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<me(!-' 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
WgC*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! ,
Px4zI9;cB surgery
Gr;~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.
z7P PwTBa 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|b4w7I service reports
x:2[E- 2,3
Nl@Hx and a community assessment
e2*^;&|% 4
[U jbox ), there has
/BIPLDN6 been no systematic assessment of cataract or its surgery.
D!mhR?t A
9M7P]$^ BSTRACT
i5n'f6C Purpose:
|;_
yAL To determine the prevalence of visually significant
u\E.H5u27 cataract, unoperated blinding cataract, and cataract surgery
-xcz+pHQ for those aged 50 years and over in Papua New Guinea.
rzTyHK[ Also, to determine the characteristics, rate, coverage and
?B}>[ outcome of cataract surgery, and barriers to its uptake.
V+Tj[:
ok Methods:
R#ZDB]2 Using the World Health Organization Rapid
0?:ZER v Assessment of Cataract Surgical Services protocol, a population-
Fu`g)#Z based cross-sectional survey was conducted in
Qxvz}r.l] 2005. By two-stage cluster random sampling, 39 clusters of
@KpzxcEoO 30 people were selected. Each eye with a presenting visual
.6"7Xxe]< acuity worse than 6/18 and/or a history of cataract surgery
RTU:J67E was examined.
^$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
7q 2YsI =
~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.
pL@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}^s5ztm 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?Wtm } 50 years and older were then enumerated by trained volunteers
bOxjm`B< from the Port Moresby St John Ambulance Services.
|T$a+lHMD This continued until 30 subjects were enrolled. If the
<S8I"8
{Mb required number of subjects was not obtained from a particular
8?j&{G cluster, the fieldworkers completed enrolment in the
[Yx-l;78 nearest adjacent cluster. Verbal informed consent was
8g#
Y obtained prior to all data collection and examinations.
R5NRCI A standardized survey record was completed for each
t|#NMRz participant. The volunteers solicited demographic and general
EAC(^+15K information, and any history of cataract surgery. They
4lY&=_K[) also measured visual acuity. During a methodology pilot in
M=\d_O#;Z the Morata settlement area of Port Moresby, the kappa statistic
c;b[u:>~- for agreement between the four volunteers designated
iC\rhHKQ to perform visual acuity estimations was over 0.85.
gQ
I(=in The widely accepted and used ‘presenting distance visual
[L*[j.r7[ acuity’ (with correction if the subject was using any), a measure
'{j\0 of ocular condition and access to and uptake of eye care
*C3uMiz services, was determined for each eye separately. This was
1F3QI|
done in daylight, using Snellen illiterate E optotypes, with
JO&;bT< four correct consecutive or six of eight showings of the
,);=
(r9 smallest discernible optotype giving the level. For any eye
OUlxeo/ with presenting visual acuity worse than 6/18, pinhole acuity
)I Y 5Y was also measured.
rSF;Lp)} An ophthalmologist examined all eyes with a history of
/^z/]!JG:V cataract surgery and/or reduced presenting vision. Assessment
k Z+ q of the anterior segment was made using a torch and
%S
>xSqX loupe magnification. In a dimly lit room, through an undilated
k\mXo-:V6 pupil, the status of the visually important central lens
~>N`<S was determined with a direct ophthalmoscope. An intact red
3P+4S|@q(4 reflex was considered indicative of a ‘normal’ clear central
G_2gKkIK- lens. The presence of obvious red reflex dark shading, but
~J:$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
sowbg<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,
LFEp 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
(OjjRm 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
%0NL Rfp afterward, including reasons for not wearing them if that was
#uQrJh1o8 the case.
5kK=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
!$xzAX,
882 Garap
uRP
Ff77 et al.
[`q.A`Fd © 2006 Royal Australian and New Zealand College of Ophthalmologists
X )I/%{ year 2000
X88F>1} 1
,&0Z]* was used, and 95% CI were derived around these
Xu6jHJ@ x point estimates. Additional analysis for potential associations
n:F@gZd` of cataract, its surgery and surgical outcomes employed the
S<*' ;{5~ STATA (version 8.0; StataCorp LP, TX, USA). Fisher’s exact
m{VL\ g) test and the chi-square test for bivariate analysis and a multiple
&.hoCPo$ 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$]&< 0.05 was taken as significant for this analysis.
