Outcomes of Bilateral Cataract Surgery in Tanzanian Children

The outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa: a systematic review

IMPORTANCE

Cataract is one of the leading causes of childhood blindness in Africa. The management of this condition requires timely surgical extraction of the cataractous lens with immediate optical correction and long-term follow-up to monitor visual improvement and manage complications that may arise. This review provides an opportunity to benchmark outcomes and to shed light on the reasons for those outcomes.

OBJECTIVES

To review the published literature and report on the outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa.

DATA SOURCE

The EMBASE, PubMed, Scopus, and Web of Science were searched for relevant articles.

STUDY SELECTION

We included all published primary studies from sub-Saharan Africa on cataract surgery outcomes in children aged 0-16 years with primary intraocular lens implantation conducted between 1990 and 2020. Eligible studies were those published in English or for which an English translation was available. In addition, reviewers screened the reference lists of all studies included in the full-text review for eligible studies. During the review, studies fitting the inclusion criteria above except for having been conducted in middle and high-income countries were tagged and placed in a comparison arm.

DATA EXTRACTION AND SYNTHESIS

Study eligibility was determined by two independent reviewers, and data extraction was conducted by one reviewer with entries checked for accuracy by another reviewer. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for data synthesis were followed. The Joanna Briggs Institute (JBI) critical appraisal checklist was used for quality appraisal of the studies. The statistical software R was used in the analysis, and data were pooled using a random-effects model. Forest plots were generated using the R package 'metafor'.

MAIN OUTCOMES AND MEASURES

The primary outcome was visual acuity (VA) after cataract surgery and the proportions of eyes that achieved good, borderline, or poor visual outcome according to the World Health Organisation (WHO) categorisation of post-operative visual acuity. The secondary outcome measures reported included lag time to surgery, rates of follow-up, and rate of complications.

RESULTS

Eight out of 4763 studies were eligible for inclusion in this review, and seven were included in the quantitative analysis. There was a male preponderance in the study population, and the mean age at the time of cataract surgery ranged from 3.4 to 8.4 years. Visual outcomes were available for short-term visual outcomes (1 to 6 months) as the studies had a significant loss to follow-up. The pooled proportion of eyes that achieved a good visual acuity (i.e. equal to or greater than 6/18) in the short-term period was 31% (CI, 20-42). The comparative studies from middle and high-income countries reported proportions ranging from 41 to 91%, with higher thresholds for good visual acuity of 6/12 and 6/15.

CONCLUSION AND RELEVANCE

This review reports that there is a lower proportion of eyes with good outcomes after undergoing paediatric cataract surgery in sub-Saharan Africa than in middle- and high-income countries. Furthermore, this review states that there is a high proportion of patients lost to follow-up and suboptimal refractive correction and amblyopia treatment after paediatric cataract surgery.

Surgical Outcomes of Lensectomy-Vitrectomy with Primary Intraocular Lens Implantation in Children with Bilateral Congenital Cataracts

In this study, we evaluated the long-term surgical outcomes of lensectomy-vitrectomy with primary intraocular lens (IOL) implantation in children with bilateral congenital cataracts (CCs) and investigated the potential risk factors for low vision. A total of 148 eyes in 74 children who underwent lensectomy-vitrectomy with primary IOL implantation were enrolled in this study. The surgery age was 44.04 ± 14.60 months, with a follow-up period of 46.66 ± 14.34 months. The final BCVA was 0.24 ± 0.32 logMAR, and low vision was found in 22 eyes (14.9%). Postoperative complications requiring additional surgeries included VAO (4 eyes, 5.4%), IOL pupillary captures (2 eyes, 2.0%), iris incarceration (1 eye, 0.7%), and glaucoma (1 eye, 0.7%). A higher incidence of VAO and larger postoperative refractive error was observed in younger children (≤2 years old) than in elder children (>2 years old) (p = 0.003, p = 0.047, respectively). Final BCVA was affected by preexisting comorbidity (p < 0.001), cataract density (p < 0.001), cataract size (p = 0.020), occurrence of postoperative complications (p = 0.011), and ASE (p = 0.008). Multivariate analysis showed that denser cataracts (OR = 9.303, p = 0.035) and preexisting comorbidity (OR = 4.712, p = 0.004) were the significant predictors of low vision. In conclusion, lensectomy-vitrectomy with primary IOL implantation is an effective and safe treatment for CC. The long-term visual outcome is encouraging in children with bilateral CC undergoing this procedure with a low rate of postoperative complications requiring surgeries. Moreover, eyes with denser cataracts and preexisting comorbidity may have a high risk of low vision.

Universal newborn eye screening: a systematic review of the literature and review of international guidelines

Background

This systematic review assessed the effectiveness of universal screening for newborn eye abnormalities compared with no screening in improving infant vision and health outcomes.

Methods

We searched CENTRAL (Cochrane Library), MEDLINE, Embase, Global Health, Global Index Medicus, clinical trials databases, and bibliographies of relevant articles. We included randomized and observational studies of all newborns, regardless of illness or risk factors, that compared universal screening for any eye abnormality by eight weeks of age with no universal screening. Two authors independently selected studies, extracted data, and evaluated the risk of bias. We used GRADE to assess the certainty of evidence. We also reviewed available recommendations on newborn eye screening.

Results

Fourteen studies were identified but only three compared universal red reflex screening with no screening. Findings suggest that universal red reflex testing in maternity wards (MWs) may increase the number of newborns with congenital cataracts referred for eye care from MWs or well-baby clinics (WBCs) in the first year of life (risk ratio (RR) = 9.83, 95% confidence interval (CI) = 1.36-71.20; low certainty evidence). However, the effect of screening in WBC is uncertain (RR = 6.62, 95% CI = 0.87-50.09). The effect of MW or WBC screening on referral from any health care facility (MWs, WBCs, paediatrician clinic, other) in the first year is uncertain (MW screening: RR = 1.22, 95% CI = 0.63-2.39; WBC screening: RR = 0.97, 95% CI = 0.46-2.05). However, referral or surgery by 6 weeks of age may be higher with universal MW screening (early referral: RR = 4.61, 95% CI = 1.12-19.01; early surgery: RR = 8.23, 95% CI = 1.13-59.80; low certainty evidence). The effect of WBC screening on early referral and surgery is uncertain (early referral: RR = 1.98, 95% CI = 0.43-9.19; early surgery: RR = 3.97, 95% CI = 0.50-31.33; very low certainty evidence). Universal red reflex testing may increase clinical conjunctivitis (OR = 1.22, 95% CI = 1.01-1.47; low certainty evidence) but the effect on confirmed bacterial conjunctivitis is uncertain (OR = 1.20, 95% CI = 0.76-1.90; very low-certainty evidence). Nine guidelines recommended universal newborn eye screening using red reflex testing.

Conclusions

Evidence supports the role of red reflex testing shortly after birth to increase early identification, referral, and surgery for congenital cataracts.

Prevalence and Factors Related to Visual Impairments in Children With Bilateral Cataract Following Surgery and the Potential Need for Education and Rehabilitation Services

Introduction

Pediatric cataract is still a major cause for childhood visual impairment. The goal of our study was to analyze the prevalence of children with impaired vision (6/15 or worse) after surgery for bilateral cataract, to evaluate factors associated with it and to emphasize the importance for visual rehabilitation including the use of visual aids, educational measures, and social worker services.

Methods

Retrospective analysis of medical records from children who underwent surgery for cataract up to age 6 years, with a follow-up of at least 4 years. Clinical characteristics retrieved from medical records included visual acuity, presence of nystagmus and/or strabismus, age at surgery, intraocular lens (IOL) implantation, and others.

Results

Fifty-five children were included in the study. Follow-up ranged from 4 to 13 years (Mdn = 6.8). Visual impairment was found in 15/24 (62.5%) of children operated on before the age of 6 months (group 1), and in 7/31 (22.5%) n those operated after the age of 6 months (group 2; p = .019). Thirty-eight of the 55 children had a primary IOL implantation; nystagmus and microphthalmos were also associated with higher rates of visual impairment.

Discussion

Despite early and modern surgery, long-term visual outcome remains poor in children undergoing bilateral cataract surgery at young age. When discussing visual prognosis with parents, it is important to recognize factors associated with visual impairment, such as need for surgery before age 6 months, nystagmus and microphthalmos, as well as the importance for early visual rehabilitation services when needed.

Implications for Practitioners

Our study aims to highlight the high number of children left with visual impairment and blindness following modern and timely treatment for early cataract. Early referral for visual rehabilitation will optimize quality of life in these children and will probably allow a wider range of opportunities as adults.

