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Outcomes of Pediatric Cataract Surgery at a Tertiary Care Center in Rural Southern Ethiopia

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Outcomes of Pediatric Cataract Surgery at a Tertiary Care Center in Rural Southern Ethiopia CLINICAL SCIENCES Outcomes of Pediatric Cataract Surgery at a Tertiary Care Center in Rural Southern Ethiopia Oren Tomkins, MD, PhD; Itay Ben-Zion, MD; Daniel B. Moore, MD; Eugene E. Helveston, MD Objective: To evaluate the etiologies, management, and (n=33), congenital glaucoma-related (n=3), partially ab- outcomes of pediatric cataracts in a rural sub-Saharan Afri- sorbed cataracts (n=3), and congenital rubella infec- can setting. tions (n=2). At presentation, visual acuity ranged from 6/60 to light perception, with 13 eyes (14%) having am- Methods: A retrospective, consecutive case series of pa- bulatory vision (better than hand motion). The mean post- tients presenting to a tertiary referral center in southern operative visual acuity was significantly improved, rang- Ethiopia during a 13-month period. All patients under- ing from light perception to 6/9. Seventy-five eyes (82%) went clinical examination, were diagnosed as having cata- achieved ambulatory vision. Of the 61 eyes with an im- ract on the basis of standard clinical assessment, and im- planted intraocular lens, 56 (92%) reached ambulatory mediately underwent surgical management. Visual acuity visual acuity following surgery. This was significantly results were grossly divided into ambulatory and non- greater than preoperative visual acuity results (PϽ.001). ambulatory vision according to patient age and coopera- tion. Conclusions: The underlying cause and management of pediatric cataracts in the developing world can differ sig- Results: Ninety-one eyes of 73 consecutive patients (57 nificantly from that commonly reported in the litera- boys and 16 girls) were included in the study. The mean ture. The effects of appropriate intervention on both vi- (SEM) age at diagnosis was 7.1(0.5) years (range, 0.5-15 sual outcome and associated survival statistics may be years). Fifty-five patients had unilateral cataract and 18 profound. had bilateral cataract. Cataracts were categorized accord- ing to the etiologic cause: congenital (n=50), traumatic Arch Ophthalmol. 2011;129(10):1293-1297 HERE ARE AN ESTIMATED 1.4 ficiency and measles should decrease, and million blind children cataract will likely become even more worldwide, with roughly prominent as a cause of blindness. 320 000 of affected individu- Cataract extraction has become the most als residing in sub-Saharan frequent pediatric intraocular surgery per- TAfrica.1 There is wide regional and socio- formed in the United States. Advances in economic variation in the etiology of child- pediatric cataract surgery instrumenta- hood blindness, but it is estimated that tion and technique have led to a signifi- worldwide 200 000 children are blind from cant decrease in complication rates.11,12 cataract, with an additional 20 000 to 40 000 Conversely, in developing countries, the born each year with congenital cataract.2 A delayed time to treatment as well as lim- VISION 2020 report3 estimated that 133 000 ited resources result in a poor outcome in cataract-blind children live in developing many cases.13 A significant number of chil- countries. The prevalence of cataract as a dren remain blind because of deprivation Author Affiliations: cause for severe visual impairment and amblyopia, surgical complications, and Department of Ophthalmology, blindness may reach more than 30% of cases limited rehabilitation.4,14 Bnai Zion Medical Center, in the developing world,3-9 and it is con- With a limited number of reported hos- Haifa, Israel (Drs Tomkins and sidered one of the most common causes of pital studies demonstrating surgical out- Ben-Zion); ORBIS International, avoidable and treatable blindness, follow- comes in pediatric cataract patients in New York, New York ing vitamin A deficiency, measles, and cor- Africa,15,16 we present a retrospective study (Drs Ben-Zion and Helveston); 1,10 and Department of neal scarring. With implemention of ba- of the outcome of consecutive pediatric Ophthalmology, University of sic preventative health care measures, such cataract operations, performed by a single Washington School of as immunization and nutritional supple- surgeon (I.B.