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Original Article

Cataract Blindness in , : Results of a Survey

Olubayo U. Kolawole, Adeyinka O. Ashaye1, Abdulraheem O. Mahmoud2, Caroline O. Adeoti

ABSTRACT Access this article online Website: Purpose: To estimate the burden of blindness and visual impairment due to cataract in www.meajo.org Egbedore Local Government Area of Osun State, Nigeria. DOI: Materials and Methods: Twenty clusters of 60 individuals who were 50 years or older were 10.4103/0974-9233.102741 selected by systematic random sampling from the entire community. A total of 1,183 persons Quick Response Code: 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.

Key words: Barriers, Cataract Blindness, Nigeria, Prevalence, Surgery

INTRODUCTION countries.7 In developed and even some developing countries, declining total fertility rate and increased life expectancy result ataract blindness presents an enormous problem in terms in sharp increase in the number of people aged 60 and above.8 Cof magnitude,1 functional disability, loss of self-esteem,2,3 In many of these countries, as the mean and median ages of the considerable economic loss, and social burden.4-6 It has been population increase, the prevalence of cataract and other age- estimated that cataract accounted for 47.8% of the 37 million related causes of blindness will increase, resulting in an increase people who were blind worldwide in 2002.1 Age-related demand for cataract surgery.9 cataract constitutes more than 80% of all cataracts, and a large proportion of the burden is borne by elderly people who live The results from the recent national blindness and visual in remote underserved rural communities of most developing impairment survey revealed that 1.8% of adult Nigerians

Department of Ophthalmology, College of Health Sciences, Ladoke Akintola University of Technology, , Osun State, 1Department of Ophthalmology, University College Hospital, Ibadan, 2Department of Ophthalmology, University of Ilorin Teaching Hospital, Ilorin, Nigeria Corresponding Author: Dr. Olubayo U. Kolawole, Department of Ophthalmology, College of Health Sciences, Ladoke Akintola University of Technology, Osogbo, Osun State, Nigeria. E-mail: [email protected]

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Kolawole, et al.: Cataract Blindness, Prevalence, Surgery, Barriers

aged 40 and above had cataract-related blindness.10 However, caused by cataract. Thus, the prevalence of cataract blindness surveys conducted earlier showed that the prevalence of cataract in Egbedore LGA would be 0.56%. Assuming that cataract blindness among people aged 50 and above ranged between 2.1 blindness in individuals younger than 50 years is negligible, the and 3.8% in Northern Nigeria11-13 and 4.1% in the Niger Delta.14 prevalence of bilateral cataract blindness in people aged 50 and It was 0.84% in South-Western Nigeria.15 older is expected to be 0.56/9.31% = 6.01%.

