|Year : 2019 | Volume
| Issue : 2 | Page : 77-82
Establishing a pediatric ophthalmology service in malawi: Developments in childhood cataract surgery
Aaron Jamison1, Jane R Mackinnon1, Timothy E Lavy1, Chatonda Manda2, Gerald Msukwa2
1 Vision 2020 Glasgow-Blantyre Link, Glasgow Team, Scotland, UK
2 Lions Sight First Eye Hospital, Queen Elizabeth Central Hospital, Blantyre, Malawi
|Date of Web Publication||26-Aug-2019|
Dr. Aaron Jamison
Tennent Institute of Ophthalmology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow G12 0YN
Source of Support: None, Conflict of Interest: None
| Abstract|| |
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.
Keywords: Africa, cataract, pediatric, surgery
|How to cite this article:|
Jamison A, Mackinnon JR, Lavy TE, Manda C, Msukwa G. Establishing a pediatric ophthalmology service in malawi: Developments in childhood cataract surgery. Middle East Afr J Ophthalmol 2019;26:77-82
|How to cite this URL:|
Jamison A, Mackinnon JR, Lavy TE, Manda C, Msukwa G. Establishing a pediatric ophthalmology service in malawi: Developments in childhood cataract surgery. Middle East Afr J Ophthalmol [serial online] 2019 [cited 2019 Sep 17];26:77-82. Available from: http://www.meajo.org/text.asp?2019/26/2/77/265374
| Introduction|| |
Bilateral cataract is now the main cause of childhood blindness in Africa, necessitating the position of pediatric cataract as the World Health Organization (WHO)-Vision 2020 key priority. It is estimated that there are up to 82,000 children with congenital or developmental cataract in sub-Saharan Africa, with approximately 19,000 new cases each year. Left untreated, these will lead to reduced educational prospects, economic loss, social burden, and ultimately, a lifetime of dependence. Traumatic cataract also places a burden of visual morbidity, although, the incidence is unknown in this population.
Prompt surgical correction and adequate visual rehabilitation is the solution, but the barriers to implementation are considerable. The WHO and the International Agency for the Prevention of Blindness have recommended that there be one Child Eye Health Tertiary Facility (CEHTF)/10 million people in developing countries. Development of Pediatric Ophthalmology Services able to meet the demand is a huge undertaking in itself, with all of the financial/aid implications associated. The effectiveness of each service then depends on its uptake by the local population which requires first, effective diagnosis of the condition, and second, consideration of the socioeconomic barriers, such as poor health education, distance to the hospital, transport costs and other family implications, which might stop a child from presenting to the service. Schulze Schwering et al. showed, in 2014, that only 30% of children accept an offer of cataract surgery in Malawi; the two main contributing factors identified were economic hardship and long distances to the health-care facility. The cost of pediatric cataract surgery in Malawi has been calculated to be $202/case based on 2011 figures. This cost is borne by the state.
Following prompt cataract surgery, immediate (and regularly updated) refractive correction, usually with spectacles, is essential to maximize visual acuity (VA) and prevent the onset of amblyopia, in both the aphakic and pseudophakic. If not treated early, dense congenital cataracts may cause nystagmus and vision deprivation amblyopia which, if bilateral, will likely lead to life-long, irreversible blindness.
Malawi, with an estimated population of 17,215,000 (in 2015), is a country facing many of these challenges. About 45.2% its population (7,774,000) are aged 0–14, resulting in an estimated 1314 new cases of childhood cataract (both congenital and developmental) in Malawi each year (based on an overall childhood cataract incidence of 1.69/10,000 children).
