Journal of Pediatric Ophthalmology and Strabismus

Original Article 

Outcomes of Pediatric Cataract Surgery in the Copperbelt Province of Zambia

Chileshe Mboni, MBBS, MD; Parikshit M. Gogate, MD, FRCS; Ariel Phiri, BSc; Asiwome Seneadza, MD; Prasidh Ramson, B.Optom M.Optom; Halli Manolakos-Tsehisi, BAS; Lillian Musonda, MBBS, MD; Larry Benjamin, FRCOphth; Lene Øverland, Cand.Polit

Abstract

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.]

Abstract

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.]

Introduction

Pediatric cataract is one of the few causes of treatable blindness in children. Hence, it has been the focus of childhood blindness amelioration programs.1 To date, there have been few reports providing insight into the outcomes of cataract surgery in children in Africa, other than cases from Tanzania, Kenya, and Malawi.2–4 There are no reports from the central part of the African continent, which is perhaps the poorest.

Zambia is a landlocked Anglophone country of 13 million inhabitants in the South Central part of Africa. Its northern Copperbelt Province is adjacent to the Katanga region of the Democratic Republic of Congo. Mining is a major industry and the region is considered stable.5 The population is concentrated mainly around the capital and the Copperbelt Province to the northwest of the country. The World Bank classifies Zambia as a middle income country in Africa. In terms of basic development progress, it is ranked 27 of 63 countries.5 An estimated 60% of the population lives below the poverty line—one of the highest in the world, although there has been an improvement from 10 years ago when the estimated figure was 80%. The majority of Zambians are subsistence farmers, but the country is also fairly urbanized, with 43% of the population residing in cities.

As with most African countries, one of the leading causes of treatable blindness in children in the Copperbelt Province is cataract.6 There are few centers that treat congenital, developmental, and traumatic cataract cases in the community.7 This is largely because of the lack of specialized centers and trained personnel to manage these cases. Even where facilities are available, issues of accessibility and awareness remain a huge hindrance.8,9 Tackling this backlog of cataracts in children is essential in reducing the prevalence of blindness among them.

The prevalence of blindness in Zambia may be as high as 1%, with major causes being cataract (50%), corneal scarring (15%), glaucoma (15%), and diabetic retinopathy (8%).10 Childhood blindness constitutes 3% of all blindness. However, the total burden of blindness on the community due to childhood blindness may be second only to that of cataract because of the many years that the children have to live with blindness.11,12 Orbis International has supported the pediatric ophthalmology center at the provincial hospital of Copperbelt Province at Kitwe. This study describes the outcomes of cataract operations on children of the region between October 2012 and September 2013.

Patients and Methods

Permission was sought and obtained from the ethical committee at the Tropical Diseases Research Centre in Ndola, the provincial capital of the Copperbelt Province, for the procedure to be performed at Kitwe Central Hospital. Kitwe Central Hospital is the third largest government public hospital in Zambia. It is a tertiary referral hospital that was built in 1957 and has a capacity of 630 beds. The eye department was established in 1974. In 2001, the Community Eye Service Programme was initiated. Its aim was to establish equitable, quality, comprehensive eye care within and beyond the Copperbelt Province. The project was designed to bridge the gap between tertiary and primary levels of eye care, with the former often being poorly integrated with primary health care in Zambia. In 2011, the Childhood Eye Health Tertiary Facility was established at Kitwe Central Hospital in response to the growing need to manage pediatric eye diseases in Zambia. Since then, a total of 11,036 children have been screened.

The children were screened in schools and out-reach camps in villages, by health and immunization workers, and in peripheral centers. They were then referred to the pediatric ophthalmology department of Kitwe Central Hospital. Demographic details of the children were obtained from either the parents or guardian. A simple examination was performed with flashlight by the health care worker before the patient was referred for further examination at the center.

Further examination was performed at the center to confirm the cases that had been referred. This included assessing visual acuity and refraction, slit-lamp examination, fundus examination (especially in unilateral cases for the normal eye), tonometry, and orthoptic evaluation. Visual acuity was assessed using Cardiff cards and Kay pictures tests for children 6 years or younger and by Snellen charts for the older patients. A systemic examination was performed in the pediatric medical unit to rule out systemic illness. This was complemented by the preoperative anesthetic review.

