ORBIS International & Lions NAB E NAB Eye Hospital, Miraj H - - PowerPoint PPT Presentation

ORBIS International & Lions NAB E H it l Mi j NAB Eye Hospital, Miraj

Operational Research Project, AED/USAID Cycle VI July 25, 2011 July 25, 2011

Partnership – ORBIS & Lions NAB Eye Hospital p

 ORBIS & Lions NAB Eye Hospital (LNEH) partnered under AED/USAID Child Blindness Fund Cycle VI to implement operational research project (November 2010 – July 2011)

• ‘Post-operative continued follow-up leads to better visual outcomes which leads to

Post operative continued follow up leads to better visual outcomes, which leads to better patient quality of life’  ORBIS direct partner of AED & LNEH the implementing sub-partner

• ORBIS India & HQ – responsible for technical assistance, monitoring & reporting

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Q p , g p g

• LNEH implementing arm

– Principal Investigator, Parikshit Gogate, MS DNB FRCSEd MSc IPS – Director, Research & Education, Shailbala Patil, Lions NAB Eye Hospital

Acknowledgement

ORBIS International: Dr. Joan McLeod, Kerry St l D G V R Ri hi R j B Stalonas, Dr. G V Rao, Rishi Raj Bora AED/FDI Development 360: Kelly Josiah Lions NAB Eye Hospital, Miraj, India: Prof. A N Kulkarni, Dr. A H Mahadik, Dr. Mitali Shah, Dr. Kulkarni, Dr. A H Mahadik, Dr. Mitali Shah, Dr. Mohini Sahasrabudhe, Rahin Tamboli, Rekha Mane,

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Project Objectives

T d t i th f li t f ll

• To determine the causes of poor compliance to follow-up
• f eye care for children after cataract surgery
• To assess the visual acuity/outcomes of children who
• To assess the visual acuity/outcomes of children who

received pediatric cataract surgery

• To better understand the impact of pediatric cataract

interventions on the quality of life and vision function of a child

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Childhood Blindness Situation in India C d ood d ess S tuat o d a

• 320,000 children are blind; 9.2 million children are visually

impaired (Gogate P, Gilbert CE. Blindness in children – a world wide perspective: Journal of

Community Eye Health 2007; 20 (62): 32-33 )

• 50% of pediatric eye conditions are treatable or

t bl preventable

• Main causes: cataract, refractive errors, corneal

ulcer/opacity, retinopathy of prematurity, glaucoma, trauma, strabismus

• Life expectancy of a blind child is about 48 years (BR Shamanna

et.al.; Economic burden of blindness in India; Ind J Ophthalmol 1998;46 :169-172) , thus

disproportionate burden of blindness

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disproportionate burden of blindness (Rahi J, et.al. Measuring the burden of

childhood blindness. Br J Ophthalmol 1999;83:387–388)

ORBIS India Childhood Blindness Initiative (ICBI) ( )

• ORBIS in coordination with the Government of India,

identified a need for 100 pediatric eye care facilities identified a need for 100 pediatric eye care facilities by 2020.

• The ORBIS Initiative intends to:
• Establish 50 well equipped & staffed pediatric

eye care centers around the country by 2020 .

• Key Components of the model include:

1.Introduce child-friendly pediatric eye care services

• 2. Build institutional capacity

3 T i di t i t

• 3. Train pediatric eye care teams
• 4. Conduct outreach in local communities to identify &

refer children with eye problems

• 5. Educate parents & caregivers

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p g

Before Initiation of ICBI : 4 pediatric centers

for nearly 400 million children y

R P C t N D lhi R P Centre, New Delhi L V Prasad Eye Institute, Hyderabad Sankara Nethralaya, Chennai A i d E

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y , Aravind Eye Hospital, Madurai

Current Partners: Pediatric Eye Care Centers

Established & In Development Established & In Development

National Training and Research Partners Aravind Eye Hospital, Madurai, Tamil Nadu Sankara Nethralaya, Chennai, Tamil Nadu

• L. V. Prasad Eye Institute, Hyderabad, A. P.

