Ocular morbidity among children (aged 6-18 yr) of the tribal area of Melghat, India: A community-based study.

BACKGROUND OBJECTIVES: Most of the ocular morbidities among school children are preventable or treatable. Melghat, a difficult to access, hilly, forest, tribal area with poorly developed infrastructure in the Amravati district of Maharashtra. Scarcity of ophthalmologists and low health-seeking behaviour of tribal people contributes to the high burden of ocular morbidity. Given the lack of published studies on the ocular morbidity among children in Melghat, outreach programmes are essential to diagnose and treat visual impairments promptly. The objective was to determine the prevalence of ocular morbidity among children in the tribal area of Melghat. METHODS: A community-based observational study was carried out in the Chikhaldara and Dharni blocks of Melghat. Children from 15 tribal villages were screened for eye disorders by trained paramedics. Most of the children were examined by an ophthalmologist. We used Chi-square test for categorical variables. RESULTS: A total of 4357 children aged between 6 and 18 yr were examined. Of these 2336 (53.6%) were females and 2021 (46.4%) were males. Out of 4357 children, 507 (11.63%) had an ocular morbidity. The prevalence of ocular morbidity and refractive error increased in the age group of 8-10 yr (P<0.05 and <0.001, respectively). Refractive error was the most common ocular morbidity (n=339; 7.8%), followed by vitamin A deficiency (VAD) (n=120; 2.8%). INTERPRETATION CONCLUSIONS: The prevalence of refractive error and VAD in this study was significantly higher than the rest of India and the world. For the prevention of childhood blindness, immediate intervention programme, including eye screening by trained paramedics, treatment by an ophthalmologist and prophylaxis, is crucial.

Vision centre helps reduce blindness and vision impairment. Proof of concept in a four-year longitudinal study in an urban area in India.

Purpose: To estimate the prevalence of blindness and severe visual impairment (SVI) by using a door-to-door screening and vision center (VC) examination strategy in an urban area in western Maharashtra (Pune), India and repeat the exercise after 4 years to study its impact. Methods: Four trained community health workers measured the visual acuity and performed an external ocular examination in patients' homes. People with vision <6/18 were requested to visit the VC for a comprehensive eye examination by an optometrist. An ophthalmologist examined people whose vision did not improve to 6/12. A home examination was done for people who did not visit the VC despite two requests. The same population was examined twice in an interval of 4 years. Results: In the study, 44,535 people in 2015-16 and 98.14% (n = 43,708) of them in 2018-19 were examined. Blindness (vision < 3/60 in better eye), and moderate-to-severe visual impairment (MSVI, vision 6/18-6/60 in better eye) were 0.26% and 1.3%, respectively, in the first cohort, and 0.16% and 1.1%, respectively, in the second cohort (P < 0.001). When the worse eye was considered, the prevalence of blindness reduced from 0.72% to 0.44%, SVI reduced from 0.1% to 0.07%, and MVI decreased from 1.7% to 1.49% between 2015 and 2019 (P < 0.001). Females (P < 0.001) and older individuals (P < 0.001) were more likely to have blindness or SVI. In the VC, 8211 people were examined in 4 years. Conclusion: The reduction of blindness and MSVI in the urban area of Pune can be partly ascribed to the presence of a VC and attendant screening in this locality.

Eye screening can be used to perform anemia screening and treatment in adolescent girls using ToucHb.