Limitations in cataract surgical services for children in Ethiopia: a nationwide survey of pediatric cataract surgeons

Background

Bilateral cataract is a significant cause of blindness in children in Ethiopia. This study aimed to identify the resources available for cataract surgery in children, and to assess current surgical practices, surgical output and factors affecting the outcome of surgery in Ethiopia.

Methods

A Google Forms mobile phone questionnaire was emailed to nine ophthalmologists known to perform cataract surgery in young children (0–5 years).

Results

All nine responded. All but one had received either 12- or 3–5-month’s training in pediatric ophthalmology with hands-on surgical training. The other surgeon had received informal training from an experienced colleague and visiting ophthalmologists. The surgeons were based in seven health facilities: five in the capital (Addis Ababa) and eight in six public referral hospitals and one private center.

Over 12 months (2017–2018) 508 children (592 eyes) aged 0–18 years (most < 15 years) were operated by these surgeons. 84 (17%) had bilateral cataract, and 424 (83%) had unilateral cataract mainly following trauma. A mean of 66 (range 18–145) eyes were operated per surgeon. Seventy-one additional children aged > 5 years were operated by other surgeons. There were substantially fewer surgeons per million population (nine for 115 million population) than recommended by the World Health Organization and they were unevenly distributed across the country.

Methylcellulose and rigid intraocular lenses were generally available but less than 50% of facilities had a sharp vitrectomy cutter and cohesive viscoelastic. Mean travel time outside Addis Ababa to a facility offering pediatric cataract surgery was 10 h.

Conclusion

Despite the high number of cases per surgeon, the output for bilateral cataracts was far lower than required. More well-equipped pediatric ophthalmology teams are urgently required, with deployment to under-served areas.

Tribal Odisha Eye Disease Study (TOES). Report # 8. Childhood cataract surgery and determinants of visual outcome in tribal districts

Purpose

The purpose of this study is to describe the demographic profile, clinical features, visual outcomes, and follow-up patterns after successful cataract surgery in children from the tribal community in Odisha, India.

Methods

We retrospectively reviewed records of tribal children aged 4 months-16 years, who underwent public health financed cataract surgery at our institute from January 1, 2015, to December 31, 2019. Collected data included demographic profile, clinical features, outcomes, and follow-up. Univariate and multivariate linear regression identified factors affecting the visual outcome at a 6-week follow-up.

Results

During this period, a total of 352 children [536 eyes; mean age: 9.11 ± 4.4 years, 219 boys (62%)] underwent cataract surgery. The most common etiology and presenting complaints were idiopathic congenital cataract and decreased vision, respectively. In 304 children (86%), presenting best-corrected visual acuity (BCVA) was <20/200 (1.0 LogMAR), 113 (32%) had associated strabismus, and 57 (16%) had associated nystagmus. The public health agency did not sponsor postoperative follow-up, and only 195 (56%) and 61 (17.3%) children completed a 6-week and a 3-month follow-up, respectively. Median BCVA at 6-week and 3-month review was 20/125 (0.8, interquartile range [IQR], 0.2-2 LogMAR) and 20/60 (0.5, IQR, 0.25-1.35 LogMAR), respectively.

Conclusion

This study showed that children from the tribal community presented late with poor presenting VA and had suboptimal visual outcomes with inconsistent follow-ups. Greater advocacy, delivery of care closer to the place of residence, and financial support for follow-up care could improve early detection, regular evaluation, and outcomes.

Bilateral paediatric cataract surgery - outcomes of 298 children from Kinshasa, the Democratic Republic of the Congo

INTRODUCTION

The leading cause of childhood blindness globally is paediatric cataract. Bilateral cataract surgery can help to improve visual performance and to diminish the burden of childhood blindness.

OBJECTIVE

To report in a retrospective observational cohort study the long-term outcomes of 298 children who had bilateral cataract surgery with IOL implantation from 2001-2016 in Kinshasa.

METHODS

A standardized surgical treatment of paediatric cataract was practiced on 298 children. Patient's follow-up, complications, and visual outcomes were recorded and analysed.

RESULTS

The mean age was 5.7 ± 4.3 years and males were predominant (64.9%). Most of children were living mainly in urban poorest areas (96.3%). Strabismus, nystagmus and microcornea were encountered in 20.1%, 25.1% and 8.7% of children, respectively. Using WHO criteria most of patients were classified as blind preoperatively and 81.9% of them had improved visual outcomes after surgery. Main reasons for reduced vision during follow-up were secondary cataract (5.7%), IOL decentration (1.2%), retinal detachment (1.2%), and secondary glaucoma (1.5%).

CONCLUSION

In spite of the post conflict challenges, elimination of cataract blindness in children remains a priority. Children present at a late age for surgery and long term follow-up is poor. There is need for program strengthening in these areas.

Red reflex examination in reproductive and child health clinics for early detection of paediatric cataract and ocular media disorders: cross-sectional diagnostic accuracy and feasibility studies from Kilimanjaro, Tanzania

BACKGROUND/OBJECTIVES

Late presentation of congenital cataract in the developing world has led to poor outcomes such that cataract is the leading cause of childhood blindness. Our hypothesis was that, sensitivity of red-reflex testing is greater than sensitivity of torchlight examination. We aimed to compare sensitivity of new red reflex screening tools and assess the feasibility of Arclight red reflex screening in the community.

SUBJECT/METHODS

We compared the diagnostic accuracy of four different screening tools for cataract and retinoblastoma performed by ophthalmic nurses, using a clinic based enriched sample of 41 positives and 60 negatives. We then conducted a separate feasibility study, training non-specialist community nurses. Following the training, community nurses examined 2827 children <5 years with Arclight who were attending their clinics for growth monitoring and immunisation.

FINDINGS

Diagnostic accuracy study: estimated sensitivities were 97.6% for Catcam, 92.7% for Arclight, 90.2% for PEEK retina and 7.3% for torchlight. Estimated specificities were above 90% for Catcam, Arclight and torchlight and 87% for PEEK retina. Feasibility study: twenty-four out of 2728 children screened failed community screening, seven were true positive (six cataract, one retinoblastoma). Prevalence of bilateral cataract was 1.5/1000 (95% CI: 0.40-3.75 per 1000).

CONCLUSIONS

Arclight and CatCam have higher sensitivity than torchlight, are easy to learn and use by primary health care nurses. Red reflex testing should be recommended in the WHO guidelines instead of torchlight examination to help early detection of potential blinding causes including congenital cataract and retinoblastoma.

Presentation, surgery and 1-year outcomes of childhood cataract surgery in Tanzania

Background

Recent reports have suggested a significant change in the causes of blindness in children in low-income countries cataract becoming the leading cause. We aimed to investigate the presentations and surgical outcomes in children with cataract operated at different ages in Tanzania.

Methods

We conducted a prospective study of 228 children aged ≤192 months at three tertiary centres, 177 with bilateral cataracts and prospectively followed them for 1-year postsurgery. We collected demographic, surgical, preoperative and postoperative clinical characteristics using the standard childhood cataract surgical assessment questionnaire. Families were encouraged to return for follow-up by phone with travel reimbursement where necessary.

Results

Preoperatively, 76% bilateral children were blind in the better eye. 86% of children were followed up at 1 year and 54% bilateral children achieved visual acuity of 0.48 logMAR or better in the better eye and 5% were blind. 33% of unilateral children achieved visual acuity of 0.48 logMAR or better and 17% were blind. Preoperative blindness (adjusted OR (AOR) 14.65; 95% CI 2.21 to 97.20), preoperative nystagmus/strabismus (AOR 9.22; 95% CI 2.66 to 31.97) and aphakia (AOR, 5.32; 95% CI 1.05 to 26.97) predicted poor visual outcome in bilateral cases. 9% of 342 refracted eyes had initial postoperative cylinder of 1.5 D or more, as did a similar proportion (11%) of 315 eyes refracted 1 year after surgery. Acute fibrinous uveitis occurred in 41 (12%) eyes.

Conclusion

Three-quarters of children were blind preoperatively whereas over half had good vision 1-year postoperatively. Preoperative blindness, nystagmus/strabismus and aphakia predicted poor visual outcome, suggesting that cataract density determines density of amblyopia.

Causes of delayed presentation of pediatric cataract: A questionnaire-based prospective study at a tertiary eye care center in central rural India

Purpose

To find out the sociodemographic, sociocultural, and socioeconomic factors leading to delay in pediatric cataract surgery and its impact on final visual outcome.

