Clinical and Experimental Ophthalmology
_-mSK/Z 2006;
Z'=:Bo{ 34
YytO*^e}} : 880–885
K{DsGf, doi:10.1111/j.1442-9071.2006.01342.x
<Cv6wC= © 2006 Royal Australian and New Zealand College of Ophthalmologists
X$mCn#8m V&e9?5@
Correspondence:
JO3"$s|t Dr Garry Brian, 5 Hazelmere Parade, Sherwood, Qld 4075, Australia. Email:
grbrian@tpg.com.au tAPn? d5 Received 11 April 2006; accepted 19 June 2006.
tE=;V) %we Original Article
`hpX 97v Cataract and its surgery in Papua New Guinea
^/c v8M= Jambi N Garap
iG+hj:5 MMed(Ophthal)
Y8l
8B> ,
LeP;HP| 1,2
'\g-z Sethu Sheeladevi
J]m
G!# 9 MHM
gdr"34%vbM ,
4{zz-4= 3
`|rF^~6(dR Garry Brian
[T}Lq~ FRANZCO
A [c1E[ ,
gPT<%F 2,4
B
r`a;yT BR Shamanna
3:]c> GPQ MD
nXRT%[o
& ,
!v fb
gK 3
lq'MLg Praveen K Nirmalan
C
srxi'Pe MPH
/BN_K8nb` 3
WgTD
O3 and Carmel Williams
U\'HB.P
\ MA
](@HPAG] 4
d}:eL
C 1
s;!_'1pi@ The Fred Hollows Foundation – Papua New Guinea Eye Care Program,
|43dyJW 2
Q4R*yRk Department of Ophthalmology, School of Medicine and Health
Y?'Krw ` Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea;
3xX^pjk 3
t@vVE{` International Center for Advancement of Rural Eye Care,
c>b!{e@* L.V. Prasad Eye Institute, Hyderabad, India; and
E;MelK<8( 4
^0tO2$ The Fred Hollows Foundation (New Zealand), Auckland, New Zealand
xQ0.2[*5 Key words:
8\BGL blindness
,L&d\M"f ,
%
|^V) cataract
Jk=_8Xvr` ,
"tF#]iQQ
u Papua New Guinea
+bDBc?HZ{$ ,
ZJf:a}=h surgery
/$'|`jKsB ,
Kl/n>qEt vision impairment
j;yKL-ycB .
\=&F\EV I
!)4'[5t"U NTRODUCTION
: *8t,f~s^ Just north of Australia, tropical Papua New Guinea (PNG)
e.VQ!)> has more than five million people spread across several major
f`K[oCfu and hundreds of other smaller islands. Almost 50% of the
6>NK2} ` land area is mountainous, and 85% of inhabitants are rural
wTe 9OFv dwellers. Forty per cent of the population is age 14 years or
[pxC3{|d$ younger, and 9% is 50 years or older.
ua!43Bp 1
s H(io Papua New Guinea was administered by Australia until
&dky_H 1975, when independence was granted. Since that time, governance,
U
ATF}x
particularly budgetary, economic performance, law
A}4 ", and justice, and development and management of basic
{!&^VXZIT health and other services have declined. Today, 37% of the
Y(&rlL(sPK population is said to live below the poverty line, personal
_;mA(j and property security are problematic, and health is poor.
{|B
2$1': There are significant and growing economic, health and education
$d*PY_ disparities between urban and rural inhabitants.
;_S
DW Papua New Guinea has one referral hospital, in Port
|,Kk#`lW<f Moresby. This has an eye clinic with one part-time and two
1t/mq?z: full-time consultant ophthalmologists, and several ophthalmology
f= A`{8^ training registrars. There are also two private ophthalmologists
)kEH}P& in the city. Elsewhere, four provincial hospitals
2.
q\!V}yQ have eye clinics, each with one consultant ophthalmologist.
4^Og9}bm One of these, supported by Christian Blind Mission and
4Opf[3] based at Goroka, provides an extensive outreach service.
