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Cataract and its surgery in Papua New Guinea

Clinical and Experimental Ophthalmology C"cBlru8B  
2006; G0mvrc- (  
34 +eVm+4WK  
: 880–885 +01bjM6F_1  
doi:10.1111/j.1442-9071.2006.01342.x ;kLp}CqV  
© 2006 Royal Australian and New Zealand College of Ophthalmologists 0ZJN<AzbA  
 KkPr08  
Correspondence: C%QC^,KL  
Dr Garry Brian, 5 Hazelmere Parade, Sherwood, Qld 4075, Australia. Email: grbrian@tpg.com.au  0N`'a?x  
Received 11 April 2006; accepted 19 June 2006. "tUc  
Original Article dMDSyd<(  
Cataract and its surgery in Papua New Guinea w<m e(!-'  
Jambi N Garap Epm%/ {sHV  
MMed(Ophthal) lfe^_`ij(+  
, `XK+Y  
1,2 'U{6LSaCb  
Sethu Sheeladevi Y6OR I  
MHM 8 huB<^  
,  G{{Or  
3 *+>R^\uT  
Garry Brian 1`I#4f  
FRANZCO Nk/Ms:57y  
, SPY4l*kX  
2,4 iT"H%{+~  
BR Shamanna Wg C*bp{  
MD #^;^_  
, +H8;*uZ|k,  
3 ^p!4`S  
Praveen K Nirmalan m8ydX6~max  
MPH 0CS80 pC  
3 ) bPF@'rF2  
and Carmel Williams Y'S9   
MA fl18x;^I  
4 w=H4#a?fc  
1 Ch9A6?=Hj8  
The Fred Hollows Foundation – Papua New Guinea Eye Care Program, `O/RNMaC  
2 r]vD]  
Department of Ophthalmology, School of Medicine and Health m%?b"kxL[  
Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea; *>XY' -;2e  
3 b1{X GK'  
International Center for Advancement of Rural Eye Care, pd{;`EW|  
L.V. Prasad Eye Institute, Hyderabad, India; and k^PqB+P!  
4 umWZ]8  
The Fred Hollows Foundation (New Zealand), Auckland, New Zealand _\Cd.  
Key words: ^D0BGC&&  
blindness V-(LHv  
, fJ3qL# '  
cataract ;Q.g[[J/p  
, S hM}w/4  
Papua New Guinea _(\\>'1q!  
, Px4 zI9;cB  
surgery G r;~P*  
, V8xv@G{;  
vision impairment wzMWuA4vX  
. n~d`PGs?f  
I (;T; ?v`-  
NTRODUCTION A{E0 a:v  
Just north of Australia, tropical Papua New Guinea (PNG) t747SZWgB  
has more than five million people spread across several major Tj{!Fx^H  
and hundreds of other smaller islands. Almost 50% of the -7" >A~c  
land area is mountainous, and 85% of inhabitants are rural _+8$=k2nM  
dwellers. Forty per cent of the population is age 14 years or uBks#Y*3$  
younger, and 9% is 50 years or older. Z3R..vy8  
1  j>s%q .  
Papua New Guinea was administered by Australia until y( MF_'l  
1975, when independence was granted. Since that time, governance, _}!Q4K  
particularly budgetary, economic performance, law {F k]X#j  
and justice, and development and management of basic ;:9 x.IkxC  
health and other services have declined. Today, 37% of the `>8|  
population is said to live below the poverty line, personal kQIWD N  
and property security are problematic, and health is poor. y::;e#.  
There are significant and growing economic, health and education |<ke>j/6n  
disparities between urban and rural inhabitants. !4jS=Lhe>  
Papua New Guinea has one referral hospital, in Port m ]K.0E  
Moresby. This has an eye clinic with one part-time and two ;g m){ g  
full-time consultant ophthalmologists, and several ophthalmology s !8]CV>  
training registrars. There are also two private ophthalmologists jd2Fh):q  
in the city. Elsewhere, four provincial hospitals XtfL{Fy|T  
have eye clinics, each with one consultant ophthalmologist. z7PPwTBa  
One of these, supported by Christian Blind Mission and E7_^RWG  
based at Goroka, provides an extensive outreach service. \k1Wh-3  
Visiting Australian and New Zealand ophthalmology teams ;5Sr<W\:;  
and an outreach team from Port Moresby General Hospital *=/XlSWF  
provide some 6 weeks of provincial service per year. C#I),LE|d{  
Cataract and its surgery account for a significant proportion K.z}%a  
of ophthalmic resource allocation and services delivered DR0W)K ^  
in PNG. Although the National Department of Health keeps Zo0&<QWj  
some service-related statistics, and cataract has been considered sa#"@j)  
in three PNG publications of limited value (two district z|b4w7 I  
service reports x:2[E-  
2,3 N l@Hx  
and a community assessment e2*^;&|%  
4 [U jbox  
), there has /BIPLDN6  
been no systematic assessment of cataract or its surgery. D!m hR?t  
A 9M7P]$^  
BSTRACT i5n 'f6C  
Purpose: |;_ yAL  
To determine the prevalence of visually significant u\E.H5u27  
cataract, unoperated blinding cataract, and cataract surgery -xcz+pHQ  
for those aged 50 years and over in Papua New Guinea. rzTyHK[  
Also, to determine the characteristics, rate, coverage and ?B}>[  
outcome of cataract surgery, and barriers to its uptake. V+Tj[: ok  
Methods: R #ZDB]2  
Using the World Health Organization Rapid 0?:ZERv  
Assessment of Cataract Surgical Services protocol, a population- Fu`g)#Z  
based cross-sectional survey was conducted in Qxvz}r.l]  
2005. By two-stage cluster random sampling, 39 clusters of @KpzxcEoO  
30 people were selected. Each eye with a presenting visual .6"7Xxe]<  
acuity worse than 6/18 and/or a history of cataract surgery RTU:J67E  
was examined. ^$L/Mv+  
Results: 7RLh#D|  
Of the 1191 people enumerated, 98.6% were ~8X' p6  
examined. The 50 years and older age-gender-adjusted +|?c_vD  
prevalence of cataract-induced vision impairment (presenting NWpRzh8$u  
acuity less than 6/18 in the better eye) was 7.4% (95% us cR/d  