Methods

A prospective interview-based analytical cohort study was conducted on 156 children aged 0-16 years with either unilateral or bilateral congenital/developmental cataracts. Caregivers were interviewed using a pretested validated questionnaire. Time intervals between recognition by a caregiver to consultation were denoted as Delay-1 and between consultations to surgical intervention as Delay-2. Spearman's rank correlation was used to determine the presence of correlation between causes of delay and visual outcome.

Results

The mean age of presentation was 7.78 ± 4.34 years. Mothers were the first informant of the problem (n = 110, 70.5%). Out of 156 children, only 8 (5.1%) children presented to the hospital within 1 month by caregivers and 26 (16.7%) children underwent surgery within 2 months of advice. About 22 (14.1%) children had total cumulative delay of 1-6 months, 11 (7%) had delay of 6-12 months, and 115 (73.71%) had delay of >12 months. The most common cause identified for Delay-1 was unawareness in 41 cases (26.28%), however, for Delay-2 major factor responsible was cost (n = 38, 24.35%). The median preoperative visual acuity was 1.31 logMAR and median postoperative visual acuity at 4 weeks was 0.61 logMAR. (P < 0.001) Less age at surgery, upper socioeconomic status, less time delay, and better preoperative vision were positively correlated to better visual outcomes.

Conclusion

Delay in presentation for childhood cataract surgery remains a significant problem in central rural India. Delay in surgery is multifactorial which includes unawareness, cost, misdiagnosis, self-treatment, distance from the hospital, lack of family support, and poor socioeconomic status.

Accuracy of 8 intraocular lens power calculation formulas in pediatric cataract patients

PURPOSE

To compare the accuracy of the eight formulas for intraocular lens (IOL) power calculation in pediatric cataract patients.

METHODS

A retrospective study. A total of 68 eyes (68 patients) that underwent uneventful cataract surgery and posterior chamber IOL implantation in the capsular bag were enrolled. We compared the calculation accuracy of the 8 formulas at 1 month postoperatively and performed subgroup analysis according to age or axial length (AL).

RESULTS

The mean age at surgery was 34.07 ± 24.60 months and mean AL was 21.12 ± 1.42 mm. The mean prediction errors (PE) of eight formulas for all patients were as follows: SRK II (- 0.66), SRK/T (- 0.44), Holladay 1 (- 0.36), Hoffer Q (- 0.09), Olsen (0.71), Barrett (0.37), Holladay 2 (- 0.70), and Haigis (0.50). There was significant difference among the 8 formulas (p < 0.0001), while no significant difference of absolute PE was found among the 8 formulas in all patients (p = 0.053). Moreover, in patients younger than 2 years old or with AL ≤ 21 mm, SRK/T formula was relatively accurate in 34% and 39% of eyes, respectively. While in patients older than 2 or with AL > 21 mm, Barrett and Haigis formulas were better (58% and 47% for Barrett, 52% and 53% for Haigis).

CONCLUSION

Overall, in patients younger than 2 years old or with AL ≤ 21 mm, SRK/T formulas were relatively accurate, while Barrett and Haigis formulas were better in patients older than 2 or with AL > 21 mm.

Establishing a Pediatric Ophthalmology Service in Malawi: Developments in Childhood Cataract Surgery

PURPOSE:

The purpose of this study is to report on the establishment of a Pediatric Ophthalmology Service for Malawi using childhood cataract surgery as a surrogate measure of its effectiveness.

MATERIALS AND METHODS:

A retrospective review of pediatric cataract surgery at Lions Sight First Eye Hospital, Blantyre, between 2011 and 2016. The paucity of comprehensive records allowed for the sampling of a maximum of 25 cases/year (n = 150) for comparison. Theatre records and population statistics were used to calculate childhood cataract surgical rates (CCSR).

RESULTS:

A total of 949 cataract operations were performed during the six years studied – 55.8% of these were boys. The number of operations per year remained generally stable. Of the 150 cases reviewed, the mean age at presentation was 6.01 years, with a trend toward a slightly younger age over the period. Over the years studied, the geographical distribution of referrals became more reflective of the population's distribution. Where the logarithm of the minimum angle of resolution (LogMAR) visions were available, these demonstrated a mean improvement from 2.008 (n = 43) preoperatively to 0.613 (n = 51) postoperatively. The mean follow-up was 106 days (0 days–3.25 years). Complication rates were low. The CCSR was 9.2/million population.

CONCLUSIONS:

A Pediatric Ophthalmology Service has been established in Malawi delivering safe, effective surgery on a country-wide scale for childhood cataract. Over the period studied, the age at presentation reduced, and there was an improvement in the geographical distribution of patients, likely due to an improvement in referral systems throughout Malawi.

Migration to aphakia and contact lens treatment is the trend in the management of unilateral congenital cataract in Britain and Ireland

BACKGROUND

The Infant Aphakia Treatment Study (IATS) compared the treatment of unilateral cataract in infants aged 1-6 months with primary intraocular lens (IOL) implantation vs aphakia with contact lens (CL) correction.

AIMS

This study aims to assess the current trends in the treatment of unilateral congenital cataract in infants less than 6 months at surgery in the UK and Ireland.

METHODS

An anonymous survey was emailed to the 200 members of the BIPOSA mailing list with 14 questions to assess treatment choice (primary intraocular lens (IOL) vs aphakia with contact lens (CL)), reasons for this choice, and assessment of local CL services.

RESULTS

There were 56 respondents, 39 of whom completed the entire survey. Aphakia with CL was the treatment choice for 74.4% of respondents. A quarter (25.6%) of respondents said they were performing primary IOL implantation prior to the publication of the Infant Aphakia Treatment Study (IATS), but now choose aphakia with CL. Amongst the 20.5% (n = 8) of respondents who chose primary IOL implantation, 5 attributed their choice to "inadequate CL service". The majority (84.6%) of respondents rated their infant CL service as either "good" or "very good".

CONCLUSION

Aphakia with CL rehabilitation was the most common approach to the treatment of unilateral congenital cataract in infants less than 6 months in this study. The results of the IATS appear to have influenced a change in practice from primary IOL implantation to aphakia and CL visual rehabilitation in approximately one quarter of those surveyed.

Five-Year Postoperative Outcomes of Bilateral Aphakia and Pseudophakia in Children up to 2 Years of Age: A Randomized Clinical Trial

PURPOSE

Comparative evaluation of complications and visual outcomes following bilateral congenital cataract surgery in children up to 2 years of age with and without primary intraocular lens (IOL) implantation at 5 years follow-up.

DESIGN

Randomized controlled clinical trial.

METHODS

Sixty children (120 eyes) up to 2 years of age undergoing bilateral congenital cataract surgery were randomized to Group 1, primary aphakia (n = 30), or Group 2, primary IOL implantation (pseudophakia) (n = 30). A single surgeon performed surgeries with identical surgical technique. All patients were followed up regularly until 5 years postoperatively. At each follow-up, glaucoma, visual axis obscuration (VAO) requiring surgery, and inflammation (cell deposits, posterior synechiae) were assessed. Visual acuity was assessed until 5 years follow-up. The first operated eye was selected for statistical analysis.

RESULTS

Median age of the patients at time of surgery was 5.11 months (aphakia group) and 6.01 months (pseudophakia group) (P = .56). Five years postoperatively, incidence of glaucoma was 16% and 13.8% in Groups 1 and 2 (P = .82). Incidence of posterior synechiae was significantly higher in the pseudophakia group (27.6%) compared to the aphakia group (8%) (P = .004). VAO requiring surgery was seen in 8% and 10.3% of eyes in Groups 1 and 2 (P = .76). Mean logMAR visual acuity at 5 years follow-up was 0.59 ± 0.33 and 0.5 ± 0.23 in Groups 1 and 2, respectively (P = .79). However, more eyes in the pseudophakic group started giving documentable vision earlier in their postoperative follow-ups.

CONCLUSIONS

Incidence of postoperative complications was comparable between the groups, except for a higher incidence of posterior synechiae in pseudophakic eyes. Visual rehabilitation was faster in the pseudophakic group.

Outcome of paediatric cataract surgery in Northwest Ethiopia: a retrospective case series

AIM

To assess visual acuity outcomes, and factors associated with the outcome, of paediatric cataract surgery at the Child Eye Health Tertiary Facility, Gondar, Northwest Ethiopia.