Purpose: Anemia is common in adolescent girls. Apprehension while drawing blood to estimate hemoglobin concentration is a barrier for confirming anemia. ToucHb, a noninvasive instrument that estimates the hemoglobin by taking an image of the exposed conjunctiva, was used during eye screening to help diagnose and treat anemia. Methods: ToucHb was used during secondary school eye screening and during house-to-house eye screening to estimate the hemoglobin concentration in the body. Each of the girls was distributed a packet of 60 tablets of ferrous and folate and a tablet of albendazole. They were followed up after 3 months. Results: Exactly 1511 municipal school girls aged 10-19 years (mean 12.9; standard deviation [SD] 1.64) were examined. Of them, 949 (62.8%) had hemoglobin of ≤9 mg%. Among those girls with hemoglobin ≤9 mg%, the mean (SD) during the initial and follow-up examinations was 6.1 (1.4) and 9.6 (1.03), respectively, by paired t-test (P < 0.001). Another 588 girls (average age 14.4 years, SD 1.2) had their eyes examined and hemoglobin estimated during a house-to-house eye screening. Of them, 116 (19.7%) had hemoglobin level of ≤9 mg%. Their pre-Hb was 7.9 (SD 1.05) on average and after 3 months, it was 9.6 (SD 1.02). Among those girls with hemoglobin ≤9 mg%, the mean (SD) during the initial and follow-up examinations was 6.2 (1.4) and 7.9 (1.1), respectively, by paired t-test (P < 0.001). Conclusion: ToucHb was useful to diagnose anemia while doing eye screening and to ensure its treatment. Anemia diagnosis and management would enhance the health of adolescent girls.

Why are we not doing retinoscopy in the school eye screening? Is distant visual acuity a sensitive tool for making referrals?

PURPOSE: School eye screening program is an integrated part of SarvaShikshyaAbhiyan. Distance visual acuity was the only tool used in such school eye screening for making referrals. We aim to evaluate the referral rate when only distance visual acuity was used as the screening tool versus using retinoscopy. METHODS: School children were earlier screened using distant visual acuity as the sole criteria. They were again examined as per the guidelines recommended by State of Alaska and American Academy of Pediatrics, and the results of the two examinations were compared. Microsoft Excel 2007 was used for the statistical analysis. RESULTS: Earlier 384 school children of class first to fourth (aged 6-10 years) had been screened using distant visual acuity. Of them, 87 (22.6%) were referred. The rest 297 (male 183 61.6%) students with a mean age of 7.8 years (standard deviation ± 1.23) were again examined and 42/384 (11%) were detected as having visual anomaly that were false negative/or missed during the initial screening. Refractive errors were detected in 33/42 (78.6%) students by retinoscopy. Retinoscopy showed the highest sensitivity (78.6%) and negative predictive value (96.6%) to detect all types of refractive error among all types of tests. Of 42 pair of eyes, 36 right eyes and 39 left eyes had refractive errors, mostly astigmatic, or hyperopic, which were missed earlier. CONCLUSION: Only distance visual acuity failed to detect hyperopia and astigmatism properly. Introduction of retinoscopy would increase the validity of school eye screening.

Making Blind Children See: Impact of Correcting Moderate and Severe Visual Impairment in Schools for the Blind.

PURPOSE: Childhood blindness and visual impairment accounts for enormous burden of blindness. This study aimed to analyze the causes of severe visual impairment and blindness in students attending schools for the blind and to identify those whose vision could be improved by optical aids. On dispensing such aids, the study also aimed to analyze the improvement in their vision function. METHODS: This was a prospective interventional study of 428 certified students from four special schools for blind. All the students underwent a comprehensive ophthalmic examination by a team of four ophthalmologists and four optometrists. The World Health Organization-Prevention of Blindness forms were used to record history and examination details. Spectacles and low-vision aids (LVAs) were dispensed to those whose vision could be improved. The main outcome measure was L V Prasad- Functional Vision Questionnaire (LVP-VFQ), which was used to compare the vision function before and 6 months after the intervention. RESULTS: Two hundred and thirteen (49.5%) students were girls. The causes of blindness in 370 children (<18 years) with vision <6/60 were whole globe involvement in 117 (31.6%) students (this included anophthalmos 47 [12.7%], microphthalmos 61 [16.4%], both 9 [2.4%]), nystagmus 29 (7.8%), optic atrophy 22 (5.9%), retinal causes 42 (11.3%), cataract 18 (4.9%), phthisis bulbi 24 (6.4%), corneal scarring in 40 (10.8%), and retinopathy of prematurity in 4 (1.1%). Fifty-four (12.6%) students were given spectacles and 41 (9.57%) LVA. There was a statistically significant difference in all questions (P < 0.01) of LVP-VFQ for the students dispensed with optical aids 6 months after the intervention. Twenty-four students had their vision improved to 6/60 or better, whereas 26 could now identify letters and print. CONCLUSION: A significant proportion of students in schools for the blind can be helped to improving vision function using optical aids. Students in schools for the blind, nay all visually impaired individuals, need periodic ocular examination and ophthalmic care.

