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Cataract and its surgery in Papua New Guinea

Clinical and Experimental Ophthalmology mR@d4(:J?  
2006; #.HnO_sK_  
34 v :/!OvLe  
: 880–885 0'pB7^y  
doi:10.1111/j.1442-9071.2006.01342.x +z?gf*G_W'  
© 2006 Royal Australian and New Zealand College of Ophthalmologists V^[&4  
 ]9/A=p?J@  
Correspondence: H OWpTu(  
Dr Garry Brian, 5 Hazelmere Parade, Sherwood, Qld 4075, Australia. Email: grbrian@tpg.com.au W& 0R/y7  
Received 11 April 2006; accepted 19 June 2006. QA0uT{x90  
Original Article h>GbJ/^  
Cataract and its surgery in Papua New Guinea `+\$  
Jambi N Garap 6X h7Bx1  
MMed(Ophthal) ~=OJCKv5(  
, GyQF R?  
1,2 O5p$ A @  
Sethu Sheeladevi b=MW;]F  
MHM -kLBq :M  
, |U{~t<BF#  
3 T2w4D !  
Garry Brian zi6J|u  
FRANZCO F=e;[uK\  
, iEtR<R>=  
2,4 Fik ;hB  
BR Shamanna }?mSMqnB  
MD (!{*@?S  
, |Sjy   
3 F6yFKNK!n  
Praveen K Nirmalan +\_\53  
MPH {z 5YJ*C  
3 oZY|o0/9  
and Carmel Williams = >TU  
MA )YEAk@h@  
4 EL3X8H  
1 l]zQSXip  
The Fred Hollows Foundation – Papua New Guinea Eye Care Program, Ir>4-@  
2 Xv!Gg6v6  
Department of Ophthalmology, School of Medicine and Health u=qK_$d4  
Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea; 7M~/ q.  
3 }W 5ks-L6  
International Center for Advancement of Rural Eye Care, l([aKm#  
L.V. Prasad Eye Institute, Hyderabad, India; and OV;VsF  
4 &)Qq%\EP4  
The Fred Hollows Foundation (New Zealand), Auckland, New Zealand "0PsCr}!  
Key words: Ve"(}z  
blindness Ip7#${f5M  
, n5"oXpcIx  
cataract Yu" Q  
, ].J;8}  
Papua New Guinea 6:%lxG  
, s/hWhaS<  
surgery P]^OSPRg  
, |z3!3?%R  
vision impairment T8g\_m  
. # lqH/>`>  
I '/UT0{2;rS  
NTRODUCTION QpQ2hNf  
Just north of Australia, tropical Papua New Guinea (PNG) zOSUYn  
has more than five million people spread across several major !\{2s!l~  
and hundreds of other smaller islands. Almost 50% of the ?F] P=S :x  
land area is mountainous, and 85% of inhabitants are rural E-X z  
dwellers. Forty per cent of the population is age 14 years or ;0m J4G  
younger, and 9% is 50 years or older. 6|q"lS*$S  
1 3YLfh`6  
Papua New Guinea was administered by Australia until )!rD&l$tE  
1975, when independence was granted. Since that time, governance, Ws3z-U>j  
particularly budgetary, economic performance, law S)z w[m  
and justice, and development and management of basic f@ |[pT  
health and other services have declined. Today, 37% of the =/'>.p3/S  
population is said to live below the poverty line, personal a"xRc  
and property security are problematic, and health is poor. d_$0  
There are significant and growing economic, health and education rMJ@oc  
disparities between urban and rural inhabitants. m=E/um[D  
Papua New Guinea has one referral hospital, in Port \6a' p Q,  
Moresby. This has an eye clinic with one part-time and two 'MYKAnZ-i  
full-time consultant ophthalmologists, and several ophthalmology 1yF9zKs&_  
training registrars. There are also two private ophthalmologists `UzH *w@e  
in the city. Elsewhere, four provincial hospitals H(n fHp.3  
have eye clinics, each with one consultant ophthalmologist. UGM:'xa<T  
One of these, supported by Christian Blind Mission and )Rb t0   
based at Goroka, provides an extensive outreach service. {}'Jr1  
Visiting Australian and New Zealand ophthalmology teams :tFc Pc'  
and an outreach team from Port Moresby General Hospital J| &aqY  
provide some 6 weeks of provincial service per year. 7lF;(l^Z>}  
Cataract and its surgery account for a significant proportion N4VZl[7?  
of ophthalmic resource allocation and services delivered * wqR.n?  