cY{I:MA+h@ The Cataract Surgical Coverage (Eyes) (CSC(Eyes)) was
Vfb<o"BQk calculated. This is a surgical service impact indicator. It measures
.6LS+[ the proportion of cataract that has been operated on
^[0"vtb in a defined population at a particular point in time, being
l
i@kLh the eyes having had cataract surgery as a percentage of the
f]c<9Q>* combined total of all of those eyes operated with those
D_Guc8* currently blind (less than 6/60) from cataract (CSC(Eyes) at
Ny]lvgu9X 6/60
%S c=_%6 =
f0OgK<.>T 100
KLW&bJ$|j a
(VEp~BW@-R /(
(,shiK[5f a
'g2vX&=$A +
XYMxG: b
yYg ), where
>C:If0S4X a
b1H7 =
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
BZE ), 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
ikIzhUWE 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\Z C 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
$H;+}VQ cause of vision impairment (46.7%) and functional blindness
vYdlSe=6G (75.0%) (Table 1). On bivariate analysis, increasing age
{g_@Tuu (
Gkmsaf> P
l;0y
-m1 <
J*K<FFp3< 0.001), illiteracy (
R&Ci/ P
j3 P$@< <
?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"D5e 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\60n 45.3%.
avBu a6i' 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
]xYa yN!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
$CM4&{B"i acuity less than 6/18 in the
}d@LSaM better eye)
P$Axc/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
C9G U6Ao %
]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
fmatc#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)$zC The limitations of the standardized rapid assessment methodology
[Gh%nsH used for this study are discussed elsewhere.7 Caution
(ffOu#RQ3 should be exercised when extrapolating this survey’s
PHe~{"|d? Table 2. Circumstances of cataract surgery; Koki and Rigo, Papua New Guinea (2005)
)<H
91:. Category 136 cataract surgeries
Bd N{[2 Male Female Aphakia
%l9WZ*yZ`2 (n = 74)
#*ZnA, Pseudophakia
;T"m[D (n = 60)
3 cV+A]i Couched
mcP{-oJ0W (n = 2)
#J<`p Male, n (%) 83 (61.0) 45 (60.8) 38 (63.3) 0 (0.0)
)Rm
'YmO Female, n (%) 53 (39.0) 29 (39.2) 22 (36.7) 2 (100)
&y+PSa%n Undergone surgery in the last 5 years, n (%) 19 (22.9) 20 (37.7) 10 (13.5) 29 (48.3) 0 (0.0)
((hJmaq Range of age at the time of surgery, years 39–84 40–87 39–87 45–85 52
W?4&lC^G Age at the time of surgery, years, mean ± SD 61.3 ± 9.7 60.5 ± 11.6 60.8 ± 10.6 63.4 ± 10.9 52 ± 0.0
.zSimEOF Surgery in a government hospital, n (%) 72 (86.7) 44 (83.0) 63 (85.1) 53 (88.3) 0 (0.0)
5Xy^I^J Surgery in a private hospital, n (%) 10 (12.1) 7 (13.2) 10 (13.5) 7 (11.7) 0 (0.0)
lO5gkOJ? Surgery in an eye camp, n (%) 1 (1.2) 0 (0.0) 1 (1.4) 0 (0.0) 0 (0.0)
cfy/*| Surgery by traditionalist, n (%) 0 (0.0) 2 (3.8) 0 (0.0) 0 (0.0) 2 (100)
yv#c=v| Totally free surgery, n (%) 32 (38.6) 26 (49.1)
; ei<Q =[ Paid full price asked for surgery, n (%) 25 (30.1) 14 (26.4)
0.{oA`5N Paid partial price asked for surgery, n (%) 26 (31.3) 13 (24.5)
AT'_0>x8 Totally free surgery in a government hospital, n (%) 55 (47.4)
R>YMGUH~w Full price surgery in a government hospital, n (%) 23 (19.8)
Ep,0Z*j Partially paid surgery in a government hospital, n (%) 38 (32.8)
J*q=C%}. Table 3. Characterization of cataract surgery outcomes; Koki and Rigo, Papua New Guinea (2005)
BF1O|Q|d6 (a) 136 cataract surgeries
L]L~TA<D9i (b) 97 people with at least one eye operated on for cataract
*F%ol;|
Q (c) 67 (69.1%) cataract operated people not currently using distance correction: 38 (56.7%) male; 29 (43.3%) female
:.'T+LI Aphakia Pseudophakia Couched
J9$]]\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$7Q . Aphakia Pseudophakia‡ Couched
KiRt
' Unilateral† Bilateral n % n %
I?B,rT3h n % n %
"<n"A7e Total 28 28.9 17 17.5 51 52.6 1 1.0
O^="T^J Presenting vision 6/18 or better in better eye 15 53.6 11 64.7 35 68.6 0 0.0
Mbi+Vv- Presenting vision worse than 6/60 in better eye 13 46.4 3 17.6 9 17.6 1 100
rEpKX Reason n %
J-%PyvK$? Never provided 20 29.9
d`q)^ Damaged 2 3.0
4U y>#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$Sl&: 884 Garap et al.
Z We$(? © 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&