-Z.), during a 13-month pe- Medicine, Seattle (Dr Moore). mentation, the prevalence of vitamin A de- riod at a tertiary care center in Ethiopia. ARCH OPHTHALMOL / VOL 129 (NO. 10), OCT 2011 WWW.ARCHOPHTHALMOL.COM 1293 ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 METHODS A B A retrospective study of all consecutive pediatric patients, younger than 15 years, who were diagnosed as having unilat- eral or bilateral cataract from July 31, 2007, through August 1, 2008, in rural southern Ethiopia was conducted at a single cen- ter at Hawassa University School of Medicine. The hospital is a referral center for an estimated population of 15 million people, with nearly half being children younger than 15 years. This work was part of the ORBIS International and Cyber-Sight project implementing pediatric ophthalmology services in Ethio- pia. The work was approved by the Hawassa University School C of Medicine ethics review board. All patients were diagnosed as having cataract on the basis of standard clinical assessment and criteria. Before surgery, written informed consent was given for each patient by an accompanying guardian. All patients un- derwent a full clinical eye examination of the anterior and pos- terior segments. When clinically possible, intraocular lens (IOL) power was estimated according to biometric measurements (axial D length and keratometry) based on the SRKII formula. In cases when it was not possible to obtain such measurements, fellow eye refraction was used to help determine the required IOL. Younger children underwent evaluation under anesthesia fol- lowed immediately by surgical treatment, whereas older chil- dren (Ͼ7 years) underwent a local anesthesia (LA) trial, and Figure 1. Late presentation of pediatric cataract. A, Traumatic cataract. when successful, surgery was performed under LA. Visual acu- B, Anterior dislocation of lens. Bilateral congenital cataract before (C) and after (D) surgery. ity (VA) was measured or estimated, depending on the pa- tient’s age and level of cooperation, with the aid of a translator for the tribal language. To facilitate comparing VA results among capsular cataract extraction or cataract aspiration was per- children of different ages, verbal skills, and cultural back- formed, and in 6 eyes, an intracapsular cataract extrac- ground, the VA results were recorded into 2 main categories: tion was performed. An IOL was implanted in 61 eyes (60 (1) ambulatory—VA at this level results in better than hand posterior chamber IOLs and 1 anterior chamber IOL; mean motion vision (including the ability to follow an object, fixate [range] power, 23 [17-27] diopters). Anterior vitrectomy and follow an object, and finger counting or better), and (2) was performed in 44 cases, 5 eyes underwent synechioly- nonambulatory VA—this was limited to hand motion or light sis, and in 4 cases a corneal or scleral tear was repaired. perception. Statistical analysis was performed using SPSS, version 13 (SPSS Following surgery, several complications were noted: Inc, Chicago, Illinois). All results are presented as mean SEM. 1 eye with a traumatic cataract developed IOL dislocation that required IOL repositioning, 2 eyes had secondary vi- sual axis opacities and underwent anterior vitrectomy, 1 RESULTS eye developed a significant anterior chamber reaction with a fibrinous membrane covering the IOL requiring ante- Ninety-one eyes of 73 consecutive patients (57 boys and rior vitrectomy and membrane peel, 3 eyes had a tran- 16 girls) were included in the study. The mean age at di- sient raise in intraocular pressure requiring topical medi- agnosis was 7.1(0.5) years (range, 0.5-15 years). Fifty- cation, and 2 eyes had choroidal effusions that were five patients had unilateral cataract and 18 had bilateral managed conservatively (Table). There was no statisti- cataract. cally significant difference in the complications rate be- Cataracts were categorized according to the etiologic tween patients who underwent surgery under general an- cause: congenital (n=50), traumatic (n=33), congenital esthesia and those who did so under LA. No cases of retinal glaucoma-related (n=3), partially absorbed cataracts (n=3), detachment or endophthalmitis were noted during the fol- and congenital rubella infections (n=2) (Figure 1). Pa- low-up period. tients presenting subsequent to trauma all had unilateral Mean follow-up time was 7.8(0.4) months (range, 2-13 cataract and were generally older than those presenting months), and all patients attended at least 3 follow-up ex- with idiopathic cataract (8.4[0.7] vs 6.1[0.7] years; P=.04, aminations (1 day, 1 week, and 1 month after the opera- t test). tion). The mean postsurgical uncorrected VA was signifi- At presentation, uncorrected VA ranged from 6/60 to cantly improved, ranging from light perception to 6/9 light perception, with 13 eyes (14%) having ambulatory (Figure 2B). Seventy-five eyes (82%) achieved ambula- vision (better than hand motion) (Figure 2A). Of the tory vision (Figure 2C). Of the 61 eyes with an implanted 18 patients with bilateral cataract, 12 had nystagmus on IOL, 56 (92%) reached ambulatory VA following surgery presentation. (Figure 2C, inset). This was significantly greater than pre- All patients underwent cataract extraction surgery. Fifty- surgical VA results (PϽ.001, ␹2 test). This improvement five operations were performed under general anesthesia was maintained also among the bilateral cataract subpopu- and 36 with LA. Patients who had operations under LA lation (PϽ.001, ␹2 test). There was no significant differ- were older than those who had general anesthesia (10.1[0.6] ence in VA results between unilateral congenital and trau- vs 4.9[0.5] years; PϽ.001, t test). In 85 eyes, an extra- matic cases. Among verbal bilateral cataract patients ARCH OPHTHALMOL / VOL 129 (NO. 10), OCT 2011 WWW.ARCHOPHTHALMOL.COM 1294 ©2011 American Medical Association.
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