Clinical and Experimental Ophthalmology
Rg~F[j$N 2006;
1cY,)Z%l # 34
f'
%Pkk : 880–885
a474[? doi:10.1111/j.1442-9071.2006.01342.x
)jHH-=JM © 2006 Royal Australian and New Zealand College of Ophthalmologists
J0,;F9<C#X 52#Ac;Y Correspondence:
(V9 ; Dr Garry Brian, 5 Hazelmere Parade, Sherwood, Qld 4075, Australia. Email:
grbrian@tpg.com.au SRek:S, Received 11 April 2006; accepted 19 June 2006.
o2W^!#]= Original Article
#0'%51Jcl Cataract and its surgery in Papua New Guinea
BSHtoD@e7 Jambi N Garap
j-9Zzgr MMed(Ophthal)
SCo; Ek ,
EiCEB;*z|d 1,2
9q_c` Sethu Sheeladevi
"ot#g" MHM
z`(">J ,
}b=Cv?Zg$m 3
p d(W(-`8! Garry Brian
Am"e%|: FRANZCO
^j]_MiA4 ,
B<oBo&uA 2,4
LZ<^b6Dxk BR Shamanna
<P.'r,"[ MD
SaSj9\o ,
jchq\q)_z 3
r>cN,C Praveen K Nirmalan
'T(@5%Db MPH
tQ(4UHqa~ 3
ug^esB and Carmel Williams
d;.H9Ne MA
JasA
w7 4
;"|QW?>$D 1
^]MLEr!S The Fred Hollows Foundation – Papua New Guinea Eye Care Program,
-Pc6W9$ 2
`T3B Department of Ophthalmology, School of Medicine and Health
R*DQLBWc Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea;
%
Ou'+A 3
M< /
International Center for Advancement of Rural Eye Care,
CaR-Yk
L.V. Prasad Eye Institute, Hyderabad, India; and
OJ r~iUr 4
Uj)Wbe[)p0 The Fred Hollows Foundation (New Zealand), Auckland, New Zealand
1P?|.W_^1 Key words:
T{)_vQ blindness
g
cb6*@u! ,
]94`7@ cataract
'Ov
M ,
\3`r/,wY Papua New Guinea
"3/&<0k ,
3,- [lG@o surgery
JJK-+a6cX ,
:
0Z\-7iK vision impairment
jl5&T{z .
e~7FK_y#0 I
*/2nh%>$ NTRODUCTION
l=ZD&uK Just north of Australia, tropical Papua New Guinea (PNG)
FLXn%/ has more than five million people spread across several major
<~P!yL r and hundreds of other smaller islands. Almost 50% of the
DTG-R>y^ land area is mountainous, and 85% of inhabitants are rural
Bj<s!}i{[ dwellers. Forty per cent of the population is age 14 years or
cQ
|Q-S younger, and 9% is 50 years or older.
U~USwUzgY 1
D -d Papua New Guinea was administered by Australia until
kc(m.k!|f\ 1975, when independence was granted. Since that time, governance,
@)U;hk)j; particularly budgetary, economic performance, law
*2pf
>UzL and justice, and development and management of basic
o(4gh1b% health and other services have declined. Today, 37% of the
Em !%3C1
r population is said to live below the poverty line, personal
+abb[ and property security are problematic, and health is poor.
ka6E
s~ There are significant and growing economic, health and education
|1zfXG,R disparities between urban and rural inhabitants.
(cyvE}g Papua New Guinea has one referral hospital, in Port
JOJuG
B-d Moresby. This has an eye clinic with one part-time and two
[$;cjys full-time consultant ophthalmologists, and several ophthalmology
,H%[R+) training registrars. There are also two private ophthalmologists
b.v +
5=)B in the city. Elsewhere, four provincial hospitals
8&M<?oe have eye clinics, each with one consultant ophthalmologist.
O-[ One of these, supported by Christian Blind Mission and
FSm.o?> based at Goroka, provides an extensive outreach service.
bX$1PYX Visiting Australian and New Zealand ophthalmology teams
r-go921 and an outreach team from Port Moresby General Hospital
L""ZI5J{F9 provide some 6 weeks of provincial service per year.
IT{c:jo1{` Cataract and its surgery account for a significant proportion
cc3B}^@p= of ophthalmic resource allocation and services delivered
#/o~h|g in PNG. Although the National Department of Health keeps
')0@J` some service-related statistics, and cataract has been considered
^lt2,x in three PNG publications of limited value (two district
/#
]eVD
service reports
Km
$o@ 2,3
"w%:5~u9 and a community assessment
e5 L_<V^Jo 4
?_d6; ), there has
}8"
|q3k been no systematic assessment of cataract or its surgery.
