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

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.

Management of childhood cataract: practice patterns among ophthalmologists in Nigeria

OBJECTIVE

To describe the practice patterns for the management of paediatric cataracts among ophthalmologists practising in Nigeria.

METHODS

A cross-sectional study of fully trained Nigerian ophthalmologists who perform cataract surgery in children aged 16 years and below. An online questionnaire was distributed via e-mail and social media platforms to respondents. Data on socio-demographic characteristics, type, location and years of practice, status and preferred approach to management of childhood cataracts were obtained and analysed.

RESULTS

A total of 41 ophthalmologists responded that they perform paediatric cataract surgery. Of these, 25 (61.0%) were paediatric ophthalmologists while 7 (17.0%) were general ophthalmologists. Most respondents (92.7%) practise in urban settings and 30 (73.2%) work in tertiary hospitals. Most respondents (90.2%) routinely insert intraocular lenses (IOLs) in children aged 2 years and above while 32 (78.0%) routinely under-correct the IOL power. Thirty-four (82.9%) have an anterior vitrectomy machine, 31 (75.6%) routinely perform posterior capsulotomy and anterior vitrectomy, and 17 (58.5%) routinely perform same-day sequential bilateral cataract surgery. Twenty-six (63.4%) respondents routinely give near correction in aphakic children, while 24 (58.5%) respondents routinely give bifocals in pseudophakic children. Compared to other sub-specialists, paediatric ophthalmologists were 24 times more likely to routinely under-correct IOL power (p = 0.001) and 4 times more likely to routinely correct near vision in aphakic children (0.036) as well as prescribe bifocals for pseudophakic children respectively (0.029).

CONCLUSION

The practice of paediatric cataract surgery in Nigeria is mainly in line with expected standards, but there is a need for the development of detailed practice guidelines.

Analysis of age at detection and outcomes of dense unilateral congenital cataract surgery for children on the paediatric cataract register

AIM

Analysis of age at time of detection and surgery of dense unilateral cataract and investigation of best-corrected visual acuity (BCVA) in a nationwide register-based cohort study, based on the routine of maternity ward eye screening.

METHODS

Data were derived from the Paediatric Cataract Register (PECARE). All children (n = 54) diagnosed with dense congenital unilateral cataract between January 2007 and September 2014 who had surgery before 1 year of age, and for whom 5-year follow-up records were available, were included.

RESULTS

The majority, 35/54 (65%), were detected and operated on before age 6 weeks and 30/35 (86%) were referred from maternity wards. Visual acuity (VA) ≥ 0.5 (decimal, 0.3 logMAR) was found in 7/53 (13%) of the cohort at age 5 years; further, 19 children achieved VA ≥ 0.1 (decimal, 1.0 logMAR) (36%) and 19 children VA < 0.05 (decimal, 1.30 logMAR) (36%). Ten-year follow-up records were available for 17/53 (32%) children; 1/17 (6%) achieved VA ≥ 0.5 (decimal, 0.3 logMAR), 4/17 (24%) VA ≥ 0.3-<0.5 (decimal, 0.52-0.30 logMAR), 3/17 (18%) VA ≥ 0.05-0.1 (decimal, 1.30-1.0 logMAR) and 10/17 (59%) VA < 0.05 (decimal, 1.30 logMAR).

CONCLUSION

A total of 90% of the children were detected with cataract within 100 days of birth and 80% were operated on within this period. This study showed better visual acuity in those treated for dense unilateral cataracts than previously reported in an earlier Swedish cohort study.

Ocular Morbidity-A Critical Analysis to Improve Outpatient Services in an Eye Department in a Sub-Saharan Megacity

The aim of this study was to analyse outpatient services in an ophthalmic clinic of a church-run hospital providing secondary level care in an African megacity, paying special attention to the poorest users of the services. The range of examination was reviewed from 500 patient records of all ages consecutively chosen on random days attending the outpatient department for the first time in order to optimize workflow and to analyse the offered treatment modalities. Mean age was 41.9 ± 21.9 years, and 53.6% of the patients were female. Of the patients, 74.8% presented with visual impairment. The most frequent findings were refractive errors (35.8%), presbyopia (21.2%), allergic conjunctivitis (14.0%), cataract (13.2%) and glaucoma (6.4%). Patient management consisted of optical treatment (49.6%), surgery (11.4%) and medical treatment (39.0%). These results show the importance of the demand in refractive services and the need to train specific service providers. Knowing the frequencies of common conditions enables more appropriate diagnostic and treatment strategies, e.g., the importance of refractive errors, and should lead to improvements in training, staffing, therapeutics and patient outcomes. This approach can be applied to many other outpatient services and should be evaluated in light of the city’s impoverished health outreach and educational situation.

Editor's choice: this December 2020

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