in PNG. Although the National Department of Health keeps VWdTnu  
some service-related statistics, and cataract has been considered l8+1{ 6xP  
in three PNG publications of limited value (two district d <ES  
service reports 9 fbo  
2,3 h){#dU+&  
and a community assessment [W[awGf  
4 EqD@o  
), there has 8TH;6-RT  
been no systematic assessment of cataract or its surgery. {7IZN< e  
A !T)_(}|6}  
BSTRACT Wn;%B].I  
Purpose: ||cI~qg  
To determine the prevalence of visually significant 4>Ht_B<<  
cataract, unoperated blinding cataract, and cataract surgery ,{iMF (Nj  
for those aged 50 years and over in Papua New Guinea. FR50y+h^$  
Also, to determine the characteristics, rate, coverage and Wkb>JnPo  
outcome of cataract surgery, and barriers to its uptake. [}Rs  
Methods: >PdrLwKS  
Using the World Health Organization Rapid BB1_EdoG  
Assessment of Cataract Surgical Services protocol, a population- &kWT<*;J)  
based cross-sectional survey was conducted in .gRb'  
2005. By two-stage cluster random sampling, 39 clusters of bTYR=^9  
30 people were selected. Each eye with a presenting visual F DGzh/  
acuity worse than 6/18 and/or a history of cataract surgery 5D^2 +`$/  
was examined. p*zTuB~e<  
Results: E7SmiD@)  
Of the 1191 people enumerated, 98.6% were  HsG3s?*  
examined. The 50 years and older age-gender-adjusted |a0@4 :  
prevalence of cataract-induced vision impairment (presenting iy8Ln,4z(  
acuity less than 6/18 in the better eye) was 7.4% (95% aJs! bx>K  
confidence interval [CI]: 6.4, 10.2, design effect [deff] ]REF1<)4z  
= |D;I>O^"R  
1.3). [4])\q^q  
That for cataract-caused functional blindness (presenting 7 0R_O&f-k  
acuity less than 6/60 in the better eye) was 6.4% (95% CI: uXGAcUx(  
5.1, 7.3, deff *L<<S=g$2  
= ob)c0Pz  
1.1). The latter was not associated with `a pCu  
gender ( w0.;86<MV  
P ,}^;q58  
= JAmpU^(C  
0.6). For the sample, Cataract Surgical Coverage kf' 4C "}  
at 6/60 was 34.5% for Eyes and 45.3% for Persons. The 2tp95E `(O  
Cataract Surgical Rate for Papua New Guinea was less than }f6_ 7W%5  
500 per million population per year. The age-genderadjusted *M~BN}.  
prevalence of those having had cataract surgery YO.+ 06X  
was 8.3% (95% CI: 6.6, 9.8, deff `q y@Qo  
= S]c&T`jx  
1.3). Vision outcomes of T'  )l  
surgery did not meet World Health Organization guidelines. #.@D}7y5  
Lack of awareness was the most common reason for not al]-*=v7}  
seeking and undergoing surgery. m8* )@e  
Conclusion: Pfg.'Bl  
Increasing the quantity and quality of cataract `jGG^w3  
surgery need to be priorities for Papua New Guinea eye b5%T)hn=  
care services. {@X)=.Zf  
Cataract and its surgery in Papua New Guinea 881 X_wPuU%  
© 2006 Royal Australian and New Zealand College of Ophthalmologists Gl>*e|}  
This paper reports the cataract-related aspects of a population- 0 SDyE  
based cross-sectional rapid assessment survey of 8SO(pw9  
those 50 years and older in PNG. ShU1RQk  
M Cl!qdh6  
ETHODS 1n>(CwLG"  
The National Ethical Clearance Committee of The Medical 3c[TPD_:  
Research Advisory Committee granted ethics approval to 4Mv]z^  
survey aspects of eye health and care in Papua New Guinea 9.l*#A^  
(MRAC No. 05/13). This study was performed between 6tBe,'*  
December 2004 and March 2005, and used the validated 2fMKS  
World Health Organization (WHO) Rapid Assessment of &^K,"a{  
Cataract Surgical Services qbD[<T  
5,6 :sJQ r._L  
protocol. Characterization of SH1)@K-  
cataract and its surgery in the 50 years and over age group -h, ?_d>  
was part of that study. N9BfjT}  
As reported elsewhere, ]R]%c*tA  
7 A0gRX]  
the sample size required, using a *f3? 0w  
prevalence of bilateral cataract functional blindness (presenting ,^&amWey  
visual acuity worse than 6/60 in both eyes) of 5% in the Ox&]{  
target population, precision of C"g bol^  
± V%[34G  
20%, with 95% confidence %HcCe[d5l  
intervals (CI), and a design effect (deff) of 1.3 (for a cluster ~ qezr\$2  
size of 30 persons), was estimated as 1169 persons. The Yp;? Zq9  
sample frame used for the survey, based on logistics and  ^_G@a,  
security considerations, included Koki wanigela settlement trMwFpfu  
in the Port Moresby area (an urban population), and Rigo `]wk)50BVp  
coastal district (a rural population, effectively isolated from ~r?VXO p"  
Port Moresby despite being only 2–4 h away by road). From U'0e<IcY  
this sample frame, 39 clusters (with probability proportionate ^W ,~   
to population size) were chosen, using a systematic random ugS  
sampling strategy. b-HELS`nX  
Within each cluster, the supervisor chose households E5g|*M.+f  
using a random process. Residency was defined as living in &r1]A&  
that cluster household for 6 months or more over the past sk7]s7  
year, and sharing meals from a common kitchen with other WM9z~z'2a  
members of the household. Eligible resident subjects aged y=SVS3D  
50 years and older were then enumerated by trained volunteers 7,5Bur   
from the Port Moresby St John Ambulance Services. 9i+`,r  
This continued until 30 subjects were enrolled. If the QfRo`l/V9  
required number of subjects was not obtained from a particular > - U+o.o  