Outcomes of Pediatric Cataract Surgery in the Copperbelt Province of Zambia.

PURPOSE: To study the outcomes of pediatric cataract surgeries in children operated on in the Copperbelt Province of Zambia and the barriers to accessing surgery. METHODS: All children who had congenital, developmental, and traumatic cataracts operated on by lens aspiration, primary posterior capsulotomy, and anterior vitrectomy with posterior chamber intraocular lens implantation from 2012 to 2013 and followed up beyond 6 months were studied. Each child underwent a comprehensive preoperative evaluation. An active, assisted follow-up was done and parents were asked about reasons for delay between presentation and surgery. RESULTS: One hundred two eyes of 70 children met the inclusion criteria of the study. Preoperatively, 76 of 77 (98.7%) eyes in the congenital and developmental cataract group had presenting visual acuity of worse than 6/60. This improved postoperatively, with 19 (29.7%) eyes having best corrected visual acuity (BCVA) of better than 6/18, 23 (35.9%) having BCVA of 6/24 to 6/60, and 22 (34.4%) having BCVA of worse than 6/60. Older age (P = .005), better preoperative vision (P = .045) at presentation, unilaterality (P = .012), and delay between presentation and surgery (P = .004) were predictors of a better postoperative outcome. On multivariate analysis, only age was significant (P = .025). Distance and cost of travel and surgery were the causes of delay in presentation. In the patients with traumatic cataracts, 17 of 25 (68%) had BCVA of better than 6/18, 6 (24%) had BCVA between 6/24 and 6/60, and 2 (8%) had BCVA of worse than 6/60 at the 6-month follow-up. The most common causes of injury were being struck by sticks and stones (10 children, 25%). CONCLUSIONS: Visual outcomes after pediatric cataract surgery in Zambia were comparable and satisfactory. Cost of treatment was a barrier, but delay did not adversely affect outcome. [J Pediatr Ophthalmol Strabismus. 2016;53(5):311-317.].

Long term outcomes of bilateral congenital and developmental cataracts operated in Maharashtra, India. Miraj pediatric cataract study III.

AIM: To study long term outcome of bilateral congenital and developmental cataract surgery. SUBJECTS: 258 pediatric cataract operated eyes of 129 children. MATERIALS AND METHODS: Children who underwent pediatric cataract surgery in 2004-8 were traced and examined prospectively in 2010-11. Demographic and clinical factors were noted from retrospective chart readings. All children underwent visual acuity estimation and comprehensive ocular examination in a standardized manner. L. V. Prasad Child Vision Function scores (LVP-CVF) were noted for before and after surgery. STATISTICS: Statistical analysis was done with SPSS version 16 including multi-variate analysis. RESULTS: Children aged 9.1 years (std dev 4.6, range 7 weeks-15 years) at the time of surgery. 74/129 (57.4%) were boys. The average duration of follow-up was 4.4 years (stddev 1.6, range 3-8 years). 177 (68.6%) eyes had vision <3/60 before surgery, while 109 (42.2%) had best corrected visual acuity (BCVA) >6/18 and 157 (60.9%) had BCVA >6/60 3-8 years after surgery. 48 (37.2%) had binocular stereoacuity <480 sec of arc by TNO test. Visual outcome depended on type of cataract (P = 0.004), type of cataract surgery (P < 0.001), type of intra-ocular lens (P = 0.05), age at surgery (P = 0.004), absence of post-operative uveitis (P = 0.01) and pre-operative vision (P < 0.001), but did not depend on delay (0.612) between diagnosis and surgery. There was a statistically significant improvement for all the 20 questions of the LVP-CVF scale (P < 0.001). CONCLUSION: Pediatric cataract surgery improved the children's visual acuity, stereo acuity and vision function. Developmental cataract, use of phacoemulsification, older children and those with better pre-operative vision had betterlong-termoutcomes.