&Jd_@F#J Visiting Australian and New Zealand ophthalmology teams
'{w[).c. and an outreach team from Port Moresby General Hospital
l5nm.i<M provide some 6 weeks of provincial service per year.
y!c<P,Lt3f Cataract and its surgery account for a significant proportion
.*B@1q
of ophthalmic resource allocation and services delivered
N~ajrv}kd in PNG. Although the National Department of Health keeps
/@64xrvIl= some service-related statistics, and cataract has been considered
=I0J1Ob in three PNG publications of limited value (two district
BvS!P8 service reports
o@L2c3?c5 2,3
D*/fY=gK and a community assessment
qpjiQ,\:b 4
5<M$ XT ), there has
^CK
D[s been no systematic assessment of cataract or its surgery.
|AXV4{j_i A
s"5nfl BSTRACT
nlZJ}xZ Purpose:
\5-Dp9vG To determine the prevalence of visually significant
EE*|# cataract, unoperated blinding cataract, and cataract surgery
r4ljA@L for those aged 50 years and over in Papua New Guinea.
{55f{5y3
c Also, to determine the characteristics, rate, coverage and
#qARcxbK| outcome of cataract surgery, and barriers to its uptake.
Uz=ol.E Methods:
'w=aLu5dY Using the World Health Organization Rapid
p
+nh] Assessment of Cataract Surgical Services protocol, a population-
.7M.bpmqE based cross-sectional survey was conducted in
_U9.u#>sV 2005. By two-stage cluster random sampling, 39 clusters of
}:Y)DH%u 30 people were selected. Each eye with a presenting visual
CM6! 1 7 acuity worse than 6/18 and/or a history of cataract surgery
RXo 6y(^ was examined.
R?y_tho4A Results:
#.vp\W Of the 1191 people enumerated, 98.6% were
[dXa, examined. The 50 years and older age-gender-adjusted
x |gYxZ prevalence of cataract-induced vision impairment (presenting
1h#/8X acuity less than 6/18 in the better eye) was 7.4% (95%
l;$FR4}d confidence interval [CI]: 6.4, 10.2, design effect [deff]
l](!2a=[ =
e}n(mq 1.3).
F'"-aB ~ That for cataract-caused functional blindness (presenting
49HP2E acuity less than 6/60 in the better eye) was 6.4% (95% CI:
vY"I 5.1, 7.3, deff
+_25E.>ml =
8kC$
Z ) 1.1). The latter was not associated with
HXX9D&c4R gender (
76]Z~^Y P
A-d<[@d0 =
k2fJ 0.6). For the sample, Cataract Surgical Coverage
(N/-b
lto at 6/60 was 34.5% for Eyes and 45.3% for Persons. The
XfflD9M Cataract Surgical Rate for Papua New Guinea was less than
J1w3g, 500 per million population per year. The age-genderadjusted
j&U7xv prevalence of those having had cataract surgery
Efoy]6P\ was 8.3% (95% CI: 6.6, 9.8, deff
_
nz
^+ =
mY[*Cj3WJ 1.3). Vision outcomes of
feH&Ug4?G surgery did not meet World Health Organization guidelines.
nf[KD,f Lack of awareness was the most common reason for not
epG]$T![ seeking and undergoing surgery.
-0BxZ AW= Conclusion:
)A6=P%;}>I Increasing the quantity and quality of cataract
j+S&5C/{ surgery need to be priorities for Papua New Guinea eye
AZ4:3} care services.
>;F}>_i Cataract and its surgery in Papua New Guinea 881
.mg0L\ © 2006 Royal Australian and New Zealand College of Ophthalmologists
:;TF_Sv This paper reports the cataract-related aspects of a population-
F_i
"v5# based cross-sectional rapid assessment survey of
X\w["!B those 50 years and older in PNG.
