Pediatric Cataracts in Developing-World Settings
M. Edward Wilson
Rupal H. Trivedi
Parikshit Gogate
Worldwide, an estimated 1.4 million children are blind, of whom approximately 190,000 (14%) are blind due to bilateral unoperated cataract, complications of cataract surgery, amblyopia due to delayed cataract surgery, or the presence of other cataract-associated anomalies. Pediatric cataract blindness presents an enormous problem to developing countries in terms of human morbidity, economic loss, and social burden.1 Managing cataracts in children remains a challenge, even in the industrialized world. Treatment is often difficult and tedious and requires a dedicated team effort. Since the children are the future of any society, it is time to give childhood cataract treatment in the developing world the attention that adult cataract treatment has received for many years. Blindness or visual impairment in children often results in more than just loss of vision. Their overall development, educational progress, and vocational opportunities can be dramatically changed. To assure the best long-term outcome for cataract-blind children, appropriate pediatric surgical techniques need to be defined and adopted by ophthalmic surgeons in developing countries. This chapter focuses on practical guidelines and recommendations for ophthalmic surgeons and health planners dealing with childhood cataract in the developing world.
Of the 1.4 million blind children in the world, approximately 90% live in Asia and Africa, and 75% of all causes are preventable or curable.1 The prevalence of blindness varies according to the socioeconomic development of the country. In developing countries, the rate of blindness can be as high as 1.5 per 1,000 population. Compared to industrialized countries, this figure is 10 times higher.1 Due to lifetime of blindness ahead, the burden of disability in terms of “blind-years” is huge. The child who goes blind today is likely to remain with us into 2050.2 Restoring the sight of one child blind from cataracts may be equivalent to restoring the sight of 10 elderly adults in terms of blind-person years prevented.2 Irrespective of the cause, childhood blindness has far-reaching effects on the child and his/her family throughout life. It profoundly influences educational, employment, personal, and social prospects for the affected child. The control of childhood blindness has been identified as a priority of the World Health Organization’s (WHO’s) global initiative for the elimination of avoidable blindness by the year 2020.3
An uneven distribution of ophthalmologists, pediatricians, and anesthetists creates unique challenges in developing-world settings. In general, health services are concentrated in the larger cities, and people living in rural areas often live beyond the reach of the services provided by health care delivery teams.
GUIDELINES AND RECOMMENDATIONS FOR HEALTH PLANNERS AND SURGEONS
Delayed presentation and late surgical treatment are the major causes of severe visual impairment and blindness in children with cataract.4 It is important to improve the early identification and referral of children with cataracts by educating and training pediatricians, rural health clinic personnel, midwives, and eye-camp workers to screen for loss of the eye’s red reflex and poor visual functioning in newborn, toddlers, and school-aged children. Although early surgical intervention and prompt optical rehabilitation are mandatory to prevent irreversible deprivational amblyopia, surgery for cataract with delayed presentation can also help to regain functional vision.5 Delivering good pediatric eye care is a team approach, and ophthalmologists need to work in tandem with other health care and education personnel to best help the affected children.
The primary health care worker can also be taught to identify cataracts. Ophthalmic assistants, working with primary health workers, can maximize the efficiency of a limited eye care system by screening and referring only patients requiring surgery or other specialized attention. It is also important to emphasize
that all types of eye staff need to have the stimulus of continuing education and eye seminars to provide the necessary incentive and encouragement and to update their knowledge and skills.
that all types of eye staff need to have the stimulus of continuing education and eye seminars to provide the necessary incentive and encouragement and to update their knowledge and skills.
Most developing and developed nations provide health delivery services through a tiered system, with central hospitals supporting smaller and rural health delivery centers. In Africa and Asia, for example, many countries have established a three-tiered system, consisting of primary, secondary, and tertiary levels. The primary health care worker can diagnose and treat the most prevalent diseases and refer complicated cases to treatment facilities. The usual referral resource for the primary health care worker is the secondary facility. Provincial, district, and subdistrict hospitals and health centers serve as secondary medical units. Ophthalmologists are assigned to provincial and sometimes to district hospitals. The central urban hospital, usually attached to a medical school, is the tertiary resource. There may be several tertiary hospitals in larger states, provinces, or countries serving large geographic regions. This facility usually is a large general hospital and offers a wide range of specialty services. We believe that the treatment of cataract-blind children should be done in specialized, well-equipped, pediatric eye care centers that are piggy-backed on comprehensive eye surgical centers, where cataract operations on children are done on a regular basis.
There are many persons who have close contact with the community, especially at the village level. These persons, by use of appropriate knowledge, could help in the prevention of blindness. These may include, the school teacher, mukhia (leader of the village), religious leader, traditional birth attendants, and others have great influence in rural regions of most developing countries. The key informant approach used this premise to identify blind children in Bangladesh and Malawi to great success.6,7
Pediatric eye care is a teamwork of primary health and education service facilities that help in identifying children with visual impairment and pediatric eye care units based at tertiary centers where medical and surgical service is imparted. ORBIS International has used this approach as have other nongovernmental organizations working in the area of childhood blindness prevention. The referral is not just from primary to tertiary centers but also in the reverse direction, after the surgery, for better compliance with refractive correction and amblyopia treatment and to promote sensitivity to the child’s education needs. Publicity may be accomplished through a variety of mechanisms at several levels using health care personnel, radio, television, and other media. Service organizations (e.g., Lions Club, Rotary Club) are often involved in promotional activities.
The harvest season may be a time of reduced surgery since travel to a centralized treatment facility may not be possible without loss of the family livelihood. Many parents of school-age children prefer to have elective surgery done during the annual school vacation.
A significant influence in persuading parents to allow their child to undergo cataract surgery is likely to be the example of other children in the community who have had sight restored by such an operation. A reputation for good results from surgery is the major influence in the decision-making process for parents. Thus, in the initial phase, “patient selection” is very important. Patients with good visual potential (bilateral dense cataracts without nystagmus or microphthalmia in children who are progressing developmentally) should be operated on first to assure that parents and community leaders will trust and believe in the surgery being offered to the blind children. After establishing some initial success, cases with a more guarded prognosis can be operated. There are many reports of children with dense cataract operated late who nonetheless improve markedly on their preoperative visual acuity.
In some locations the facilities are in place but are underutilized. Valuable resources of trained staff have often been wasted, or at best poorly used, because they have not been given even the basic equipment to carry out their work—even though the equipment is often inexpensive and simple. Basic instruments to diagnose ophthalmic disorders should be provided (visual acuity charts, torch, direct ophthalmoscope, etc.) to such a setup. Measuring a child’s visual acuity before and after the intervention can help to gauge the outcome of the treatment. Children as young as 8 to 9 months can have their visual acuity measured by preferential looking charts.
Power fluctuations and outages are additional challenges in the developing-world setting when surgical procedures, like pediatric cataract surgery, depend on automated machinery. The development of better battery-operated vitrectomy cutting instruments would be helpful in these settings.
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