Egbedore is one of the 30 Local Government Areas (LGAs) in We allowed for a precision of ±30% of the likely prevalence Osun State, Nigeria. It is located in the South-Western part of bilateral cataract blindness, i.e., worst acceptable prevalence of Nigeria between Latitudes 07° 40″ and 07° 55″ N; and of 4.21% with a probability of 95%. For logistic reasons, we Longitudes 04° 20″ and 04° 35″ E. It covers an area of about selected a cluster size of 60 with design effect of 1.7 for cluster 102 km2. It shares borders with Irepodun (north), random sampling. Thus, the calculated sample size using the LGA (south), LGA (west), and /Osogbo LGAs sample size menu of Epi-info 6.04 (Centers for Disease Control (east). Awo, the headquarters of the LGA, is about 5 km from and Prevention, Atlanta, GA, USA) was 1,017. Allowing for a Osogbo, the Osun State capital. While other settlements such 10% non-response rate, the minimum sample size was 1,130. as Okinni, Ido-Osun, Ofatedo, and Olorunsogo are near to Thus, 20 clusters of 60 eligible subjects each were randomly Osogbo and are peri-urban, the remaining settlements are selected from the community. essentially rural. The vegetation is that of the southern lowlands and tropical rain forest. The climate is mainly tropical with Clusters were selected from a census list of all settlements in the long wet season stretching from March to November.16 the entire Egbedore LGA and their respective populations. A Ophthalmic services for the LGA are provided mainly by five column with the cumulative population was added from which consultant ophthalmologists who work at Osogbo. Four of 20 clusters were selected through systematic random sampling. these ophthalmologists work at Ladoke Akintola University of Following this procedure, clusters were selected with a probability Technology Teaching Hospital (LTH), Osogbo; one works at the proportional to the size of the population. The sampling method General Hospital, Osogbo. All the ophthalmologists perform was designed to provide reliable estimates for the entire LGA. No cataract surgeries, even though only LTH is well equipped for stratification was made between rural and peri-urban settlements microsurgery. All the five ophthalmologists performed fewer because there was homogeneity of the study population with than 100 cataract surgeries in 2005. A surgical eye camp has respect to the risk of developing age-related cataract. never been held in the LGA. In each cluster, the starting point was selected randomly by The aim of this study was to estimate the contribution of spinning a bottle in the middle of the community and moving in cataract to the burden of blindness and visual impairment in the direction of the tip of the fallen bottle. All eligible subjects Egbedore LGA of Osun State in order to provide baseline data in all the households along that direction were enrolled until for developing and conducting viable cataract surgical services the required 60 persons had been registered. In each cluster, for the area. the local guide ensured that persons who were not members of selected households were not enrolled. Such persons were MATERIALS AND METHODS examined but were not included in the study. In clusters where fewer than 60 subjects were registered, eligible subjects were This was a population-based cross-sectional survey that was enrolled and examined from the nearest settlements to make conducted in the months of May, June, and October 2005. Persons up the required number. aged 50 years and above who had resided in the LGA for at least 6 months at the time of this study formed the target population. Ethical approval for the study was obtained from the Research and Ethical Committee of LTH. According to the 1991 population census data,17 the total population of Egbedore LGA was 40,293 and the annual growth The field work was carried out by a team which consisted of an rate was 3%. Although census data by sex and age group were not ophthalmologist, three assistants (secondary school leavers) who available for the LGA, from the national population estimates, were trained to register the subjects, measure and record VA, and 9.31% of the Nigerian population represented people aged 50 record the general information section on the survey form, and a and above.18 Thus, the 2005 projected population of the LGA local guide for each settlement who was a member of the community. was 59,823 people, of whom 5,570 were adults aged 50 and older. The results of a population-based survey19 conducted in Oral informed consent was obtained from each subject before data Egbedore LGA in 1998 indicated that 1.18% of the examined collection. A standard survey record form developed for Rapid population of all age groups were bilaterally blind with visual Assessment of Cataract Surgical Services (RACSS)20 by the WHO acuity (VA) of less than 3/60. Of all blindness, 47.4% was Prevention of Blindness and Deafness Programme was modified

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Kolawole, et al.: Cataract Blindness, Prevalence, Surgery, Barriers

and completed for each participant. The form has seven different 2. Blindness: Presenting VA of less than 3/60 in the better eye. sections: General information; vision and pinhole examination; lens 3. Borderline postoperative outcome: Presenting postoperative examination; principal cause of vision < 6/18; history, if not examined; VA of 6/18-6/60. why cataract surgery has not been done; and details about cataract operation. 4. Cataract blindness: Presenting VA of less than 3/60 in an eye caused by lens opacity. A person was said to be cataract The first stage of data collection involved registration of all blind if both eyes met this criterion. eligible subjects. Information obtained included name, age, sex, 5. Couching: A traditional operative form of treating cataract occupation, and educational qualifications of the subjects. During which is done by using blunt or sharp instruments to the second stage, VA was measured in each eye of subjects at 6 m dislocate the lens into the vitreous. in full day light, in the courtyard with available correction. Snellen 6. Good postoperative outcome: Presenting postoperative VA illiterate “E” optotype was used for the illiterate subjects and the of 6/18 or better. alphabet optotype for the literate ones. All aphakics presenting 7. Non-response: Inability to obtain information on a subject without their correction had their VA tested with +10 D lens. All due to either non-availability of subject or subject’s refusal eyes with presenting VA < 6/18 had their VA tested with pinhole. to co-operate. At least two attempts/visits were made to obtain information before a subject was categorized as a In the third stage, each subject was taken inside a room or non-responder. dimly-lit area for lens and fundus examination. The lens was 8. Operable cataract: Presenting VA of less than 6/60 in an examined with a pentorch, binocular magnifying loupe and eye caused by lens opacity. direct ophthalmoscope at 20–30 cm. The lens was examined to 9. Poor postoperative outcome: Presenting postoperative VA determine whether it was normal, had obvious opacity, or was worse than 6/60. completely absent. The presence of intraocular lenses (IOLs) 10. Posterior segment disorders: Referred to diabetic with or without posterior capsule opacification was noted. retinopathy, macular degeneration, and any other posterior Inability to view the lens owing to the presence of dense corneal segment disorders. opacity, phthisis bulbi, or absent globe was also noted. Subjects 11. Pseudoaphakia: Status of an eye that has undergone with VA < 6/18 in one or both eyes with available correction couching. or pinhole were examined further to establish the possible cause 12. Pseudophakia: Status of an eye that has undergone of the low vision. The posterior segments were examined with conventional cataract surgery with implantation of an IOL. direct ophthalmoscope without dilatation because most of our 13. Uncorrected aphakia: refers to an aphakic eye whose vision subjects would not permit instillation of mydriatics into their improves to better than 3/60 with +10 D lens. eyes for fear of losing their sight. Intraocular pressure was 14. Severe visual impairment: Presenting VA 6/60 to >3/60 in measured in all subjects with suspicious discs (Cup/Disc ratio the better eye with available correction. > 0.8) with the Perkins hand-held tonometer. Causes of low 15. Visual impairment: Presenting VA 6/18 to >6/60 in the vision or blindness most amenable to treatment or prevention better eye with available correction. were adjudged to be the likely principal cause of problem for each eye and each subject in accordance with WHO convention. DATA ANALYSIS

