.

Causes of low vision and their management at Korle Bu Teaching Hospital, Accra, GHANA

BACKGROUND

Provision of low vision services to the visually impaired is vital in blindness intervention programs. Such services are avenues for low vision patients to utilize their residual vision in carrying out daily tasks.

AIM

To review the causes of low vision and services provided to low vision patients at Korle Bu Teaching Hospital.

STUDY DESIGN

A retrospective cross-sectional study.

METHODOLOGY

Study subjects were low vision patients who had been referred by ophthalmologists and optometrists from all over Ghana for low vision services. At the Low Vision Centre, patients were re-examined to confirm that they had low vision and were suitable for low vision devices. The visual acuities of all patients was determined using a Snellen chart (with letters and tumbling E chart) followed by anterior and posterior segment examination using a Haagstreit slit lamp biomicroscope and direct and/or indirect ophthalmoscope (Keeler). All patients were refracted for near and distance and best corrected visual acuities were recorded. Patients with best corrected visual acuities of less than 6/18 but better than light 3/60 in the better were considered for low vision devices. Clinical records of low vision patients managed at the Korle Bu Teaching Hospital between March 2005 and December 2014 were examined to determine the main causes of low vision and interventions given. Their demographics, clinical features, services offered and annual trend in low vision uptake were analyzed.

RESULTS

A total of 604 patients managed between March 2005 and December 2014 at the low vision centre of the Korle Bu Teaching Hospital were included in the study. The mean age was 40.55+6.95 years. There was statistically no significant difference between the mean age in either sex; p-value = 1.000. Glaucoma was the leading cause of low vision in 135 (22.35%) of cases, followed by non-glaucomatous optic atrophy 62(10.26 %), retinitis pigmentosa 54(8.94 %), maculopathy 52(8.61 %) and ARMD 48(7.95 %) respectively. Uptake of the low vision services was highest in the second year of commencing the services. Interventions were mainly magnifiers, telescopes, closed circuit television (CCTV), counselling and referral to the School for the Blind.

CONCLUSION

Glaucoma and non-glaucomatous optic atrophy were the predominant causes of low vision, and magnifiers and telescopes were the most commonly prescribed devices.

Cataract Surgical Uptake Among Older Adults in Ghana

OBJECTIVES

In sub-Saharan Africa, cataract surgical services are highly inadequate and surgical uptake for cataract is low. This paper describes cataract surgical uptake among older adults in Ghana.

METHODS

This work was based on World Health Organization's multi-country Study on global Ageing and adult health (SAGE), conducted in six countries including Ghana. Wave one of SAGE in Ghana was conducted in 2007-2008 as collaboration between WHO and Department of Community Health, University of Ghana Medical School. A nationally representative sample of 5571 older adults (≥50 years) and a small sample of persons 18-49 years were interviewed. Data was obtained on uptake of cataract surgery in older adults and analyzed using descriptive measures and chi square for associations in categorical outcome measures.

RESULTS

Overall surgical uptake was 48.9% among older adults and was slightly higher among older men (49.1%) than women (48%). Cataract surgical uptake was relatively higher in the 60-69 years group (55%), urban residents (52.6%) and those living without partners (50%). Educational and income levels of older persons did not affect cataract surgical uptake. Regional differences in cataract surgical uptake existed; was less than 60% in all ten regions (except one), and the two regions with most self-reported cataracts (Ashanti and Greater Accra) had less than 50% uptake.

CONCLUSIONS

Intensive public education, engagement of community groups and increased access to cataract surgery at health facilities and outreach services need consideration at national/sub-national levels. Further investigations to garner equity in national eye care efforts are recommended.

Use of cataract surgery in urban Beijing: a post screening follow-up of the elderly with visual impairment due to age-related cataract

OBJECTIVE

To understand the perception for the use of cataract surgical services in a population of acceptors and non-acceptors of cataract surgery in urban Beijing.

METHODS

From a community-based screening program a total of 158 patients with presenting visual acuity of less than 6/18 on either eye due to age-related cataract were informed about the possibility of surgical treatment. These patients were interviewed and re-examined 36 to 46 months after initial screening. The main reasons for not accepting surgery were obtained using a questionnaire. Vision function and vision-related quality of life scores were assessed in those who received and did not receive surgery.