Patients who had visually disabling cataracts underwent keratometry and A-scan ultrasound biometry. Keratometry was performed using a hand-held keratometer under general anesthesia. The axial length was measured using A-scan ultrasound biometry. The SRK-T formula was used to estimate the power for emmetropia. The power of the intraocular lens to be inserted was undercalculated (depending on the age group) according to a nomogram. All of the cataracts in this series were operated on by lens aspiration, primary posterior capsulotomy, and anterior vitrectomy with posterior chamber intraocular lens implantation. Intraocular lenses were implanted in the eyes of children who were older than 3 months and if their corneal diameters were 9 mm or greater, which accounted for all of the children in this series.

The majority (70%) of patients were operated on by a single pediatric ophthalmologist and the remaining patients by two pediatric-oriented ophthalmologists. General anesthesia with either halothane or isoflorane was used for all cataract cases.

Method of Cataract Extraction

First the eye was cleaned with povidone-iodine 5% and then draped with disposable drapes. A clear corneal incision was made at the 12-o'clock position for capsulorhexis and insertion of the foldable intraocular lens. Two extra side-port wounds were made using a lance or microvitreoretinal blade for an anterior chamber maintainer and anterior vitrector. Lens removal was performed using the anterior vitrector, after which a foldable intraocular lens was inserted in the bag. The anterior vitrector was then passed under the intraocular lens to perform a posterior capsulotomy and anterior vitrectomy. The wounds were closed using 10-0 polyglactin 910. The equipment was a Zeiss rumrai operating microscope (Carl Zeiss Meditec, Jena, Germany) and an Alcon Accurus anterior and posterior vitrectomy machine (Alcon Laboratories, Inc., Fort Worth, TX).

It is critical to ensure follow-up of all children who receive surgery throughout their childhood. An active assisted follow-up was done by the social worker, who kept in touch with the families by mobile device and sent text messages and letters to remind and encourage them to come for the follow-up. The pediatric eye care team ensured regular follow-up visits to monitor complications, if any, resulting from surgery. Refraction and dispensing of spectacles, provision of low-vision devices, rehabilitation, and educational support were provided, if needed.

Statistical analysis was done using SPSS for Windows software (version 16; SPSS, Inc., Chicago, IL) after entering the data in a Microsoft Excel (Microsoft Corporation, Redmond, WA) worksheet.

Results

A total of 77 children with cataract were operated on during the study period from October 2012 to September 2013. Seven children were excluded because they were younger than 3 months and visual acuity assessment was not accurate or their corneal diameters were less than 9 mm and thus an intraocular lens was not implanted. This study describes the outcome of cataract surgery in 70 children operated on at Kitwe Central Hospital, Copperbelt Province, Zambia, between October 2012 and September 2013, with at least a 6-month follow-up. This included 32 children with bilateral congenital and developmental cataracts (64 operated eyes), 13 children with unilateral cataracts (13 operated eyes), and 25 children with traumatic cataracts (25 operated eyes). This series describes the results of 77 developmental and congenital cataract surgeries and 25 traumatic cataract surgeries. The visual results are described by eyes.

Seventy-seven eyes (64 bilateral and 13 unilateral) of 41 children (53.2% were boys) had congenital and developmental cataracts. Age at time of surgery was between 3 and 5 years in 27 (35%), between 6 and 10 years in 31 (40.3%), and between 11 and 16 years in 19 (24.7%) patients. Twenty-seven (35.1%) cataractous eyes had no delay between detection and surgery and were operated on within 1 year of their detection. Twenty-two (26.6%) eyes with cataract had 13 to 24 months of delay, 16 (20.8%) had 25 to 36 months of delay, and 12 (15.6%) had more than 3 years of delay in presentation for surgery. At the 6-month follow-up, 19 (29.7%) eyes had BCVA of 6/18 or better (good outcome), 23 (35.9%) had BCVA of between 6/60 and 6/24 (borderline outcome), and 22 (34.4%) had BCVA of worse than 6/60 (poor outcome). Of the 31 children who had more than 1 year of delay between identification and surgery, 15 (43.4%) gave financial reasons as the cause for delay in surgery. Parents of 8 (25.8%) children said they had tried some type of medication, 2 (6.5%) thought the condition would disappear or get better with time, and 2 (6.5%) did not know it was a problem. Parents of 2 (6.6%) children said their children did not complain of poor vision, 1 parent (3.2%) did not have any information about the hospital, and 1 mother had refused surgery for 1 child (3.2%) on an earlier visit to the hospital.