Pediatric Eye Care Centers Established 1 Dr. Shroff’s Charity Eye Hospital, Delhi 2 Sadguru Netra Chikitsalaya, Chitrakoot, M. P. 3 H. V. Desai Eye Hospital, Pune, Maharashtra 4 Lions NAB Eye Hospital, Miraj, Maharashtra 5 Little Flower Hospital, Angamaly, Kerala 6 West Lions Eye Hospital, Bangalore, Karnataka 7 Lotus School of Optometry, Mumbai, Maharashtra 8 Sankara Eye Center, Guntur, Andhra Pradesh 9 Srikiran Institute of Ophthalmology, Kakinada, A. P. 10 Sri Sankaradeva Nethralaya, Guwahati, Assam 11 Drashti Netralaya, Dahod, Gujarat 12 Shri Ganapati Nethralaya, Jalna, Maharashtra 13 Regional Institute of Ophthalmology (RIO) – R P Center, New Delhi 14 RIO – Kolkata, West Bengal 15 Global Hospital, Mount Abu, Rajasthan 16 Kalinga Eye Hospital, Dhenkanal, Orissa 17 Ramakrishna Mission Hospital, Itanagar, Arunachal 18 Medical College, Dehradun, Uttaranchal 19 Christian Medical College, Ludhiana, Punjab 20 MGM Eye Hospital, Raipur, Chattisgarh 21 Khairabad Eye Hospital, Kanpur, Uttar Pradesh 22 Suraj Eye Institute, Nagpur, Maharashtra 23 MM Joshi Eye Hospital, Hubli, Karnataka 24 Shri Sadguru Sewa Sangh Trust, Anandpur, M. P. 25 Sahai Hospital and Research Center, Rajasthan 26 Alakh Nayan Mandir, Rajasthan 27 Choitram Nethralaya, Madhya Pradesh

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28 Gandhi Eye Hospital, Aligarh, Uttar Pradesh 29 Netra Niramoy Niketan, Haldia, West Bengal Pediatric Eye Care Centers in Development 30 Siliguri Greater Lions Eye Hospital, West Bengal

Future Locations of Pediatric Eye Care Centers

Pediatric Eye Care Centers to be Developed 31 Partner to be identified, Uttar Pradesh 32 Partner to be identified, Karnataka 33 Partner to be identified, Madhya Pradesh 34 Partner to be identified, Uttar Pradesh 35 Partner to be identified, Bihar 36 Partner to be identified, Bihar 37 Partner to be identified, Jharkhand 38 Partner to be identified, Orissa 39 Partner to be identified, Madhya Pradesh 40 Partner to be identified, Uttar Pradesh 41 Partner to be identified, West Bengal 42 Partner to be identified, West Bengal 43 Partner to be identfied, Assam 44 Partner to be identified, Gujarat 45 Partner to be identified, Gujarat 46 Partner to be identified, Haryana 47 Partner to be identified, Himachal Pradesh 48 Partner to Be identified, Uttar Pradesh 49 Partner to be identfied, Kerala 50 Partner to be identified, Rajasthan

Focusing on central and northern India

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ICBI Progress thru 2010

 29 centres across 16 states have been established  More than 5 5 million children screened  More than 5.5 million children screened  More than 978,000 children treated medically or for glasses  Over 81,500 pediatric surgeries have been performed (out of which approximately 40% were pediatric cataract) % A hi t f ICBI

74.11% 25.89%

% Achievement of ICBI

76.70% 88.99% 23.30% 11.01%

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0.00% 20.00% 40.00% 60.00% 80.00% 100.00% Already Achieved To be Achieved

ORBIS & LNEH Initial Partnership

As part of the ICBI ORBIS partnered with LNEH to As part of the ICBI, ORBIS partnered with LNEH to establish a pediatric eye care center from 2005 – 2008 More than 1,000 children operated on for various diseases, including 374 children (520 eyes) that diseases, including 374 children (520 eyes) that received pediatric cataract surgery Today the center fully functioning unit that serves Today the center fully functioning unit that serves child pop of 3.5 million in southern Maharashtra (southwest India)

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( )

Significance of Pediatric Cataract

Pediatric cataract is the leading cause of avoidable

• r treatable blindness in most developing countries
• r treatable blindness in most developing countries

Three large studies on causes of blindness and i l i i t i hild diff t severe visual impairment in children across different Indian states has put un-operated cataract & uncorrected aphakia as a significant and increasing uncorrected aphakia as a significant and increasing cause of visual impairment

1 Gogate P et al Changing pattern of childhood blindness in Maharashtra 1.Gogate P, et. al. Changing pattern of childhood blindness in Maharashtra,

• India. Br J Ophthalmol. 2007;91(1):8-12.
• 2. Bhattacharjee H, Borah RR, Guha K, Gogate P, et al. Causes of childhood

blindness in the north-eastern states of India. Indian J Ophthalmol.