RESULTS

At the follow-up examination 116 of the 158 patients were available and 36 (31.0%) had undergone cataract surgery. Cases who chose surgery had higher education level than those who did not seek surgery (OR=2.64, 95% CI: 1.08-6.63, P=0.02). There were no significant differences in vision function (P=0.11) or quality of life scores (P=0.16) between the surgery group and the non-surgery group. Main reasons for not having surgery included no perceived need (50.0%), feeling of being "too old" (19.2%), and worry about the quality of surgery (9.6%). Cost was cited by 1 (1.9%) subject as the main reason for not seeking surgery.

CONCLUSIONS

The data suggest that in China's capital urban center for patients with moderate visual impairment there is a relative low acceptance rate of cataract surgery, mainly due to people's perception of marginal benefits of surgery. Cost is not a determining factor as barrier to undergo surgery and patients with poorer education are less likely to undertake surgery.

Demographic and clinical factors associated with referrals and compliance to biopsy of oral and maxillofacial lesions

BACKGROUND

The gold standard for diagnosing oral disease is tissue biopsy. Data regarding compliance with advised oral and maxillofacial (OMF) biopsy are scarce.

PURPOSE

To quantify compliance and evaluate the demographics and clinical factors associated with referrals and compliance with OMF biopsy procedures.

METHODS

Medical records of military personnel referred for a biopsy (RB; N = 669) of OMF lesions over a 4-year period were studied retrospectively. These patients were divided into performed the biopsy (PB; N = 386) and not perform biopsy (NPB; N = 283) groups. Demographic and clinical features were analyzed, and demographics were compared to a control group of general military personnel (N > 100,000).

RESULTS

The RB group differed from the control group regarding age >21 (OR = 1.681, P < 0.001) and education >12 years of schooling (OR = 1.545, P < 0.001). Differences between the PB and NPB groups related to the clinical features of the lesion but not to demographic parameters. Exophytic and suspected potentially malignant/malignant lesions were positively associated with higher compliance to biopsy (OR = 1.75, P = 0.004 and OR = 2.18, P = 0.017, respectively).

CONCLUSION

Referrals to biopsy of OMF lesions are significantly influenced by age and education, whereas compliance is influenced by clinical features or suspected malignancy. Clinicians and health authorities should be aware of non-compliance, enhance awareness to biopsy as the gold standard in the diagnostic workup of OMF lesions, and closely monitor compliance patterns of patients with clinical and demographic risk factors.

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.

Barriers to cataract surgical uptake in central ethiopia

Purpose:

The aim of this study was to assess the factors that delay surgical intervention in patients suffering from age related mature cataract in Ethiopia.

Materials and Methods:

A short term descriptive study was performed that evaluated patients with mature cataract presenting to outreach eye care clinics in rural central Ethiopia. Patients were interviewed to determine the reasons for delay in their cataract surgeries.

Result:

A total of 146 subjects (57 male and 89 females) with operable age related cataract were evaluated at 31 outreach clinics. Over 86% of the respondents were above 55 years of age, (range, 45–78 years). The male to female ratio was 1:1.5 and 30.2% of the subjects were blind bilaterally (best corrected visual acuity <3/60). The majority of the respondents were farmers (53.4%) and 86.3% were illiterate. The major factors that delayed cataract surgery included: Cost of surgery (91.8%), insufficient family income (78.1%), good vision in the fellow (unaffected) eye (39.7%), and the distance to hospital from their village (47.9%).

Conclusion:

Surgical cost, insufficient family income, and the distance to an eye care centre were the major factors delaying cataract surgery in rural Ethiopia.

Health literacy of common ocular diseases in Nepal

BACKGROUND

Poor health literacy is often a key cause of lack of or delayed uptake of health care services. The aim of this study was to assess the health literacy of common ocular diseases, namely cataract, glaucoma, night blindness, trachoma and diabetic retinopathy in Nepal.

METHODS

A cross sectional study of 1741 participants randomly selected from non-triaged attendants in the outpatient queue at Tilganga Institute of Ophthalmology, a semi urban general population of Bhaktapur district of Kathmandu Valley and patients attending rural outreach clinics. Participants responded to trained enumerators using verbally administered, semi structured questionnaires on their awareness and knowledge of cataract, glaucoma, diabetic retinopathy, night blindness, and trachoma.