confidence interval [CI]: 6.4, 10.2, design effect [deff] ~9c9@!RA2  
= 'I~dJEW7  
1.3). /{U{smtdFl  
That for cataract-caused functional blindness (presenting l>iU Q&V  
acuity less than 6/60 in the better eye) was 6.4% (95% CI: zXD@M{  
5.1, 7.3, deff l}^#kHSyd  
= 4TKi)0 #7  
1.1). The latter was not associated with yR!>80$j  
gender ( G#V22Wca8  
P -Gpj^aBU  
= c`.:"i" k3  
0.6). For the sample, Cataract Surgical Coverage E)P1`X  
at 6/60 was 34.5% for Eyes and 45.3% for Persons. The yU.0'r5uR  
Cataract Surgical Rate for Papua New Guinea was less than ,54<U~Lg:  
500 per million population per year. The age-genderadjusted uS'ji k}  
prevalence of those having had cataract surgery >+#[O"  
was 8.3% (95% CI: 6.6, 9.8, deff 7q2YsI  
= ~c^-DAgB  
1.3). Vision outcomes of +XE21hb   
surgery did not meet World Health Organization guidelines. $-RhCnE  
Lack of awareness was the most common reason for not IMZKlU3  
seeking and undergoing surgery. L@Z &v'A  
Conclusion: o^?{j*)g  
Increasing the quantity and quality of cataract fq|2E&&v  
surgery need to be priorities for Papua New Guinea eye DR /)hAE  
care services.  o,yvi  
Cataract and its surgery in Papua New Guinea 881 FQFENq''B  
© 2006 Royal Australian and New Zealand College of Ophthalmologists 1,T9HpM  
This paper reports the cataract-related aspects of a population- |pqpF?h5|  
based cross-sectional rapid assessment survey of r!^\Q7  
those 50 years and older in PNG. p L@zZK0  
M ;ZJ,l)BNO  
ETHODS `5Btg. &  
The National Ethical Clearance Committee of The Medical i =N\[&  
Research Advisory Committee granted ethics approval to #!jRY!2Vt  
survey aspects of eye health and care in Papua New Guinea SN(=e#ljE  
(MRAC No. 05/13). This study was performed between jtv Q<4  
December 2004 and March 2005, and used the validated NE3wui1 V  
World Health Organization (WHO) Rapid Assessment of :XSc#H4  
Cataract Surgical Services _}@n_E  
5,6 cJEz>Z6[  
protocol. Characterization of 1gm/{w6O  
cataract and its surgery in the 50 years and over age group Q!X_&ao )O  
was part of that study. 1fW4=pF-K  
As reported elsewhere, 9*;isMkq<  
7 -]\E}Ti  
the sample size required, using a S}^s 5ztm  
prevalence of bilateral cataract functional blindness (presenting u)`|q_y+8  
visual acuity worse than 6/60 in both eyes) of 5% in the d._gH#&v  
target population, precision of O2]r]9sh*  
± o U}t'WU  
20%, with 95% confidence ,{?bM  
intervals (CI), and a design effect (deff) of 1.3 (for a cluster -ouJf}#R  
size of 30 persons), was estimated as 1169 persons. The @ P"`=BU&  
sample frame used for the survey, based on logistics and 5**5b9bj-9  
security considerations, included Koki wanigela settlement h:jI  
in the Port Moresby area (an urban population), and Rigo QP5:M!O<)  
coastal district (a rural population, effectively isolated from S~rVRC"<xo  
Port Moresby despite being only 2–4 h away by road). From :+ 9Ft>  
this sample frame, 39 clusters (with probability proportionate y'!p>/%v  
to population size) were chosen, using a systematic random r(1pvcWY-  
sampling strategy. ;}eEG{`Y  
Within each cluster, the supervisor chose households m0A@jWgd  
using a random process. Residency was defined as living in \e:FmG  
that cluster household for 6 months or more over the past [> &+*c  
year, and sharing meals from a common kitchen with other M,\|V3s  
members of the household. Eligible resident subjects aged Iz?W tm }  
50 years and older were then enumerated by trained volunteers bOxjm`B<  
from the Port Moresby St John Ambulance Services. |T$a+lHMD  
This continued until 30 subjects were enrolled. If the <S8I"8 {Mb  
required number of subjects was not obtained from a particular 8?j&{G  
cluster, the fieldworkers completed enrolment in the [Yx-l;78  
nearest adjacent cluster. Verbal informed consent was 8 g# Y  
obtained prior to all data collection and examinations. R5NRCI  
A standardized survey record was completed for each t|#NMRz  
participant. The volunteers solicited demographic and general EAC(^+15K  
information, and any history of cataract surgery. They 4lY&=_K[)  
also measured visual acuity. During a methodology pilot in M=\d_O#;Z  
the Morata settlement area of Port Moresby, the kappa statistic c;b[u:>~-  
for agreement between the four volunteers designated iC\rhHKQ  
to perform visual acuity estimations was over 0.85. gQ I(=in  
The widely accepted and used ‘presenting distance visual [L*[j.r7[  
acuity’ (with correction if the subject was using any), a measure  '{j\0  
of ocular condition and access to and uptake of eye care *C3uMiz  
services, was determined for each eye separately. This was 1F3QI|   
done in daylight, using Snellen illiterate E optotypes, with JO& ;bT<  
four correct consecutive or six of eight showings of the ,);= (r9  
smallest discernible optotype giving the level. For any eye OUlxeo/  
with presenting visual acuity worse than 6/18, pinhole acuity )I Y 5Y  
was also measured. rSF;Lp)}  
An ophthalmologist examined all eyes with a history of /^z/]!JG:V  
cataract surgery and/or reduced presenting vision. Assessment k Z+q  