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2008;56(6):495-9.

• 3. Gogate P, et al. The pattern of childhood blindness in Karnataka, South
• India. Ophthalmic Epidemiol. 2009 Jul-Aug;16(4):212-7.

Standard Follow-Up Protocol

1st Follow-up 1 week after surgery 2nd Follow up Month after first follow up (5 2nd Follow-up Month after first follow-up (5 weeks after surgery) - Prescription of glasses, Patching to start 3rd Follow-up 3 Months (12 weeks) from surgery Up to 16 years follow up every six months (bi Up to 16 years follow-up every six months (bi- annual) After 16 years till child follow-up once a year (annual)

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y attains adulthood p y ( )

Outcomes of Pediatric Cataract Surgery

Very few reports of outcomes pediatric cataract surgery from India and Nepal surgery from India and Nepal Most focus on short term outcome 6 weeks to 3 month follow-up As the child grows, the eye too develops and changes; and a long term follow-up is recommended by experts to maintain and if needed recommended by experts to maintain and if needed restore vision

• 1. Thakur J,et al. Pediatric cataract surgery in Nepal. J Cataract Refract Surg

2004;30:1629 1635 2004;30:1629–1635.

• 2. Khandekar R, et. Al. Pediatric cataract and surgery outcomes in Central India: a hospital based
• study. Indian J Med Sci. 2007 ; 61(1):15-22.
• 3. Gogate P, et.al. Cataracts with delayed presentation- Are they worth operating upon? Ophthalm

Epidemiology 2010; 17(1): 25 33

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Epidemiology 2010; 17(1): 25-33.

Assumptions/Rationale

• Pediatric cataract surgery is just one crucial step in the

process to rehabilitate a cataract blind child process to rehabilitate a cataract blind child

• Proper post-operative follow-up, repeated checking of

refraction and anti-amblyopia services are essential to y p restore and maintain the child’s vision

• Studies from Africa shown follow-up rates of pediatric

t t d ff t th hild’ lti t cataract surgery are poor and affect the child’s ultimate visual recovery 1

• Unfortunately no such studies exist from India or Asia

Unfortunately no such studies exist from India or Asia (which houses largest number of blind children globally)

• 1. Erickson JR, Bronsard A, Mosha M, Carmichael D, Hall A, Courtright P. Predictors of poor

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• 1. Erickson JR, Bronsard A, Mosha M, Carmichael D, Hall A, Courtright P. Predictors of poor

follow-up in children that had cataract surgery. Ophthalmic Epidemiology 2006; 13:237-243

Rationale

To determine the impact that cataract intervention has on the quality of life of a child has on the quality of life of a child

• LNEH performed hundreds of sight restoring surgeries during

ORBIS project period unfortunately little data on how the ORBIS project period, unfortunately little data on how the intervention impacts a child’s life A ti b k bli d ti l th t th

• Assumption by many key blindness prevention players that the

intervention doesn’t just improve the child’s vision but also assists in social and educational development

• Few studies available however to corroborate this

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Project Objectives Summary

 Project studied long term outcomes of pediatric cataract surgery & evaluated the barriers to the child and his/her surgery & evaluated the barriers to the child and his/her parents for not accessing follow-up eye care services  Study addressed the knowledge gap about the impact of  Study addressed the knowledge gap about the impact of pediatric cataract surgery on the child’s life, growth, mobility, education & general development  Results to assist in planning of future childhood blindness amelioration initiatives so future programs can be more effective by ensuring better follow-up effective by ensuring better follow up

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Study Methodology & Planning

 Study was completed between Oct 2010 June 2011 but  Study was completed between Oct 2010-June 2011, but planning began in July 2011  Approved by the ethical committee of Lions NAB Eye Hospital Miraj (LNEH) was obtained in August 2011 Hospital, Miraj (LNEH) was obtained in August 2011  Case records of all 520 pediatric cataracts (on 374 children)