METHODS

The medical records of children aged below 16 years who underwent cataract surgery between September 2010 and August 2014 were reviewed for preoperative, surgical and postoperative data.

RESULTS

One hundred and seventy-six eyes of 142 children (mean age 7.9 years±4.2 SD, 66% male) who had cataract surgery were included. Twenty-five per cent (35/142) of children had bilateral cataract, 18 (13%) had unilateral non-traumatic cataracts and 89 (63%) had unilateral traumatic cataracts. An intraocular lens was implanted in 93% of eyes. Visual acuities at last follow-up: bilateral cases in the better eye: good (≥6/18 or fix and follow) in 21/34 eyes (62%), borderline (<6/18-6/60) in 4 eyes (12%) and poor (<6/60) in 9 eyes (26%). In unilateral non-traumatic cases: good in 6 eyes (33%), borderline in 3 eyes (17%) and poor in 9 eyes (50%). In unilateral traumatic cases: good in 36 eyes (40%), borderline in 20 eyes (23%) and poor in 33 eyes (37%). In bilateral cataract, worse outcomes were associated with preoperative nystagmus/strabismus. In traumatic cases, worse outcomes were associated with the preoperative trauma-related complications.

CONCLUSIONS

Visual acuity improved significantly after surgery, with better outcomes in bilateral cases. Early detection and surgery by a trained surgeon with good follow-up and postoperative rehabilitation can lead to better visual outcomes.

Outcomes of Pediatric Cataract Surgery in the Copperbelt Province of Zambia

PURPOSE

To study the outcomes of pediatric cataract surgeries in children operated on in the Copperbelt Province of Zambia and the barriers to accessing surgery.

METHODS

All children who had congenital, developmental, and traumatic cataracts operated on by lens aspiration, primary posterior capsulotomy, and anterior vitrectomy with posterior chamber intraocular lens implantation from 2012 to 2013 and followed up beyond 6 months were studied. Each child underwent a comprehensive preoperative evaluation. An active, assisted follow-up was done and parents were asked about reasons for delay between presentation and surgery.

RESULTS

One hundred two eyes of 70 children met the inclusion criteria of the study. Preoperatively, 76 of 77 (98.7%) eyes in the congenital and developmental cataract group had presenting visual acuity of worse than 6/60. This improved postoperatively, with 19 (29.7%) eyes having best corrected visual acuity (BCVA) of better than 6/18, 23 (35.9%) having BCVA of 6/24 to 6/60, and 22 (34.4%) having BCVA of worse than 6/60. Older age (P = .005), better preoperative vision (P = .045) at presentation, unilaterality (P = .012), and delay between presentation and surgery (P = .004) were predictors of a better postoperative outcome. On multivariate analysis, only age was significant (P = .025). Distance and cost of travel and surgery were the causes of delay in presentation. In the patients with traumatic cataracts, 17 of 25 (68%) had BCVA of better than 6/18, 6 (24%) had BCVA between 6/24 and 6/60, and 2 (8%) had BCVA of worse than 6/60 at the 6-month follow-up. The most common causes of injury were being struck by sticks and stones (10 children, 25%).

CONCLUSIONS

Visual outcomes after pediatric cataract surgery in Zambia were comparable and satisfactory. Cost of treatment was a barrier, but delay did not adversely affect outcome. [J Pediatr Ophthalmol Strabismus. 2016;53(5):311-317.].

Visual Outcome and Related Factors in Bilateral Total Congenital Cataract Patients: A Prospective Cohort Study

This study is to evaluate the visual outcome and identify its crucial related factors in children undergoing cataract surgery for bilateral total congenital cataract (CC). This prospective study included consecutive bilateral total cataract patients undergoing primary surgery at Zhongshan Ophthalmic Center (ZOC), Guangzhou, China from Jan 2010 to May 2014. Visual outcome was estimated by best-corrected visual acuity (BCVA) at last follow-up. Potential related factors, including gender, age at last follow-up, age at primary surgery, surgical procedure, postoperative complications (PCs), frequency of follow-up and changes in spectacles were evaluated. Eighty-eight children (176 eyes) were included in the cohort. The mean post-operative BCVA (logMAR) was 1.07 ± 0.53 at the mean follow-up duration 31.07 ± 19.36 months. Multivariable generalized estimating equations (GEEs) showed BCVA was significantly associated with PCs, age at last follow-up and age at primary surgery. Partial correlation analysis indicated age at primary surgery was positively correlated with BCVA controlling for the other factors, both for the whole age range (R = 0.415, P < 0.001) and age >6 months (R = 0.867, P < 0.001). Better visual acuity was related to early primary surgery and low PC occurrence in children with bilateral total CC. Timely surgical intervention and strict control of PCs would be potential steps to achieving better visual outcome.

Visual acuity and its predictors after surgery for bilateral cataracts in children

PurposeThe objective of this study was to investigate preoperative factors associated with postoperative visual acuity outcomes and to develop a model to predict visual acuity prognosis.MethodsA retrospective study was conducted by reviewing clinical charts of pediatric patients who underwent bilateral cataract surgery by a single surgeon (MEW) at the Storm Eye Institute. A multiple logistic regression model was constructed to predict the odds of poor postoperative visual acuity, that is, worse than 20/40, based on age at surgery, gender, primary intraocular lens (IOL) placement, ethnicity, and preoperative nystagmus.ResultsA sample size of 157 children (314 eyes) was investigated with median duration of follow-up of 6.4 years. A total of 78% of children with bilateral cataract had postoperative visual acuity of 20/40 or better. The presence of preoperative nystagmus was highly correlated with poor postoperative visual acuity (OR=6.0; 95% CLs, 2.5-14.1; P-value<0.0001). Children of age <1 year at time of cataract extraction (OR=3.2; 95% CLs, 1.4-7.6; P-value=0.0073), male gender (OR=2.3; 95% CLs, 1.1-4.5; P-value=0.02), the absence of primary IOL placement (OR=3.0; 95% CLs, 1.05-8.4; P-value=0.04), and non-Caucasian ethnicity (OR=2.0; 95% CLs, 1.02-4.03; P-value 0.0447) were associated with poor visual acuity postoperatively.ConclusionsSatisfactory visual outcomes occurred in 78% of children operated on for bilateral cataracts. Preoperative nystagmus, age <1 year at time of cataract extraction, absence of primary IOL placement, male gender, and non-Caucasian ethnicity, were all factors associated with poor postoperative visual acuity.

Evaluation of a Public Child Eye Health Tertiary Facility for Pediatric Cataract in Southern Nigeria I: Visual Acuity Outcome

Purpose:

A retrospective study of the outcome of congenital and developmental cataract surgery was conducted in a public child eye health tertiary facility in children <16 years of age in Southern Nigeria, as part of an evaluation.

Materials and Method:

Manual Small Incision Cataract Surgery with or without anterior vitrectomy was performed. The outcome measures were visual acuity (VA) and change (gain) in visual acuity. The age of the child at onset, duration of delay in presentation, ocular co-morbidity, non ocular co-morbidity, gender, and pre operative visual acuity were matched with postoperative visual acuity. A total of 66 children were studied for a period of six weeks following surgery.

Results:

Forty eight (72.7%) children had bilateral congenital cataracts and 18 (27.3%) children had bilateral developmental cataracts. There were 38(57.6%) males and 28 (42.4%) females in the study. Thirty Five (53%) children had good visual outcome (normal vision range 6/6/ -6/18) post-operatively. The number of children with blindness (vision <3/60) decreased from 61 (92.4%) pre-operatively to 4 (6.1%) post-operatively. Post operative complication occurred in 6.8% of cases six week after surgery. Delayed presentation had an inverse relationship with change (gain) in visual acuity (r = - 0.342; p-value = 0.005). Pre-operative visual acuity had a positive relationship with post operative change (gain) in visual acuity (r = 0.618; p-value = 0.000).

Conclusion:

Predictors of change in visual acuity in our study were; delayed presentation and pre-operative VA. Cataract surgery in children showed clinical benefit.

Surgery for sight: outcomes of congenital and developmental cataracts operated in Durban, South Africa

PURPOSE

To study the visual outcomes of congenital and developmental cataract surgery and determine variables for presentation for pediatric cataract surgery in KwaZulu Natal province of South Africa.

METHODS

Care-givers of children presenting with cataract to a quaternary centre were asked when they first detected the condition. The reasons for delay between detection and surgery were studied. The children underwent a comprehensive eye examination and then appropriate surgery. They were prospectively followed up for 3 months and visual acuity and stereopsis were noted. Delay in presentation for surgery and visual outcomes were co-related with demographic and clinical factors.