of the anterior segment was made using a torch and %S >xSqX  
loupe magnification. In a dimly lit room, through an undilated k\mXo-:V6  
pupil, the status of the visually important central lens ~>N`<S   
was determined with a direct ophthalmoscope. An intact red 3P+4S|@q(4  
reflex was considered indicative of a ‘normal’ clear central G_2gKkIK-  
lens. The presence of obvious red reflex dark shading, but ~J:$gu~`  
transparent vitreous, was recorded as lens opacity. Where 3D?IG\3  
present, aphakia and pseudophakia with and without posterior z`86-Ov  
capsule opacification were noted. The lens was determined ;S=62_ Un  
to be not visible if there were dense corneal opacities dT0^-XSY  
or other ocular pathologies, such as phthisis bulbi, precluding |MOn0 *  
any view of the lens. The posterior segment was examined $n=W2WJ6f  
with a direct ophthalmoscope, also through an kz7vbY  
undilated pupil. vKU]80T  
A cause of vision loss was determined for each eye with _SMT.lG  
a presenting visual acuity worse than 6/18. In the absence of di]$dl|Wi  
any other findings, uncorrected refractive error was considered ql{^"8x  
to be that cause if the acuity then improved to better =Q /w%8G  
than 6/18 with pinhole. Other causes, including corneal sow bg<D  
opacity, cataract and diabetic retinopathy, required clinical O_r^oH  
findings of sufficient magnitude to explain the level of vision O tXw/  
loss. Although any eye may have more than one condition G ]L0eV  
contributing to vision reduction, for the purposes of this 92P ,:2`a  
study, a single cause of vision loss was determined for each ;eS;AHZ  
eye. The attributed cause was the condition most easily ]yyU)V0Iu  
treated if each of the contributing conditions was individually 4'+d"Ok  
treatable to a vision of 6/18 or better. Thus, for example, 96.IuwL*.s  
when uncorrected refractive error and lens opacity coexisted,  'P@=/  
refractive error, with its easier and less expensive treatment, LFE p  
was nominated as the cause. Where treatment of a condition a6;gBoV  
present would not result in 6/18 or better acuity, it was 2^ zg0!z  
determined to be the cause rather than any coincident or GAg.p?Sq   
associated conditions amenable to treatment. Thus, for JiKIm z  
example, coincident retinal detachment and cataract would Q9` s_4  
be categorized as ‘posterior segment pathology’. 98D{{j92  
Participants who were functionally blind (less than 6/60 c_~XL ^B@  
in the better eye) because of unoperated cataract were interrogated U3mXm?f  
about the reasons for not having surgery. The )vO_sIbnW  
responses were closed ended and respondents had the option bcq@N  
of volunteering more than one barrier, all of which were B"~U<6s0  
recorded in a piloted proforma. The first four reasons offered w0#% AK  
were considered for analysis of the barriers to cataract n (OjjR m  
surgery. QH& %mr.S  
Those eyes previously operated for cataract were examined  ]a78tTi  
to characterize that surgery and the vision outcome. A IJ hxE  
detailed history of the surgery was taken. This included the ' " Bex`  
age at surgery, place of surgery, cost and the use of spectacles %0NLRfp  
afterward, including reasons for not wearing them if that was #uQrJh1o8  
the case. 5k K= S  
The Rapid Assessment of Cataract Surgical Services data f&K}IM8& #  
entry and analysis software package was used. The prevalences )URwIe{  
of visually significant cataract, unoperated blinding #N; $  
cataract and cataract surgery were determined. Where prevalence }'u3U"9)  
estimates were age and gender adjusted for the population OMl8 a B9  
of PNG, the estimated population structure for the !$xzA X,  
882 Garap uRP Ff77  
et al. [`q.A`Fd  
© 2006 Royal Australian and New Zealand College of Ophthalmologists X)I/%{  
year 2000 X8 8F>1}  
1 ,&0Z]*  
was used, and 95% CI were derived around these Xu6jHJ@x  
point estimates. Additional analysis for potential associations n:F@gZd`  
of cataract, its surgery and surgical outcomes employed the S<*';{5~  
STATA (version 8.0; StataCorp LP, TX, USA). Fisher’s exact m{VL\ g)  
test and the chi-square test for bivariate analysis and a multiple &.hoC Po$  
logistic regression model for multivariate analysis were X#VEA=4{  
used. Odds ratios (OR) and 95% CI were estimated. A ;.\g-`jb  
P Ks|gL#)*Ku  
- JW-|<CJ  
value of "= FIFf  
< u]R$]&<  
0.05 was taken as significant for this analysis. cY{I:MA+h@  
The Cataract Surgical Coverage (Eyes) (CSC(Eyes)) was Vfb<o"BQk  
calculated. This is a surgical service impact indicator. It measures .6LS+[  
the proportion of cataract that has been operated on ^[0" vtb  
in a defined population at a particular point in time, being l i@k Lh  
the eyes having had cataract surgery as a percentage of the f]c <9Q>*  
combined total of all of those eyes operated with those D_Guc8*  
currently blind (less than 6/60) from cataract (CSC(Eyes) at Ny]lvgu9X  
6/60 %Sc=_%6  
= f0OgK<.>T  
100 KLW&bJ$|j  
a (VEp~BW@-R  
/( (,shiK[5f  
a 'g2vX&=$A  
+ XYMxG:  
b yYg   
), where >C:If0S4X  
a b1 H7  
= Xty# vI  
pseudophakic G#|Hu;C6"  
+ :4U0I:J#  
aphakic eyes, eJW[ ]!  