cluster, the fieldworkers completed enrolment in the y'm5Z-@o6  
nearest adjacent cluster. Verbal informed consent was `j!XWh*$  
obtained prior to all data collection and examinations. 9E}JtLgT  
A standardized survey record was completed for each Tb}op XYK  
participant. The volunteers solicited demographic and general z8cefD9F  
information, and any history of cataract surgery. They vF1Fcp.@  
also measured visual acuity. During a methodology pilot in r0*Y~ KHw  
the Morata settlement area of Port Moresby, the kappa statistic OxN[w|2\4  
for agreement between the four volunteers designated DGNn #DP  
to perform visual acuity estimations was over 0.85. C%H?vrR  
The widely accepted and used ‘presenting distance visual ]Hg6Mz>Mj  
acuity’ (with correction if the subject was using any), a measure *auT_*  
of ocular condition and access to and uptake of eye care 2d&]V]:R*  
services, was determined for each eye separately. This was -^q;e]+J  
done in daylight, using Snellen illiterate E optotypes, with @D>qo=KPM  
four correct consecutive or six of eight showings of the 3:T~$M`]  
smallest discernible optotype giving the level. For any eye R]3j6\  
with presenting visual acuity worse than 6/18, pinhole acuity _ Y7 Um  
was also measured. /}9)ZY Mx  
An ophthalmologist examined all eyes with a history of X.ecA`0  
cataract surgery and/or reduced presenting vision. Assessment }m&\I  
of the anterior segment was made using a torch and -F_c Bu81V  
loupe magnification. In a dimly lit room, through an undilated \, '4eV  
pupil, the status of the visually important central lens 3^5h:O aT  
was determined with a direct ophthalmoscope. An intact red $PRUzFZ  
reflex was considered indicative of a ‘normal’ clear central X 8):R- J  
lens. The presence of obvious red reflex dark shading, but ae" o|Q  
transparent vitreous, was recorded as lens opacity. Where Gn<0Fy2  
present, aphakia and pseudophakia with and without posterior bOSqD[?  
capsule opacification were noted. The lens was determined z /fSs tN  
to be not visible if there were dense corneal opacities &2S-scP  
or other ocular pathologies, such as phthisis bulbi, precluding 31UxYBY  
any view of the lens. The posterior segment was examined W]XM<# ^^  
with a direct ophthalmoscope, also through an "!CVm{7[  
undilated pupil. ;A4j_ 8\[  
A cause of vision loss was determined for each eye with ZMLN ;.{Na  
a presenting visual acuity worse than 6/18. In the absence of #<X4RJ  
any other findings, uncorrected refractive error was considered bR,Es~n  
to be that cause if the acuity then improved to better <v/aquLN  
than 6/18 with pinhole. Other causes, including corneal }Xfg~ % 6  
opacity, cataract and diabetic retinopathy, required clinical l(Dr@LB~  
findings of sufficient magnitude to explain the level of vision p3Ozfk  
loss. Although any eye may have more than one condition &*Xrh7K2e  
contributing to vision reduction, for the purposes of this 0U:X[2|)  
study, a single cause of vision loss was determined for each |?ZU8I^vW  
eye. The attributed cause was the condition most easily Ijap%l1I  
treated if each of the contributing conditions was individually -2!S>P Zs  
treatable to a vision of 6/18 or better. Thus, for example, #Hz9@ H  
when uncorrected refractive error and lens opacity coexisted, kvuRT`/  
refractive error, with its easier and less expensive treatment, egBk7@Ko  
was nominated as the cause. Where treatment of a condition ?iV}U  
present would not result in 6/18 or better acuity, it was IZm6.F  
determined to be the cause rather than any coincident or &@'%0s9g  
associated conditions amenable to treatment. Thus, for +nHr+7 }  
example, coincident retinal detachment and cataract would po\jhfn  
be categorized as ‘posterior segment pathology’. U<;{_!]  
Participants who were functionally blind (less than 6/60 S7WHOr9XMV  
in the better eye) because of unoperated cataract were interrogated ]n>9(Mp!M  
about the reasons for not having surgery. The M$Ui=GGq  
responses were closed ended and respondents had the option 0^\H$An*k  
of volunteering more than one barrier, all of which were D\+x/r?-I  
recorded in a piloted proforma. The first four reasons offered GD)paTwO<  
were considered for analysis of the barriers to cataract 7w" !"W#  
surgery. I4+1P1z  
Those eyes previously operated for cataract were examined yUD@oOVC0  
to characterize that surgery and the vision outcome. A |bSAn*6b  
detailed history of the surgery was taken. This included the lP)n$?u  
age at surgery, place of surgery, cost and the use of spectacles Pv,PS.,-  
afterward, including reasons for not wearing them if that was \)wVO*9*0  
the case. kjp~:Bg_(  
The Rapid Assessment of Cataract Surgical Services data Gey-8  
entry and analysis software package was used. The prevalences j^8HTa0Cy|  
of visually significant cataract, unoperated blinding {d'B._#i  
cataract and cataract surgery were determined. Where prevalence r>|S4O  
estimates were age and gender adjusted for the population Ye4 &4t  
of PNG, the estimated population structure for the `>g\gaQ  
882 Garap o6|- :u5_/  
et al. Lg,ObVt!  
