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Home , Childhood cataract

Blindness and in children in developing countries

order to increase the chances of finding 8th General Assembly of IAPB Developing programmes blind children. These methods include Course 2: Congenital and developmental examining children in anganwandis to control blindness and cataract (kindergartens), schools, vision centres, cataract in children Speakers: Paul Courtright, Parikshit Gogate, paediatric eye care centres, and during Kuldeep Dole, Mohammad Muhit, Khumbo Kalua, in children can have an special outreach initiatives such as Andrea Zin, Elizabeth Kishiki, Rohit C Khanna impact on their performance at school, as sarva siksha abhiyan (‘education for all’). well as their social interaction and devel- Session: Childhood blindness The ‘key informant’ method is another opment. Promoting eye health in children Speakers: Pablo Cibils, Mohammad Muhit, means of finding blind children. and ensuring early detection of visual Anna Rius, Deepti Bajaj, Marcela Frazier, impairment is an important part of general M Alamgir Hossain The key informant method eye health and child health strategies. This novel method of obtaining population- Since the launch of VISION 2020, Report by: based data on childhood blindness has various programmes have been developed Parikshit Gogate been piloted in Bangladesh, Ghana, Malawi, in resource-poor countries to control Head, Department of Paediatric Ophthal- 3,4,5,6 mology, Community Eye Care, HV Desai and Iran. blindness and cataract in children. Eye Hospital, Pune 411 028, India. A study in Bangladesh, in which over Speakers presented a selection of pilot or Email: [email protected] 75,000 children were screened, compared established programmes in Latin America the key informant and the house-to-house and Asia. Mohammad Muhit methods. It showed that key informants Clinical Research Fellow, International were able to identify almost two-thirds of all Latin America Centre for Eye Health, London School of Hygiene and Tropical Medicine, blind children in the study population, and Vision screening in children is gaining Keppel Street, London WC1E 7HT, UK. that this required only one-sixth of the time popularity in many low- and middle-income and one-sixth of the human resources, countries, although there is very limited data Blindness in children is considered a priority compared to a house-to-house survey. available on its effectiveness and impact. area for VISION 2020, as visually impaired Causes of blindness in children found with both In Brazil, paediatricians have been children have a lifetime of blindness ahead methods were also comparable. enlisted to identify using the red 1 of them. Various studies across the In densely populated Bangladesh, where reflex test. This approach, described by show that one-third to half of childhood community network structures are well Andrea Zin, has been successful because in 1 blindness is either preventable or treatable developed, the key informant approach has this middle-income country most births are and that cataract is the leading treatable shown that there are thousands of children institutionalised and almost all children are 2 cause of blindness in children. with unoperated . This approach seen in their infancy by a paediatrician. th The 8 General Assembly of the International has also been successful in countries that Anna Rius presented a pilot project in Agency for the Prevention of Blindness (IAPB) are less densely populated, such as Ghana Nicaragua and El Salvador, which was provided an opportunity to be acquainted with and Malawi.4,5 undertaken to develop and utilise campaign recent research and programme development The key informant method provides a and educational materials in order to train work in the prevention of childhood blindness. way to conduct large-scale population-based and sensitise schoolteachers and nurses on studies on childhood blindness in resource- children’s eye health. The project showed Obtaining population-based poor countries, in order to obtain valid data that locally developed or adapted training data on childhood blindness on prevalence and causes, which can then and campaign materials can contribute be used to plan programmes and policies. effectively to a sustainable programme for Population-based data on childhood This method is quick, cost-effective, and the promotion of child eye health. blindness are required in order to plan control involves community participation. All the Another pilot study, in Nicaragua, strategies, but they are difficult to obtain: other methods listed above have not proved trained teachers and volunteer nurses to • As childhood blindness is ten times rarer so useful to detect children with cataract, screen the vision of schoolchildren. than blindness in adults, population-based with the exception of the sarva siksha abhiyan Marcela Frazier presented a study of its surveys require a very large sample size. scheme, which also uses schoolteachers long-term outcome. During the pilot • Examining blind children in a field study and health care workers as informants. project, 5,673 children were screened by requires special expertise, nurses and schoolteachers, a trained field team, and 376 of whom were then special equipment. referred to an optometrist; • Visual acuity measurement 96 required and received is difficult in very young new spectacles. A year later, the follow-up study retraced

children and involves Child Sight Foundation special test materials 51 of those 96 children on a or charts. randomly selected day and • In many communities, blind found that only ten were children are hidden wearing their spectacles. because of stigma. Further research is needed to determine whether additional Methods used for identifying education or other factors blind children generally target can improve compliance with Finding blind children from the specific locations where spectacle wearing among community. BANGLADESH children may be found, in schoolchildren.