and 1EQvcw #  
b p+vh[+yp  
= K\~v&  
eyes with worse than 6/60 vision caused by cataract). G8noQ_-  
8 z$66\/V']  
The Cataract Surgical Coverage (Persons) (CSC(Persons)) ~x\Cmu9`  
was determined. This considers people with operated lf6|.  
cataract (either or both eyes) as a proportion of those having *<UGgnmLE  
operable cataract. (CSC(Persons) at 6/60 g1ytT%]  
= Ajg\aof0{  
100( 0`6),R'x  
x p0Z:Wkz]  
+ LZ4xfB (  
y D,E$_0  
)/ rpSr^slr  
( JCNk\@0i*  
x X5 j=C]  
+ LJj=]_  
y N2[jO+6  
+ !VFem~'d  
z bs BZ E  
), in which 0 7\02f  
x ]Z/R!y?l"G  
= DRp&IP<  
persons with unilateral pseudophakia HA1]M`&  
or unilateral aphakia and worse than 6/60 vision 7OE[RX8!f  
caused by cataract in the other eye, q1w|'V  
y xD4$0Ppu  
= IkU|W3Vo  
persons with bilateral *Q5x1!#z #  
previously operated cataract, and ik IzhUWE  
z aHC%19UN  
= [IMQIX  
persons with bilateral D^|7#b,zcH  
cataract causing vision worse than 6/60 in each). LN\[Tmd &  
8 [%?y( q  
The Cataract Surgical Rate, being the number of cataract >(3'Tnu  
operations per year per million of population, was also x9~[HuJ  
estimated. BGzO!s*@j  
R ]-a{IWVN  
ESULTS -X8eabb  
Of the 1191 people enumerated, 5 subjects were not available '?8Tx&}U8  
during the survey and 12 refused participation. Data V^2-_V]8  
from these 17 were not considered in the analysis. Of the M~p=#V1D  
remaining 1174 (98.6%), 606 (51.6%) were female, and 914 K$ AB} Fvc  
(77.9%) were domiciled in rural Rigo. :".w{0l@  
Cataract caused 35.2% of vision impairment (presenting |xeE3,8  
vision less than 6/18) and 62.8% of functional blindness auL^%M|$R  
(presenting vision less than 6/60) in the 2348 eyes sampled S=PJhAF  
(Table 1). It was second to refractive error (45.7%) S(w\ZC  
7 <xqba4O  
in the >0T Za  
former, and the leading cause of the latter. o\goE^,aeR  
For the 1174 subjects, cataract was the most prevalent $H;+}VQ  
cause of vision impairment (46.7%) and functional blindness vYdlSe=6G  
(75.0%) (Table 1). On bivariate analysis, increasing age {g_@Tuu  
( Gkmsaf>  
P l;0y -m1  
< J*K<FFp3<  
0.001), illiteracy ( R&Ci/  
P j 3P$@<  
< ?bI?GvSh  
0.001) and unemployment !Rqx2Q  
( 0Cq!\nzz  
P "i%jQL'.  
< 8t[t{"  
0.001) were associated with cataract-induced functional Rsn^eR 6^  
blindness. Gender was not significantly associated ( VYigxhP7  
P rJV?) =Z  
= |_nC6 ;  
0.6). }p{;^B  
In a multivariate model that included all variables found yoU2AMH2D^  
significant in bivariate analysis, increasing age (reference category } # Xi`<{  
50–59 years; OR: 2.6, 95% CI: 1.6, 5.9 for persons 4m /TW)  
aged 60–69, OR: 9.8, 95% CI: 4.6, 20.6 for persons aged k%Eh{dA  
70–79, and OR: 18.6, 95% CI: 8.3, 41.9 for persons aged liD47}+  
80 years and older) and illiteracy (OR 2.2, 95% CI 1.3, 3.8) (I~\,[  
were associated with functional cataract blindness. jsZY{s=  
The survey sample included 97 people (8.3%) who had &k+*3.X  
previously undergone cataract surgery, for a total of 136 eyes ?4sJw:  
(5.8%). On bivariate analysis, increasing age ( H"D 5 e  
P -|[~sj-p  
= 1i+FL''  
0.02), male ytz8 =\p_b  
gender ( !0Nf9  
P HamEIL-l.  
= T.2ZBG ~|[  
0.02), literacy ( !.X _/$c  
P 9GPb$ gtx  
< Rf:<-C0T  
0.001) and employed status $}4K `Iu  
( oZ-FF'  
P *%?d\8d  
= {_7Hz,2U  
0.03) were associated with cataract surgery. Illiteracy gIBpOPr^d  
was significantly associated with reduced uptake of cataract %YCd%lAe,  
surgery (adjusted OR 0.43, 95% CI: 0.20, 0.91) in a multivariate N5KEa]k1nw  
model that adjusted for age, gender and employment ,ey0:.!;  
status. :MBS>owR  
The CSC(Eyes) at 6/60 for the survey sample was P}l#VJWp  
34.5%, and the CSC(Persons) at the same vision level was o\60 n  
45.3%. avBua6i'  
Most cataract surgery occurred in a government hospital H+R7X71{  
( 4Cd#sQ  
P ~lk@6{`l|1  
< Uz $ @(C  
0.001), more than 5 years ago ( - `4Ty*K  
P ^r4|{  
< VWD.J  
0.001). Also, most ctK65h{Eo  
of the intracapsular extractions were performed more than 8sWr\&!  