RESULTS

The awareness of cataract across the entire sample was 49.6%, night blindness was 48.3%, diabetic retinopathy was 29%, glaucoma was 21.3% and trachoma was 6.1%. Patients presenting to rural outreach clinics had poorer awareness of cataract, glaucoma, diabetic retinopathy, night blindness and trachoma compared to those from a semi-urban community and an urban eye hospital (p<0.05), Old age was directly associated with poorer awareness of cataract, glaucoma, night blindness, trachoma and diabetic retinopathy (p<0.05). Female gender was associated with lower awareness of cataract, glaucoma, night blindness and trachoma (p<0.05). Literacy was associated with greater awareness of cataract, glaucoma, diabetic retinopathy, night blindness and trachoma (p<0.05). Higher education was significantly associated with greater awareness of cataract, night blindness and trachoma (p<0.05). Multivariate analysis found that the awareness of common ocular diseases was significantly associated with level of education (p<0.05). Similarly, awareness of cataract, glaucoma, trachoma and night blindness was associated with female gender (p<0.05) whereas awareness of cataract, night blindness, trachoma and diabetic retinopathy was associated with age (p<0.05) but the awareness glaucoma and diabetic retinopathy was associated with camps.

CONCLUSIONS

Low awareness of common ocular conditions is associated with factors such as female gender, old age, lower levels of education and rural habitation. A would be successful health promotion programs should specifically target health determinants to promote health literacy and to ensure timely utilization of eye care services.

Cataract blindness in Osun state, Nigeria: results of a survey

PURPOSE

To estimate the burden of blindness and visual impairment due to cataract in Egbedore Local Government Area of Osun State, Nigeria.

MATERIALS AND METHODS

Twenty clusters of 60 individuals who were 50 years or older were selected by systematic random sampling from the entire community. A total of 1,183 persons were examined.

RESULTS

The age- and sex-adjusted prevalence of bilateral cataract-related blindness (visual acuity (VA) < 3/60) in people of 50 years and older was 2.0% (95% confidence interval (CI): 1.6-2.4%). The Cataract Surgical Coverage (CSC) (persons) was 12.1% and Couching Coverage (persons) was 11.8%. The age- and sex-adjusted prevalence of bilateral operable cataract (VA < 6/60) in people of 50 years and older was 2.7% (95% CI: 2.3-3.1%). In this last group, the cataract intervention (surgery + couching) coverage was 22.2%. The proportion of patients who could not attain 6/60 vision after surgery were 12.5, 87.5, and 92.9%, respectively, for patients who underwent intraocular lens (IOL) implantation, cataract surgery without IOL implantation and those who underwent couching. "Lack of awareness" (30.4%), "no need for surgery" (17.6%), cost (14.6%), fear (10.2%), "waiting for cataract to mature" (8.8%), AND "surgical services not available" (5.8%) were reasons why individuals with operable cataract did not undergo cataract surgery.

CONCLUSIONS

Over 600 operable cataracts exist in this region of Nigeria. There is an urgent need for an effective, affordable, and accessible cataract outreach program. Sustained efforts have to be made to increase the number of IOL surgeries, by making IOL surgery available locally at an affordable cost, if not completely free.

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.

Profile of patients presenting at a low vision clinic in a developing country

Background

Low vision is an important public health problem; however, very few low vision clinics are available to address the needs of low vision patients in most developing countries. The purpose of this study was to describe the characteristics of patients attending the low vision clinic of a Nigerian tertiary hospital.

Methods

This was a prospective cross sectional study of all new patients seen at the low vision clinic over a 36 month period. Patients were administered with a structured questionnaire, and were examined and tested with low vision devices by the attending low vision specialist. Information on the demographic and clinical characteristics of the patients was recorded.

Results

A total of 193 new patients seen during the period were studied. The mean age was 41.4 years, and their ages ranged between 6 and 90 years with a male to female ratio of 1.9:1. Majority (58%) were aged below 50 years, 23.3% were children (≤15 years), while 21.8% were elderly patients (≥65 years). The commonest cause of low vision was retinitis pigmentosa (16.6%); 14.5% had age related macular degeneration (ARMD); 9.8% had albinism; while only 1% had diabetic retinopathy. ARMD (45.2%) was the commonest cause in the elderly patients, while albinism (24.4%) and optic atrophy (24.4%) were the commonest in children.