• perated on from 2005-2008 obtained from the medical

records unit records unit  Addresses of each child, along with phone #s recorded  Children grouped according to talukas (sub districts in Indian  Children grouped according to talukas (sub-districts in Indian administration) & villages

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Study Methodology - Case Mapping

A i i  A mapping exercise conducted using various colour stickers to visualize location of the cases location of the cases  Result was a clear idea of village-wise distribution of children & minimized children, & minimized effort/time of community workers to find the children children  Daily plans generated for community workers to visit the area & identify

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the area & identify children

Barriers to Follow-Up Questionnaire - Design & Training on its Administration

 A questionnaire to record barriers to pediatric follow-up required for development  Inputs taken from the RAAB India study [1] & additional questions added, considering pediatric population  Questionnaire translated into local language, Marathi, by two independent translators  Marathi translations translated  Marathi translations translated back into English to verify if any content changed or lost during translation, & upon satisfaction printed printed  Community workers were again

• riented to questionnaire &

trained on various methods to

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trained on various methods to administer it (direct questioning, catching information during individual or group discussions)

• 1. John N, et.al. Rapid assessment of avoidable

blindness in India. PLoS ONE 2008;3(8):e2867

Kuppusamy scale for judging socio- economic status

 To determine if parents’ education & socio-economic status had any effect on follow-up, Kuppusamy scale of measuring socio – economic status included in the questionnaire

[Kumar

socio economic status included in the questionnaire. [Kumar

N, et. al. Kuppuswamy's socioeconomic status scale-updating for 2007. Indian J Pediatr. 2007 Dec;74(12):1131-2.]

 Community workers also trained on administering the  Community workers also trained on administering the Kuppusamy scales which depended on fathers occupation, fathers education, mother’s education, mother’s occupation and family income These 5 parameters were used to score and family income. These 5 parameters were used to score and divide the family into 5 socio-economic classes.

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Child Vision Function Questionnaire - Design & Training on its Administration

 L V Prasad’s Functional Vision Questionnaire for children  L.V. Prasad s Functional Vision Questionnaire for children was adopted for determining the impact of pediatric cataract surgery on the quality of life of the child 1  Questionnaire was translated into local language by two independent translators, & back-translated to English to check for validity & upon satisfaction was printed check for validity, & upon satisfaction was printed  Children over 12 years answered questions on their own (and responses corroborated with parents); for younger ( p p ); y g children, parents were interviewed

• 1. Gothwal VK, et.al. The development of the LV Prasad-Functional Vision

Questionnaire: a measure of functional vision performance of visually

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Questionnaire: a measure of functional vision performance of visually impaired children. Invest Ophthalmol Vis Sci. 2003 Sep;44(9):4131-9.

Community/Social Worker Training

Training schedule developed & stressed: Importance of childhood blindness & pediatric cataract

• Importance of childhood blindness & pediatric cataract
• Training on use & completion of both questionnaires
• Potential problems & pitfalls in its completion discussed
• Potential problems & pitfalls in its completion discussed
• How to assist pediatric ophthalmologists in collecting

patient history & capturing data

• Entering data to excel sheets & ways to maintain data

accuracy & validity  Following the training, a pilot study conducted in nearby Savli village with 37 children - sample size of 10% identified & counseled

23 A fortified training later conducted with Pediatric

Ophthalmologist & Principal Investigator

Development of Clinical Protocol

D l d b D P ik hit G t ( i i l i ti t )  Developed by Dr. Parikshit Gogate (principal investigator)  Validated by Professor Clare Gilbert (London School of Hygiene and Tropical Medicine/International Centre for Eye Hygiene and Tropical Medicine/International Centre for Eye Health (ICEH)  Valuable inputs provided by: Dr Joan McLeod (USA); Dr  Valuable inputs provided by: Dr. Joan McLeod (USA); Dr. Rupal Trivedi (USA); Dr. H. Kishore (Oman); Dr. Millind Killedar (India)  Approved by Dr. G.V.Rao, Prof. A.N.Kulkarni, Rishi Raj Bora,

• Dr. Lutful Husain with Dr. Mitali Shah and Dr. Mohini

Sahasrabudhe of LNEH

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Sahasrabudhe of LNEH

Data collection

 Daily program scheduled for community workers & y counselors to go into the field & identify children  ‘Barriers to follow–up’ Barriers to follow up questionnaire was completed; and children & parents counseled about i t f l importance of regular follow-up  ‘Vision function questionnaire’ completed at time of clinical examination at the hospital & during the