Jr%F#/ M
ueg%D+u ETHODS
f3^qO
9R The National Ethical Clearance Committee of The Medical
O_GHvLO= Research Advisory Committee granted ethics approval to
M,yxPHlN survey aspects of eye health and care in Papua New Guinea
O2yD{i#l*# (MRAC No. 05/13). This study was performed between
2yD ?f8P4 December 2004 and March 2005, and used the validated
XR p60i6f World Health Organization (WHO) Rapid Assessment of
1(*+_TvZ Cataract Surgical Services
/VP #J<6L 5,6
{X<_Y< protocol. Characterization of
}sJ}c}b cataract and its surgery in the 50 years and over age group
YHke^Ind was part of that study.
gNZ"Kr o6 As reported elsewhere,
[3ggJcUgW> 7
3q@H8%jcw the sample size required, using a
EP<{3fy prevalence of bilateral cataract functional blindness (presenting
{zc*yV\ visual acuity worse than 6/60 in both eyes) of 5% in the
AAuwE&Gg target population, precision of
O3d
Qno ±
DY/%|w*L 20%, with 95% confidence
[9}<N2,9z intervals (CI), and a design effect (deff) of 1.3 (for a cluster
{w,<igh size of 30 persons), was estimated as 1169 persons. The
u[4h|*'"| sample frame used for the survey, based on logistics and
|mdf u= security considerations, included Koki wanigela settlement
nE0I [T( in the Port Moresby area (an urban population), and Rigo
!Htl e % coastal district (a rural population, effectively isolated from
E@l@f Port Moresby despite being only 2–4 h away by road). From
"jq6FT)O this sample frame, 39 clusters (with probability proportionate
,6f6r to population size) were chosen, using a systematic random
\<y|
[ sampling strategy.
6Bd:R}yZP7 Within each cluster, the supervisor chose households
_`laP5~ using a random process. Residency was defined as living in
Nv=% R that cluster household for 6 months or more over the past
Wcl =YB
% year, and sharing meals from a common kitchen with other
unnuSW#v= members of the household. Eligible resident subjects aged
p]toDy-} 50 years and older were then enumerated by trained volunteers
xa
!/. from the Port Moresby St John Ambulance Services.
f{\[+> This continued until 30 subjects were enrolled. If the
V,\}|_GY required number of subjects was not obtained from a particular
O`PQ4Q*F cluster, the fieldworkers completed enrolment in the
%RzkP}1>E nearest adjacent cluster. Verbal informed consent was
41rS0QAM obtained prior to all data collection and examinations.
3.=o }! A standardized survey record was completed for each
V.yDZ
" participant. The volunteers solicited demographic and general
!NKPy+v information, and any history of cataract surgery. They
*Ct
^jU7 also measured visual acuity. During a methodology pilot in
q%1B4 mF' the Morata settlement area of Port Moresby, the kappa statistic
Tv%
Z|%* for agreement between the four volunteers designated
&s\/Uq to perform visual acuity estimations was over 0.85.
(8~Hr?1B The widely accepted and used ‘presenting distance visual
3
XUsw1,[ acuity’ (with correction if the subject was using any), a measure
S6_dmTV* of ocular condition and access to and uptake of eye care
hsI9{j]f services, was determined for each eye separately. This was
=#%Vs>G done in daylight, using Snellen illiterate E optotypes, with
q _:7uQ four correct consecutive or six of eight showings of the
!;Ctz'wz smallest discernible optotype giving the level. For any eye
.[6T7fdi with presenting visual acuity worse than 6/18, pinhole acuity
Ik=bgEF was also measured.
<bywi2]z An ophthalmologist examined all eyes with a history of
qx?0]!x cataract surgery and/or reduced presenting vision. Assessment
}\W^$e- of the anterior segment was made using a torch and
S;nlC loupe magnification. In a dimly lit room, through an undilated
<sjz_::V8R pupil, the status of the visually important central lens
4X>=UO``L was determined with a direct ophthalmoscope. An intact red
Wr4Ob*2iD reflex was considered indicative of a ‘normal’ clear central
XIp>PcU^ lens. The presence of obvious red reflex dark shading, but
QGXR<