Conclusion

The demographic and clinical characteristics of low vision patients seen in this clinic are similar to that of patients in other developing countries, but different from those in developed countries. Elderly patients and females may be under-utilising low vision services. There is a need for further research into the determinants of low vision service utilisation in developing countries. This would further aid the planning and delivery of services to low vision patients in these countries.

Willingness to pay for potential enhancements to a low-cost cataract surgical package in rural southern China

PURPOSE

To assess determinants of patients' willingness to pay (WTP) for potential components of a multi-tiered cataract surgical package offered by a non-governmental organization (NGO) in rural China.

DESIGN

Cross-sectional study.

METHODS

Demographic and clinical data were collected from 505 patients presenting for cataract screening or surgery in Yangjiang, China. Willingness to pay for potential enhancements to the current surgery package was assessed using a bidding format with random payment cards.

RESULTS

Among 426 subjects (84.4%) completing interviews, the mean age was 73.9 ± 7.3 years, 67.6% were women and 73% (n = 310) would pay for at least one offering, with 33-38% WTP for each item. Among those who would pay, the mean WTP for food was US$1.68 ± 0.13, transportation US$3.24 ± 0.25, senior surgeon US$50.0 ± 3.36 and US$89.4 ± 4.19 for an imported intra-ocular lens (IOL). The estimated total recovery from these enhancements under various assumptions would be US$20-50 (compared to the current programme price of US$65). In multivariate models, WTP for the senior surgeon increased with knowledge of a person previously operated for cataract (OR = 2.13, 95% CI 1.42-3.18, p < 0.001). Willingness to pay for the imported IOL increased with knowledge of a previously operated person (OR = 1.85, 95% CI 1.24-2.75, p < 0.01) and decreased with age >75 years (OR = 0.61, 0.40-0.93, p < 0.05).

CONCLUSIONS

Opportunities exist to increase cataract programme revenues through multi-tiered offerings in this setting, allowing greater subsidization of low-income patients. Personal familiarity with cataract surgery is important in determining WTP.

Barriers to cataract surgical uptake in the upper East region of ghana

SUMMARY BACKGROUND

The Upper East Region has one of the highest cataract surgical rates in Ghana. Notwithstanding this, cataract blindness is still a major problem.

AIM

To determine patient-related barriers to cataract services in the region and their resolution.

METHODS

Focus Group Discussion (FGD) and In-depth interviews were used to explore the opinions of 66 cataract patients resident in the region between July and August 2003. Purposeful sampling was used in selecting 24 patients in the hospital while a Snowball sampling method was employed on 42 respondents resident in the village communities

RESULTS

Average age of the respondents was 67.6 years with equal proportions of males and females (0.9:1). Twelve and fifteen percent of respondents respectively cited fear and lack of escort as barriers to service up-take while 8% and 9% pointed to sociocultural beliefs and the fact that they were able to cope satisfactorily with their disability. Only 1.5% of respondents gave lack of awareness as a barrier with none citing geographical barrier as a problem. Cost of surgery, however, stood out clearly as a very significant barrier with 91% of respondents attesting to it.

CONCLUSION

It is concluded that further expansion of outreach services, coupled with a more intensive health education is needed to overcome these barriers.

Awareness and Use of Eye Care Services in Fiji

PURPOSE

To determine the awareness, use, and barriers to use of eye services in Fiji's Central Province.

METHODS

A cross-sectional survey study design with random clusters of households was used. Semi-structured interviews were conducted (152 females and 22 males). For 267 household members, presenting distance and near visual acuities were measured, and the perception of and satisfaction with their vision were recorded.

RESULTS

Most (86%; 150/174) respondents were aware of at least one conventional eye care service. However, only 66% (121/183) of household members with previous eye problems had consulted one of these; the proportion was even lower for those in the older age groups (p < 0.01). Rural dwellers expressed satisfaction with their vision, despite being more likely to regard it as limiting their activities and being less likely to seek conventional care. A higher proportion of females were reported to have (or have had) eye problems (60:40) and were found to have bilateral visual impairment (60:40). Despite this, females and males attended the hospital eye clinic (47:53) or sought treatment from conventional services (51:49) nearly equally. The reasons given for not seeking conventional care were "fatalistic attitude" ("did not bother", "could manage", or accepted the condition: 57%), expense (12%), and fear (8%).

