Pediatric cataract is the most common treatable cause of
childhood blindness(Gilbert and Foster, 2001). The proportion of
blindness in children due to cataract varies considerably between regions from
10%-30% with a global average estimated at 14%, giving 190,000 children blind
from cataract(Organization, 2000).Management of pediatric
cataract in low income countries like Nepal is challenging because of
inadequate human resources and equipment, barriers to access, poor follow up,
lack of awareness and inadequate low vision and rehabilitation services.

 

Nepal is a low-income country
with population of 30 million. The proportion of population below 15 years is
40%.Under 5 mortality rate is 40.Sagarmatha zone has population of
approximately 2 million (CBoS, 2012).The
government health system has networking of services up to the grass root level but
it  is not integrated with eye care
service run by NGO.

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There is no national population
based data on childhood blindness including cataract from Nepal. However,
recent study done in three geographical region shows the prevalence of
childhood blindness 0.07% and visual impairment 0.1%(Adhikari et al., 2015). Based on these
figures considering the proportion of cataract blindness 20%, the total number
of cataract in the region, with population of 2 million, will be 112.
(Childhood blindness= Prevalence X child population; 20% of childhood blindness
= Total pediatric cataract) (Courtright et al., 2008).

Sagarmatha Choudhary Eye
Hospital (SCEH) is situated in Lahan and serves as a tertiary care centre to
provide pediatric cataract-oriented services. A total of 1,786 pediatric
cataract operations were performed between 2007 and 2009 operations(Hennig et
al., 2013). According to hospital record, in 2016 total of 650 pediatric
cataract surgery was done but only 88 on Nepali patients which is below the
required number.

 

The major risk factors
are TORCH infection, Trauma, consanguinity, and hereditary. In a study conducted
in a tertiary hospital near Lahan found that 65% of the cataract were
hereditary and idiopathic among non-traumatic cataract. 30% were traumatic
cataract(Adhikari et
al., 2008).

 

 

 

 

 

 

Strategies
for control:

1. Primary prevention-       

v Counselling about consanguinity

v Prenatal counselling

v Good Antenatal care

v Rubella Immunization for TORCH infection

v Genetic counselling

v Ocular trauma prevention

2. Secondary prevention-
Screening, case detection and referral

3. Tertiary prevention-        High quality surgery and follow up

Low vision service

 

 

PRIMARY
PREVENTION STRATEGY:

ü  Rubella immunization

ü  Genetic counselling, though possible at
tertiary center, is primary prevention strategy.

ü  Awareness on ocular trauma, its prevention and
safety measures through school health programme, community and primary
level  health education is crucial in
preventing traumatic cataract.

ü  Increasing awareness about risk of
congenital cataract and other systemic abnormalities because of consanguinity
is important and possible at the community level.

ü  Good ante natal care helps to control
metabolic disorder like diabetes and detect infection, avoid use of steroids
which are also linked with congenital cataract.

 

SECONDARY PREVENTION STRATEGY:

The outcome of pediatric cataract surgery is very much
dependent on early detection and early surgery. Various strategies, can be
adopted to achieve this objective.

 

Ø 
Creating
Eye health awareness through eye heath education, broadcasting message about
childhood blindness and cataract on radio sensitizes the community.

 

Ø  Community
leaders, mothers group, traditional health practitioner and religious leaders
can be oriented and trained to identify blind children and bring them for
screening.

 

Ø  Using key informant method for detection of
blind children due to pediatric cataract and other condition.
The study in Bangladesh showed that key informants could identify almost
two-thirds of all blind children in the study population, and that this
required only one-sixth of the time and one-sixth of the human resources,
compared to a house-to-house survey (Muhit et al., 2007).

 

Ø  Training
of health worker at MCH and primary health center to refer any child with a
“white pupil” as an emergency to eye hospital can lead to early detection of
congenital cataract.