RESULTS

Eighty-three non-traumatic cataract surgeries in 50 children were studied. Twenty-six (52%) were males, mean age was 3 years 10 months (SD 3yrs 4 months). The mean delay between identification and surgery was 20.7 months (SD 18 months). Twenty-six (52%) children had >15 months interval between diagnosis and surgery. Only mother's occupation was significantly associated with delay (P=0.017). Post-surgery 17/69 (24.7%) had visual acuity ≥6/18, 20/69 (29.0%) had vision between 6/24-6/60, whereas 32/69 (46.3%) had visual acuity ≤6/60. The final vision was associated with age (P=0.031), delay between diagnosis and surgery (P<0.001), type of surgery (P=0.046) and preoperative vision (P<0.001).

CONCLUSION

Although the children's vision improved substantially, a longer follow-up and amblyopia treatment would be necessary to optimize the visual outcome, which depended on age and preoperative vision. Health promotion activities aimed at mothers are important in improving visual outcomes.

Unilateral Congenital and Developmental Cataracts in Children in India: How Useful Were Long-Term Outcomes of Surgery? Miraj Pediatric Cataract Study 4

PURPOSE

To study visual outcomes and stereopsis after a 3-8 year follow-up in unilateral congenital and developmental cataracts.

DESIGN

Clinical case series.

METHODS

Children who underwent surgery for unilateral pediatric cataract from 2004 to 2008 were traced and reexamined prospectively from 2010 to 2011. Demographic and clinical factors were noted from their retrospective chart readings. All children underwent visual acuity assessment and comprehensive ocular examinations including stereoacuity in a standardized manner during the prospective follow-up visits. Details of amblyopia management were recorded for univariate and multivariate analyses.

RESULTS

Forty-eight eyes of 48 children had a mean follow-up of 4.4 years between surgery and assessment (SD, 1.6 years). Twenty-four (50%) were boys, and the average age at surgery was 10.2 years (SD, 4.1). Two (4.2%) were congenital, 14 (29.2%) developmental, and 32 (66.7%) congenital/developmental cataracts. Preoperatively, 38 (79.2%) had vision less than 3/60. After surgery, 12 (25%) had improved best-corrected visual acuity (BCVA) of 6/18 or greater, 4 (8.3%) had BCVA of 6/24 to 6/60, and 32 (66.7%) had BCVA of less than 6/60. Eleven (22.9%) had binocular single vision 480 seconds or less of arc on Titmus test. Preoperative vision (P = 0.034) was significantly associated with postoperative visual outcomes, but not age at surgery (P = 0.14), sex (P = 0.897), type of surgery (P = 0.371), or type of intraocular lens (P = 0.66). The use of phacoemulsification was associated with better vision, but it was not significant (P = 0.069).

CONCLUSIONS

Long-term visual outcomes in unilateral pediatric cataracts were subnormal due to deprivation amblyopia, but vision improved over preoperative levels and helped in binocular stereoacuity. Some preoperative vision was associated with better visual outcomes.

Cataract surgery outcomes in bangladeshi children

PURPOSE

To measure visual acuity (VA) outcomes, complication rates, and the social impact of cataract surgery in a cohort who underwent surgery as children in Bangladesh.

DESIGN

Case series.

PARTICIPANTS

A total of 471 of 850 children from 6 Bangladeshi districts who had been identified as cataract blind using key informants (KIs) between 2004 and 2009 during the Bangladesh Childhood Cataract Campaign (BCCC) together with all those children not included in the BCCC database but in the Child Sight Foundation (CSF) database who had been identified as cataract blind.

METHODS

The subjects and families were contacted again by KIs and transported to local examination centers, where parents and subjects were administered a questionnaire and subjects underwent full ocular examination. Where operative data were available (15%), they were analyzed in conjunction with questionnaire and examination findings. Statistical analysis was performed using SPSS Statistics (IBM, Armonk, NY).

MAIN OUTCOME MEASURES

Presenting and best-corrected visual acuities (BCVAs), cause(s) of poor outcome, postoperative refraction, and school attendance.

RESULTS

A total of 407 of the participants had undergone bilateral surgery as children, with a mean follow-up of 8.8 years. The mean age at examination was 16 years (range, 5-28 years; standard deviation [SD], 4.6 years); 63% of those examined were male; 22% had a binocular presenting VA of >20/60; and 53% were severely visually impaired or blind (VA <20/200). After refraction, 33% had VA >20/60 in their better eye and 33% had VA <20/200. Factors that predicted poor VA in multivariate logistic regression analysis were nystagmus (P < 0.001), longer delay in presentation (P < 0.001), and magnitude of absolute spherical equivalent refractive error (P<0.001). Some 50% had nystagmus, and 69% of those currently aged ≤16 years were attending school. Better acuity was associated with school attendance (P < 0.001), whereas gender was not.

CONCLUSIONS

Approximately one third of all participants had a BCVA of ≥20/60 in their better eye. Amblyopia and nystagmus limited visual outcome, indicating the need for earlier detection and treatment. This is the first study to show the link between pediatric cataract outcome and access to education, a millennium development goal.

Results of late surgical intervention in children with early-onset bilateral cataracts

BACKGROUND

Cataracts are a major cause of childhood blindness globally. Although surgically treatable, it is unclear whether children would benefit from such interventions beyond the first few years of life, which are believed to constitute 'critical' periods for visual development.

AIMS

To study visual acuity outcomes after late treatment of early-onset cataracts and also to determine whether there are longitudinal changes in postoperative acuity.

METHODS

We identified 53 children with dense cataracts with an onset within the first half-year after birth through a survey of over 20,000 rural children in India. All had accompanying nystagmus and were older than 8 years of age at the time of treatment. They underwent bilateral cataract surgery and intraocular lens implantation. We then assessed their best-corrected visual acuity 6 weeks and 6 months after surgery.

RESULTS

48 children from the pool of 53 showed improvement in their visual acuity after surgery. Our longitudinal assessments demonstrated further improvements in visual acuity for the majority of these children proceeding from the 6-week to 6-month assessment. Interestingly, older children in our subject pool did not differ significantly from the younger ones in the extent of improvement they exhibit.

CONCLUSIONS AND RELEVANCE

Our results demonstrate that not only can significant vision be acquired until late in childhood, but that neural processes underlying even basic aspects of vision like resolution acuity remain malleable until at least adolescence. These data argue for the provision of cataract treatment to all children, irrespective of their age.

Macular structural characteristics in children with congenital and developmental cataracts

PURPOSE

To investigate macular structural characteristics in children with congenital or developmental cataracts.

METHODS

Children 5-16 years of age with a history of surgery for congenital or acquired cataract were enrolled. Eligible patients had visual acuity of 20/400 or better and ≥37 weeks gestational age at birth. Patients were divided into two groups: unilateral (n = 22) and bilateral (n = 19). Fourier domain optical coherence tomography (FD-OCT) was used to image the retinal structure. Retinal volume scans centered on the fovea were obtained. Using the instrument's segmentation software, central subfield thickness (CST) and the thickness of the inner and outer retinal layer regions were measured.

RESULTS

In the unilateral group, 1 child with persistent fetal vasculature had unidentifiable retinal structure and was excluded. Most unilateral eyes (20/21) had a CST within the normal range. However, the CST, superior, nasal, inferior, and temporal sectors were all significantly thicker in the cataractous eye compared to the noncataractous eye (all P < 0.01 [paired t test]). The interocular difference for CST was not associated with age at surgery or interocular difference for visual acuity. In the bilateral group, although 34 of 38 eyes were within the normal range, the average CST of this group was significantly thicker than the noncataractous eye in the unilateral group.

CONCLUSIONS

Following cataract extraction during infancy or childhood, most cataractous eyes had normal macular structure. Cataractous eyes of both unilaterally and bilaterally affected children have thicker CST values compared to the noncataractous eye.

Comparison of contact lens and intraocular lens correction of monocular aphakia during infancy: a randomized clinical trial of HOTV optotype acuity at age 4.5 years and clinical findings at age 5 years

IMPORTANCE

The efficacy and safety of primary intraocular lens (IOL) implantation during early infancy is unknown.

OBJECTIVE

To compare the visual outcomes of patients optically corrected with contact lenses vs IOLs following unilateral cataract surgery during early infancy.

DESIGN, SETTING, AND PARTICIPANTS

The Infant Aphakia Treatment Study is a randomized clinical trial with 5 years of follow-up that involved 114 infants with unilateral congenital cataracts at 12 sites. A traveling examiner assessed visual acuity at age 4.5 years.