4 COMMUNIty EyE HEALtH JOURNAL | VOL 22 ISSUE 69 | MARCH 2009 Surgical management of childhood cataract

Childhood cataract, congenital or develop- Surgery mental, can be readily treated. However, Paediatric cataract surgery is just one the surgical management of cataract in intervention in a series of steps needed to children is different from that of adults and restore the child’s vision. The surgery is the postoperative follow-up takes longer challenging because the is less rigid and is more complex. and the anterior capsule is elastic. It may be complicated by intraocular haemorrhage early recognition of childhood or posterior capsule rupture. cataract Early treatment is crucial. Delays in recog- • It is widely accepted that cataract extraction with primary intraocular nition and subsequent surgery can lead to young boy with cataract blindness. (IOL) implantation is safe and effective later in life. A Tanzanian study BANGLADESH showed that there was an 18-month delay when performed in children over the age between recognition of cataract and surgery.1 of two by a specialised paediatric surgeon.* • Three-monthly review is recommended Barriers to early catatact surgery in • IOLs may be implanted earlier for during the first year and an annual review children include: unilateral cataracts, to reduce the thereafter. likelihood of amblyopia. Child Sight Foundation • Lack of awareness amongst parents, • As the nucleus is invariably soft, the cataract Counselling parents especially in rural settings. can be aspirated using a Simcoe cannula Counselling parents at various stages of • Asymptomatic children who regard their or an automated irrigation/aspiration probe. care for paediatric cataract should be an poor vision as ‘normal’. • A primary posterior capsulotomy with integral part of the service. • Lack of paediatric or anaesthetic services anterior vitrectomy is essential up to the Parents should be made aware of the in the region. age of six and may be necessary in older importance of postoperative care and of 2 • Cost of surgery. children if no follow-up is available. refraction before and after surgery. Using • Lack of awareness amongst general • In-the-bag placement of the IOL is crucial key informants, not only for detection, but practitioners, paediatricians, and even to prevent decentration and capture. also to encourage and motivate parents to ophthalmologists, which means that parents • The wound must always be sutured, even comply with long-term and regular follow-up, may be wrongly advised to ‘wait’ until the if it is a 2 mm sideport. has also been very successful in a large- child is older. scale programme in Bangladesh. • Fear of surgery amongst parents, due to Postoperative care concern about the risk of anaesthesia or References Postoperative care and follow-up is extremely 1 Mwende J, Bronsard A, Mosha M, Bowman R, Geneau the experience of poor results in other R, Courtright P. Delay in presentation to hospital for important – at least as important as the operated children. surgery for congenital and developmental cataract in surgery itself. Tanzania. Br J Ophthalmol 2005;89: 1478–1482. • A belief amongst parents that congenital 2 Ericksen JR, Bronsard A, Mosha M, Carmichael D, Hall blindness (including ) • Postoperative inflammation and posterior A, Courtright P. Predictors of poor follow-up in children is simply not treatable. capsular opacification are very common. that had cataract surgery. Ophthalmic Epidemiol 2006;13(4): 237–243. Steroid antibiotic drops are required post- Preoperative evaluation operatively for up to two months, in addition *Note from the Editors It should include: A forthcoming study by the British Isles Congenital Cataract to a cycloplegic for the first two weeks. Interest Group (BCCIG) has shown that primary IOL implan- • visual acuity Oral steroids may be required for the first tation in children under the age of two has been widely • intraocular pressure week. An early Nd YAG laser capsulotomy adopted among the relatively small number of paediatric ophthalmologists who manage these children in the UK • keratometry can be performed in older children. and Ireland. There is concordance in practice with regards • biometry (under general anaesthetic • An accurate refractive correction must be to surgical technique, choice of IOL model, and choice of if necessary) given at first follow-up and amblyopia power calculation formula. However, variation exists in eligibility criteria. A national study is now underway through • external ocular and fundus examination therapy started in the form of patching the BCCIG to systematically measure the outcomes and • B-scan for opaque media (to rule out the good eye. School-age children need predictors of outcomes of primary IOL implantation in ocular morbidity, such as microphthalmos, a -split bifocal to take care of their children under the age of two. Lola Solebo A, Russell-Eggitt I, Nischal KN, Moore AT, Rahi JS, on behalf of the British coloboma, primary persistent hyperplasic near tasks, but younger children can Isles Congenital Cataract Interest Group (BCCIG). vitreous, , or tumour). simply be overcorrected for near. Forthcoming paper.

India Bangladesh to halve the prevalence of childhood Deepti Bajaj presented the childhood MA Hossain described the large-scale blindness and to eliminate cataract blindness programme in India which was programme developed by Sightsavers and blindness in children. initiated by ORBIS to support the Indian ORBIS to control cataract blindness in children References government’s goal to create 50 paediatric in Bangladesh. Since its launch in 2004, a 1 Rahi JS, Gilbert CE, Foster A, Minassian D. Measuring eye care centres by 2010. Strategies total of 6,562 children with cataract have the burden of childhood blindness. Br J Ophthalmol included: creating a child-friendly 1999;83: 387–388. been identified and 90% of them have 2 Gilbert C, Muhit M. Twenty years of childhood environment in eye care facilities, training received sight-restoring surgery. blindness: what have we learnt? Community Eye Health paediatric eye care teams, supplying appro- J 2008;21(67): 46–7. 3 Muhit MA, Shah SP, Gilbert CE, Hartley SD, Foster A. priate technology and essential equipment The key informant method: a novel means of ascer- for paediatric eye care, empowering local Conclusion taining blind children in Bangladesh. Br J Ophthalmol communities in case detection, and Blindness and cataract in children remain a 2007;91: 995–999. major challenge in resource-poor countries. 4 Boye J. Validating the key informant method in educating parents on childhood eye detecting blind children in Ghana. Community Eye diseases and their prevention. Significant work has been done to tackle Health J 2005;18(56): 131. this problem in terms of research and 5 Kalua K, Patel D, Muhit M, Courtright P. Causes of Between 2002 and 2008, ORBIS worked blindness among children identified through village key with 24 eye care partners to establish programme development. We now need to informants in Malawi. Can J Ophthalmol 2008;43(4): paediatric eye care centres in India, which use the expertise and knowledge gained to 425–7. develop larger and better programmes to 6 Razavi H. Childhood blindness: piloting the key will have a long-term impact on reducing informant method in Lorestan Province, Iran avoidable blindness in children. achieve the target of VISION 2020, which is Community Eye Health J 2008;21(68): 65.

Copyright © 2009 Parikshit Gogate and Mohammad Muhit. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.