COMMUNITY EYE CARE
|Year : 1996 | Volume
| Issue : 4 | Page : 241-244
Cataract blindness on the rise? Results of a door-to-door examination in Mohadi
Hans Limburg, K Vaidyanathan, KN Pampattiwar
Danish Assistance to the National Programme for Control of Blindness (DANPCB), New Delhi, India
DANPCB, A1/148, Safdarjung Enclave, New Delhi-110 029
| Abstract|| |
A Census survey in Mohadi block, Bhandara district of Maharashtra, indicated that the prevalence of blindness and cataract blindness has increased, compared with the 1986 survey. Around one third of the persons blind from cataract have been covered by surgical services. To increase coverage, more emphasis on information, educational and communication is essential.
|How to cite this article:|
Limburg H, Vaidyanathan K, Pampattiwar K N. Cataract blindness on the rise? Results of a door-to-door examination in Mohadi. Indian J Ophthalmol 1996;44:241-4
|How to cite this URL:|
Limburg H, Vaidyanathan K, Pampattiwar K N. Cataract blindness on the rise? Results of a door-to-door examination in Mohadi. Indian J Ophthalmol [serial online] 1996 [cited 2013 May 20];44:241-4. Available from: http://www.ijo.in/text.asp?1996/44/4/241/24570
| Introduction|| |
A door to door survey on cataract blindness in persons 40 years and older was conducted in Mohadi Block, Bhandara District of Maharashtra in 1992. Because of a decrease in cataract cases in the out patient clinic, as well as in the eye camps, an impression was created that the backlog of cataract blindness in this block had effectively been reduced. To verify this, a door-to-door survey was planned as an intensive case finding exercise, which simultaneously would provide data on prevalence of cataract blindness in Mohadi Block, the remaining backlog of cataract blindness and reasons why cataract blind persons had not availed of surgical services so far.
| Materials and Methods|| |
Mohadi Block in Bhandara District, Maharashtra, is a rural block with a population of 148,803 (1991 census), having 74,291 males and 74,512 females. It is close to and well connected with the District headquarters Bhandara. All persons 40 years and older could easily be identified through a household census, which was conducted a year earlier in Mohadi Block under the UNFPA programme.
In the survey a total of 26,770 persons 40 years and older were examined: 12,672 males and 14,008 females. The coverage was 91% of the persons 40 years and older that were enlisted by UNFPA.
Cataract surgical services in Bhandara district have been relatively good for the limited number of eye surgeons.
[Table - 1] shows that the indicator cataract operations per lakh population in Bhandara is comparable with India as a whole. Mohadi block always has a good attendance in the district. The performance per surgeon is high. The annual performance of the entire district has increased from 2357 in 1989 to nearly 5000 in 1995. More than 80% of the performance is done by the District Mobile Unit of Bhandara.
Ten experienced Para-medical Ophthalmic Assistants (PMOAs) were specially trained for this assignment by the senior eye surgeon of Bhandara District. Patients with different stages of cataract were examined independently by all PMOAs and the senior eye surgeon to assess any inter-observer variation. As reported elsewhere, inter-observer agreement with the straight forward criteria used in this study was very high. The PMOAs were also trained in entering their findings on the specially designed Survey form.
The ophthalmic examination was limited to the examination of the lens (categories used - obvious opacity, aphakia or pseudophakia, other lens pathology, no lens pathology) and measuring of the visual acuity with the available correction. In this study, cataract blindness was defined as obvious lens opacity, combined with a visual acuity of less than 3/60 in the better eye with the available correction.
When operated, patients were asked few additional questions on where they were operated, who motivated them to go for surgery, how much expenses they incurred and whether spectacles were provided and used. Patients, blind from cataract, were asked why they had not been operated upon so far.