INTERVENTIONS

Cataract surgery with or without primary IOL implantation. Contact lenses were used to correct aphakia in patients who did not receive IOLs. Treatment was determined through random assignment.

MAIN OUTCOMES AND MEASURES

HOTV optotype visual acuity at 4.5 years of age.

RESULTS

The median logMAR visual acuity was not significantly different between the treated eyes in the 2 treatment groups (both, 0.90 [20/159]; P = .54). About 50% of treated eyes in both groups had visual acuity less than or equal to 20/200. Significantly more patients in the IOL group had at least 1 adverse event after cataract surgery (contact lens, 56%; IOL, 81%; P = .02). The most common adverse events in the IOL group were lens reproliferation into the visual axis, pupillary membranes, and corectopia. Glaucoma/glaucoma suspect occurred in 35% of treated eyes in the contact lens group vs 28% of eyes in the IOL group (P = .55). Since the initial cataract surgery, significantly more patients in the IOL group have had at least 1 additional intraocular surgery (contact lens, 21%; IOL, 72%; P < .001).

CONCLUSIONS AND RELEVANCE

There was no significant difference between the median visual acuity of operated eyes in children who underwent primary IOL implantation and those left aphakic. However, there were significantly more adverse events and additional intraoperative procedures in the IOL group. When operating on an infant younger than 7 months of age with a unilateral cataract, we recommend leaving the eye aphakic and focusing the eye with a contact lens. Primary IOL implantation should be reserved for those infants where, in the opinion of the surgeon, the cost and handling of a contact lens would be so burdensome as to result in significant periods of uncorrected aphakia.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00212134

A pilot study to evaluate incorporating eye care for children into reproductive and child health services in Dar-es-Salaam, Tanzania: a historical comparison study

Background

Many blinding eye conditions of childhood are preventable or treatable, particularly in developing countries. However, primary eye care (PEC) for children is poorly developed, leading to unnecessary visual loss. Activities for control by health workers entail interventions for systemic conditions (measles, vitamin A deficiency), identification and referral of children with sight threatening conditions and health education for caregivers. This pilot study evaluated integrating a package of activities to promote child eye health into Reproductive and Child Health (RCH) services in Dar-es-Salaam, Tanzania.

Methods

Design: historical comparison study. Fifteen Clinical Officers and 15 nurses in 15 randomly selected RCH clinics were trained in PEC for children in July 2010. They were given educational materials (poster and manual) and their supervisors were orientated. Knowledge and practices were assessed before and 3 weeks after training. One year later their knowledge and practices were compared with a different group of 15 Clinical Officers and 15 nurses who had not been trained.

Results

Before training staff had insufficient knowledge to identify, treat and refer children with eye diseases, even conjunctivitis. Some recommended harmful practices or did not know that cataract requires urgent referral. Eye examination, vitamin A supplementation of mothers after delivery and cleaning the eyes at birth with instillation of antibiotics (Crede’s prophylaxis) were not routine, and there were no eye-specific educational materials.

Three weeks after training several clinics delivering babies started Crede’s prophylaxis, vitamin A supplementation of women after delivery increased from 83.7% to 100%, and all staff included eye conditions in health education sessions. At one year, trained staff were more likely to correctly describe, diagnose and treat conjunctivitis (z=2.34, p=0.04)(30%-vs-60.7%). Mystery mothers observed health education sessions in 7/10 RCH clinics with trained staff, five (71.4%) of which included eye conditions.

Conclusions

Primary eye care for children in Dar-es-Salaam is inadequate but training RCH staff can improve knowledge in the short term and change practices. Attendance by mothers and their children is high in RCH clinics, making them ideal for delivery of PEC. Ongoing supportive supervision is required to maintain knowledge and practices, as well as systems to track referrals.

Clinical and cost impact of a pediatric cataract follow-up program in western Nepal and adjacent northern Indian States

BACKGROUND

High-quality, comprehensive pediatric cataract surgery programs have recently developed in low-income countries, but postoperative care has lagged. This study evaluated the post-cataract surgery follow-up program implemented in March 2011 at the Lumbini Eye Institute in Bhairahawa, Nepal, which included a full-time pediatric counselor and program director, a specific database, a tracking system, and cell phone reminders.

METHODS

Baseline data for all cataract surgical patients <16 years of age were obtained retrospectively from hospital administrative records for 2009, the year prior to program introduction, and prospectively for all cases between March 1, 2011, and February 28, 2012. The statistical significance of the difference in the proportion of children attending follow-up in 2009 versus 2011-12 was calculated, and the overall program costs for 2011-12 was determined based on hospital records.

RESULTS

In 2011-12, 334 children (248 males [74%]) underwent cataract surgery, including 89 Nepali (27%) and 245 Indian (73%) children. The proportion of boys was significantly higher in 2011-12 compared to 2009, but there were no differences in terms of age or distance to hospital. In 2009, 87%, 60%, and 37% attended their first, second, and third follow-up visits, respectively. Follow-up rates improved significantly to 96%, 81%, and 57%, respectively, after the implementation of the postoperative follow-up program. The 2011-12 program is estimated to have cost US$17,444.

CONCLUSIONS

The new post-cataract surgery program resulted in improved follow-up at relatively little additional cost.

Long term outcomes of bilateral congenital and developmental cataracts operated in Maharashtra, India. Miraj pediatric cataract study III

AIM

To study long term outcome of bilateral congenital and developmental cataract surgery.

SUBJECTS

258 pediatric cataract operated eyes of 129 children.

MATERIALS AND METHODS

Children who underwent pediatric cataract surgery in 2004-8 were traced and examined prospectively in 2010-11. Demographic and clinical factors were noted from retrospective chart readings. All children underwent visual acuity estimation and comprehensive ocular examination in a standardized manner. L. V. Prasad Child Vision Function scores (LVP-CVF) were noted for before and after surgery.

STATISTICS

Statistical analysis was done with SPSS version 16 including multi-variate analysis.

RESULTS

Children aged 9.1 years (std dev 4.6, range 7 weeks-15 years) at the time of surgery. 74/129 (57.4%) were boys. The average duration of follow-up was 4.4 years (stddev 1.6, range 3-8 years). 177 (68.6%) eyes had vision <3/60 before surgery, while 109 (42.2%) had best corrected visual acuity (BCVA) >6/18 and 157 (60.9%) had BCVA >6/60 3-8 years after surgery. 48 (37.2%) had binocular stereoacuity <480 sec of arc by TNO test. Visual outcome depended on type of cataract (P = 0.004), type of cataract surgery (P < 0.001), type of intra-ocular lens (P = 0.05), age at surgery (P = 0.004), absence of post-operative uveitis (P = 0.01) and pre-operative vision (P < 0.001), but did not depend on delay (0.612) between diagnosis and surgery. There was a statistically significant improvement for all the 20 questions of the LVP-CVF scale (P < 0.001).

CONCLUSION

Pediatric cataract surgery improved the children's visual acuity, stereo acuity and vision function. Developmental cataract, use of phacoemulsification, older children and those with better pre-operative vision had betterlong-termoutcomes.

Bilateral pediatric cataract surgery: outcomes of 390 children from Nepal and Northern India

PURPOSE

To report the outcomes of bilateral pediatric cataract surgery from eastern Nepal and northern India.

METHODS

Preoperative, intraoperative, and postoperative data of 390 children who underwent surgery bilaterally between 2007 and 2009 were analyzed.

RESULTS

Forty-two (10.8%) children came from Nepal and 348 (89.2%) from India (mainly Bihar State). Intraocular lens (IOL) implantation with posterior capsule opening and anterior vitrectomy were achieved in 386 (99.0%) children bilaterally. Median age at surgery was 7 years and 69.2% were male. At first presentation, 243 (62.3%) of the children were blind (< 3/60 in the better eye). After more than 1 year, 53.5% had a normal visual status (range: 6/6 to 6/18), 5.6% of children were still blind, and mean refractive error spherical equivalent was +1.0 ± 2.4 diopters. Astigmatism changed from suture-induced with the rule at discharge to against the rule within 3 weeks of surgery. Mean long-term astigmatic error was 1.0 ± 0.9 diopters after 1 year. Glaucoma was rare.