© 2006 Royal Australian and New Zealand College of Ophthalmologists ZL0k  
year 2000 m*HUT V  
1 a6ryyt 5  
was used, and 95% CI were derived around these 0S;Ipg  
point estimates. Additional analysis for potential associations 2?Ryk`2i)  
of cataract, its surgery and surgical outcomes employed the 2B6u ) 95  
STATA (version 8.0; StataCorp LP, TX, USA). Fisher’s exact g#l!b%$  
test and the chi-square test for bivariate analysis and a multiple .Jg<H %%f  
logistic regression model for multivariate analysis were @XL49D12c  
used. Odds ratios (OR) and 95% CI were estimated. A Y>FLc* h  
P c[X6!_  
- _X<V` , p  
value of UHi^7jQ  
< zK 1\InP  
0.05 was taken as significant for this analysis. 5syzh S  
The Cataract Surgical Coverage (Eyes) (CSC(Eyes)) was 1 YtY=  
calculated. This is a surgical service impact indicator. It measures H&F2[j$T  
the proportion of cataract that has been operated on Bqa_l|  
in a defined population at a particular point in time, being jL5O{R[ x:  
the eyes having had cataract surgery as a percentage of the V_v+i c^  
combined total of all of those eyes operated with those { i3x\|  
currently blind (less than 6/60) from cataract (CSC(Eyes) at Qd% (]L[N.  
6/60  _uJ6Vy  
= d3T7$'l$  
100 #&S<{75A  
a kaEu\@%n  
/( C5Fq%y{$.  
a DX3jE p2  
+ -ECnX/ "  
b ji ,`?  
), where aOoWB^;6  
a \4 t;{_  
= 1_}k)(n  
pseudophakic hiR+cPSF  
+ =PLy^%  
aphakic eyes, waV4~BdL  
and ,0>_(5  
b j=>WWlZ  
= =E~SaT  
eyes with worse than 6/60 vision caused by cataract). /h&>tYVio  
8 AucX4J<  
The Cataract Surgical Coverage (Persons) (CSC(Persons)) SS,'mv  
was determined. This considers people with operated % = v<3  
cataract (either or both eyes) as a proportion of those having ,?GAFg K:  
operable cataract. (CSC(Persons) at 6/60 <lSo7NkR  
= Qm?o^%a  
100( &gm/@_  
x +n8,=}  
+ KR4RIJZ_t  
y MP8s}  
)/ U3c!*i  
( _Q\u-VN*hv  
x QlxlT$o}  
+ qSL~A-  
y lG X_5R  
+ s8kkf5bu  
z SRk-3:  
), in which #+P)X_i`  
x Hn(L0#Oqy  
= Yr+ghl/ V  
persons with unilateral pseudophakia TqMy">>  
or unilateral aphakia and worse than 6/60 vision V6 ,59  
caused by cataract in the other eye, ?Wp{tB9N0  
y ~7=w,+  
= Ucok&)7-  
persons with bilateral UbV} !  
previously operated cataract, and X?.LA7)CK  
z 30/ (  
= ma26|N5  
persons with bilateral -n$fh::^  
cataract causing vision worse than 6/60 in each). xo_Es?  
8 %S4pkFR  
The Cataract Surgical Rate, being the number of cataract CpICb9w  
operations per year per million of population, was also <El6?ml@  
estimated. :ITz\m  
R dmD ':1  
ESULTS X\1'd,V  
Of the 1191 people enumerated, 5 subjects were not available iPJZ%  
during the survey and 12 refused participation. Data -xf=dzm)  
from these 17 were not considered in the analysis. Of the yN~: 3  
remaining 1174 (98.6%), 606 (51.6%) were female, and 914 wBXgzd%L  
(77.9%) were domiciled in rural Rigo. %k3a34P@  
Cataract caused 35.2% of vision impairment (presenting S\jN:o#b  
vision less than 6/18) and 62.8% of functional blindness +x0-hRD  
(presenting vision less than 6/60) in the 2348 eyes sampled u]ZCYJ>  
(Table 1). It was second to refractive error (45.7%) `7|v  
7 T{j&w%(z  
in the ( UV8M\  
former, and the leading cause of the latter. Tl Z|E '_C  
For the 1174 subjects, cataract was the most prevalent dYJW`Q;j.|  
cause of vision impairment (46.7%) and functional blindness ZuF-$]oL&  
(75.0%) (Table 1). On bivariate analysis, increasing age U:xr['  
( 8\t~ *@"  
P m`-{ V<(M  
< C=AX{sn  
0.001), illiteracy ( 6kKIDEX  
P r!etj3  
< z&d&Ky  
0.001) and unemployment H5=-b@(  
( [>4Ou^=1  
P [HK[{M =v=  
< 5"6Y=AuQ6  
0.001) were associated with cataract-induced functional $} 7/mS@c  
blindness. Gender was not significantly associated ( h4S,(*V$!  