All persons were examined in their villages. Since all ten PMOAs were mobile with motorcycles, repeat visits could be made to ensure a high coverage. Data were entered by the PMOAs on the survey forms. The names of the persons examined were all checked against the lists provided by UNFPA to ensure optimal coverage. All data from the forms were entered in a specially designed database (EPI INFO, Version 6) in duplicate and compared afterwards to eliminate data entry errors.
| Results|| |
A total of 26,770 persons 40 years and older were examined - 12,762 males and 14,008 females. The coverage of the enumerated persons was 91 % of the persons listed in UNFPA family folder as 40 years or older.
[Table - 2] gives a break up of the prevalence of all blindness and cataract blindness in age groups and in sex.
A total of 1823 persons, 657 males and 1,166 females, were found to have a obvious lens opacities in both eyes and a visual acuity of less than 3/60 in the better eye with available correction. That gave an overall blindness prevalence of 6.8% in the population of 40 years and older of Mohadi block. For females, the prevalence was 8.3%, in males 5.1%.
Bilaterally blind due to cataract was found in 1673 persons - 609 males and 1064 females. That gave a prevalence for cataract blindness of 6.2% for persons 40 years and older: 7.6% in females and 4.8% in males. Unilateral blindness due to cataract was present in 1060 persons - 418 men and 642 women.
The prevalence of both blindness as well as cataract blindness was around 60% higher in females than in males. According to this study, 91.8% of all blindness in Mohadi block was caused by cataract in 1992.
Adjusted for the entire population of the block, the prevalence of blindness (VA <3/60 in the better eye with the available correction) was 1.23%:1.57% for females and 0.88% in males. Adjusted for the entire population in Mohadi block, the prevalence of cataract blindness was 1.12% - 1.43% in females and 0.82% in males.
Compared with the results of the 1986 WHO-NPCB survey for the State of Maharashtra, the prevalence of social blindness (VA < 3/60) was 0.82% in the entire population, 0.98% in the rural population of Maharashtra. District level data are not available from the 1986 survey, but assuming a similar prevalence rate in Mohadi block, Bhandara district, the prevalence rates for blindness and cataract blindness have increased; overall blindness by 25% and cataract blindness by 33%. The increase was much more in females than in males, as is illustrated in [Figure - 1]. By this indirect comparison, in 1986 cataract was the cause of blindness in 86.1 %, and in 1995 it had increased to 91.8%.
Cataract operation had been done in 841 persons earlier: 291 in both eyes and 550 in one eye. In absolute numbers, more females had been operated than males, but females had a 60% higher prevalence for cataract blindness.
This may suggest that females are at higher risk for developing blinding cataract.
The Cataract Surgical Coverage is an useful indicator to measure to what extent the total problem of cataract blindness has been covered by surgical services. It can be calculated for eyes, as well as for persons.
As can be seen from the [Table - 4], of all cataract blind persons in Mohadi block, 31% of the females and 38% of the males have been operated upon. Two thirds of all cataract blind patients have not been covered so far and are in need of surgical services.
Information was also collected on some of the operational aspects of surgical services for cataract in Mohadi. Of the 841 operated patients, 78% were operated in eye camps or the District Hospital and 22% by a private ophthalmologist. There was no difference between males and females.
The distance travelled from the place of residence to an eye camp was less than 10km for 50% of the patients, 73% came from within 20 km and 90% of the patients travelled less than 50km. There were no marked differences between males and females.
Patients were mostly accompanied by relatives to eye camps: 80% of the females and 71% of the males. Only 18% of the males went alone, but mainly when the camp was not far, less than 20 km. Of the females, only 7% went alone and most of them did not travel more than 10 km. In all other cases males as well as females were accompanied by neighbours or health workers.
Relatives motivated patients to go for cataract surgery in 32% of the cases. Health workers were able to motivate another 33%. The remaining 35% of patients were motivated by other villagers or by themselves.
Of the 841 patients operated, 88% were wearing spectacles. Of the 104 aphakics, persons not wearing spectacles (52%) said they could not see well with the spectacles, 25% said they were broken, 10% lost them and 7% said they never received any.
Persons blind from cataract in one or two eyes were asked why they had not been operated so far. The reasons are indicated in [Figure - 2].