In 2005, with no dedicated Pediatric Ophthalmology Service in the country, the Malawian Ministry of Health identified children's eye health as a priority and with assistance from the Vision 2020 Links Programme, signed a Memorandum of Understanding linking the Lions Sight First Eye Hospital (LSFEH) in Blantyre, Malawi with Glasgow's Royal Hospital for Sick Children (RHSC, now the Royal Hospital for Children), Scotland, UK. The original focus of this link was the training of health workers to staff such a service, and in particular, Malawi's first Pediatric Ophthalmologist (our fifth author, GM). Development of pediatric anesthetics was another early key area in this process. To encourage referrals from across the country, attention turned to training Ophthalmic Clinical Officers (OCOs) – Malawi's frontline ophthalmic health workers, responsible for the diagnosis and initial management of eye conditions within their local community, and referral to opticians, orthoptists, or hospital-based Ophthalmology Departments where necessary. In 2011, the Glasgow-Blantyre link developed an annual Pediatric Ophthalmology training course, targeted at OCOs, which combines wide-ranging lectures and group work with practical sessions that cover, in addition to many other topics, VA measurement, eye examination, and diagnosis/management in the context of the child. As the course has grown in popularity, it has expanded to include optometrists and some junior doctors, including one who has recently become Malawi's second dedicated Pediatric Ophthalmologist (fourth author, CM).
The unit at Blantyre encourages and receives referrals of all serious and treatable causes of visual impairment in children. As well as cataract, this includes glaucoma, trauma, retinoblastoma, and numerous congenital eye conditions. All eye surgery on infants and early follow-up is carried out in LSFEH, Blantyre. Later follow-up is transferred to regional services where possible. Within the wider hospital setting, there is a Pediatric Oncology Unit on the same campus that provides 3-agent chemotherapy for retinoblastoma. The LSFEH employs a childhood low vision coordinator to record numbers and causes of visual impairment, provide training for key informants, and coordinate available support services.
The aim of this paper was to use childhood cataract surgery as a surrogate measure of this recently established service's effectiveness and to evaluate any change in their referrals since the training course was introduced, using the limited data available.
| Materials and Methods|| |
A retrospective case note review was performed at the LSFEH, collecting available data of children who had undergone cataract surgery between 2011 and 2016. With very limited local storage of case notes, comprehensive reporting was not possible. In certain years, a maximum of 25 case notes were available, and hence, this number was selected per year (6 years, n = 150), chosen at random if >25 were available for an individual year. Data collected included patient demographics and details of preoperative assessment, procedure performed, follow-up, any complications, and postoperative refraction.
Separate to this review, LSFEH records monthly numbers of each operation retrieved from theatre records, allowing us to present total numbers of cataract procedures. By dividing the number of annual procedures performed by the total population of Malawi (17,215,000 in 2015) we calculated annual childhood cataract surgical rates (CCSR) per one million total population as described previously in Tanzania.,
An unpaired t-test was performed to compare age at presentation in the three earlier years (2011–13) with the three later years (2014–16).
This study did not require approval by an ethics committee but adheres to the principles of the Declaration of Helsinki.
| Results|| |
Over the six year period studied, 949 pediatric cataract procedures were performed at LSFEH with the highest number in 2011 [Table 1]. Overall, 55.8% (n = 530) of the procedures were performed on boys with a slight male predilection persistent throughout. The mean annual CCSR per million population was 9.2 [Table 1]. The mean age at presentation was 6.01 years over the years studied. We looked for any change in age at presentation following the introduction of the Pediatric Ophthalmology course, but this was only evident when comparing the three earlier years (2011–13, mean age 6.6 years) with the three later years (2014–16, mean age 5.3 years) by means of a Student's t-test (P = 0.03).
|Table 1: Yearly total pediatric cataract procedures performed at the Lions Sight First Eye Hospital, including childhood cataract surgical rate per million population|
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Considering the procedures month-by-month, there is often a drop in the number performed during the hottest months (October–January) of the year.
Malawi is divided into three administrative regions, namely the Northern, Central, and Southern Regions. For the purposes of this paper, this data was grouped to illustrate the cases referred from each region in the 150 cases studied. [Figure 1] compares the distribution of referral source year-to-year and with the distribution of the Malawian population, as described by the 2008 Malawian census (Total – 13,077,160, Northern Malawi – 1,708,930, Central Malawi – 5,510,195, Southern Malawi – 5,858,035). The distribution of cases by referral source has varied over the six years studied, with a trend toward the distribution of the population as a whole, with the final year studied (2016) matching the population distribution most closely.
|Figure 1: Year-by-year geographical distribution of pediatric cataract by “region of origin” (n = 25/year)|
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Sub-analysis of 150 case sample
Sixty-six of the 150 cases included in the study were reported to have congenital cataract (44.0%), 42 had traumatic cataract (28.0%), 13 had developmental cataract (8.7%), and the remaining 29 cases did not have a cataract type recorded.