CONCLUSION

Central Province Fijians, particularly the old, rural, and female, under-utilise conventional eye care services. As in developing countries elsewhere, fatalistic attitudes to visual impairment are a significant contributor to this. To improve eye health, planning and implementation of eye care services must overcome under-utilisation by addressing local barriers to uptake through community participation in education and affirmative action.

Development of a Scale to Determine Barriers to Paediatric Eye Care

Childhood blindness has huge socio-economic costs. India's commitment to the goal of vision 2020 has put priority to elimination of preventable blindness in children. Although adult blindness has been extensively studied, the literature is seen to be generally lacking in providing in-depth understanding of childhood blindness, especially about barriers that impede access to eye care. The present study attempts to fill this gap. This article explains the procedure adopted in developing a scale to determine the barriers to paediatric eye care. A 22-item barrier to paediatric eye care scale was specifically developed. The scale, along with the full-length questionnaire, was pre-tested and later administered to 207 parent-respondents at Sadguru Netra Chikitshalaya (SNC), Chitrakoot, in the state of Madhya Pradesh (India). A fiveround factor analysis variable deletion process resulted in a three factor structure. Although this procedure reduced the number of items in the scale from 22 to 9, the variance explained by the factors increased from 61 to 78 per cent. The three factors were labelled as economic, logistic and perception of service. Regression analyses of the three factors/barriers, economic, logistic and belief, showed significant results. Further analysis showed that parents’ demographic profile and health seeking behaviour significantly explained the economic barrier. Health seeking behaviour was a significant predictor of logistic barrier.

Cataract surgery in Andhra Pradesh state, India: an investigation into uptake following outreach screening camps

PURPOSE

Prevalence of cataract related blindness and visual impairment is extremely high in India. Service utilization, on the contrary, is sub-optimal. Services offered through outreach screening are often not taken up. Against this background, the decision making processes leading to the uptake of cataract surgery services offered during outreach screening camps were investigated in people with cataract in India.

METHODS

The study used an exploratory, qualitative approach. Sixty one cataract patients from two eye hospitals in Hyderabad, India, were interviewed using convenience sampling. Two focus group discussions with cataract patients and interviews with seven key informants helped triangulate the information.

RESULTS

Lack of access to personal funds limited and delayed the utilization of offered services by patients who had been advised of surgery at outreach screening camps or eye hospitals. Stigma, fatalism and ageism were other limiting factors. The majority of patients did not make the decision regarding uptake of services themselves. Hearsay reports of the outcome of surgery and quality of services had a strong influence on service uptake. Women, particularly widows and those from rural areas, were least likely to use cataract surgery services.

CONCLUSION

Provision of affordable and accessible eye care does not guarantee that the care or service will be utilized. Within the decision making process about cataract surgery, dependency on and importance of the wider family was found to be an often cited context of patients' decisions. Future research and programming activities need to put an emphasis on underserved groups, especially those who may be marginalized or disempowered.

Epidemiology of cataract: accomplishments over 25 years and future directions

The purpose of this review is to highlight the advances made by epidemiologic research into cataract. Considerable progress has been made in characterizing phenotypes, determining the prevalence and incidence in various population groups, and understanding risk factors for cataract. Cataract surgery research has documented functional improvements following surgery and has identified aspects of surgery delivery that could be made. Cataract is an independent marker of early mortality, providing a possible system for studying the aging process. Promising future work in cataract epidemiology is highlighted. Despite the availability of cataract surgery, cataract is still the leading cause of blindness worldwide. From a public health standpoint, research that can identify ways to delay onset or progression, or achieve the holy grail of prevention of cataract, should remain a leading priority.