P 6`{Y#2T  
= 0\Qqv7>  
0.6). 5+'1 :Sa(i  
In a multivariate model that included all variables found +=^10D  
significant in bivariate analysis, increasing age (reference category $v+Q~\'  
50–59 years; OR: 2.6, 95% CI: 1.6, 5.9 for persons F\Ex$:%~  
aged 60–69, OR: 9.8, 95% CI: 4.6, 20.6 for persons aged o6ec\v!l-  
70–79, and OR: 18.6, 95% CI: 8.3, 41.9 for persons aged &aaXw?/zr  
80 years and older) and illiteracy (OR 2.2, 95% CI 1.3, 3.8) S=ebht=  
were associated with functional cataract blindness. vVmoV0kGt  
The survey sample included 97 people (8.3%) who had f 6Bx>lh  
previously undergone cataract surgery, for a total of 136 eyes `TOm.YZG  
(5.8%). On bivariate analysis, increasing age ( Y dmYE $  
P (5re'Pl  
= vu;pILN  
0.02), male ? A;x%8}  
gender ( r%JJ5Al.S  
P t0d1? ?G  
= x-+Hy\^@|  
0.02), literacy ( #HpF\{{v  
P SZW`|ajH  
< 1WRQjT=o  
0.001) and employed status 5fMVjd  
( F$y3oX  
P Tz[ck 'k  
= \wEHYz  
0.03) were associated with cataract surgery. Illiteracy m-4P*P$X  
was significantly associated with reduced uptake of cataract FCnOvF65  
surgery (adjusted OR 0.43, 95% CI: 0.20, 0.91) in a multivariate 9AO`Zk{/Ez  
model that adjusted for age, gender and employment /]zn8 d  
status. w{l}(:xPp  
The CSC(Eyes) at 6/60 for the survey sample was d(9ZopJrQ  
34.5%, and the CSC(Persons) at the same vision level was SEa'>UG  
45.3%. (3~h)vaJ  
Most cataract surgery occurred in a government hospital ,RjE?M%  
( S-l<+O1fy  
P P0VXHE1p  
< `Y>'*4a\  
0.001), more than 5 years ago ( yNCd} 4Ym5  
P 4&%0%  
< 0M=A,`qk  
0.001). Also, most 0z&]imU  
of the intracapsular extractions were performed more than q@k/"ee*?  
5 years ago ( tQ=3Oa[u  
P 9U~fc U6  
< >T84NFdz+  
0.001). Patients are now more likely to wW &q)WOi  
receive intraocular lens surgery ( O0^m_  
P &:Q^j:  
< eXKpum~  
0.001). Although most \Lu aI  
surgery was provided free ( ZHu"& &  
P Kk.a9uKI}  
= mok94XuK)  
0.02), males, who were more 1 S<E=7  
likely to have surgery ( 5&)T[Q X`  
P HSwC4y}  
= W%ml/ 4  
0.02), were also more likely to }%75 Wety  
pay for it ( S\76`Ot  
P Q|KD$2rB  
= ":v^Y 9  
0.03) (Table 2). )FQxVT,.  
As measured by presenting acuity, the vision outcomes of ,FIG5-e,}  
both intracapsular surgery and intraocular lens surgery were ^%5 ;Sc1V  
poor (Table 3). However, 62.6% of those people with at least 6~34L{u  
Table 1. 2CMWJi  
Vision impairment and blindness by eye and person; Koki and Rigo, Papua New Guinea (2005) pk8`suZ  
Category 2348 eyes/1174 people surveyed !LR9}Xon  
Vision impairment Blindness ~"J7=u1o  
Eye (presenting ?_-5W9  
visual acuity less than 6/18) /np05XhEa  
Person (presenting visual :3N6Ej  
acuity less than 6/18 in the 3>>Ca;>$  
better eye) wY]ejK$0R  
Eye (presenting visual Prc (  
acuity less than 6/60) 0VnRtLnqI  
Person (presenting visual Ddh  
acuity less than 6/60 in the _TwE ym.V  
better eye) L,yq'>*5s  
Total Cataract Total Cataract Total Cataract Total Cataract -G[TlH06  
n QVF561Yz  
% fBb: J+  
n XL/V>`E@  
% xsIfR3Ze9  
n eN'b" _D  
% j/8q  
n ')T*cLQ><  
% T |&u?  