CONCLUSIONS

Even in a setting with limited resources, successful, cost-effective, high-volume surgery for pediatric cataract is possible. Despite late presentation and limited follow-up, more than half achieved good outcomes after more than 1 year. Only 5.6% remained blind due to amblyopia or eye anomalies. Bilateral surgery during one hospital stay, IOL implantation with undercorrection according to age, aggressive surgery to prevent secondary cataract, intensive anti-inflammatory therapy, and provision of durable, high-quality spectacles to take home all proved beneficial because many children cannot attend for regular follow-up.

Childhood cataract in sub-Saharan Africa

Investment by organizations and agencies has led to a growing body of evidence and information to assist ophthalmologists and others to meet the needs of children with cataract in Africa. The geographic distribution of research, training, and programme development across Africa has been uneven; investment has been greatest in eastern and southern Africa. Population based surveys (using key informants) suggest that 15-35% of childhood blindness is due to congenital or developmental cataract. There may be up to 82,000 children with non-traumatic cataract in Africa, with approximately 19,000 new cases each year. Effective strategies to find and refer children are those that engage the community in case detection. Identification and referral does not automatically mean surgical intervention with distance to the surgical facility being the most common reason for failure to seek care. Surgical management has become more specialized and a team based approach has been adopted by many paediatric ophthalmologists and their programmes. Although many children still present late for surgery, outcomes of surgery are much improved from previous experiences. Research suggests that post-operative follow up, still a challenge, can be improved through adoption of specific strategies. There has been limited success in ensuring that children are placed in appropriate educational settings. While eye care professionals may feel their responsibility ends with clinical care, it is important for the paediatric eye care team to be engaged with educational and rehabilitation services.

Causes, epidemiology, and long-term outcome of traumatic cataracts in children in rural India

Purpose:

To describe preoperative factors, long-term (>3 years) postoperative outcome and cost of traumatic cataracts in children in predominantly rural districts of western India.

Subjects:

Eighty-two traumatic cataracts in 81 children in a pediatric ophthalmology department of a tertiary eye-care center.

Materials and Methods:

Traumatic cataracts operated in 2004–2008 were reexamined prospectively in 2010–2011 using standardized technique. Cause and type of trauma, demographic factors, surgical intervention, complications, and visual acuity was recorded.

Statistical Analysis:

Data analysis done by using SPSS (Statistical package for social sciences) version 17.0 We have used Chi-square test, Fisher's exact test, paired t-test to find the association between the final vision and various parameters at 5% level of significance; binary logistic regression was performed for visual outcome ≥6/18 and ≥6/60.

Results:

The children were examined in a 3–7 year follow-up (4.35 ± 1.54). Average age at time of surgery was 10.4 ± 4.43 years (1.03 to 18). Fifty (61.7%) were boys. Forty (48.8%) were blunt and 32 (39%) were sharp trauma. The most common cause was wooden stick 23 (28.0%) and sharp thorn 14 (17.1%). Delay between trauma and presentation to hospital ranged from same day to 12 years after the injury with median of 4 days. The mean preoperative visual acuity by decimal notation was 0.059 ± 0.073 and mean postoperative visual acuity was 0.483 ± 0.417 (P < 0.001). Thirty-eight (46.3%) had best corrected visual acuity (BCVA) ≥6/18 and 51 (62.2%) had BCVA ≥ 6/60. In univariable analysis, visual outcome (≥6/18) depended on type of surgery (P = 0.002), gender (P = 0.028), and type of injury (P = 0.07)–sharp trauma and open globe injury had poorer outcomes; but not on age of child, preoperative vision, and type of surgeon. On multivariable binary logistic regression, only gender was significant variable. Of the 82 eyes, 18 (22%) needed more than one surgery. The parents spent an average of 2250 ($45) for the surgery and 55 (66.4%) were from lower socio-economic class.

Conclusion:

The postoperative visual outcomes varied and less than half achieved ≥ 6/18.

Eye conditions and blindness in children: priorities for research, programs, and policy with a focus on childhood cataract

The major causes of blindness in children encompass intrauterine and acquired infectious diseases, teratogens and developmental and molecular genetics, nutritional factors, the consequences of preterm birth, and tumors. A multidisciplinary approach is therefore needed. In terms of the major avoidable causes (i.e., those that can be prevented or treated) the available evidence shows that these vary in importance from country to country, as well as over time. This is because the underlying causes closely reflect socioeconomic development and the social determinants of health, as well as the provision of preventive and therapeutic programs and services from the community through to tertiary levels of care. The control of blindness in children therefore requires not only strategies that reflect the local epidemiology and the needs and priorities of communities, but also a well functioning, accessible health system which operates within an enabling and conducive policy environment. In this article we use cataract in children as an example and make the case for health financing systems that do not lead to 'catastrophic health expenditure' for affected families, and the integration of eye health for children into those elements of the health system that work closely with mothers and their children.

Simultaneous bilateral cataract surgery with IOL implantation in children in Kenya

PURPOSE

To investigate the cost implications, safety, and refractive outcomes of simultaneous bilateral cataract surgery (SBCS) with intraocular lens implantation in pediatric patients in a developing world setting.

METHODS

Children aged 3 months to 10 years with bilateral congenital or developmental cataracts who underwent surgery between January 1, 2007, and December 31, 2009, were eligible for inclusion in this retrospective study. Cost data were compared for simultaneous and sequential cases. Postoperative complications and refraction data were analyzed.

RESULTS

Ninety-six children (192 eyes) were included, 48 in the SBCS group and 48 in the sequential group. The mean age of the SBCS group and the sequential group was 3.4 and 4.7 years, respectively (P = .04). The total estimated surgical cost was $274 per child for SBCS and $344 for sequential surgery, a reduction of 20.3% for cases of SBCS. Fibrin formation of any amount occurred in 52 of 192 eyes (27.1%), 25 in the SBCS group and 27 in the sequential group (P = .75). Twenty-one eyes (10.9%) had additional surgery to remove visual axis obstruction, 14 in the SBCS group and 7 in the sequential group (P = .11). The incidence of early endophthalmitis in all cases of pediatric cataract surgery in an 11-year period was 0.16%. The incidence of anesthetic-related death during the same period was 0.11%.

CONCLUSION

Bilateral simultaneous pediatric cataract surgery with intraocular lens implantation may be a safe alternative to sequential surgery, with advantages in cost reduction and no difference in sight-threatening complications.

Clinical characteristics and early postoperative outcomes of pediatric cataract surgery with IOL implantation from Lahan, Nepal

PURPOSE

To report clinical characteristics and early postoperative outcomes of pediatric cataract surgery with intraocular lens (IOL) implantation from Lahan, Nepal.

METHODS

Demographics and surgical, preoperative, and postoperative clinical characteristics data were collected and analyzed.

RESULTS

Of 2,633 eyes with primary IOL implantation, 2,003 eyes were in the non-traumatic group, whereas 630 eyes were from trauma. Median age at surgery was 7 and 9 years in the non-traumatic and traumatic groups, respectively. Boys comprised 74.2% of the non-traumatic and 85.4% of the traumatic cataract patients. Unilateral cataracts accounted for only 7.7% (154 of 2,003) of the non-traumatic group. Average follow-up was 35 days with greater than 6 months follow-up in 134 of 2,633 (5.1%) eyes. Most (68.5% [1,804 of 2,633]) of the lens opacities were described as total cataract. Although early postoperative best-corrected visual acuity improved from the preoperative recording in 95.0% (2,495 of 2,626) of eyes, 78.1% (2,050 of 2,626) remained in the poor (20/100 or worse) category. Median preoperative and early postoperative best-corrected visual acuity was hand motions and 20/200, respectively.

CONCLUSION

A high-volume cataract surgical center in Lahan, Nepal, is able to provide cost-effective and high-quality pediatric surgery. Most of the patients in this series were noted to have complete cataracts and were boys. Visual improvement was achieved, but excellent visual outcomes were rarely documented due to late referral and inadequate follow-up. Educating families and primary caregivers with regard to the importance of earlier referral and postoperative optical correction and tracking will improve outcomes.

Effect of intracameral cefuroxime on fibrinous uveitis after pediatric cataract surgery

PURPOSE

To determine whether intracameral cefuroxime reduces postoperative fibrin formation after pediatric cataract surgery.

METHODS

Children aged 3 months to 10 years with bilateral congenital or developmental cataracts who underwent surgery between February and July 2008 were eligible for inclusion in this prospective double-masked study. The same surgical technique was used in each eye. The intraocular lens was placed in either the bag or sulcus in both eyes. The same intraocular lens type was used in both eyes (polymethylmethacrylate). One eye was randomized to receive intracameral cefuroxime at the end of surgery and the fellow eye received saline. The surgeon was masked to the treatment assignment. The amount of fibrin formation in the anterior chamber of each eye was assessed by a masked grader on the fourth postoperative day.