During the last stage, subjects with operable cataract were asked A special software program (RACSS version 1.01)20 for data entry why cataract surgery had not been performed. Further information and automatic standardized data analysis has been developed in was requested from those with aphakia, pseudophakia, or Epi-Info version 6.04. After data entry was completed, the couched eye where and when the procedure was done, mode of required level of vision (VA < 3/60, VA < 6/60, or VA < payment, and whether or not they were given glasses. They also 6/18) were selected, and then the required analysis report was were asked whether an IOL was implanted during the surgery. generated using the menu system.

All subjects with cataracts or any other serious eye conditions By dividing the number of cataract surgeries (number of people were referred to LTH for treatment. Subjects with minor eye with bilateral pseudophakia/aphakia/pseudoaphakia plus number problems were given prescriptions during the survey. of people with unilateral pseudophakia/aphakia/pseudoaphakia and unilateral visually significant cataract) by the sum of the OPERATION DEFINITIONS number of surgeries plus the number of persons who are visually impaired from cataract, we calculated the Cataract Surgical/ For the purpose of this study, the following definitions were Couching Coverage and Cataract Intervention (surgery + applied: couching) Coverage for persons. We also calculated Cataract 1. Aphakia: Status of an eye that has undergone conventional Surgical/Couching Coverage and Intervention Coverage for eyes. cataract surgery without implantation of an IOL. This represents the proportion of all cataract blind people, or

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eyes, that have been provided with cataract surgery/couching, their visual status was obtained from their relatives or neighbors. independent of the visual outcome. This was calculated for various These data were not included in the analysis. levels of VA, for males and females. It indicated which proportion of the cataract blindness has been covered so far by surgery The prevalence of all-cause blindness in the sample was 6.4%. and also gave an idea about the availability and accessibility of In the sample, 30 (2.5%) subjects were bilaterally blind due to the cataract surgical services to the population of the survey cataract. Forty-two (3.6%) persons in the sample had operable area. Means with standard deviation and odds ratios with 95% cataract [Table 2]. The prevalence of cataract blindness increased confidence intervals (CIs) were calculated where appropriate. with age in both sexes. There was no statistically significant P < 0.05 was considered statistically significant. gender difference in the prevalence of bilateral cataract blindness in the sample (odds ratio (OR) = 0.92 (95% CI = 0.41 – 2.03); RESULTS P = 0.98).