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hospital & during the home visits

Clinical Examination

 Children identified were transported by vehicle to LNEH transported by vehicle to LNEH along (along with parents) for eye examination  Children underwent complete

• cular examination – slit lamp

examination, orthoptic l ti f d & evaluation, fundoscopy & cycloplegic refraction  Clinical data was recorded If Clinical data was recorded. If any treatment required, they were informed, & relevant treatment provided. Also

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ea e p o ded so counseled during the visit about importance of follow-up

Patient Home Visit

 In spite of home visits & counseling, 74 children did not g, visit LNEH  Developed schedule for home visits of these children by Pediatric Ophthalmologist along with optometrist & g p community workers  Home visits were conducted with required equipments (portable visual acuity charts, portable slit lamp,

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p p, Keratometer, A-Scan) & children were examined

Summary: Project outputs

374 children (520 eyes) were operated for pediatric t t t Li NAB E H it l Mi j cataract surgery at Lions NAB Eye Hospital, Miraj from 2005 to 2008. Out of these, 328 children (88%) were identified and completed the Barriers to Follow-Up Questionnaire 262 children -70% (393 eyes) were examined

• All but 19 required some form of intervention

262 children/parents completed the Vision Function Questionnaire

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Questionnaire

Result: Age Group

Demographic Data – Age wise Distribution

Age Frequency % 0 – 5 12 4.6 6 – 10 59 22.5 11 – 15 94 35.9 16 – 20 97 37.0

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Total 262 100.0

Result: Gender & Laterality

Frequency Percent

Gender

Frequency Percent Male 150 57.3 Female 112 42.7 Total 262 100.0

Laterality

Frequency Percent Both Eyes 131 50.0 y Left Eye 64 24.4 Right Eye 67 25.6

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Total 262 100.0

Number of children in the family

Boys Girls Boys Girls Frequency Percent Frequency Percent One 106 40.5 102 38.9 One 106 40.5 102 38.9 Two 118 45.0 60 22.9 Three 17 6 5 30 11 5 Three 17 6.5 30 11.5 Four 4 1.5 11 4.2 Five 1 0 4 2 0 8 Five 1 0.4 2 0.8 None 16 5.8 57 21.8 T t l 262 100 0 262 100 0

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Total 262 100.0 262 100.0

Study Variables, Result: Ordinal Status of the child

Frequency Percent Eldest 92 35.1 Middle 65 24.8 Youngest 105 40.1 Total 262 100.0

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Result: Any other similarly affected child in family Frequency Percent Yes 39 14.9 No 223 85.1 Total 262 100.0 Frequency Percent No 223 85.1 Yes, one child 29 11.1 Yes-2 children 10 3.8

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Total 262 100.0

Result: Mother's Occupation

Mother's occupation Number of patients Percentage (%) U l d 1 117 44 7 Unemployed 1 117 44.7 Unskilled worker/ home maker 2 62 23.7 Semi-skilled 3 11 4.2 Skilled 4 6 2.3 Clerical/Shop owner / farmer 5 56 21.4 Semi profession 6 1 0 4 Semi-profession 6 1 0.4 Profession 7 2 0.8 Missing 7 2 7

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Missing 7 2.7 Total 262 100

Kuppusamy Score for Socio economic class

Socio Socio economic class Frequency Percentage (%) I (Hi h t) 2 0 8 I (Highest) 2 0.8 II 13 5.0 III 75 28.6 IV 161 61.5 V (Lowest) 11 4.2 Total 262 100.0

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Total 262 100.0

Compliance for Follow-up

N b f P t N Number of patients Percentage (%) Compliance 53 20.2 Compliance 53 20.2 Non 209 79 8 Non compliance 209 79.8 T t l 262 100 0 Total 262 100.0

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Compliance to follow-up: Regular (compliant)

• r not regular (Non-compliant)

g ( p )

Percentage Follow-up Total p- Percentage (%) Non- Non- value Comp. comp. Comp. comp. Age 0 - 5 8 4 12 group 66.7 33.3 6 - 10 19 40 59 32.2 67.8 < 0 001 11 -15 11 83 94 11.7 88.3 ≥ 16 15 82 97 15 5 84 5