Table 1 shows the factors associated with visual outcome after development and congenital cataract surgery. Age at surgery (P = .005), laterality (P = .012), and preoperative vision (P = .045) were the only factors significantly associated with surgical outcome. Gender (P = .55) was not significantly associated with the outcome. It was observed that some children with delayed presentation had better outcomes because they were older (P = .004). On multivariate analysis, age at surgery (P = .025) was the only significant variable affecting visual outcome, whereas delay between presentation and surgery (P = .12) and age when first detected (P =.096) were not.


Visual Outcome at the 6-Month Follow-up After Developmental and Congenital Cataract Surgery

Table 1:

Visual Outcome at the 6-Month Follow-up After Developmental and Congenital Cataract Surgery

Traumatic Cataracts

Of the 25 children with traumatic cataracts, 17 (68%) were boys. At the time of surgery, their ages ranged from younger than 5 years for 6 (24%) children, 5 to 10 years for 13 (52%) children, and older than 10 years for 6 (24%) children. One had the injury in infancy and two had it in the second year of life. Eight (32%) had less than 1 year of delay, 6 (24%) had 13 to 24 months' delay, 8 (32%) had 25 to 36 months' delay, and 3 (12%) had more than 3 years' delay between injury detection and presentation for surgery. Visual acuity had been recorded by Cardiff cards in 4 (16%), Kay pictures in 7 (28%), and Snellen charts in 14 (56%) patients. Preoperative visual acuity in the eyes with traumatic cataracts was worse than 6/60 in 16 (64%) patients, whereas 7 (28%) patients had between 6/24 and 6/60. Sixteen (64%) children were accompanied by their mother, 6 (24%) by their father, and 3 (12%) by another relative or friend. The causes of injury were bicycle spoke, bird beak, catapult, door handle, bottle, fist, football, glass, fell on floor, pressing iron, sharp metal, and unknown in 1 child each. Six children were injured with stones, 4 with sticks, and 3 with metal bars. None had any intraoperative complications, but 4 had a postoperative complication of transient raised intraocular pressure. Table 2 demonstrates the factors associated with outcome of traumatic cataract surgery. At 6-months of follow-up, 17 of 25 (68%) patients had BCVA of better than 6/18, 6 (24%) had BCVA of 6/24 to 6/60, and 2 (8%) had BCVA of worse than 6/60.


Factors Associated With Visual Outcomes in Traumatic Cataract

Table 2:

Factors Associated With Visual Outcomes in Traumatic Cataract

On being questioned regarding the reasons for delayed presentation for surgery (time between injury and surgery) even in the presence of history of trauma and poor visual acuity, parents/caretakers of 8 (32%) children reported distance and financial problems as constraints. Eight (32%) patients had been given some medication, 3 (12%) thought the condition would disappear, another 3 (12%) had been told to wait more time, 2 (8%) had time constraints, and 1 (4%) had no information about the hospital.

Discussion

The 6-month outcome of pediatric cataract surgery in Kitwe, Zambia, is in line with results from Nepal, India, China, and Bangladesh.13–16 Nineteen (29.7%) patients having eyes with developmental and congenital cataract had BCVA of better than 6/18, 23 (35.9%) had BCVA between 6/60 and 6/24, and 22 (34.4%) had BCVA of worse than 6/60. Roughly one-third was divided among the good, borderline, and poor outcome. Other studies reported 58% of eyes with BCVA of better than 6/18 in Tanzania,3 44% in Kenya,2 42.2% in Miraj, India,14 and 36.6% in Nepal.13 The outcome was slightly poorer compared to the British Congenital Cataract Study (40.6% better than 6/18)17 and a study from the United States (46.6% better than 6/18).18 Many of these series had more than 1 year of follow-up and children's vision may have improved over time with development of the visual system. This study presents results from one of the most remote parts of Africa where children with dense cataracts and a preoperative BCVA of worse than 3/60 underwent surgery.

The patients with traumatic cataract surgeries had a relatively better result. Seventeen (68%) eyes with traumatic cataract had BCVA of better than 6/18, 6 (24%) had BCVA between 6/60 and 6/24, and 2 (8%) had BCVA of worse than 6/60. This may be because their visual systems were fully developed before being interrupted by the cataract. Even traumatic cataracts operated on after considerable delay had better outcome.