As can be seen from the pie diagram, the main reasons given by patients are lack of information, not interested and able to see well with the other eye. Other reasons like fear, no time, nobody to accompany or no money are barriers to less number of persons.
Publicity has always been given a lot of attention in Bhandara district, which was one of the Pilot Districts under the NPCB. Nevertheless, these data indicates that the publicity material, designed by the service providers, may not have been able to get the message across where and when to go for cataract surgical services. This has also been indicated in the recently commissioned study on communication needs assessment.
Around 20% indicated that they were not interested in cataract surgery and 34% answered that they could see well with the other eye. Data analysis showed that there is overlap between these two groups. It is surprising that many persons, with a visual acuity between 1/60 and 3/60 in the better eye still indicate that they can see well with one eye. This is more pronounced in the elderly age groups, with no marked difference between males and females. This confirms the belief amongst patients that one can only be operated for cataract when one is completely blind, that is, cannot see light anymore.
| Discussion|| |
This door to door survey indicates that cataract blindness in Mohadi block, Bhandara district, despite many years of hard work, has not been brought under control yet. Both blindness as well as cataract blindness may have increased by 25-30%, compared with the 1986 survey. In females, the increase was more apparent than in males. As can be seen from [Table - 2], most patients are in the age groups above 60 years. However, there are still quite a few patients below 60, who have better chance of taking up their previous skills again and regain economic and social independence for a longer period. The Cataract Surgical Rate, the number of cataract operations per lakh population, in Mohadi is comparable with average for India, which may indicate that the increase in cataract blindness may be of similar size in the rest of India.
The survey was also planned as a case finding exercise, to identify and operate as many cataract blind persons as possible. The assumption that every patient identified would be willing to come for surgery did prove wrong. More than 50% of the cataract blind persons were not interested in surgery or were satisfied with their vision.
This emphasizes the definite and clear need for more, and especially, better quality information, education and communication on eye care to reach the public. People in general are unaware of the possibilities to get their sight restored through operation. There are old beliefs that they have to wait until they are totally blind, thereby reducing chances for economic rehabilitation, and many still do not know where to go for surgery.
More cataract operations have to be performed, but there are also limitations on the capacity of manpower and infrastructure. Just increasing the number of operations alone is not enough, and may indeed be counter productive if not combined with good case selection.
If case finding would concentrate on the bilateral blind persons in the younger age groups and aim to operate at least the first eye in as many bilateral blind persons as possible, the surgical capacity would be utilized most effectively.
Eye surgeons have to select patients at an earlier stage for cataract surgery. The simplest and cheapest way for the eye surgeon to double the number of cataract operations is to move two steps backwards when examining the visual acuity of the patients. That will change the selection criteria from 1 / 60, which is used commonly in eye camps even today, to 3 / 60.
Visual correction after surgery needs to be optimal. If not done adequetely, it results in dissatisfaction of the patients and damages the reputation of the surgeon. Much time, effort and money is spent on the surgery, but in many cases good quality surgery is made useless by providing poor quality spectacles. Provisions are made in the Guidelines for District Blindness Control Societies to provide indiviually adjusted spectacles for optimal sight restoration. The extra efforts to provide them are definitely worthwhile.
| Acknowledgements|| |
The authors would like to express their gratitude to Mr. V.B. Mathankar, Collector, Bhandara, Mr. Sayeed, Mr. Srinivasan, Mr. Darlinge and all other PMOAs and health officers in Mohadi block and Bhandara district for their cooperation and help in training and data collection.
| References|| |
|1.||Venkataswamy G, et al. Rapid epidemiological assessment of cataract blindness. Intl J Epidemiol. 18: No. 4 (Suppl.2), 1989. |
|2.||Communication Needs Assessment. National Programme for Control of Blindness. ORG. Vol. 1, 1995. |
|3.||Limburg H, Kumar R. How to reduce cataract blindness: more case finding or less case rejection? Community Eye Health, Indian Supplement 7: No. 4, 1994. |
[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3], [Table - 4]