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0.001 15.5 84.5 Total 53 209 262

Barriers to Follow-Up

Th t b i d The most common barriers emerged as – We cannot afford to travel, visit the hospital - 25.3%

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The hospital is too far - 20.6%

Barriers to Follow–Up

Did not find time/ I had more urgent things to do - 26.9% 26.9%

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Barriers to Follow-Up

The child was seeing fine.- 24.5% Did not feel the need - 14 8% Did not feel the need - 14.8%

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Barriers to Follow-Up

No one told to visit us again - 20.6%

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Barriers to Follow-Up

I thought whatever I d ill t do will not improve the child’s the child s vision - 0.4%

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Barriers to Follow-Up

Some of the other reasons:

• The surgery made no difference to child’s vision – 3.9%
• Doctors or staff kept me waiting for a longtime - 1.2%

I th ht diti ill i b it lf 0 4%

• I thought condition will improve by itself - 0.4%
• Unaware of complications & risk of cataracts – 0.8%
• Others - 2%

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Summary Findings on Barrier to Follow-Up:

 20.6% Children complied with regular follow-up  Only 1 2% respondents felt that the doctors or staff in Only 1.2% respondents felt that the doctors or staff in the pediatric unit kept them waiting for a long time. (So child friendly atmosphere worked & was maintained)  14.8% respondents did not feel the need for follow-up.  20.6% respondents cited that no one told them to visit h h i l i

Education &

the hospital again  26.9% respondents said that didn’t find time to take their children to the hospital 24.5% respondents felt that th hild i fi

Education & Awareness Issues

the child was seeing fine  20 6% respondents said that the hospital is too far

Access & Affordability

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 20.6% respondents said that the hospital is too far  25.3% respondents said that they can not afford to travel to the hospital

Affordability Issues

Compliance to follow-up

P-value Significance Age group <0.001 Significant Gender 0 676 Not significant Gender 0.676 Not significant Ordinal status 0.818 Not significant Number of boys in family 0.860 Not significant Number of girls in family 0.391 Not significant Any other affected child 0.365 Not significant Mother’s education 0 012 Significant Mother s education 0.012 Significant Mother’s occupation 0.327 Not significant Father’s education 0.256 Not significant Father’s occupation 0.031 Significant Social strata 0.492 Not significant Accompanied by parent/ other 0 062 Not significant

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Accompanied by parent/ other 0.062 Not significant Money spent on travel 0.033 Significant Paid / Free 0.001 Significant

Vision Function: Before and After surgery

• 1. Do you have any difficulty in

making out whether the person making out whether the person you are seeing across the room is a boy or a girl, during the day? Pre op Score Ave(SD)-2 62 (0 8) Pre op Score Ave(SD)-2.62 (0.8) Post op Score Ave(SD)-0.95(1.0) 2 Do you have any difficulty in

• 2. Do you have any difficulty in

seeing whether somebody is calling you by waving his or her hand from across the road? hand from across the road? Pre op Score Ave(SD)- 2.57 (0.9) Post op Score Ave(SD )-0.95 (1.0)

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Vision Function: Before and After surgery

• 3. Do you have difficulty in walking

alone in the corridor at school without b i i t bj t l ? bumping into objects or people? Pre op - 2.34 (1.0) Post op - 0.77 (1.2)

• 4. Do you have any difficulty in

copying from the blackboard while sitting on the first bench in your class? Pre op - 2.44 (0.9) Post op - 0.96 (1.0) 5 Do you have any difficulty in

• 5. Do you have any difficulty in

reading your textbooks at an arm’s length? Pre op - 2.47 ( 0.8)

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p ( ) Post op - 0.96 (1.1)

Vision Function: Before and After surgery

• 6. Do you have difficulty in

surgery

y y reading the bus numbers? Pre op - 2.57 (0.8) Post op - 1 03 (1 0) Post op 1.03 (1.0)

• 7. Do you have any difficulty

i di th th d t il in reading the other details

• n the bus (such as its

destination?) Pre op - 2.53 (0.8) Post op - 0.99 (0.9)

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Vision Function: Before and After surgery