Visual outcomes of bilateral congenital and developmental cataracts in young children in south India and causes of poor outcome.

CONTEXT: Bilateral pediatric cataracts are important cause of visual impairment in children. AIM: To study the outcome of bilateral pediatric cataract surgery in young children. SETTING AND DESIGN: Retrospective case series in a tertiary center. MATERIALS AND METHODS: Records of pediatric cataracts operated between January 2001 and December 2003, with a minimum follow-up of 3 months, were reviewed retrospectively. STATISTICAL METHODS: Independent sample t-test, Fisher's exact test, and logistic regression using SPSS (Statistical Package for Social Science, Chicago, USA) version 12. RESULTS: 215/257 (83.7%) patients had a minimum follow-up of 3 months. The mean age of presentation to the hospital was 53 months (range: 0-168 months). Congenital cataract was present in 107 patients (58.2%) and developmental cataract in 77 patients (41.8%). The mean age at surgery was 55.2 months (range: 1-168 months). Out of 430 eyes, 269 (62.6%) had an intraocular lens implanted. The mean duration of follow-up was 13.1 months (range: 3-38 months). Pre-operatively, 102 patients (47.3%) had visual acuity <6/60, in the better eye, compared to 37 patients (17.2%) post-operatively ( P < 0.001). Eighty-five patients (39.5%) had visual acuity >6/18. The most common early post-operative complication was fibrinous uveitis in 57 eyes (13.3%) and the most common delayed post-operative complication was posterior capsular opacification in 118 eyes (27.4%). The most important prognostic factor for poor outcome was congenital cataract (odds ratio [OR]: 26.3; 95% confidence interval [CI], 4.4-158.5) and total cataract (OR: 4.8; 95% CI, 1.3-17). CONCLUSION: Nearly half of the eyes had visual acuity >6/18. The outcome was poorer in congenital cataracts, especially those operated after >1 year of age.

Clinical audit of horizontal strabismus surgery in children in Maharashtra, India.

BACKGROUND: The study aimed to audit the results of horizontal strabismus surgery in the hospital's pediatric ophthalmology department in Maharashtra, India. METHOD: Medical records of strabismus surgeries done over 3 years were collated. Preoperative visual acuity, deviation, refraction, and orthoptic evaluation were noted as well as post-operative residual deviation and patient satisfaction. Post-operative residual deviation < or = 10Delta was considered good outcome, 11-20Delta borderline, and > 20Delta was considered poor outcome. The surgeons were briefed about their results periodically and the cause of poor outcomes discussed. RESULT: Between March 2004 and December 2007, 529 children were operated upon, of whom 461 (87.1%) completed the 6-week follow-up. Average age was 9 years 7 months (range 1-19 years). 260/461 (56.3%) patients had good, 100/461 (21.6%) borderline, and 101/461 (21.9%) had poor outcome. 133/231 (57.6%) cases of esotropia and 127/230 (55.2%) cases of exotropia had a good outcome, while the poor outcome was 50/231 (21.6%) and 51/230 (22.1%), respectively. Bilateral medial rectus recession for esotropia had 25/56 (44.6%) good outcome and 15/56 (26.7%) poor outcome, while recess-resect procedures (R/R) for esotropia had 108/175 (61.7%) good and 35/175 (20%) poor outcome (p = 0.062). Bilateral lateral rectus recession for exotropia had 30/56 (53.6%) good and 12/56 (21.4%) had poor outcome, while for recess-resect procedures for exotropia it was 97/174 (55.7%) good and 39/174 (22.4%) poor outcome (p = 0.97). The result did not significantly change over 3 years. 433/461 (93.9%) expressed satisfaction about the surgery on 6-week follow-up. Large pre-operative deviations and amblyopic eyes accounted for 63/101 (62.3%) cases of poor outcome. Fifty-seven patients recorded an improvement in stereopsis. CONCLUSION: Recess-resect procedures had better outcome as compared to bilateral recess procedures, but it was not statistically significant. Clinical audit helped maintain and improve good outcome over the 3 years.