A total of 1,200 persons aged 50 and above were eligible for When the survey results were extrapolated to the target examination, of whom 1,183 persons (98.6%) were examined: population in Egbedore, approximately 112 persons aged 50 496 (41.9%) males and 687 females, giving a male:female ratio and above were bilaterally blind from cataract in the LGA. In the of 1:1.4. The age and sex distribution of the sample is presented same vein, about 484 eyes of persons aged 50 and above were in Table 1. The age range was 50–99 years with a mean age of blind as a result of cataract in the area. There were an estimated 65.9 ± 11.4 years. The modal age group was 60–64 years. There 612 operable cataracts among persons 50 years and older in was underrepresentation of people in the 50–54 years age group the LGA [Table 3]. The cumulative prevalence of presenting and slight overrepresentation of people aged 75 and above in the VA < 6/18 due to cataract was 6.8% (95% CI = 6.1 – 7.5%). sample. Seventeen persons either refused or were absent during The age-and gender-adjusted prevalence of bilateral cataract the survey period despite two repeated visits. Information about blindness was 2.0% (95% CI = 1.6 – 2.4%) and that of bilateral operable cataract, 2.7% (95% CI = 2.3 – 3.1%). Table 1: Age group and sex distribution of sample and LGA estimates The major barriers to uptake of cataract services in the area Age group Male Female were lack of awareness (30.4%), “need not felt” (17.6%), cost Sample LGA Sample LGA of surgery (14.6%), fear (10%), “waiting for cataract to mature” estimate estimate (8.8%), and surgical services not available (5.8%). Others such 50–54 79 (15.9) 933 (30.8) 104 (15.1) 795 (31.3) 55–59 85 (17.1) 431 (14.2) 110 (16.0) 323 (12.7) as “no one to accompany,” fatalism, and presence of diseases 60–64 80 (16.1) 603 (20.0) 129 (18.8) 533 (20.9) making cataract surgery not feasible accounted for 12.6%. 65–69 51 (10.3) 274 (9.0) 71 (10.3) 241 (9.5) 70–74 68 (13.7) 331 (10.9) 80 (11.6) 264 (10.4) 75–79 48 (9.7) 130 (4.3) 85 (12.4) 105 (4.1) In the sample, 29 eyes of 22 persons had undergone either 80+ 85 (17.1) 328 (10.8) 108 (15.7) 279 (11.0) conventional cataract surgery or couching. Fourteen eyes Total 496 3030 687 2540 (48.3%) had couching, 8 (27.6%) had IOL implants, while 7 LGA: Local government area (24.1%) had no IOL implant.

Table 2: Prevalence of blindness and visual impairment in the survey sample, by gender Sample size people 50+ Males Females Total n = 496 n = 687 n = 1183 No. of cases Prev. (95% CI) No. of cases Prev. (95% CI) No. of cases Prev. (95% CI) Blindness (VA < 3/60 with available correction) All bilateral cases 40 8.1 (5.2–11.0) 36 5.2 (3.4–7.0) 76 6.4 (4.6–8.2) Bilateral cataract cases 12 2.4 (1.1–3.7) 18 2.6 (1.5–3.8) 30 2.5 (1.7–3.8) Eyes with cataract 58 5.9 (3.8–8.0) 72 5.2 (3.5–6.9) 130 5.5 (4.2–6.8) Blindness + severe visual impairment (VA < 6/60 with available correction) All bilateral cases 50 10.1 (7.1–13.0) 51 7.4 (5.1–9.8) 101 8.5 (6.5–10.6) Bilateral cataract cases 17 3.4 (1.8–5.1) 25 3.6 (2.2–5.1) 42 3.6 (2.5–4.6) Eyes with cataract 72 7.3 (5.0–9.6) 98 7.1 (5.1–9.1) 17 0 7.2 (5.7–8.7) Blindness + low vision (VA < 6/18 with available correction) All bilateral cases 131 26.4 (20.1–32.7) 169 24.6 (19.7–29.5) 300 25.4 (20.7–30.0) Bilateral cataract cases 39 7.9 (5.6–10.2) 76 11.1 (8.3–13.8) 115 9.7 (8.2–11.2) Eyes with cataract 119 12.0 (9.1–14.9) 196 14.3 (11.6–17.0) 315 13.3 (11.3–15.3) Bilateral pseudo (aphakia) 3 0.6 (-0.2 to 1.5) 4 0.6 (-0.3–1.5) 7 0.6 (0.0–1.2) Unilateral pseudo (aphakia) 7 1.4 (0.4–2.5) 8 1.2 (0.3–2.1) 15 1.3 (0.5–2.1) (Pseudo) aphakic eyes 13 1.3 (0.3–2.3) 16 1.2 (0.4–2.1) 29 1.2 (0.6–1.8)

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Kolawole, et al.: Cataract Blindness, Prevalence, Surgery, Barriers