5 years ago ( *;P2+cE>H3  
P j[H0SBKC  
< /sV?JV[t  
0.001). Patients are now more likely to J[6VBM.Y  
receive intraocular lens surgery ( P{Lg{I_w.B  
P %Gu][_.L  
< lZvS0JS  
0.001). Although most "8?TSm8  
surgery was provided free ( Y-= /,   
P =R2l3-HA=  
= k{1b20  
0.02), males, who were more kJ__:rS(T_  
likely to have surgery ( ?y46o2b*)  
P WDvV LU`  
= N"K\ick6J  
0.02), were also more likely to ]xYayN!n  
pay for it ( +NT:<(;|i5  
P E^82==R  
= ,$ mLL  
0.03) (Table 2). mQL8QW[c  
As measured by presenting acuity, the vision outcomes of -aT=f9u  
both intracapsular surgery and intraocular lens surgery were fSr`>UpxC  
poor (Table 3). However, 62.6% of those people with at least jQkUNPHu  
Table 1. Uqr{,-]5v  
Vision impairment and blindness by eye and person; Koki and Rigo, Papua New Guinea (2005) YMK>+y[+4  
Category 2348 eyes/1174 people surveyed OSj%1KL  
Vision impairment Blindness I0(8 Z ]x  
Eye (presenting ze ?CoDx2  
visual acuity less than 6/18) !bieo'c  
Person (presenting visual $CM4&{B"i  
acuity less than 6/18 in the }d@LSaM  
better eye) P$Ax c/H  
Eye (presenting visual BjN{@ aEO  
acuity less than 6/60) 98=XG1sQ@  
Person (presenting visual VSx%8IM+X  
acuity less than 6/60 in the b~F!.^7Q  
better eye) e`vUK.UoW  
Total Cataract Total Cataract Total Cataract Total Cataract Bg5;Q)  
n C9GU6Ao  
% ]yw_ n^@  
n ^971<B(v  
% k-io$  
n |HNQ|r_5S  
% 6NU8 HJp  
n 2YaTT& J  
% p?_'|#tz  
n ^GrNfB[Qu  
% Vvx a.B  
n *1R##9\jU7  
% neK*jdaP  
n dE+CIjW5  
% sb8z_3   
n XryQ)x(  
% UUZ6N ZQI  
50–59 years 266 27.9 49 14.6 84 22.8 23 13.4 74 18.0 37 14.3 17 14.2 10 11.1 k\Yu5)  
60–69 years 298 31.3 93 27.8 121 32.9 50 29.1 119 29.0 67 26.0 31 25.8 18 20.0 yY-FL`-  
70–79 years 252 26.5 119 35.5 106 28.8 57 33.1 133 32.4 94 36.4 42 35.0 34 37.8 fma tc#G  
80 i0i.sizu  
+ cC7"J\+r*  
years 136 14.3 74 22.1 57 15.5 42 24.4 85 20.6 60 23.3 30 25.0 28 31.1 aE%eJ)+K  
Male 467 49.1 157 46.9 180 48.9 77 44.8 203 49.4 123 47.7 59 49.2 41 45.6 !E4E'I=]N  
Female 485 50.9 178 53.1 188 51.1 95 55.2 208 50.6 135 52.3 61 50.8 49 54.4 }G"r3*  
All cases 952 100 335 35.2 368 100 172 46.7 411 100 258 62.8 120 100 90 75 eTLI/?|+N  
Cataract and its surgery in Papua New Guinea 883 _%AJmt}  
© 2006 Royal Australian and New Zealand College of Ophthalmologists ^yzo!`)fso  
one eye operated on for cataract felt that their uncorrected !"Z."fm*  
vision, using either or both eyes, was sufficiently good that > u'/$ k  
spectacles were not required (Table 3). &':UlzG  
‘Lack of awareness of cataract and the possibility of surgery’ buMiJzU  
was the most common (50.1%) reason offered by 90 Q1P,=T@  
cataract-induced functionally blind individuals for not seeking vHZX9LQU0+  
and undergoing cataract surgery. Males were more likely >w%d'e$  
to believe that they could not afford the surgery (P = 0.02), ;m2"cL>{l  
and females were more frequently afraid of undergoing a awj}K  
cataract extraction (P = 0.03) (Table 4). U*`  
DISCUSSION WHhR )$zC  
The limitations of the standardized rapid assessment methodology [Gh%nsH  
used for this study are discussed elsewhere.7 Caution (ffOu#RQ3  
should be exercised when extrapolating this survey’s PHe~{"|d?  
Table 2. Circumstances of cataract surgery; Koki and Rigo, Papua New Guinea (2005) )<H 91:.  
Category 136 cataract surgeries Bd N{[2  
Male Female Aphakia %l9WZ*yZ`2  
(n = 74) #*ZnA,  
Pseudophakia ;T"m [D  
(n = 60) 3cV+A]i  
Couched mcP{-oJ0W  
(n = 2) #J<`p  
Male, n (%) 83 (61.0) 45 (60.8) 38 (63.3) 0 (0.0) )Rm 'YmO  
Female, n (%) 53 (39.0) 29 (39.2) 22 (36.7) 2 (100) &y+PSa%n  
Undergone surgery in the last 5 years, n (%) 19 (22.9) 20 (37.7) 10 (13.5) 29 (48.3) 0 (0.0) ((hJmaq  
Range of age at the time of surgery, years 39–84 40–87 39–87 45–85 52 W?4&lC^G  
Age at the time of surgery, years, mean ± SD 61.3 ± 9.7 60.5 ± 11.6 60.8 ± 10.6 63.4 ± 10.9 52 ± 0.0 .zSimEOF  
Surgery in a government hospital, n (%) 72 (86.7) 44 (83.0) 63 (85.1) 53 (88.3) 0 (0.0)  5Xy^I^J  
Surgery in a private hospital, n (%) 10 (12.1) 7 (13.2) 10 (13.5) 7 (11.7) 0 (0.0) lO5gkOJ?  