 

Ø  There
should be programme to have a visit by eye care team to detect children with
cataract and other treatable and avoidable conditions and refer them to
tertiary center for surgery, refraction, or low vision aids (Gnyawali et al., 2012).

 

Ø  Pediatrician
can be sensitized to use red reflex test for the detection of cataract during
the visit by children.

 

Ø 
Organizing
regular pediatric camp for non-school going children, school screening camp and
red reflex screening test at MCH clinic and general hospital for early detection
of Cataract.

 

 

All the strategies mentioned above is
possible in my settings but detection and referral is not the solution. We must
ensure that they receive appropriate treatment and other services on time.

 

 

TERTIARY PREVENTION STRATEGY:

 

The tertiary prevention of pediatric cataract aims at
providing high quality surgery, good follow up, good refraction, and low vision
and rehabilitation service.

 

In my setting, there is facility for high quality pediatric
cataract surgery and provision for good refraction and low vision service. But
it is the only tertiary center for population of 2 million. The hospital has
separate pediatric department with 1 pediatric ophthalmologist,
anesthesiologist,1 trained and qualified low vision specialist, 2 Optometrist
trained in pediatric refraction and low vision which is inadequate in terms of
the population in the service area.

 

 

 

 

Based on the above strategies and interventions, the
following are feasible to be integrated into the existing services and
implemented:

 

A.
Community level

i) Increasing awareness about childhood blindness and
pediatric cataract

ii) Immunization against Rubella

iii) Training and orientation to community leaders, mothers
group, traditional healers to identify blind children

iv) Formation of self-help group of parents of blind
children or operated children

vi)Identification of blind children through key informant
method.

vii) Health awareness on prevention of ocular injury

B. Primary level

i) Health education and promotion activities, radio
message, poster, pamphlets

ii) Good Antenatal check-up at MCH clinic exploring
infection, drug and metabolic disease history.

iii) Counselling by community health worker to parents and
families about cataract, importance of early intervention, surgery and follow
up.

iv)Immunization against Rubella

v) Identification and referral of blind children or
children with white pupil by community health worker to eye hospitals

C. Secondary level

      i.        
Conduct school screening
programme, pediatric screening programme (For non-school going children), Red
reflex test screening at MCH clinic, Health Post etc.

    
ii.        
Diagnosis and referral of
pediatric cataract

  
iii.        
Training of community health
worker and MCH worker to identify white pupil and refer them urgently to
tertiary level hospital

  
iv.        
Counselling of parents and
family members about pediatric cataract

    
v.        
Follow up evaluation of
operated case and manage less complex cases.

  
vi.        
Low vision assessment and referral
to tertiary center if required.

  vii.        
Optical dispensing for simple
prescription

viii.        
Conduct screening programme in
Blind school, school with integrated education.

  
ix.        
Management of simple ocular
injury; Diagnosis and referral of open globe injury

     x.        
Neonatal screening by red
reflex test for lenticular opacity MCH clinic, Maternity hospital, Health post

 

D. Tertiary level

Ø  Provide
high quality pediatric cataract surgery

Ø  Perform
refraction and low vision assessment and provide good quality spectacles or low
vision device as needed

Ø  Amblyopia
management in children with amblyopia

Ø  Maintain
record of blind children, children operated with cataract in HMIS and utilize
it for calling for follow up.

Ø  Provide
counselling to parents to motivate them for complying with regular and long
term follow up.

Ø  Provide
training on pediatric eye examination, diagnosis and medical management to
Ophthalmic Assistant stationed at secondary level and primary level

Ø  Establish
linkage with institute providing rehabilitative services, integrated education,
and blind schools.

Ø  Management
of ocular injury

Ø  Capacity
building of pediatrician, obstetrician, and general physicians and

Ø  establish
referral pathways in coordination with them.