Table 3: Estimates of prevalence of blindness and visual impairment in Egbedore LGA, Nigeria, after applying rates observed by age and gender in a survey Sample size people 50+ Males Females Total n = 3030 n = 2540 n = 5570 No. of cases Prev. (95% CI) No. of cases Prev. (95% CI) No. of cases Prev. (95% CI) Blindness (VA < 3/60 with available correction) All bilateral cases 205 6.8 (5.9–7.7) 94 3.7 (3.0–4.4) 299 5.4 (4.8–6.0) Bilateral cataract cases 61 2.0 (1.5–2.5) 51 2.0 (1.4–2.6) 112 2.0 (1.6–2.4) Eyes with cataract 285 4.7 (3.9–5.5) 199 3.9 (3.1–4.7) 484 4.4 (3.9–4.9) Blindness + severe visual impairment (VA < 6/60 with available correction) All bilateral cases 253 8.3 (7.3–9.3) 127 5.0 (4.1–5.9) 380 6.8 (6.1–7.5) Bilateral cataract cases 87 2.9 (2.3–3.5) 66 2.6 (2.0–3.2) 153 2.7 (2.3–3.1) Eyes with cataract 347 5.7 (4.6–6.5) 265 5.2 (4.3–6.1) 612 5.5 (4.9–6.1) Blindness + low vision (VA < 6/18 with available correction) All bilateral cases 622 20.5 (19.0–22.0) 468 18.41 (16.9– 1090 19.57 (18.5–20.6) 19.9) Bilateral cataract cases 176 5.8 (5.0–6.6) 202 7.9 (6.8–9.0) 378 6.8 (6.1–7.5) Eyes with cataract 266 8.8 (7.8–9.8) 260 10.23 (9.0–11.4) 526 9.4 (8.6–10.2) Bilateral pseudo (aphakia) 10 0.3 (0.1–0.5) 12 0.5 (0.2–0.8) 22 0.4 (0.2–0.6) Unilateral pseudo (aphakia) 36 1.2 (0.8–1.6) 20 0.8 (0.4–1.2) 56 1.0 (0.7–1.3) (Pseudo) aphakic eyes 56 0.9 (0.6–1.2) 44 0.9 (0.5–1.3) 100 0.9 (0.6–1.2)

Couching was performed in unhygienic facilities as described Table 4: Cataract intervention coverage in Egbedore LGA, Nigeria by the patients (48.3% eyes), 24.1% had cataract surgery Cataract Intervention (Surgery + Couching) Coverage (CIC) in in government hospitals, and 13.8% each were operated in people 50+ (in sample) voluntary and private hospitals. Of note, no eye was operated CIC, persons % CIC, eyes % in a surgical eye camp. Surgery was fully paid for by patients or VA < 3/60 their relations in 89.7% eyes while 10.3% eyes were operated Male 29.4 18.3 Female 21.7 18.1 on free of charge. More than 80% of the operated patients Total 25.0 18.2 were not using glasses. Of all the cataract surgeries/couching, VA < 6/60 22 (75.9%) were performed on the “first” eyes and 7 (24.1%) Male 22.7 15.3 Female 21.9 14.0 on the fellow eyes. Total 22.2 14.6 VA < 6/18 The CSC at VA < 3/60 was low; CSC (persons) and Couching Male 11.4 9.9 Coverage (persons) had similar value of 14.3%. Cataract Female 9.5 7.6 Total 10.2 8.4 Intervention Coverage (CIC) for persons was 25.0% (male: 29.4%; female: 21.7%). CSC (eyes) and Couching Coverage (eyes) were 10.3 and 9.7%, respectively. The CIC (eyes) was indicated as the cause of poor outcome in 12 (60%) eyes, 18.2% [Table 4]. In essence, 75% of persons with cataract in posterior segment disorders in 5 (25%) eyes, and uncorrected one or both eyes (and >80% of cataract blind eyes) have neither aphakia in 3 (15%) eyes. had surgery nor couching.

VA was measured in all aphakic, pseudoaphakic, and pseudophakic DISCUSSIONS eyes in the sample [Table 5] to document the visual outcome after cataract surgery and couching. Eyes with IOL implants Individuals who were - 50 years and older formed the target had better visual outcome than eyes without IOL implants; all population in this study because there is a higher prevalence the four eyes with postoperative VA ≥ 6/18 had IOL implants. of age-related cataract in this age group compared to younger With pinhole, seven eyes with IOL implants attained VA ≥ 6/18; individuals.20 Using a lower age group, for example, 40 years one eye still had VA < 6/60 due to optic atrophy. Among the old and above, would increase the sample size by 60–70% to couched eyes, only one achieved VA = 6/18 with +10 D lens; 3 arrive at the same level of precision,20 and this was not logistically eyes had borderline outcome and 10 eyes had poor postoperative feasible as there was only one survey team. visual outcome. No improvement in VA was achieved among the eyes operated without IOL implants with either pinhole or The survey coverage of 98.6% in this study was very high. +10 D lens. Twenty (69%) eyes had presenting VA < 6/60 This was made possible by the immense support given by the (poor outcome). Cataract surgery-related complications were community leaders and the entire Egbedore people in mobilizing

