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Blindness and Cataract in Children in Developing Countries

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Blindness and Cataract in Children in Developing Countries CHILDHOOD BLINDNESS Blindness and cataract 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, Visual impairment 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 leukocoria using the red 1 of them. Various studies across the globe 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 cataracts. 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 sclera 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 lens nition and subsequent surgery can lead to Young boy with cataract blindness. (IOL) implantation is safe and effective amblyopia 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 congenital cataract) • 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
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