n : IO"' b  
% >Qqxn*O  
n aECpe'!m4  
% e= XC$Jv  
n vA{DF{S 4  
% 2K^xN]]rG  
n 9!PM1<p  
% Z6zLL   
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 dUBf.2 ry  
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 g,G{% dGsk  
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 k$.l^H u  
80 Uw?25+[b  
+ e< G[!m  
years 136 14.3 74 22.1 57 15.5 42 24.4 85 20.6 60 23.3 30 25.0 28 31.1 )h]tKYx  
Male 467 49.1 157 46.9 180 48.9 77 44.8 203 49.4 123 47.7 59 49.2 41 45.6 cR&d=+R&  
Female 485 50.9 178 53.1 188 51.1 95 55.2 208 50.6 135 52.3 61 50.8 49 54.4 )afH:  
All cases 952 100 335 35.2 368 100 172 46.7 411 100 258 62.8 120 100 90 75 1]W8A.ZS  
Cataract and its surgery in Papua New Guinea 883 Pz|}[Cx-  
© 2006 Royal Australian and New Zealand College of Ophthalmologists A9WOu*G1O  
one eye operated on for cataract felt that their uncorrected BwYR"  
vision, using either or both eyes, was sufficiently good that MH]?:]K9V  
spectacles were not required (Table 3). DB'3h7T  
‘Lack of awareness of cataract and the possibility of surgery’ DG=_E\"#  
was the most common (50.1%) reason offered by 90 ,D.@6 bJW  
cataract-induced functionally blind individuals for not seeking OTEx9  
and undergoing cataract surgery. Males were more likely w[uw hd  
to believe that they could not afford the surgery (P = 0.02), `uc`vkVZ  
and females were more frequently afraid of undergoing a "/x/]Qx2  
cataract extraction (P = 0.03) (Table 4). m:g%5' qDZ  
DISCUSSION _AiGD  
The limitations of the standardized rapid assessment methodology 4)9Pgp :  
used for this study are discussed elsewhere.7 Caution OYOczb]  
should be exercised when extrapolating this survey’s 9Z:pss@  
Table 2. Circumstances of cataract surgery; Koki and Rigo, Papua New Guinea (2005) km}E&ao  
Category 136 cataract surgeries V'AZs;  
Male Female Aphakia ^Uldyv/  
(n = 74) G)=+Nt\ *  
Pseudophakia >SS979  
(n = 60) AVp"<Uv  
Couched YY$O"!."  
(n = 2) tY?evsVgz  
Male, n (%) 83 (61.0) 45 (60.8) 38 (63.3) 0 (0.0) UQ 2;Dg G%  
Female, n (%) 53 (39.0) 29 (39.2) 22 (36.7) 2 (100) \U?{m)N  
Undergone surgery in the last 5 years, n (%) 19 (22.9) 20 (37.7) 10 (13.5) 29 (48.3) 0 (0.0) . "j*4  
Range of age at the time of surgery, years 39–84 40–87 39–87 45–85 52 EkP(] F  
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 P' k`H  
Surgery in a government hospital, n (%) 72 (86.7) 44 (83.0) 63 (85.1) 53 (88.3) 0 (0.0) PLWx'N-kqL  
Surgery in a private hospital, n (%) 10 (12.1) 7 (13.2) 10 (13.5) 7 (11.7) 0 (0.0) ulXe;2  
Surgery in an eye camp, n (%) 1 (1.2) 0 (0.0) 1 (1.4) 0 (0.0) 0 (0.0) .7H* F9  
Surgery by traditionalist, n (%) 0 (0.0) 2 (3.8) 0 (0.0) 0 (0.0) 2 (100) ="[6Z$R  
Totally free surgery, n (%) 32 (38.6) 26 (49.1) ;7yt,b5&C  
Paid full price asked for surgery, n (%) 25 (30.1) 14 (26.4) +'D #VG  
Paid partial price asked for surgery, n (%) 26 (31.3) 13 (24.5) Il#9t?/  
Totally free surgery in a government hospital, n (%) 55 (47.4) zj'uKBDl  
Full price surgery in a government hospital, n (%) 23 (19.8) !%YV0O0  
Partially paid surgery in a government hospital, n (%) 38 (32.8) G6j9,#2@  
Table 3. Characterization of cataract surgery outcomes; Koki and Rigo, Papua New Guinea (2005) y &%2  
(a) 136 cataract surgeries QLyBP!X-  
(b) 97 people with at least one eye operated on for cataract -cWxS{vO  
(c) 67 (69.1%) cataract operated people not currently using distance correction: 38 (56.7%) male; 29 (43.3%) female E9S&UU,K  
Aphakia Pseudophakia Couched 3Y=?~!,Jk  
n % n % n % n5 jzVv  
Total 74 54.4 60 44.1 2 1.5 3.I:`>;EO  
Presenting vision 6/18 or better 27 36.5 24 40 0 0.0 9@z" ~H  
Presenting vision worse than 6/60 40 54.1 11 18.3 2 100 KfLp cV  
Aphakia Pseudophakia‡ Couched J9/}ZD^  
Unilateral† Bilateral n % n % #k<j`0kiq  
n % n % "4qv yVOE  
Total 28 28.9 17 17.5 51 52.6 1 1.0 m-!Uy$yM  
Presenting vision 6/18 or better in better eye 15 53.6 11 64.7 35 68.6 0 0.0 ~@bh[o~rF  
Presenting vision worse than 6/60 in better eye 13 46.4 3 17.6 9 17.6 1 100 HWT^u$a"  
Reason n % Gd%E337d  
Never provided 20 29.9 *f$wmZ5A  
Damaged 2 3.0 K ZSvT{  
Lost 3 4.5 {QTnVS't 0  
Do not need 42 62.6 !5K9L(gqb  
†Unilateral aphakes with an unoperated contralateral eye. ‡Bilateral pseudophakes (n = 9) + those with one eye aphakic and the other }e*OprF  
pseudophakic (n = 12) + unilateral pseudophakes with an unoperated contralateral eye (n = 30). 2hI|] p  
884 Garap et al. K0O&-v0"1  
© 2006 Royal Australian and New Zealand College of Ophthalmologists T#e ;$\  
results to the entire population of PNG. However, this &udlt//^%  
study’s results are the most systematically collected and Sq,x57-  
objective currently available for eye care service planning. &I$MV5)u  
Based on this survey sample, the age-gender-adjusted WD7IF+v  
prevalence of vision impairment from all causes for those 0xYPK7a=L\  