Small incision cataract surgery: Complications and mini-review.

This article reviews the literature on manual small incision cataract surgery (MSICS) and its complications. Various articles on MSICS published in indexed journals were reviewed, as well as the sections on complications of MSICS. The Pubmed search engine on the Internet was used to find out articles published since 1985 on MSICS in any language in indexed journals. Books published by Indian authors and the website of Indian Journal of Ophthalmology were also referred to. MSICS has become very popular technique of cataract surgery in India, and it is often used as an alternative to phacoemulsification. Studies on its efficacy and safety for cataract surgery show that, being a variant of extracapsular cataract surgery, MSICS also has similar intraoperative and postoperative complications. The considerable handling inside the anterior chamber during nucleus delivery increase the chances of iris injury, striate keratitis, and posterior capsular rupture. The surgeon has to be extra careful in the construction of the scleral tunnel and to achieve a good capsulorrhexis. Postoperative inflammation and corneal edema are rare if surgeons have the expertise and patience. The final astigmatism is less than that in the extracapsular cataract surgery and almost comparable to that in phacoemulsification. There is, however, a concern of posterior capsular opacification in the long term, which needs to be addressed. Although MSICS demands skill and patience from the cataract surgeon, it is a safe, effective, and economical alternative to competing techniques and can be the answer to tackle the large backlog of blindness due to cataract.

Safety and efficacy of phacoemulsification compared with manual small-incision cataract surgery by a randomized controlled clinical trial: six-week results.

OBJECTIVE: To compare the efficacy, safety, and refractive errors of astigmatism after cataract surgery by phacoemulsification and manual small-incision cataract surgery techniques. DESIGN: Masked randomized control clinical trial. PARTICIPANTS: Four hundred eyes of 400 patients, 1:1 randomization with half in each arm of the trial. METHODS: A total of 400 eyes was assigned randomly to either phacoemulsification or small-incision groups after informed consent and were operated on by 4 surgeons. They were masked to the technique of surgery before, during, and after cataract surgery and followed up to 1 year after surgery. The intraoperative and postoperative complications, uncorrected and best-corrected visual acuity, and astigmatism were recorded at 1 and 6 weeks postoperatively. MAIN OUTCOME MEASURES: The proportion of patients achieving visual acuity better than or equal to 6/18 with and without spectacles after cataract surgery in the operated eye up to 6 weeks, postoperative astigmatism, and complications during and after surgery. RESULTS: This article reports clinical outcomes up to 6 weeks. Three hundred eighty-three of 400 (95.75%) patients completed the 1-week follow-up, and 372 of 400 (93%) patients completed the 6-week follow-up. One hundred thirty-one of 192 (68.2%) patients in the phacoemulsification group and 117 of 191 (61.25%) patients in the small-incision group had uncorrected visual acuity better than or equal to 6/18 at 1 week (P = 0.153). One hundred fifty of 185 (81.08%) patients of the phacoemulsification group and 133 of 187 (71.1%) patients of the small-incision group (P = 0.038) were better than or equal to 6/18 at the 6-week follow-up for presenting visual activity. Visual acuity improved to > or = 6/18 with best correction in 182 of 185 patients (98.4%) and 184 of 187 (98.4%) patients (P = 0.549), respectively. Poor outcome (postoperative visual acuity < 6/60) was noted in 1 of 185 (0.5%) in the phacoemulsification group and none in the small-incision group. The mode of astigmatism was 0.5 diopters (D) for the phacoemulsification group and 1.5 D for the small-incision group, and the average astigmatism was 1.1 D and 1.2 D, respectively. There was an intra-surgeon variation in astigmatism. The phacoemulsification group had 7 posterior capsular rents compared with 12 in the small-incision group, but the phacoemulsification group had more corneal edema on the first postoperative day. CONCLUSIONS: Both the phacoemulsification and the small-incision techniques are safe and effective for visual rehabilitation of cataract patients, although phacoemulsification gives better uncorrected visual acuity in a larger proportion of patients at 6 weeks.