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Table 5: Visual acuity of eyes with or without an intraocular lens Categories of VA Eyes with intraocular lens Eyes without an intraocular lens n (%) Surgery n (%) Couching n (%) Total eyes n (%) Good (6/18 or better) 4 (50.0) 4 (13.8) Borderline (<6/18 to 6/60) 3 (37.5) 1 (14.3) 1 (7.1) 5 (17.2) Poor (<6/60) 1 (12.5) 6 (85.7) 13 (92.9) 20 (69.0) Totals 8 (100.0) 7 (100.0) 14 (100.0) 29 (100.0)

and encouraging eligible subjects to participate in the survey. In As in other related studies11-15,22,23 conducted in developing addition, the survey was conducted around the farming period countries, lack of awareness, “need not felt,” and “cannot afford” when most of the eligible subjects were near their settlements. were the most cited reason why surgery had not been done. These are followed by fear, “waiting for cataract to mature,” The sample prevalence of bilateral cataract blindness (2.5%) and “surgical services not available,” and others. Ophthalmologists at that of operable cataract of 3.6% in Egbedore LGA were higher Osogbo need to work in concert with the authority of the LGA than the National prevalence of 1.8%,10 implying that there was to establish viable and subsidized cataract outreach program to a huge backlog of operable cataract in the community. This is deal with the cataract backlog in this community. surprising in view of the fact that there are two ophthalmic centers within 60 km from the farthest village in the LGA. At VA < 3/60, couching was being performed in Egbedore Studies21-23 have shown that presence of facilities do not translate at almost the same rate as conventional cataract surgery. automatically to utilization. In this study, lack of awareness of This indicates that patients who were blind due to cataract the existence of these facilities and poverty hampered the people consulted couchers at about the same rate as they consulted from accessing the service. ophthalmologists for treatment of cataract. This might be due to lack of awareness of where to get conventional cataract surgery High prevalence of cataract blindness with attendant low done. Conventional cataract surgery has been shown to have 34 cataract surgical coverage had been reported in studies from superior outcome over couching. Besides, prohibitive direct different parts of Nigeria.11-14 The lower prevalence from and indirect costs hamperered the cataract blind persons from Akinyele LGA15 was due to the fact that there was a good referral accessing good quality surgeries in government and private system between a Primary Care facility in that community hospitals. They therefore approached couchers who were and an active tertiary eye center at Ibadan. The prevalence readily available in their locality and who allowed more flexible of cataract blindness in this study was, however, lower than mode of payment in cash, kind, or by installments. Additionally, African estimates for individuals ≥50 years old which ranged the lower cost ($35 to $75 for couching vs. $125 to $160 for between 4.5% and 4.95% in 2002.1 Similarly, high prevalence cataract surgery) for couching was a factor in the selection of couching. All but one couched eyes encountered during this of cataract blindness (2.5%) was reported from Malawi24 and survey had VA < 6/60 (poor outcome), whereas only one Zanzibar25 where uptake of cataract was as low as found in (12.5%) pseudophakic eye had a poor outcome. There is a this study in spite of availability of cataract surgical service. In need for public enlightenment on the drawbacks of couching. a similar study in rural Ethiopia,26 the prevalence of cataract Appropriate health education on cataract, with emphasis on the blindness was as high as 3.2% despite higher cataract surgical availability and affordability of available cataract services, needs coverage (47.8%) than Egbedore LGA. Lower prevalence of to be instituted in this community. cataract blindness was, however, reported from similar studies 27 28 in South-western parts of Cameroon (1%), Kenya (0.84%), Twenty-two (75.9%) of all 29 cataract intervention procedures 29 30 Rwanda (1.2%), Kilimanjaro, Tanzania (1.2%), Pakistan performed in this study were carried out on the first eyes. Most 31 32 33 (2.0%), Turkmenistan (0.5%), and Oman (0.5%) probably likely, the majority were so dissatisfied with the postoperative because these countries had well established and better cataract visual outcome that they considered surgery in the second eyes intervention programs and higher cataract surgical coverage worthless. In addition, most of the subjects who had surgery than Egbedore LGA. Apart from differences in service uptake, in this study area are elderly retirees and farmers who resided the observed variations in prevalence of cataract blindness might in rural settlements and had little or no formal education. be related to varying climatic and genetic factors in various Therefore, the need for good binocular vision for their routine communities; future researches might elucidate these. Most activities might not be very strong. of the inhabitants of Egbedore LGA, an agrarian community, are engaged in outdoor activities most times of the day with With 69.0% of the operated eyes unable to see 6/60, the outcomes attendant prolonged exposure to ultraviolet light rays which of cataract surgery in this survey are in the same range as reported might increase their risk of developing cataract. in other surveys in Nigeria11-14 and other parts of Africa.26-29 It