Surgery in an eye camp, n (%) 1 (1.2) 0 (0.0) 1 (1.4) 0 (0.0) 0 (0.0) cfy/*|  
Surgery by traditionalist, n (%) 0 (0.0) 2 (3.8) 0 (0.0) 0 (0.0) 2 (100) yv#c =v|  
Totally free surgery, n (%) 32 (38.6) 26 (49.1) ; ei<Q =[  
Paid full price asked for surgery, n (%) 25 (30.1) 14 (26.4) 0.{oA`5N  
Paid partial price asked for surgery, n (%) 26 (31.3) 13 (24.5) AT'_0> x8  
Totally free surgery in a government hospital, n (%) 55 (47.4) R>YMGUH~w  
Full price surgery in a government hospital, n (%) 23 (19.8) Ep,0Z*j  
Partially paid surgery in a government hospital, n (%) 38 (32.8) J*q=C%}.  
Table 3. Characterization of cataract surgery outcomes; Koki and Rigo, Papua New Guinea (2005) BF1O|Q|d6  
(a) 136 cataract surgeries L]L~TA<D9i  
(b) 97 people with at least one eye operated on for cataract * F%ol;| Q  
(c) 67 (69.1%) cataract operated people not currently using distance correction: 38 (56.7%) male; 29 (43.3%) female :.'T+LI  
Aphakia Pseudophakia Couched J9$]]\52s.  
n % n % n % p#8LQP~0$  
Total 74 54.4 60 44.1 2 1.5 0F0(]7g^  
Presenting vision 6/18 or better 27 36.5 24 40 0 0.0 e2=,n6N]c  
Presenting vision worse than 6/60 40 54.1 11 18.3 2 100 coP$7Q .  
Aphakia Pseudophakia‡ Couched KiRt '  
Unilateral† Bilateral n % n % I?B,rT3 h  
n % n % "<n"A7e  
Total 28 28.9 17 17.5 51 52.6 1 1.0 O^="T^J  
Presenting vision 6/18 or better in better eye 15 53.6 11 64.7 35 68.6 0 0.0 Mbi+Vv-  
Presenting vision worse than 6/60 in better eye 13 46.4 3 17.6 9 17.6 1 100 rEpKX  
Reason n % J-%PyvK$?  
Never provided 20 29.9 d`q)^  
Damaged 2 3.0 4Uy>#IL  
Lost 3 4.5 t=pkYq5t8  
Do not need 42 62.6 U%PMV?L{  
†Unilateral aphakes with an unoperated contralateral eye. ‡Bilateral pseudophakes (n = 9) + those with one eye aphakic and the other WSB|-Qj}W  
pseudophakic (n = 12) + unilateral pseudophakes with an unoperated contralateral eye (n = 30). MzW$Sl&:  
884 Garap et al. ZWe$(?  
© 2006 Royal Australian and New Zealand College of Ophthalmologists {arjW3~M:  
results to the entire population of PNG. However, this %?G.lej,x  
study’s results are the most systematically collected and /a/uS3&  
objective currently available for eye care service planning. qA_DQ):  
Based on this survey sample, the age-gender-adjusted Kmf-l*7}  
prevalence of vision impairment from all causes for those u'n%BVt   
50 years and older in PNG is 29.2% (95% CI: 27.6, 35.1, {ZYCnS&?CL  
deff = 2.3), with 13.1% (95% CI: 11.3, 15.1, deff = 1.2) due l0bT_?LhK  
to uncorrected refractive error.7 Cataract (7.4% [95% CI: = Ow&UI  
6.4, 10.2, deff = 1.3]) is the second most frequent cause. The p{#7\+}  
adjusted prevalence for functional blindness from all causes ?*5l}y=  
in people aged 50 years and older is 8.9% (95% CI: 8.4, 12.0, E2/U']R  
deff = 1.2),7 with cataract the leading cause at 6.4% (95% eDZ3SIZ  
CI: 5.1, 7.3, deff = 1.1). This is typical of developing countries. WaK{/6?T,  
However, atypically, it would seem that cataract blindness 2{tJ'3  
in PNG is not associated with female gender.9 (C[S?@S  
Assuming that ‘negligible’6 cataract blindness (less than %_LHD|<  
5% at visual acuity less than 3/60,8 although it may be as 0<Y&2<v  
much as 10–15% at less than 6/6010) occurs in the under rG%_O$_dO  
50 years age group, then, based on a 2005 population estimate lxJ.h&"P  
of 5.545 million, PNG would be expected to currently ~SUl,Cs  
have 32 000 (25 000–36 000) cataract-blind people. An !Y i<h/:  
additional 5000 people in the 50 years and older age group zi 14]FWo  
will have cataract-reduced vision (6/60 and better, but less o ;P;=<  
than 6/18), along with an unknown number under the age of s-DL=MD  
50 years. {8Nd-WJ{  
The age-gender-adjusted prevalence of those 50 years 1pr_d"#4  
and older in PNG having had cataract surgery is 8.3% (95% oRF"[G8BV  
CI: 6.6, 9.8, deff = 1.3). Prevalences for males and females, gV>\lMc[-%  
respectively, are 10.2% (95% CI: 7.7, 12.7) and 6.4% (95% +FK<j;}C7  
CI: 4.5, 8.4), with the expected9 association with male gender 9r*T3=u.S  
(age adjusted OR 1.6, 95% CI: 1.2, 2.1). Assuming negligible At|tk  
cataract surgery is performed on those under age kpUU '7Q  
50 years (noting mean age and age range of surgery in 3"%44'  
Table 2), there would be about 41 400 people in PNG today 6Izv&  
who have had this surgery. In the survey sample, 28.7% of @Ec9Do>  
surgery occurred in the last 5 years (Table 2). Assuming that \kO_"{7n  
there have been no deaths, annual surgical numbers have ![n`n(oN  
been steady during this time, and a population mean of the iB_j*mX]  
2000 and 2005 estimates, this would equate to about 2400 A84HaRlkF5  
people per year, being a Cataract Surgical Rate (CSR) of {q4"x5|  
approximately 440 per million per year. j!H?dnE||  
Unfortunately, no operation numbers are available from ^;_b!7*  
the private Port Moresby facility, which contributed 12.5% A*i_- ;W)  
(Table 2) of the surgeries in this study. However, from b)@x@3"O  
records and estimates, outreach, government and mission Or|LyQU  
hospital surgical services perform approximately 1600 cataract tB7aHZ|  
surgeries per year. Excluding the private hospital, this GTvb^+6  
equates to a CSR of about 300 per million population per v836nxLM  
year. B!anY}/U  
Whatever the exact CSR, certainly less than the WHO jT0fF  
estimate of 716,11 the order of magnitude is typical of a $!@f{9+  
country with PNG’s medical infrastructure, resourcing and 9tQk/niMM5  
bureacratic capability.11 With the exception of the Christian mqw.v$>  
Blind Mission surgeon, who performs in excess of 1000 cases  UW3F)  
per year, PNG’s ophthalmologists operate, on average, on KS_d5NvYl  
fewer than 100 cataracts each per year. This is also typical.6 w6 .HvH-@?  