^8_yJ=~V A
B{R [z%Y BSTRACT
&3Yj2Fw Purpose:
zWhj>Za To determine the prevalence of visually significant
/AADFa cataract, unoperated blinding cataract, and cataract surgery
) WbWp4 for those aged 50 years and over in Papua New Guinea.
!u@P\8M} Also, to determine the characteristics, rate, coverage and
r
dSL outcome of cataract surgery, and barriers to its uptake.
(_"Zbw%cJy Methods:
Yi?bY Using the World Health Organization Rapid
{
'tfU Assessment of Cataract Surgical Services protocol, a population-
@,GL&$Y:W based cross-sectional survey was conducted in
wpuK?fP 2005. By two-stage cluster random sampling, 39 clusters of
OcO/wA(&{ 30 people were selected. Each eye with a presenting visual
V~[b`&F
acuity worse than 6/18 and/or a history of cataract surgery
lUB?eQuN_ was examined.
5RN!"YLI3 Results:
>fzyD(> Of the 1191 people enumerated, 98.6% were
ioD8- examined. The 50 years and older age-gender-adjusted
I2WP/ prevalence of cataract-induced vision impairment (presenting
Lm~<BBp. acuity less than 6/18 in the better eye) was 7.4% (95%
}n4 T!N confidence interval [CI]: 6.4, 10.2, design effect [deff]
(O4oIU =
QR#>Ws 1.3).
`
= O That for cataract-caused functional blindness (presenting
dhob]8b acuity less than 6/60 in the better eye) was 6.4% (95% CI:
88v8lt;R 5.1, 7.3, deff
"H[K3 =
dT*Yv`
h 1.1). The latter was not associated with
P.XT1)qo* gender (
&|{1Ws P
aE5-b ub c =
B#S8j18M 0.6). For the sample, Cataract Surgical Coverage
|-}.Y(y at 6/60 was 34.5% for Eyes and 45.3% for Persons. The
MSQ^ovph Cataract Surgical Rate for Papua New Guinea was less than
/RJ 500 per million population per year. The age-genderadjusted
?d-w#<AiV prevalence of those having had cataract surgery
PiKP.
was 8.3% (95% CI: 6.6, 9.8, deff
N9_* {HOy =
cZxY,UvYa 1.3). Vision outcomes of
hU""YP~y surgery did not meet World Health Organization guidelines.
V'j+)!w5 Lack of awareness was the most common reason for not
4-.K<-T%D seeking and undergoing surgery.
_J!^iJ Conclusion:
]@Zv94Z( Increasing the quantity and quality of cataract
>N Bc-DX^ surgery need to be priorities for Papua New Guinea eye
/>S^`KSTM care services.
^<OYW|q?\r Cataract and its surgery in Papua New Guinea 881
T"z<D+pN © 2006 Royal Australian and New Zealand College of Ophthalmologists
{oqbV#/& This paper reports the cataract-related aspects of a population-
m>vwpRBOA based cross-sectional rapid assessment survey of
nXRa_M(z8 those 50 years and older in PNG.
FYYc+6n M
k\ #; ETHODS
=o##z5j
K The National Ethical Clearance Committee of The Medical
+-<G(^ Research Advisory Committee granted ethics approval to
g{yw&q[B= survey aspects of eye health and care in Papua New Guinea
}i~k:k
mV (MRAC No. 05/13). This study was performed between
M_ukG~/ December 2004 and March 2005, and used the validated
{1Ra|,; World Health Organization (WHO) Rapid Assessment of
z,TH}s6 Cataract Surgical Services
AabQ)23R2 5,6
P5<9;PPbZ protocol. Characterization of
z{L'7 cataract and its surgery in the 50 years and over age group
eG,x\ was part of that study.
epiviCYC As reported elsewhere,
:8)Jnh\5 7
|eu8;~A the sample size required, using a
Uqel
UL} prevalence of bilateral cataract functional blindness (presenting
"] V\ Y! visual acuity worse than 6/60 in both eyes) of 5% in the
'."_TEIF target population, precision of
jKml:)k ±
_c>ww<*3 20%, with 95% confidence
*-9i<@|(U^ intervals (CI), and a design effect (deff) of 1.3 (for a cluster
d0 )725Ia size of 30 persons), was estimated as 1169 persons. The
;|Mfq`s sample frame used for the survey, based on logistics and
3lp'U&3`5 security considerations, included Koki wanigela settlement
T>B'T3or in the Port Moresby area (an urban population), and Rigo
'.bf88D coastal district (a rural population, effectively isolated from
n*7^lAa2 Port Moresby despite being only 2–4 h away by road). From
"&2 F this sample frame, 39 clusters (with probability proportionate
vu+g65" to population size) were chosen, using a systematic random
v])ew| sampling strategy.