Forty-six (30.7%) cases underwent surgery to the right eye, 32 (21.3%) to the left, and 72 (48%) had both eyes operated (only the first eye was included in the analysis).
Preoperative VA measurements were recorded in 70.7% of cases with a mean logarithm of the minimum angle of resolution (LogMAR) of 2.008, excluding 63 children with Perception of Light (PoL) [Table 2]. Preoperative refraction was recorded in 2.7% of cases.
|Table 2: Pre- and post-operative visual acuity measurement and refraction (n=150)|
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Postoperative VA measurements were recorded in 58 (38.7%) of the 150 cases, with a mean LogMAR of 0.613, excluding seven children with “PoL” only, showing an overall acuity improvement achieved by surgery [Table 2]. Postoperative refraction was recorded in 94 (62.7%) of the 150 cases.
All children underwent a lensectomy with anterior vitrectomy. One hundred and sixteen (77.3%) of these cases involved implantation of a foldable hydrophilic poly (hydroxyethyl methacrylate) intraocular lens, with a mean age at the time of operation of 7.0 (0.2–15.0) years. The remaining 34 cases (22.7%), with a much lower mean age of 2.5 (also 0.2–15.0) years, were left aphakic. Of the eight children left aphakic that were ≥3 years old, five had traumatic cataract; three had no cataract type reported.
Children waited a mean of 11.7 days (excluding three outliers who had a significant delay due to recorded patient-related socioeconomic factors) for their first eye operation, with no convincing trend noted over the studied years. The 49 children undergoing bilateral cataract surgery waited a further mean 11.1 days for their second operation (excluding two outliers who were also delayed due to patient-related socioeconomic factors recorded in the case notes).
The mean length of follow-up for the 150 cases studied was 106 days (range 0 days–3.25 years) [Table 3]. Follow-up duration appears reduced over the latter three years, however the proximity of the date of data collection to the more recent procedures will limit the follow-up recorded. Only three patients (2%) received no follow-up. Reported complications for the 150 collected cases [Table 3] include only one postoperative endophthalmitis.
| Discussion|| |
This study demonstrates that a significant number of safe pediatric cataract operations are being performed in Malawi in a newly established Pediatric Ophthalmology Service. The focus on cataract surgery allows a measurable indication of an effective service as it encompasses all aspects of Pediatric Ophthalmology care: medical, surgical, anesthetic, nursing, optometric, administrative support, and a functioning infrastructure.
Development of an effective service relies not only on accurate diagnosis of a condition but also on appropriate communication with the child's family, timely referral, and strategies to ensure the child travels to the correct facility for treatment. It may be that children with cataract are going undiagnosed, are not being referred, or are refusing treatment due to a range of socioeconomic factors, the most prevalent likely to be the distance required to travel to the LSFEH in the south of Malawi. Despite Malawi's size, it may take three days to travel to Blantyre from some parts of the country's Northern region.
The annual number of operations has not increased over the years studied, and the reasons for this are unclear. It is likely that the maximum capacity of the service has been reached due to its dependence on a single pediatric ophthalmologist. Available cataract theatre time in this CEHTF may be limited by increasing referrals by OCOs of other vision or life-threatening conditions such as glaucoma or retinoblastoma also requiring surgery. Pediatric cataract surgery is not known to be performed by any other Ophthalmologist (n = 10 in 2017) in Malawi.
There was a slight reduction in the mean age at presentation over the study period which is encouraging. We believe this is largely due to improved local diagnosis and referral by OCOs following high-quality training of nearly all Malawian OCOs (n = 107) plus 27 optometrists on the annual Pediatric Ophthalmology course. During the course, participants are given opportunities to examine children with cataract, as well as other causes of a “white pupil,” and the need for prompt referral of cataracts to the LSFEH is stressed.
The patient demographic data reveal a slight preponderance for boys (1.26:1) undergoing cataract surgery, which is similar to studies in other developing countries (for example, 1.48:1 in Tanzania).