Remote Indigenous Australians with cataracts: they are blind and still can’t see

Aboriginal and Torres Strait Islander people are three times more likely than non-Indigenous Australians to report vision loss due to cataracts, but are four times less likely to have cataract surgery. To increase access for Aboriginal and Torres Strait Islander people to cataract surgery, we need to identify the barriers to current services and trial strategies to overcome these barriers. Barriers to cataract surgery exist at the health service, community and individual level. Health service factors include infrastructure, cost, and provision of interpreters, escorts and transport. Community factors include social support, perceptions about the success of surgery, and beliefs about the causes of cataracts. Individual factors include ignorance that cataracts can be cured, fear of surgery or poor outcome, and comorbidity. Strategies proven to increase uptake of cataract surgery in other countries could be trialled in remote Australia.

The surgical management of cataract: barriers, best practices and outcomes

Cataract is the leading cause of blindness in the world. Cataract surgery has been shown by multiple studies to be one of the most cost-effective health interventions, and leads to a dramatic increase in quality of life and productivity for many patients. Though there has been marked improvement in the last several decades, surgical delivery services in developing nations are still suboptimal, and a large backlog in cataract cases continues to grow. To decrease this backlog, barriers to surgery, such as direct and indirect patient costs, geographic access to surgical facilities and surgeons, cultural factors, and patient education, must be addressed. In particular, access to services by women and rural patients needs to be improved. It is clear that extracapsular techniques are cost-effective and lead to better post-operative outcomes than intracapsular cataract extraction with aphakic correction. In addition, monitoring surgical outcomes is essential for improving the quality of surgical services. However, other issues regarding the delivery of cataract surgical services, including the role of average power intraocular lenses and the role of non-physician surgeons, are yet unresolved. Information about the true cost of surgery, including costs of surgeon training, equipment, and patient outreach programs, is needed so that the goal of self-sustaining programs may be obtained.

Cataracts in India: current situation, access, and barriers to services over time

BACKGROUND

Blindness, especially related to cataracts, poses a major challenge all over the developing world. India, as one of the biggest developing countries, has a large number of blind requiring sight-restoring cataract surgery. Despite the increase in service availability and heightened outreach screening efforts, blindness has not decreased and uptake of offered cataract surgery services is suboptimal.

METHODS

Barriers to access cataract surgery services in India have been investigated in several studies, which were reviewed after having been identified through a Medline and Pubmed search and summarized by using a model of health care utilization.

RESULTS

Numerous barriers, such as financial reasons, distance, fear, lack of service awareness, lack of support, or other obligations, could be identified but have not been put into the wider context of health care utilization behavior. Financial barriers continue to be a major reason not to take up offered cataract surgery services.

DISCUSSION

More in-depth research of underlying factors is needed to increase self-motivated uptake of offered cataract surgery services. This would free resources currently invested into patient recruitment such as outreach screening. Freed resources could then be invested into treatment and further interventions such as health literacy promotion.

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.

Coverage, utilization and barriers to cataract surgical services in rural South India: Results from a population-based study

OBJECTIVES

To determine the cataract surgical coverage, utilization and barriers to cataract surgery in a rural taluk of south India.

STUDY DESIGN

A cross-sectional, community-based survey.

METHODS

A house-to-house survey was carried out in 15 villages that were selected by cluster sampling during January to October, 2002. A total of 1505 people aged 50 years and above were tested for visual acuity (VA) and their eyes examined. Cataract surgical coverage was calculated for people and eyes, and for VA levels of <3/60 and <6/60. Information about details of cataract surgery and barriers to cataract surgery were collected using a pre-designed proforma.

RESULTS

Cataract surgical coverage was 63% (people) and 51% (eyes) for VA<3/60 compared with 49% (people) and 36% (eyes) for VA<6/60. Of 109 operated eyes, 51.2% of operations were carried out in private hospitals and 33.3% in voluntary/charitable hospitals. Inability to afford the operation (22.9%) and fear of the operation (19.2%) were the main barriers to cataract surgery.

CONCLUSIONS

The reasons for underutilization of government hospitals are to be investigated. Awareness of low-cost cataract intraocular lens (IOL) non-governmental organization (NGO) surgery and free-of-cost NGO services available in the region needs to be raised. Barriers to cataract surgical services should be addressed by community-based health-education programmes to improve the uptake of existing services.

Surgical interventions for age-related cataract

BACKGROUND

Cataract accounts for 50% of blindness globally and remains the leading cause of visual impairment in all regions of the world, despite improvements in surgical outcomes (WHO 2005). This number is expected to rise due to an aging population and increase in life expectancy. Although cataracts are not preventable, their surgical treatment is one of the most cost-effective interventions in healthcare.