RESULTS

Seventy eyes of 35 children were included in the study. Fibrin formation was noted on the fourth postoperative day in 14 of 70 eyes (20%), 7 in the cefuroxime group and 7 in the saline group. The mean fibrin score was 0.57 ± 1.31 in the cefuroxime group and 0.49 ± 1.07 in the saline group. There was no statistically significant difference in the amount of fibrin formation between groups (P = .857, Wilcoxon ranked signs test).

CONCLUSION

Intracameral cefuroxime did not significantly reduce postoperative fibrin formation in this study. Fibrin formation does not appear to be due to bacterial contamination in most cases of pediatric cataract surgery.

Visual impairment and delay in presentation for surgery in chinese pediatric patients with cataract

PURPOSE

To report visual impairment and blindness and delay in presentation for surgery in Chinese pediatric patients with cataract.

DESIGN

Retrospective case series.

PARTICIPANTS

A total of 196 children (309 eyes) with congenital or developmental cataract.

METHODS

Surgery was performed in all patients. Visual impairment and blindness were defined as best-corrected visual acuity < 20/60. The characteristics, visual acuity, and time delay to surgery of these children were evaluated.

MAIN OUTCOME MEASURES

Incidence of visual impairment and blindness, ages at disease recognition and at surgery, and duration of delay in presentation for surgery.

RESULTS

Visual acuity was 20/25 or better in 22 eyes (7.1%), between 20/25 and 20/40 in 72 eyes (23.3%), and between 20/40 and 20/60 in 87 eyes (28.2%). Visual impairment and blindness occurred in 41.4% of eyes, 52.0% of patients, 35.4% of patients with bilateral cataract, and 74.7% of patients with unilateral cataract. The frequency of visual impairment and blindness in eyes with combined nystagmus, combined strabismus, total cataract, nuclear cataract, and posterior polar cataract was 84.4%, 75%, 63.8%, 48%, and 48.3%, respectively. Severe postoperative complications resulted in 14.8% of visual impairment and blindness. The mean ages at disease recognition and at surgery were 22.6 ± 30.4 months and 68.3 ± 40.0 months, respectively. The mean delay of presentation for surgery was 49.6 ± 39.8 months in all patients and 35.7 ± 32.2 months in the patients with congenital cataract. The disease was recognized within 6 months of age in 46 children (40.7%) with bilateral cataract and 10 children (12.0%) with unilateral cataract. Among these children, only 18 (15.9%) with bilateral cataract and 1 (1.2%) with unilateral cataract underwent surgery between 3 and 6 months of age. No patients received surgical intervention within 3 months.

CONCLUSIONS

Severe visual impairment is common in pediatric patients with cataract in China. Delayed presentation to the hospital and late surgical treatment are the major reasons and deserve greater attention.

Child Eye Health Tertiary Facilities in Africa

PURPOSE

The World Health Organization and the International Agency for Prevention of Blindness recommends that there be 1 Child Eye Health Tertiary Facility (CEHTF) per 10 million people in developing countries. We sought to assess the current situation in Africa with regard to manpower, facilities, training, and output and to identify gaps in supportive services in CEHTFs.

METHODS

A survey was conducted by sending comprehensive questionnaires to all CEHTFs across Africa. Of the 27 CEHTFs in Africa, 21 (77.8%) returned forms.

RESULTS

Results show significant variability of resources (manpower, training, infrastructure, equipment, and refractive services). The mean population catchment area of the CEHTFs was 9.42 million. In 2007 the mean number of surgeries for congenital and developmental cataract, strabismus, and other conditions was 72.0, 37.1, and 169, respectively, with wide variation between the centers. Overall there were 1.26 operated boys for every girl. The mean surgical fee charged was US$117. The presence of a dedicated optometrist, childhood blindness coordinator, and a full-time anesthetist was associated with higher surgical output.

CONCLUSIONS

Although the 21 CEHTFs cover an estimated population of 197 million, the number of children receiving services was generally low. Findings suggest that an additional 20 sub-Saharan countries are not large enough to support a CEHTF, and some large countries require additional facilities. Strengthening existing CEHTFs would require investment in manpower (especially support by optometrists and childhood blindness coordinators), programs to identify and refer children needing services, and internally and externally supported mechanisms to support the relatively high cost of providing this service.

Improving postoperative follow-up of children receiving surgery for congenital or developmental cataracts in Africa

PURPOSE

Access to cataract surgery for children has improved in recent years, and there are a number of tertiary facilities for children's eye health in sub-Saharan Africa. However, surgery alone will have limited value if postoperative follow-up is poor. We have developed a program to improve follow-up after pediatric cataract surgery and compare the follow-up rates before and after implementation.

METHODS

Baseline information was collected from 2003 to 2004. Program activities were implemented in 2005. Postintervention information was collected from 2006. During both periods all children younger than 16 who had cataract surgery at Kilimanjaro Christian Medical Centre Hospital were included. Follow-up, defined at both 2 weeks and 10 weeks, was recorded.

RESULTS

Baseline data showed that 67% and 43% of children, respectively, came for 2-week and 10-week postoperative follow-up. After the intervention, 89% came for 2-week follow-up and 83% came for 10-week follow-up. Gender inequity, documented in the baseline data, was eliminated in the postintervention period.

CONCLUSION

Follow-up of children who have had cataract surgery can be greatly enhanced in Africa. Improved follow-up enables children to receive the spectacles and low vision devices necessary for visual rehabilitation. Multiple strategies will probably be needed to improve follow-up.

Cataract in children attending schools for the blind and resource centers in eastern Africa

OBJECTIVE

The aim of this study was to describe results of a representative sample of children who have undergone cataract surgery in schools for the blind in 4 African countries.

DESIGN

Cross-sectional study.

PARTICIPANTS

Children enrolled at schools for the blind in Kenya, Malawi, Tanzania, and Uganda.

METHODS

We used a population-proportional-to-size methodology to select a representative sample of schools for the blind and annexes and included all the children attending the selected schools. Trained teams using standardized examination methods and a modified World Health Organization form examined the children. The form was modified specifically to collect information on outcomes of cataract surgery.

MAIN OUTCOME MEASURES

Operative status and postoperative visual acuity.

RESULTS

Of 1062 children examined, 196 (18%) had undergone cataract surgery or had cataract as the major cause of visual impairment; 140 (71%) had bilateral surgery, 24 (12%) had unilateral surgery, and 32 (16%) had not had surgery. Of operated eyes, 118 (41%) had visual acuity > or =20/200. Intraocular lenses were implanted in 65% of the operated eyes. Eyes with intraocular lens were more likely to have better vision than those without (P for trend = 0.04). Amblyopia was the most common cause of poor visual acuity in children who had undergone cataract surgery.

CONCLUSIONS

The number of children in the schools who receive cataract surgery has increased greatly since 1995. The high rate of amblyopia highlights the critical need for programs to find children earlier and to ensure adequate follow-up after surgery. Without such programs, the value of training pediatric surgeons will not be fully realized.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Bilateral paediatric cataract surgery in the same session

PURPOSE

To evaluate the results of bilateral paediatric cataract surgery in the same session with a focus on patient selection criteria, operative guidelines, and controversial issues.

SETTING

Departments of Ophthalmology, Inönü University Turgut Ozal Medical Center (Malatya) and Fatih University Hospital (Ankara, Turkey).

METHODS

This retrospective noncomparative case series comprised 39 children (78 eyes), who underwent bilateral cataract surgery and/or primary or secondary IOL implantation in one sitting. Ten patients had bilateral lensectomy-primary posterior capsulotomy-anterior vitrectomy, and the remaining 29 patients had bilateral IOL implantation either primarily (20 cases) at the time of cataract extraction or secondarily for aphakic correction (9 cases). Both eyes were treated as two separate but consecutive surgeries in the same session. Maximum possible care was taken to ensure surgical asepsis.

RESULTS

Age at surgery ranged from 2 months to 17 years. Average follow-up was 12 months. No serious intraoperative or postoperative complications occurred leading to permanent vision loss. During the last follow-up, 91% of eyes tested had a visual acuity of 20/40 or better.

CONCLUSION

Bilateral paediatric cataract surgery in one session may be a safe and useful approach alternative to sequential surgery in selected patients, if operative guidelines and surgical asepsis are strictly followed.