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Kolawole, et al.: Cataract Blindness, Prevalence, Surgery, Barriers

is important to realize that these cases included eyes operated 4. Frick KD, Foster A. The magnitude and cost of global blindness: recently as well as decades earlier, by skilled as well as less skilled An increasing problem that can be alleviated. Am J Ophthalmol 2003;135:471-6. surgeons under optimal as well as less optimal conditions. The 5. Smith AF, Smith JG. The economic burden of global blindness: outcomes in the current study were worse than those reported A price too high. Br J Ophthalmol 1996;80:276-7. in surveys conducted in Pakistan,31 Turkmenistan,32 Nepal,2 and 6. Rein D, Zhang P, Wirth KE, Lee PP, Hoerger TJ, McCall N, et al. China.35 The high couching rate with associated visually disabling The economic burden of major adult visual disorders in the postoperative complications and very low IOL implantation rate United States. Arch Ophthalmol 2006;124:1754-60. (27.6%) made achievement of good postoperative visual outcome 7. Osuntokun O. Blindness in Nigeria: The challenge of cataract blindness. Fourth Faculty of Ophthalmology Lecture. Lagos: almost impossible in this study area. It is comforting to note National Postgraduate Medical College of Nigeria; 2001. p. 2-22. that all the five ophthalmologists at Osogbo are well trained in 8. Kalache A. Ageing: A global perspective. Community Eye cataract surgery with IOL implantation. Efforts have to be made Health 1999;12:1-4. to increase the number of IOL surgeries through better utilization 9. Foster A. Vision 2020: The cataract challenge. Community Eye of available surgical facilities and making IOL surgery available Health 2000;13:17-9. 10. Abdull MM, Sivasubramaniam S, Murthy GVS, Gilbert C, locally at an affordable price. They also need to introduce self- Abubakar T, Ezelum C, et al. Causes of blindness and visual auditing and assessments of outcomes in order to identify and impairment in Nigeria: The nigeria national blindness and visual address the causes of poor outcome to improve the quality of impairment survey. Invest Ophthalmol Vis Sci 2009;50:4114-20. their cataract surgeries. 11. Rabiu MM, Muhammed N. Rapid assessment of cataract surgical services in Birnin-Kebbi local government area of Kebbi State, Nigeria. Ophthalmic Epidemiol 2008;15:359-65. CONCLUSION 12. Rabiu MM. Cataract blindness and barriers to uptake of cataract surgery in a rural community of northern Nigeria. Br J This study showed that more than 600 operable cataract Ophthalmol 2001;85:776-80. existed among persons aged 50 and above in the study area. 13. Ndife TI. Rapid assessment of cataract surgical services at Giwa The existing Cataract Surgical Services only covers less than local government area of Kaduna State. Fellowship Dissertation. Lagos: National Postgraduate Medical College of Nigeria; 2003. one-fifth of the need for cataract surgery. This is due to the p. 41-64. fact that majority of the blind members of the community were 14. Patrick-Ferife G, Ashaye AO, Osuntokun OO. Rapid assessment unaware of the fact that their sight could be restored by surgery. of cataract blindness among Ughelli clan in an urban/rural A few of them could not afford the cost of surgery; those who district of Delta State, Nigeria. Ann Afr Med 2005;4:52-7. could afford surgery were ignorant of where to obtain quality 15. Oluleye TS. Cataract blindness and barriers to cataract surgical surgery. There is an urgent need for an effective, affordable, intervention in three rural communities of Oyo State, Nigeria. Niger J Med 2004;13:156-60. and accessible cataract outreach program in this community. 16. Egbedore Local Government Local Economic Empowerment The results from this survey could be very useful in starting a and Development Strategy (LEEDS) 2004-2007 Handbook. planning exercise involving all eye care providers in order to Awo: Egbedore Local Government; 2004. p. 1-5. optimize the utilization of all eye care resources located close 17. Annual abstract of statistics. 1995 ed. Lagos: Federal Office of to the community. Statistics; 1995. p. 39. 18. 1991 Population census of the Federal Republic of Nigeria: Analytical report at the national level. Abuja: National ACKNOWLEDGEMENTS Population Commission; 1998. p. 40. 19. Adeoti CO. Prevalence and causes of blindness in a tropical We appreciate Dr. C. D. Mpyet, Dr. K. S. Oluwadiya and Dr. Asekun- African population. West Afr J Med 2004;23:249-52. Olarinmoye for their constructive criticisms. We also thank the 20. Limburg H. Estimating Cataract Surgical Services in National former Chairman and the staff of the Health department of Egbedore Programmes. Computer software. World Health Organisation (WHO) Prevention of Blindness and Deafness. Geneva: World Local Government Area for their support. The support of the survey Health Organisation (WHO); 2001. participants and the survey team is highly appreciated. 21. Stock R. Distance and utilisation of health facilities in rural Nigeria. Soc Sci Med 1983;17:563-70. REFERENCES 22. Snellingen T, Shrestha BR, Gharti MP, Shrestha JK, Upadhyay MP, Pokhrel RP. Socioeconomic barriers to cataract surgery 1. Resnikoff S, Pascolini D, Etya’ale D, Kocur I, Pararajasegaram R, in Nepal: The South Asian cataract management study. Br J Pokharel GP, et al. Global data on visual impairment in the year Ophthalmol 1998;82:1424-8. 2002. Bull World Health Organ 2004;82:844-51. 23. Johnson JG, Goode V, Faal H. Barriers to uptake of cataract 2. Pokharel GP, Selvaraj S, Ellwein LB. Visual function and quality surgery. Trop Doct 1998;28:218-20. of life outcomes among cataract operated and unoperated blind 24. Eloff J, Foster A. Cataract surgical coverage: Results of a populations in Nepal. Br J Ophthalmol 1998;82:606-10. population-based survey at Nkhoma, Malawi. Ophthalmic 3. Fletcher AE, Ellwein LB, Selvaraj S, Vijaykumar V, Rahmathullah Epidemiol 2000;7:219-21. R, Thulasiraj RD. Measurements of vision function and quality 25. Kikira S. Rapid assessment of avoidable blindness in Pemba of life in patients with cataracts in southern India. Report of and Unguja islands, Zanzibar. M.Sc. London: CEH dissertation; instrument development. Arch Ophthalmol 1997;115:767-74. 2007.