OBJECTIVES

To compare the effects of different surgical interventions for age-related cataract.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE up to July 2006, NRR Issue 3 2005, the reference lists of identified trials and we contacted investigators and experts in the field for details of published and unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTS).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and discrepancies were resolved by discussion. Where appropriate, risk ratios, odds ratios and weighted mean differences were summarised after assessing heterogeneity between the studies.

MAIN RESULTS

We identified 17 trials that randomised a total of 9627 people. Phacoemulsification gave a better visual outcome than extracapsular surgery but similar average cost per procedure in Europe but not in poorer countries. Extracapsular surgery with posterior chamber lens implant and ICCE with or without an anterior chamber intraocular lens (IOL) implant gave acceptable visual outcomes but extracapsular surgery had less complications. Manual small incision surgery provides better visual outcome than ECCE but slightly inferior unaided visual acuity compared to phacoemulsification.

AUTHORS' CONCLUSIONS

This review provides evidence from seven RCTs that phacoemulsification gives a better outcome than ECCE with sutures. We also found evidence that ECCE with a posterior chamber lens implant provides better visual outcome than ICCE with aphakic glasses. The long term effect of posterior capsular opacification (PCO) needs to be assessed in larger populations. The data also suggests that ICCE with an anterior chamber lens implant is an effective alternative to ICCE with aphakic glasses, with similar safety. Phacoemulsification provides the best visual outcomes but will only be accessible to the poorer countries if the cost of phacoemulsification and foldable IOLs decrease. Manual small incision cataract surgery provides early visual rehabilitation and comparable visual outcome to PHACO. It has better visual outcomes than ECCE and can be used in any clinic that is currently carrying out ECCE with IOL. Further research from developing regions are needed to compare the cost and longer term outcomes of these procedures e.g. PCO and corneal endothelial cell damage.

Predictors of poor follow-up in children that had cataract surgery

BACKGROUND

Centers for high quality cataract surgery for children have been developed in a number of sub-Saharan African countries. Surgery, however, is only the first stage of a long, often complex, rehabilitation program. There are indications that follow-up in these settings is poor. In a setting with a high quality surgical service an active program to identify and manage children with cataract and a newly developed low vision program, we sought to measure routine follow-up and to determine the factors associated with good or poor follow-up.

METHODS

This prospective study included all children (under the age of 16 years) having surgery for congenital, developmental, or traumatic cataract at KCMC Hospital between March 2003 and October 2004. Standardized data was collected pre-, intra-, and postoperation. Follow-up was assessed at two weeks and ten weeks.

RESULTS

Among the 154 children included 35.1% had congenital cataract, 32.5% had developmental cataract, and 31.8% had traumatic cataract. Overall, 66.9% attended two-week follow-up and 42.9% attended ten-week follow-up. Multivariate analysis revealed that sex (being a boy), close proximity to a hospital, and minimal delay in presentation for surgery all independently predicted good follow-up at two weeks. Only distance from a hospital and preoperative vision (not blind in operative eye) predicted good ten-week follow up.

DISCUSSION

Current follow-up practices are inadequate. Significant investment in surgical interventions may not lead to improved visual rehabilitation or quality of life, if investments in follow-up are not increased. Linking individual children, their families, and the hospital needs to be approached systematically, if follow-up is to be improved. Improved hospital-based counseling should focus on families who bring their child late for surgery and with girls.

High-volume surgery in developing countries

BACKGROUND

Cataract remains the world's leading cause of blindness. In the developing world, many eye clinics provide cataract surgery for only a small proportion of those in need. This is partly because of low demand-caused by barriers related to awareness, bad services, cost, and distance--and partly because of deficiencies in the supply of services. This article reviews innovations in cataract surgery in poor countries that are intended to reverse this trend.

CONCLUSIONS

Increasing the number of operations, through close involvement with the community, and improved surgical outcomes, enables the cost of surgery to be reduced, leading to further growth in volume. Recent innovations, such as low-cost intraocular lenses, and small-incision extracapsular cataract extraction, have contributed to improving the results of surgery without increasing the costs. Effective management enables the delivery of increasing the numbers of operations, while at the same time improving outcomes and controlling costs.