• 8. Do you have any difficulty in

writing along a straight line? P 2 32 (0 9)

surgery

Pre op - 2.32 (0.9) Post op - 0.70 (1.0) 9 Do you have any difficulty in

• 9. Do you have any difficulty in

finding the next line while reading when you take a break and then resume reading? resume reading? Pre op - 2.40 (0.9) Post op - 0.94 (1.0)

• 10. Do you have any difficulty in

locating dropped objects (pen, pencil, eraser) within the

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classroom? Pre op - 2.34 (1.0) Post op - 0.69 (1.0)

Vision Function: Before and After surgery

• 11. Do you have any difficulty in threading

a needle? Pre op - 2 55 (0 8)

surgery

Pre op - 2.55 (0.8) Post op - 1.25 (1.2)

• 12. Do you have any difficulty in walking

home at night (from tuition or a friend’s house) without assistance when there are streetlights? Pre op - 2.41 (1.0) Pre op 2.41 (1.0) Post op - 0.74 (1.0)

• 13. How much difficulty do you have in

distinguishing between 1 rupee and 2 distinguishing between 1 rupee and 2 rupee coins (without touching)? Pre op - 2.44 (0.9) Post op - 0.80 (1.0)

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Vision Function: Before and After surgery

• 14. Do you have difficulty in lacing your

shoes? Pre op 2 13 (1 1)

surgery

Pre op - 2.13 (1.1) Post op - 0.53 (1.0)

• 15. Do have difficulty in locating a ball while

y g playing in the daylight ? Pre op - 2.34 (0.9) Post op - 0.68 (0.9)

• 16. Do you have difficulty in climbing

d t i ? up or down stairs? Pre op - 2.22 (1.0) Post op - 0.49 (0.9)

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Vision Function: Before and After surgery

• 17. Do you have difficulty in applying paste
• n your toothbrush?

Pre op - 1 93 (1 2)

surgery

Pre op - 1.93 (1.2) Post op - 0.27 (0.8) 18 D h diffi lt i l ti

• 18. Do you have difficulty in locating

food on your plate while eating? Pre op - 1.87 (1.2) Post op - 0.32 (0.8)

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Post op 0.32 (0.8)

Vision Function: Before and After surgery

19 Do you difficulty in

• 19. Do you difficulty in

identifying colours (e.g., while colouring) ? Pre op - 2.17 (1.0) p ( ) Post op - 0.54 (0.9)

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Vision Function: Before and After surgery

20 Do you think your

• 20. Do you think your

vision is as good as your friend,? A bit less? A lot less? Pre op – 1.75 (0.5) Post op - 0.81 (0.5)

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Summary: Vision Function: Before and

After surgery

On every question, children fared better after the i t ti th b f intervention than before Even if visual recovery was not dramatic by visual acuity measurement, it made an immense difference to the child’s functioning Children reported more confidence in negotiating with their environment, peers & community at large Intervention was worth it

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Visual Acuity

Post-operative vision >6/18 in 40 7% Post-operative vision >6/60 in 57 8% >6/18 in 40.7% >6/60 in 57.8%

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Visual acuity

>= 6/18 <6/18 >=6/60 <6/60 Total

Complicated

4 (36.4%) 7 (63.6%) 8 (72.7%) 3 (27.3%) 11

Congenital

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Congenital

7 (20.6%) 27 (79.4%) 15 (44.1%) 19 (55.9%) 34

Developemental

51 (45 5%) 61 (54 5%) 72 (64 3%) 40 (35 7%) 112 51 (45.5%) 61 (54.5%) 72 (64.3%) 40 (35.7%)

Subluxlated

4 (100%) 0.00 4 (100%) 0.00 4

Total cataract

148

Total cataract

55 (37.2%) 93 (62.8%) 76 (51.4%) 72 (48.7%) 148

Traumatic

38 (46 3%) 44 (53 7%) 51 (62 2%) 31 (37 8%) 82

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38 (46.3%) 44 (53.7%) 51 (62.2%) 31 (37.8%)

Visual Acuity

P-value (>6/18) P-value (>6/60) Gender 0.053 0.094 Not significant Age-group 0.125 0.002 Significant Type of surgeon 0 419 0 999 Not significant Type of surgeon 0.419 0.999 Not significant Type of surgery 0.041 Significant Type of cataract 0 011 0 042 Significant Type of cataract 0.011 0.042 Significant Post-operative uveitis 0.097 0.013 Not significant Secondary glaucoma 0.627 0.883 Not significant Post cap opacification <0.001 <0.001 Significant Delay between diagnosis & surgery 0.067 Not significant Phaco used / not used 0.052 Not significant