The delay between presentation and surgery did not greatly affect the final outcome, as shown in studies from India.14,19 Less delay was seen in younger children whose visual systems had not developed and matured. If the cataract developed after the first year of life, when the visual systems had matured to an extent, visual outcome after surgery was good even if it was performed after a delay of several years. Thus, on multivariate analysis only age at surgery was a significant variable. Ophthalmologists should operate on such cataracts even if they present after a considerable delay. Many of them have good visual potential. The childhood blindness initiatives that actively looked for visually impaired children with cataracts were useful, even if the cost for setting up such systems was considerable.20

The results from this study demonstrate that it was possible to have comparable outcomes after pediatric cataract surgery in even the poorest and least developed parts of Africa provided systems were put in place to identify, treat, and follow up the children affected by cataract. The Kitwe team should be commended for their diligent follow-up in a vast, impoverished, and remote region.

A recent publication on costs of pediatric cataract surgery in Zambia estimated that each surgery would cost the service provider $277, which is slightly more than the cost in Malawi ($203) because the country is larger.20 This is similar to an estimate of $122 to $475 in India, where costs were lower and surgical volume and population density were higher.21 The outcome is comparable to 32 (46.4%) patients having BCVA of better than 6/18 in Durban, South Africa.22 Unlike the South African series, there were differences in the outcomes of unilateral, bilateral, congenital, and developmental cataract.

A series of long-term outcomes of traumatic cataract surgeries in children in rural India had 46.3% eyes with BCVA of 6/18 or better.23 However, that series had many open globe injuries with sharp objects. Injuries by sticks, stones, and metal bars represent a society where children play outdoors. Traumatic cataracts were much more common in boys due to their play habits. The results are similar to a series from East Africa where 64.7% of eyes had BCVA of better than 6/18 after traumatic cataract surgery.24

Distance, cost, and lack of awareness (among the populace and health care workers) remain the major barriers in accessing eye care for affected children. Eight of 25 (32%) patients with traumatic cataracts were being treated medically and told to wait. These barriers are present even after a successful surgery, resulting in poor follow-up and inadequate postoperative medical and optical treatment. This culminates in suboptimal outcomes, resulting in many children who have had cataract surgery in Africa still ending up in special schools for the blind.25 The proactive follow-up by the Kitwe pediatric eye care team was responsible for the decent outcomes. Studies from Tanzania, Mexico, India, and Nepal underline the importance of follow-up.26–30

The international aid program, which built the capacity of the regional hospital and helped set up a pediatric eye care center of excellence, did go a long way to help the affected children.

References

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  23. Gogate P, Sahasrabudhe M, Shah M, Patil S, Kulkarni A. Causes, epidemiology and long-term outcome of traumatic cataracts in children in rural India. Indian J Ophthalmol. 2012;60:481–486. doi:10.4103/0301-4738.100557 [CrossRef]
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  25. Msukwa G, Njuguna M, Tumwesigye C, Shilio B, Courtright P, Lewallen S. Cataract in children attending schools for the blind and resource centers in eastern Africa. Ophthalmology. 2009;116:1009–1012. doi:10.1016/j.ophtha.2008.12.020 [CrossRef]
  26. Kishiki E, Shirima S, Lewallen S, Courtright P. Improving postoperative follow-up of children receiving surgery for congenital or developmental cataracts in Africa. J AAPOS. 2009;13:280–282. doi:10.1016/j.jaapos.2008.12.002 [CrossRef]
  27. Congdon NG, Ruiz S, Suzuki M, Herrera V. Determinants of pediatric cataract program outcomes and follow-up in a large series in Mexico. J Cataract Refract Surg. 2007;33:1775–1780. doi:10.1016/j.jcrs.2007.06.025 [CrossRef]
  28. Gogate P, Patil S, Kulkarni A, et al. Barriers to follow-up for pediatric cataract surgery in Maharashtra, India: how regular follow-up is important for good outcome. The Miraj Pediatric Cataract Study II. Indian J Ophthalmol. 2014;62:327–332. doi:10.4103/0301-4738.116465 [CrossRef]
  29. Rai SK, Thapa H, Kandel RP, Ishaq M, Bassett K. Clinical and cost impact of a pediatric cataract follow-up program in western Nepal and adjacent northern Indian states. J AAPOS. 2014;18:67–70. doi:10.1016/j.jaapos.2013.09.008 [CrossRef]
  30. Gogate P, Gilbert C. Clinical and cost impact of a pediatric cataract follow-up program in Western Nepal and adjacent northern Indian States. J AAPOS. 2015;19:94. doi:10.1016/j.jaapos.2014.07.160 [CrossRef]