Considering only the 150 cases who underwent full casenote review, the male:female ratio (1.54:1 overall) was 2.00:1 for traumatic cataracts, and 1.40:1 for nontraumatic cases. No further data are available on pediatric cataract surgery in Malawi other than presented in this paper. Training of Malawi's first Pediatric Ophthalmologist commenced in 2005 and records earlier than those reported here (i.e., earlier than 2011) are sparse and incomplete.
The CCSR figures [Table 1], mean = 9.2] compare favorably with those reported in Tanzania (10.7 in 2004/5, 9.9 in 2006). The CCSR is a useful tool allowing the assessment of a cataract service, identification of gaps in service (e.g., age, gender, and region of origin) and monitoring of annual progress. This figure for Malawi, therefore, reveals the limitations of the service in both keeping up with the incidence of childhood cataract (estimated to be 20/million population in sub-Saharan Africa) as well as dealing with the backlog of untreated cases (estimated to be 100/million population).
In those cases with available records, the average wait time before receiving first eye cataract surgery was 11.7 days, which contrasts very favorably with that achieved in the developed world.
Preoperative recording of VA was encouraging at a mean of 70.7%. Postoperative VA measurements were less common (38.7%), but a significant number had recorded refraction (62.7%) following surgery. Data for these measurements may be limited by dual recording in the patient-held case books which were not available for data collection. In this setting of a single consultant pediatric ophthalmologist service without embedded orthoptic, and limited optometric, support, these figures are commendable.
Mean postoperative VA was 0.613 LogMAR, excluding seven patients with “PoL” vision, with 58.1% of the patients with postoperative VA recorded achieving 6/18 vision or better. Although the reliability of this rate is limited by incomplete data collection, it is comparable with the findings of other papers measuring the visual outcomes following pediatric cataract surgery in Africa: Tanzania, 58% achieving ≥6/18; Kenya, 44%; Northwest Ethiopia, 37%; Zambia, 29.7%; and KwaZulu-Natal province of South Africa, 24.7%.
There appears to be a reduction in mean follow-up time over the latter three years studied. For those cases performed in 2015 and 2016, their proximity to the date of data collection (late 2016) would limit the total length of follow-up recorded.
A low number of complications per year were reported [Table 3], with postoperative uveitis and posterior capsular opacification known to be prevalent following pediatric lensectomy in other similar settings. The occurrence of only one case of postoperative endophthalmitis in the 150 cases sampled suggests the presence of a safe surgeon. The paucity of notes kept for the total of 949 cataract operations over the studied period does not allow further analysis of the complication rate. It is to be expected, however, that records are more likely to have been kept for cases requiring further intervention. Bilateral simultaneous cataract surgery was not performed in this center in keeping with clinical practice in other countries, with the aim of preventing catastrophic bilateral endophthalmitis.
The main limitation of this study is incomplete data due to a combination of the absence of an easily accessible health record system and the incomplete documentation of clinical details. Comprehensive record-keeping, familiar in the developed world, is not as readily found in poorer nations. The use of incomplete data will affect the reliability of the subsequent statistical analysis. The small number of records available has, however, allowed us to produce this paper-the first of its kind from Malawi. The selection of 150 cases, from those that were available, was performed at random by a data collector with no knowledge of the individual cases, but the possibility of selection bias cannot be completely excluded.
Malawi remains one of the most underdeveloped nations in the world but the progress in establishing this safe, reliable, and inclusive Pediatric Ophthalmology Service over such a short period of time is encouraging.
| Conclusion|| |
An effective and valuable Pediatric Ophthalmology Service has been established in Malawi which seeks to relieve children of life-long blindness due to cataract. A CCSR of 9.2/million population provides a baseline figure for the impact of this CEHTF. Achieving appropriate follow-up remains an ongoing challenge, particularly to ensure adequate refractive rehabilitation. The geographical distribution of cataract referrals has improved and the age at presentation of children receiving cataract surgery has shown some reduction over the six-year period studied. We suggest that these changes are due to the positive impact of an annual teaching program aimed at OCOs.
- The Scottish Government for funding the Vision 2020 link partnership between LSFEH and RHSC over nine years
- Yorkhill Children's Charity for their support with the administration and accounting required to maintain this Vision 2020 Links partnership
- Catherine Lunduka, administrator at LSFEH, for continued maintenance of health records
- Fiona's Eye Fund for providing financial support to AJ for travel to collect the data which has made this study possible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]