Prevalence of blindness and distance vision impairment in the Gambia across three decades of eye health programming.

BACKGROUND/AIMS: The 1986 Gambia National Eye Health Survey provided baseline data for a National Eye Health Programme. A second survey in 1996 evaluated changes in population eye health a decade later. We completed a third survey in 2019, to determine the current state of population eye health, considering service developments and demographic change. METHODS: We estimated prevalence and causes of vision impairment (VI) in a nationally representative population-based sample of adults 35 years and older. We used multistage cluster random sampling to sample 10 800 adults 35 and above in 360 clusters of 30. We measured monocular distance visual acuity (uncorrected and with available correction) using Peek Acuity. Participants with either eye uncorrected or presenting (with available correction) acuity <6/12 were retested with pinhole and refraction, and dilated exams were completed on all eyes by ophthalmologists using a direct ophthalmoscope, slit lamp and 90 D lens. RESULTS: We examined 9188 participants (response rate 83%). The 2013 census age-sex adjusted prevalence of blindness (presenting acuity<3/60 in better seeing eye) was 1.2% (95% CI 0.9 to 1.4) and of moderate or severe VI (MSVI,<6/18 to ≥3/60) was 8.9% (95% CI 9.1 to 9.7). Prevalence of all distance VI (<6/12) was 13.4% (12.4-14.4). Compared with 1996, the relative risk of blindness decreased (risk ratio 0.7, 95% CI 0.5 to 1.0) and MSVI increased (risk ratio 1.5, 95% CI 1.2 to 0.17). CONCLUSION: Significant progress has been made to reduce blindness and increase access to eye health across the Gambia, with further work is needed to decrease the risk of MSVI.

Congenital cataract: a guide to genetic and clinical management.

Worldwide 20,000-40,000 children with congenital or childhood cataract are born every year with varying degrees and patterns of lens opacification with a broad aetiology. In most cases of bilateral cataract, a causative genetic mutation can be identified, with autosomal dominant inheritance being most common in 44% of cases. Variants in genes involve lens-specific proteins or those that regulate eye development, thus giving rise to other associated ocular abnormalities. Approximately 15% of cases have systemic features, hence paediatric input is essential to minimise comorbidities and support overall development of children at high risk of visual impairment. In some metabolic conditions, congenital cataract may be the presenting sign, and therefore prompt diagnosis is important where there is an available treatment. Multidisciplinary management of children is essential, including ophthalmic surgeons, orthoptists, paediatricians, geneticists and genetic counsellors, and should extend beyond the medical team to include school and local paediatric visual support services. Early surgery and close follow up in ophthalmology is important to optimise visual potential and prevent amblyopia. Routine genetic testing is essential for the complete clinical management of patients, with next-generation sequencing of 115 genes shown to expedite molecular diagnosis, streamline care pathways and inform genetic counselling and reproductive options for the future. Lay abstract: Childhood cataract: how to manage patients Cataract is a clouding of the lens in the eye. Cataract occurring in children has many different causes, which may include infections passed from mother to child during pregnancy, trauma, medications and exposure to radiation. In most cases of cataract occurring in both eyes, a genetic cause can be found which may be inherited from parents or occur sporadically in the developing baby itself while in the womb. Cataracts may occur on their own, with other eye conditions or be present with other disorders in the body as part of a syndrome. Genetic testing is important for all children with cataract as it can provide valuable information about cause, inheritance and risk to further children and signpost any other features of the disease in the rest of the body, permitting the assembly of the correct multidisciplinary care team. Genetic testing currently involves screening for mutations in 115 genes already known to cause cataract and has been shown to expedite diagnosis and help better manage children. Genetic counselling services can support families in understanding their diagnosis and inform future family planning. In order to optimise vision, early surgery for cataract in children is important. This is because the brain is still developing and an unobstructed pathway for light to reach the back of the eye is required for normal visual development. Any obstruction (such as cataract) if left untreated may lead to permanent sight impairment or blindness, even if it is removed later. A multidisciplinary team involved in the care of a child with cataract should include ophthalmic surgeons, orthoptists, paediatricians, geneticists and genetic counsellors, and should extend beyond the medical team to include school and local child visual support services. They will help to diagnose and manage systemic conditions, optimise vision potential and help patients and their families access best supportive care.

Factors influencing the decision-making of carers of children with bilateral cataract in Nepal.

OBJECTIVES: Two hundred thousand children worldwide are blind from cataract. Late presentation for surgery resulting in poor visual outcomes is a problem globally. We aimed to explore the reasons why children are not brought earlier for surgery in Nepal. METHODS AND ANALYSIS: Mixed-method study of carers of children with bilateral cataract attending a large non-government eye hospital were administered a proforma. A random sample took part in semistructured interviews and focus group discussions. RESULTS: Carers of 102 children completed proformas; 10 interviews and 2 focus group discussions were held. 80.4% were Indian, 35.3% of children were female, and their mean age was 58 months (range 4 months to 10 years). Median delay in time between the carer first noticing a problem to presentation was 182 days IQR (60.8-364.8). This was significantly longer for girls (median 304 IQR (91.2-1094.4)) than boys (median 121.6 IQR (30.4-364.8); p=0.02). Cost to access care was a problem for 42 (41.2%) carers. 13 (12.8%) participants were not aware of treatment and 12 (11.8%) were aware but did not seek treatment. The community influenced carer's health-seeking behaviour. Cataract was sometimes described as 'phula', meaning something white seen on the eye. CONCLUSION: Fewer girls presented for surgery, and they also had a significantly longer delay to presentation than boys. Carers are influenced by factors at family, community and socio-organisational levels. Approaches to increase timely access, particularly by girls, are required, such as health education using the term phula, which is widely understood.