gE6'A Within each cluster, the supervisor chose households
0>od1/` using a random process. Residency was defined as living in
Lu}jk
W* that cluster household for 6 months or more over the past
9A"s7iJ) year, and sharing meals from a common kitchen with other
4QA~@pBX^{ members of the household. Eligible resident subjects aged
CV
@P
+ 50 years and older were then enumerated by trained volunteers
f'=u`*(b7 from the Port Moresby St John Ambulance Services.
p]mN) This continued until 30 subjects were enrolled. If the
fxd+0R;f required number of subjects was not obtained from a particular
$P{`-Y }a cluster, the fieldworkers completed enrolment in the
J%CCUl2 nearest adjacent cluster. Verbal informed consent was
+.!D>U$)} obtained prior to all data collection and examinations.
_Tj&gyS A standardized survey record was completed for each
|6Q5bV participant. The volunteers solicited demographic and general
>/A]C$?3 information, and any history of cataract surgery. They
uHKEt[PS$ also measured visual acuity. During a methodology pilot in
PLkS-B the Morata settlement area of Port Moresby, the kappa statistic
3=d%WPgQ for agreement between the four volunteers designated
{32
m&a to perform visual acuity estimations was over 0.85.
1d< b\P0 The widely accepted and used ‘presenting distance visual
S"&Gutu3o acuity’ (with correction if the subject was using any), a measure
N6._Jb of ocular condition and access to and uptake of eye care
(F&LN!Hn>p services, was determined for each eye separately. This was
m#'eDO: done in daylight, using Snellen illiterate E optotypes, with
\E?3nQM four correct consecutive or six of eight showings of the
$9X
+dvu* smallest discernible optotype giving the level. For any eye
LTe ({6l0 with presenting visual acuity worse than 6/18, pinhole acuity
xE8?%N U was also measured.
vxZ'-&;t An ophthalmologist examined all eyes with a history of
'W(u. cataract surgery and/or reduced presenting vision. Assessment
;}E}N:A of the anterior segment was made using a torch and
A`uHZCwJ5 loupe magnification. In a dimly lit room, through an undilated
ID_4M_G pupil, the status of the visually important central lens
o-@01_j
was determined with a direct ophthalmoscope. An intact red
ZPH_s^ reflex was considered indicative of a ‘normal’ clear central
g[(@@TiG lens. The presence of obvious red reflex dark shading, but
?"Ez transparent vitreous, was recorded as lens opacity. Where
`PbY(6CF present, aphakia and pseudophakia with and without posterior
~3
.*b%, capsule opacification were noted. The lens was determined
A&M_ J to be not visible if there were dense corneal opacities
Pg8.RvmQ or other ocular pathologies, such as phthisis bulbi, precluding
.z gh,#= any view of the lens. The posterior segment was examined
<mFDC?j with a direct ophthalmoscope, also through an
J!l/.:`6 undilated pupil.
[_JdV(]$ A cause of vision loss was determined for each eye with
v/ N[)< a presenting visual acuity worse than 6/18. In the absence of
,,uhEoH any other findings, uncorrected refractive error was considered
4z(~)#'^ to be that cause if the acuity then improved to better
/F;2wT; than 6/18 with pinhole. Other causes, including corneal
rC!O}(4t%$ opacity, cataract and diabetic retinopathy, required clinical
qGA|.I9, findings of sufficient magnitude to explain the level of vision
}!_z\'u loss. Although any eye may have more than one condition
@4y?XL(n contributing to vision reduction, for the purposes of this
mFTuqujO study, a single cause of vision loss was determined for each
$0 .6No_| eye. The attributed cause was the condition most easily
~-k,$J?7 treated if each of the contributing conditions was individually
}B'-*)^|e{ treatable to a vision of 6/18 or better. Thus, for example,
'!^7 *@z when uncorrected refractive error and lens opacity coexisted,
')v,<{ refractive error, with its easier and less expensive treatment,
<KX9>e was nominated as the cause. Where treatment of a condition
Q!q6R^5!K present would not result in 6/18 or better acuity, it was
i975)_X( determined to be the cause rather than any coincident or
rhkKK_ associated conditions amenable to treatment. Thus, for
T!,5dt8L example, coincident retinal detachment and cataract would
<\epj=OclV be categorized as ‘posterior segment pathology’.
_S{TjGZ&
Participants who were functionally blind (less than 6/60
\H .Cmm^I in the better eye) because of unoperated cataract were interrogated
_+48(QF<