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Kolawole, et al.: Cataract Blindness, Prevalence, Surgery, Barriers

26. Bejiga A, Tadesse S. Cataract surgical coverage and outcome 32. Amansakhatov S, Volokhovskaya ZP, Afanasyeva AN, Limburg in Goro district, Central Ethiopia. Ethiop Med J 2008;46:205-10. H. Cataract blindness in Turkmenistan: Results of a national 27. Oye JE, Kuper H, Dineen B, Befidi-Mengue R, Foster A. survey. Br J Ophthalmol 2002;86:1207-10. Prevalence and causes of blindness and visual impairment 33. Khandekar R, Mohammed AJ. Cataract prevalence, cataract in Muyuka: A rural health district in South West Province, surgical coverage and its contribution to the reduction of visual Cameroon. Br J Ophthalmol 2006;90:538-42. disability in Oman. Ophthalmic Epidemiol 2004;11:181-9. 28. Mathenge W, Kuper H, Limburg H, Polack S, Onyango O, 34. Schémann JF, Bakayoko S, Coulibaly S. Traditional couching Nyaga G, et al. Rapid assessment of avoidable blindness in is not an effective alternative procedure for cataract surgery in Nakuru district, Kenya. Ophthalmology 2007;114:599-605. Mali. Ophthalmic Epidemiol 2000;7:271-83. 29. Mathenge W, Nkurikiye J, Limburg H, Kuper H. Rapid 35. He M, Xu J, Li S, Wu K, Munoz SR, Ellwein LB. Visual acuity assessment of avoidable blindness in Western Rwanda: and quality of life in patients with cataract in Doumen County, Blindness in a postconflict setting. PLoS Med 2007;4:e217. China. Ophthalmology 1999;106:1609-15. 30. Habiyakire C, Kabona G, Courtright P, Lewallen S. Rapid assessment of avoidable blindness and cataract surgical services in Kilimanjaro region, Tanzania. Ophthalmic Epidemiol 2010;17:90-4. Cite this article as: Kolawole OU, Ashaye AO, Mahmoud AO, Adeoti CO. 31. Haider S, Hussain A, Limburg H. Cataract blindness in Chakwal Cataract blindness in Osun state, Nigeria: Results of a survey. Middle East Afr J Ophthalmol 2012;19:364-71. district, Pakistan: Results of a survey. Ophthalmic Epidemiol 2003;10:249-58. Source of Support: Nil, Conflict of Interest: No.

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