Ø  Advocacy
on childhood blindness and integrated eye care service at all level of
government health system

Challenges:

1.Late presentation for surgery and poor follow up after
surgery is a huge challenge besides barrier related to access, surgery.

a) In studies conducted in Lahan hospital, the mean age of
presentation was 6-7 years(Hennig et al., 2013).  In a hospital based study conducted in
tertiary hospital of Kathmandu, the mean age of presentation was 7.4 years(Shrestha, 2011). The reasons for late
presentations were mainly related to socio cultural factors, level of
awareness, cost, fear, and distance.

To address the issue of
late presentation, strategies
& activities mentioned in secondary prevention for case detection and
referral should be implemented.

 

b) Another major challenge is poor regular and long term
follow up. From the hospital record, it has been seen that only 30% of children
are brought to follow up after 3 months. In a study in tertiary hospital in
Nepal, the follow up rate was 20%(Shrestha, 2011). It is very important
to develop strategies to improve the follow up of operated children and those
who are under rehabilitation process.

 

1) Counselling of
parents: Level of awareness about cataract is very low so counselling is important
in ensuring acceptance, good postoperative medication and regular follow up.
Parents should be counselled about treatment, its benefits, importance of
follow up, and postoperative care (Eriksen et al., 2006).

 

2) There should be a good database system in the hospital
with record of all the children of the catchment area who are blind, visually
impaired and those with cataract including operated ones. The hospital based
record is well maintained but it is not utilized for improving follow up
strategies. Nevertheless, the data and system can be utilized for improving
follow up.

 

3)Development of child tracking form that includes date for
next follow up, description of the need for follow up, anticipated activities
during follow up and contact number helps in ensuring regular follow up.

 

4) In our experience, we have seen that reminding parents
through use of a cell phone call or messages improves follow up
considerably.  This opportunity can be
utilized to send messages about follow up and for health education also.

 

5) One of the most important barrier for follow up is
distance and cost of travel. Reimbursement of the travel cost, providing free spectacles, and minimum waiting time
at the hospital has proved to be effective in increasing the
follow up.

 

6) Ophthalmic Assistants or Optometrists who are
responsible for managing eye care at primary or secondary eye care center level
should be trained to assess and evaluate pediatric visual status, perform
refraction, and provide counselling.

 

Similarly, other challenges are:

 

Ø  Lack
of data on childhood blindness for evidence based planning and programme

Ø  Lack
of awareness about pediatric cataract in the community and even in primary
health worker, has a major impact on follow up, presentation and acceptance for
surgery.

 

Ø  Unavailability
of pediatric services at primary and secondary level of eye care thus making
child eye care less accessible.

 

Ø  Lack
of integration with government health system- 
If integrated, we can take advantage of the existing network and health
worker to expand and provide eye care service to the primary level. This will
also help in long term sustainability of the programme.

Ø  Human
resource scarcity at all levels and retention problem- It is a perennial
problem. There is only one pediatric ophthalmologist and one low vision
specialist for 2 million   population.   Availability of anesthesiologist is also a
problem. Retaining them is a huge challenge in place like Lahan.

 

Ø  Gender
inequity – female children are less in number accessing the cataract surgery

 

Ø  Overcoming
different barriers related to access, treatment, follow up and special education

 

Ø  Lack
of rehabilitation service and special or integrated education thus making the
rehabilitation more difficult.

 

Ø  Disproportionate
distribution of eye care center in the region, thus making the eye care service
less accessible in hilly and mountainous region.

 

Ø  School
screening, pediatric screening and teachers training focused in area closer to
hospital and urban areas.

 

Ø  Pediatric
cataract and childhood blindness programme overall is run by external support.
So, the issue of sustainability is a major challenge. Cost of consumables and
equipment are high.

 

Ø  Providing
good spectacle frame, quality glass and low vison device is a challenge

 

It is important to
consider a comprehensive approach for the management of pediatric cataract
which includes case
detection and referral, surgery, follow up, refraction and low vision
correction, and educational placement. There is strong need for advocacy,
improvement in surgical uptake, human resources availability, coverage, follow
up and overcoming the barriers to achieve a sustainability and reduction in the
prevalence of childhood blindness.