It will be evident that the current surgical capability in `^[ra% a  
PNG is insufficient to address the cataract backlog. The Hua8/:![+  
CSC(Persons) of 45.3%, relating directly to the prevalence \266N;JrN  
of bilateral cataract blindness, and CSC(Eyes) of 34.5%, / [ M~##%:  
relating to the total surgical workload, are in keeping with na)_8r~  
other developing countries.6,8,10 If an annual cataract blindness {HeMdGn9  
incidence of 20% of prevalence12 is accepted, and surgery ly@CX((W  
is only performed on one eye of each person, then 6400 {`> x"Y5  
(5000–7200) surgeries need to be performed annually to meet 5KzU&!Zh9  
this. While just addressing the incidence, in time the backlog x uF_^  
will reduce to near zero. This would require a three- or \D=B-dREq  
fourfold increase in CSR, to about 1200. Despite planning +W`~bX+  
for this and the best of intentions, given current circumstances )uP= o  
in PNG, this seems unlikely to occur in the near future. "cx" d:  
Increasing the output of surgical services of itself will be wSDDejg  
insufficient to reduce cataract-related blindness. As measured *KAuyJr  
by presenting acuity, the outcome of cataract surgery is poor X+iULr.^`~  
(Table 3). Neither the historical intracapsular or current Zh$Z$85p  
intraocular lens surgical techniques approach WHO outcome sQw-#f7t  
guidelines of more than 80% with 6/18 and better l_WY];a  
presenting vision, and less than 5% presenting functionally u CXd% CzE  
blind.13 Better outcomes are required to ensure scarce Sl1N V  
Table 4. Reasons that cataract-blind (worse than 6/60) people do not seek or undergo cataract surgery; Koki and Rigo, Papua New Guinea \c)XN<HH  
(2005) KH-.Z0 2U  
90 people functionally blind due to cataract +;T%7j"wz  
Responses by 41 +t f=  
males (45.6%) _B2t|uQ  
Responses by 49 %zGPF  
females (54.4%) Dqki}k~{  
Responses by all KE_Ze\ P  
n % n % n % :}lE@Y,R   
Lack of awareness of cataract and the possibility of surgery 18 43.9 28 57.1 46 50.1 lWR  
Too old to do anything about vision 7 17.1 6 12.2 13 14.4 Q]\x O/  
Believes unable to afford surgery 10 24.4 7 14.3 17 18.9 h W-[omr0  
No time available to attend surgery 4 9.8 6 12.2 10 11.1 m~v Ie c  
Waiting for cataract to mature 4 9.8 5 10.2 9 10.0 &8N\ 6K=  
None available to accompany person to surgery 4 9.8 2 4.1 6 6.7 mEA w^  
Fear of the surgery 2 4.9 6 12.2 8 8.9 }v:h EMO  
Believes no services available 2 4.9 2 4.1 4 4.4 \l`;]cA  
Cataract and its surgery in Papua New Guinea 885 ,i}"e(f  
© 2006 Royal Australian and New Zealand College of Ophthalmologists 9X-DR  
resources are well used.14 Routine monitoring of surgical wZ\0<skU  
activity and outcome, perhaps more likely to occur if done t6tqv  
manually, may contribute to an improvement.15,16 So too `f (!i mN  
would better patient selection, as many currently choose not TZ/u"' ZS  
to wear postoperation correction because they see well wL{Qni3A  
enough with the fellow eye (Table 3). Improving access to Lczcz"t  
refraction and spectacles will also likely improve presenting Tb}b*d3  
acuities (Table 3). E yNCky  
Of those cataract blind in the survey, 50.1% claimed to i}Y:o}  
be unaware of cataract and the possibility of surgery zUOYH4+  
(Table 4). However, even when arrangements, including Aam2Y,B  
transportation, were made for study participants with visually G#csN&|,  
significant cataract to have surgery in Port Moresby, not 6K,AQ.=V2  
all availed themselves of this opportunity. The reasons for J9o ]$.e  
this need further investigation. {P*RA'H3G  
Despite the apparent ignorance of cataract among the !$O +M#  
population, there would seem little point in raising demand 1PWDK1GI8  
and expectations through health promotion techniques until 9Gy1T3y5"  
such time as the capacity of services and outcomes of surgery T3bBc  
have been improved. Increasing the quantity and quality of RxAZ<8T_  
cataract surgery need to be priorities for PNG eye care V%"aU}   
services. The independent Christian Blind Mission Goroka FN G]  
and outreach services, using one surgeon and a wellresourced w|NLK  
support team, are examples of what is possible, <FP&1Eg!|  
both in output and in outcome. However, the real challenge -?j'< g0  
is to be able to provide cataract surgery as an integrated part 5Ba eHzI  
of a functioning service offering equitable access to good eye %/4ChKf!VR  
health and vision outcomes, from within a public health m'Ran3rp  
system that needs major attention. To that end, registrar 6<gh:vj  
training and referral hospital facilities and practice are being hivWQ$6%  
improved. aCQAh[T  
It may be that the required cataract service improvements F6yMk%  
are beyond PNG’s under-resourced and managed public x2 l~aw#?  