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g

Secondary glaucoma

P-value Type of cataract 0 001 Significant Type of cataract 0.001 Significant Type of surgeon 0.99 Not significant Gender 0.51 Not significant Age 0.142 Not significant

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Posterior capsular opacification

P-value Type of cataract <0.001 Significant Type of surgeon 0.452 Not significant Gender 0.742 Not significant Age <0.001 Significant

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Summary

 Study showed that of the 262 children examined, all t 19 d d ki d f i t ti except 19 needed some kind of intervention 103 needed Nd:YAG LASER capsulotomy and 22 required surgery. Most needed a change of spectacles, 5 needed contact lenses and 4 required low vision aids low vision aids Demonstrates importance of regular follow-up as th hild’ d l & f ti the child’s eye develops, grows & refraction may change

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Summary

Visual outcomes were comparable to other studies ld id ( t l I di M i N l Chi world wide (central India, Mexico, Nepal, China, Tanzania & Kenya), but were lesser than those from the developed world the developed world While differences are small, results are poorer compared to visual outcomes of adult cataracts compared to visual outcomes of adult cataracts As the vision function questionnaires shows however, hild f d b tt ti it d d children performed better on every activity graded after cataract surgery

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What gaps remain in this research or what new questions have been shown?

We need more information on the causation of cataract & how much rubella contributes to it cataract & how much rubella contributes to it Outcomes in pediatric cataract vary with time – we have a cross section of results after 3-5 years, have a cross section of results after 3 5 years, perhaps for the first time in the developing world More research is needed as to why less girls More research is needed as to why less girls compared to boys Vision function scores may be affected by recall - Vision function scores may be affected by recall the questionnaire was completed by the children or parents and not the service providers

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What is the best modality for pediatric cataract treatment depending on age

Cost of pediatric cataract surgery (in rupees) rupees)

Minimum Maximum Fixed 3,270 3,270 facility , ($83.85) , ($83.85 ) Consum 1,452 15,267 ables ($37.23) ($391.46 ) Total 4,722 18,537

Gogate P, et.al. Cost of pediatric cataract in Maharashtra, I di I t J O hth l l 2010 10(7) 1248 52

($122) ($ 475)

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• India. Int J Ophthalmology 2010; 10(7): 1248-52

How can results inform planning for effective pediatric eye care services? p y

 Need for effective follow-up mechanism in the outreach strategy - to address issues of affordability & accessibility strategy to address issues of affordability & accessibility among beneficiaries  Need for effective counseling - to increase awareness levels and motivate parents/guardians about the importance of timely examination, treatment & follow-up  Need for encouragement to undergo surgical intervention  Need for encouragement to undergo surgical intervention irrespective of age, for improvement in quality of life post cataract surgery  Need to encourage involvement of both parents during the course of the treatment of their child from identification to follow-up

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How can results be used to change policies and/or programs? p g

 Combine case identification & post-operative follow-up in each of the outreach initiatives to enhance timely follow- up up  Sponsor an annual week for pediatric cataract follow-up if needed  More effort to strengthen IEC & BCC to increase awareness levels, especially among parents/guardians on the importance of child eye care p y  Continue development of child-friendly ambience of pediatric unit and child-friendly attitude of trained staff as enablers for greater acceptance of pediatric enablers for greater acceptance of pediatric

• phthalmology services

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How can results be used to change policies and/or programs? – cont. p g

 Insist on anterior vitrectomy and primary posterior  Insist on anterior vitrectomy and primary posterior capsulotomy for all children till 7-8 years of age.  Need to design, develop and use appropriate tools to record and monitor post operative surgical outcomes & compliance and monitor post-operative surgical outcomes & compliance to follow-up of all beneficiaries on a continuous basis  Design outcome guidelines for pediatric cataract, like WHO f d l g g p

• nes for adult cataract

 Presenting study findings to larger audience including Government, V2020, IAPB, other global blindness prevention Government, V2020, IAPB, other global blindness prevention stakeholders, etc.

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Thank you for a patient hearing

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