50 years and older in PNG is 29.2% (95% CI: 27.6, 35.1, >ps=z$4j*  
deff = 2.3), with 13.1% (95% CI: 11.3, 15.1, deff = 1.2) due t\$P*_  
to uncorrected refractive error.7 Cataract (7.4% [95% CI: aqk0+  
6.4, 10.2, deff = 1.3]) is the second most frequent cause. The ]FNqNZ  
adjusted prevalence for functional blindness from all causes RrGFGn{  
in people aged 50 years and older is 8.9% (95% CI: 8.4, 12.0, 0qj:v"~ Q  
deff = 1.2),7 with cataract the leading cause at 6.4% (95% "ebm3t@C  
CI: 5.1, 7.3, deff = 1.1). This is typical of developing countries. U\ Et  
However, atypically, it would seem that cataract blindness x$;I E  
in PNG is not associated with female gender.9 ;5bzXW#U  
Assuming that ‘negligible’6 cataract blindness (less than V_T.#"C4=z  
5% at visual acuity less than 3/60,8 although it may be as z Mf .  
much as 10–15% at less than 6/6010) occurs in the under Is $I;`  
50 years age group, then, based on a 2005 population estimate hv.$p5UY*  
of 5.545 million, PNG would be expected to currently j[Y$)HF  
have 32 000 (25 000–36 000) cataract-blind people. An 1@)kNg)*$  
additional 5000 people in the 50 years and older age group Wz~=JvRHh  
will have cataract-reduced vision (6/60 and better, but less ;p !|E3o.  
than 6/18), along with an unknown number under the age of PtUea  
50 years. `m.).Hda  
The age-gender-adjusted prevalence of those 50 years 'edd6yTd  
and older in PNG having had cataract surgery is 8.3% (95%  jIMT&5k  
CI: 6.6, 9.8, deff = 1.3). Prevalences for males and females, =r3%jWH6  
respectively, are 10.2% (95% CI: 7.7, 12.7) and 6.4% (95% GESEj%R/b  
CI: 4.5, 8.4), with the expected9 association with male gender #E?TE  
(age adjusted OR 1.6, 95% CI: 1.2, 2.1). Assuming negligible vU:FDkx*nn  
cataract surgery is performed on those under age ?*36&Iq}  
50 years (noting mean age and age range of surgery in HH-A\#6J  
Table 2), there would be about 41 400 people in PNG today )"W(0M] >  
who have had this surgery. In the survey sample, 28.7% of _(K)(&  
surgery occurred in the last 5 years (Table 2). Assuming that 6`>WO_<z  
there have been no deaths, annual surgical numbers have h%9> js^~  
been steady during this time, and a population mean of the yJCqP=  
2000 and 2005 estimates, this would equate to about 2400 R Obo4  
people per year, being a Cataract Surgical Rate (CSR) of e ;+6U"Jx*  
approximately 440 per million per year. x)Y?kVw21"  
Unfortunately, no operation numbers are available from #Jm Vq-)  
the private Port Moresby facility, which contributed 12.5% O_zW/#  
(Table 2) of the surgeries in this study. However, from  ZA u=m  
records and estimates, outreach, government and mission |[)k5nUQ|  
hospital surgical services perform approximately 1600 cataract 4pvT?s>68  
surgeries per year. Excluding the private hospital, this n{d 0}N =  
equates to a CSR of about 300 per million population per +3a} ~pW  
year. g*]hmkYe9  
Whatever the exact CSR, certainly less than the WHO V`c" q.8  
estimate of 716,11 the order of magnitude is typical of a :]Nn(},  
country with PNG’s medical infrastructure, resourcing and r{cefKJHg  
bureacratic capability.11 With the exception of the Christian <>n-+Kr  
Blind Mission surgeon, who performs in excess of 1000 cases ''bh{ .x  
per year, PNG’s ophthalmologists operate, on average, on aVg~/  
fewer than 100 cataracts each per year. This is also typical.6 F@8G,$  
It will be evident that the current surgical capability in $?_/`S1 3  
PNG is insufficient to address the cataract backlog. The @U8}K#  
CSC(Persons) of 45.3%, relating directly to the prevalence jW,b"[  
of bilateral cataract blindness, and CSC(Eyes) of 34.5%, Oe)d|6=  
relating to the total surgical workload, are in keeping with 8t1XZ  
other developing countries.6,8,10 If an annual cataract blindness #r=Jc8J_  
incidence of 20% of prevalence12 is accepted, and surgery 8a,uM :  
is only performed on one eye of each person, then 6400 ^n|yfvR  
(5000–7200) surgeries need to be performed annually to meet  !^yH]v  
this. While just addressing the incidence, in time the backlog LD=eMk: ~  
will reduce to near zero. This would require a three- or %ER"Udh  
fourfold increase in CSR, to about 1200. Despite planning -JEiwi,  
for this and the best of intentions, given current circumstances |)+s,LT5  
in PNG, this seems unlikely to occur in the near future. <2n5|.:>  
Increasing the output of surgical services of itself will be %.h&W;  
insufficient to reduce cataract-related blindness. As measured oimM)Yo  
by presenting acuity, the outcome of cataract surgery is poor *;&[q{hz  
(Table 3). Neither the historical intracapsular or current khc1<BBsT  
intraocular lens surgical techniques approach WHO outcome 1dhuLN%Ce  
guidelines of more than 80% with 6/18 and better h-f`as"d  
presenting vision, and less than 5% presenting functionally EED0U?  