health system. The survey reported here provides a baseline *M09Y'5]  
against which progress may be measured. ,|D<De\v&  
ACKNOWLEDGEMENTS ?8pRRzV$  
The authors thankfully acknowledge the technical support )A,M T i  
provided by Renee du Toit and Jacqui Ramke (The International ?3[as<GZ8  
Centre for Eyecare Education), Doe Kwarara (FHFPNG x:GuqE  
Eye Care Program) and David Pahau (Eye Clinic, Port L2+~I<|>  
Moresby General Hospital). Thanks also to the St Johns &iez{[O  
Ambulance Services (Port Moresby) volunteers and staff for Db@$'  
their invaluable contribution to the fieldwork. This survey Ns Pt1_ Y8  
was funded in part by a program grant from New Zealand 2{(_{9<>z  
Agency for International Development (NZAID) to The oUoDj'JN{  
Fred Hollows Foundation (New Zealand). h_n`E7&bG  
REFERENCES D5^wT>3>  
1. National Statistical Office, Government of the Independent "dQ02y  
State of PNG. Papua New Guinea 2000 Census. Port Moresby: fgdqp8~  
PNG Government, 2000. o!bV;]  
2. Parsons G. Ophthalmic practice in Papua New Guinea. PNG k^K>*mcJ  
Med J 1975; 18: 79–82. MfQ 9d9  
3. Parsons G. A decade of ophthalmic statistics in Papua New Yv>kToa\^  
Guinea. PNG Med J 1991; 34: 255–61. y\k#83aU|  
4. Dethlefs R. The trachoma status and blindness rates of selected \SKobO?qI  
areas of Papua New Guinea in 1979–80. Aust J Ophthalmol 1982; ZOw%Fw4B  
10: 13–18. (ZSd7qH"  
5. WHO. Rapid assessment of cataract surgical services. In: Vision stQRl_('  
2020: The Right to Sight: Developing an Action Plan Version 2 CDROM. :J6 xYy$  
World Health Organization and International Agency Y].,}}9k  
for the Prevention of Blindness, 2004. Available from: http:// zo83>bt  
www.who.int/ncd/vision2020_actionplan/documents/raccs/ ?sD4S   
installation_racss.htm _xY dnTEl  
6. Amansakhatov S, Volokhovskaya ZP, Afanasyeva AN, Limburg 6--t6>5  
H. Cataract blindness in Turkmenistan: results of a national G{CKb{  
survey. Br J Ophthalmol 2002; 86: 1207–10. Zo`_vx/{j  
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vision impairment in the elderly of Papua New Guinea. Clin duQ ,6  
Experiment Ophthalmol 2006; 34: 335–41. g|T WoRx:  
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to measure the impact of cataract intervention programmes. :_k5[KT.]9  
Community Eye Health J 1998; 11: 3–6. hg7^#f95u  
9. Lewallen S, Courtright P. Gender and use of cataract surgical Y]VLouzl  
services in developing countries. Bull World Health Organ 2002; }i._&x`):  
80: 300–3. cS#yfN,  
10. Bassett KL, Noertjojo K, Liu L et al. Cataract surgical coverage U'@#n2p:k  
and outcome in the Tibet Autonomous Region of China. Br J OMf w#  
Ophthalmol 2005; 89: 5–9. ^|%u%UR  
11. WHO. State of the World’s Sight: Vision 2020: The Right to Sight: ;W{2\ Es  
1999–2005. Geneva: World Health Organization, 2005. 2Q=I `H _  
12. WHO. How to plan cataract intervention in a district. In: Vision H7FOf[3'  
2020: The Right to Sight: Developing an Action Plan Version 2 CDROM. >=1Aa,_tc  
World Health Organization and International Agency w"{mDL}c  
for the Prevention of Blindness, 2004. Available from: http:// +I3j 2u8L  
www.who.int/ncd/vision2020_actionplan/contents/4.1.htm Z H 2   
13. WHO. Informal Consultation on Analysis of Blindness Prevention Outcomes. ',Y`\X  
WHO/PBL/98.68. Geneva: World Health Organization, U4=m>Ty  
1998. / %1-tGh  
14. Brian G, Ramke J, Szetu J et al. Towards standards of outcome t|P+^SL  
quality: a protocol for the surgical treatment of cataract in i&KBMx   
developing countries. Clin Experiment Ophthalmol 2006; 34: 383– ZZ>F ^t  
7. LNcoTdv}k  
15. Yorston D, Gichuhi S, Wood M et al. Does prospective monitoring n"w>Y)C(X)  
improve cataract surgery outcomes in Africa? Br J Ophthalmol .B?fG)'WsF  
2002; 86: 543–7. |G)P I`BH  
16. Limburg H. Monitoring cataract surgical outcomes: methods V%'' GF   
and tools. Community Eye Health J 2002; 15: 51–3.
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