Visual Outcome at the 6-Month Follow-up After Developmental and Congenital Cataract Surgery

VariableGood (≥ 6/18)Borderline (6/60 to 6/24)Poor (< 6/60)PTotal
Gender
  Male12 (29.3%)16 (39.9%)13 (31.7%).5541
  Female15 (41.7%)12 (33.3%)9 (25%)36
Age (y)
  < 53 (11.1%)12 (44.4%)12 (44.4%).00527
  5 to 1017 (54.8%)10 (32.3%)4 (12.9%)31
  > 107 (36.8%)6 (31.6%)6 (31.6%)19
Delay in surgery (mo)
  ≤ 123 (11.5%)13 (50%)10 (38.5%).00426
  13 to 2411 (61.1%)5 (27.8%)2 (11.1%)18
  25 to 364 (22.2%)6 (33.3%)8 (44.4%)18
  > 369 (60%)4 (26.7%)2 (13.3%)15
Delay vs no delay
  No delay3 (11.5%)13 (50%)10 (38.5%).00626
  Delay24 (47.1%)15 (29.4%)12 (23.5%)51
Laterality
  Bilateral19 (29.7%)23 (35.9%)22 (33.4%).01264
  Unilateral8 (61.5%)5 (38.5%)013
Preoperative visual acuity
  < 3/6019 (29.7%)25 (39.1%)20 (31.3%).04564
  3/60 to < 6/608 (66.7%)3 (25%)1 (8.3%)12
  6/60 to 6/24001 (100%)1
Total27 (35.1%)28 (36.4%)22 (28.6%)77 (100%)

Factors Associated With Visual Outcomes in Traumatic Cataract

FactorGood (≥ 6/18)Borderline (6/24 to 6/60)Poor (< 6/60)PTotal
Gender
  Male12 (70.6%)3 (17.7%)2 (11.8%).51917
  Female5 (62.5%)3 (37.5%)08
Age at surgery (y)
  < 54 (66.7%)2 (33.3%)0.9996
  5 to 109 (69.2%)3 (23.1%)1 (7.7%)13
  > 104 (66.7%)1 (16.7%)1 (16.7%)6
Delay in presentation (y)
  < 16 (75%)2 (25%)0.5918
  1 to 23 (50%)2 (33.3%)1 (16.7%)6
  > 2 to 36 (75%)2 (25%)08
  > 32 (66.7%)01 (33.3%)3
Delay vs no delay
  No delay6 (75%)2 (25%)0.998
  Delay11 (64.7%)4 (23.5%)2 (11.8%)17
Preoperative visual acuity
  Good (≥ 6/18)1 (50%)1 (50%)0.6532
  Borderline (6/24 to 6/60)6 (85.7%)1 (14.3%)07
  Poor (< 6/60)10 (62.5%)4 (25%)2 (12.5%)16
Intraocular pressure
  Raised4 (80%)01 (20%).5545
  Normal10 (71.4%)3 (21.4%)1 (7.1%)14
Total17 (68%)6 (24%)2 (8%)25
Authors

From the Department of Ophthalmology, Kitwe Central Hospital, Kitwe, Copperbelt Province, Republic of Zambia (CM, AP, AS, LM); Orbis International, Africa Office, Cape Town, Republic of South Africa (PR, HM-T, LØ); Dr. Gogate's Eye Clinic, Pune, India (PMG); the Department of Ophthalmology, Padmashri Dr. D.Y. Patil Medical College, Pimpri, Pune, India (PMG); and Stoke Mandeville Hospital, Aylesbury, Bucks, United Kingdom (LB).

Supported by Orbis International, Africa Office.

The authors have no financial or proprietary interest in the materials presented herein.

The authors thank the Kitwe team for the data collection; Dr. John Mwelwa (Senior Medical Superintendent) for permitting this work at Kitwe Central Hospital; Kitwe Central Hospital staff Winston Mbao, Dianna Nakazwe, and Collins Kayeye; and Shrivallabh Sane of the data clinic, Pune, India, for the statistical analysis.

Correspondence: Parikshit M. Gogate, MD, FRCS, Dr. Gogate's Eye Clinic, 102, Kumar Garima, Tadiwala Road, Pune, India. 411001. E-mail: parikshitgogate@hotmail.com

Received: May 13, 2015
Accepted: December 22, 2015
Posted Online: July 07, 2016

10.3928/01913913-20160204-01

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