blind.13 Better outcomes are required to ensure scarce `SH14A*  
Table 4. Reasons that cataract-blind (worse than 6/60) people do not seek or undergo cataract surgery; Koki and Rigo, Papua New Guinea ? K,d  
(2005) ,M.phRJ-`  
90 people functionally blind due to cataract K1+4W=|  
Responses by 41 V0<g$,W=  
males (45.6%) 45, ):U5  
Responses by 49 qs%UJ0tR  
females (54.4%) @DNwzdP  
Responses by all S}b^_+UbP  
n % n % n % *mJ\Tzc)  
Lack of awareness of cataract and the possibility of surgery 18 43.9 28 57.1 46 50.1 ~n~j2OE  
Too old to do anything about vision 7 17.1 6 12.2 13 14.4 h"y~!NWn  
Believes unable to afford surgery 10 24.4 7 14.3 17 18.9 GBl[s,g[|  
No time available to attend surgery 4 9.8 6 12.2 10 11.1 T)I\?hqTB  
Waiting for cataract to mature 4 9.8 5 10.2 9 10.0 Dv*d$  
None available to accompany person to surgery 4 9.8 2 4.1 6 6.7 <])]1 r8  
Fear of the surgery 2 4.9 6 12.2 8 8.9 VaW^;d#  
Believes no services available 2 4.9 2 4.1 4 4.4  6oI/*`>  
Cataract and its surgery in Papua New Guinea 885 p/qu4[Mm  
© 2006 Royal Australian and New Zealand College of Ophthalmologists (!PsK:wc  
resources are well used.14 Routine monitoring of surgical 'T|EwrS j  
activity and outcome, perhaps more likely to occur if done hD[r6c  
manually, may contribute to an improvement.15,16 So too D<`M<:nq  
would better patient selection, as many currently choose not >"+ ho  
to wear postoperation correction because they see well Hr7?#ZX;e  
enough with the fellow eye (Table 3). Improving access to RrT`]1".  
refraction and spectacles will also likely improve presenting x_x_TEyyh  
acuities (Table 3). ~z\a:+  
Of those cataract blind in the survey, 50.1% claimed to 1cc~UQ  
be unaware of cataract and the possibility of surgery >,QCKZH  
(Table 4). However, even when arrangements, including po(pi|  
transportation, were made for study participants with visually ${rWDZ0Z  
significant cataract to have surgery in Port Moresby, not Ai"MJ6)  
all availed themselves of this opportunity. The reasons for P+Gz'  
this need further investigation. $)  M2  
Despite the apparent ignorance of cataract among the !Eg2#a?  
population, there would seem little point in raising demand ~ MsHV%  
and expectations through health promotion techniques until Vc;g$Xr[  
such time as the capacity of services and outcomes of surgery C=(Q0-+L|  
have been improved. Increasing the quantity and quality of jhPbh5E  
cataract surgery need to be priorities for PNG eye care %wXj P`#  
services. The independent Christian Blind Mission Goroka k ~Q 5Cs  
and outreach services, using one surgeon and a wellresourced q7r b3d  
support team, are examples of what is possible, Rc3!u^?u  
both in output and in outcome. However, the real challenge ~]#-S20  
is to be able to provide cataract surgery as an integrated part `K:n=hpF  
of a functioning service offering equitable access to good eye 7_P33l8y  
health and vision outcomes, from within a public health .vctuy&  
system that needs major attention. To that end, registrar mr/?w0(C  
training and referral hospital facilities and practice are being Trs2M+r)  
improved. Phk3Jv  
It may be that the required cataract service improvements z5oJQPPi  
are beyond PNG’s under-resourced and managed public w;{Q)_A  
health system. The survey reported here provides a baseline , *dLE   
against which progress may be measured. \q*-9_M  
ACKNOWLEDGEMENTS X(eW +,H  
The authors thankfully acknowledge the technical support fI`gF^u(  
provided by Renee du Toit and Jacqui Ramke (The International [|YvVA  
Centre for Eyecare Education), Doe Kwarara (FHFPNG =+K?@;?  
Eye Care Program) and David Pahau (Eye Clinic, Port 9)  ,|h  
Moresby General Hospital). Thanks also to the St Johns ~c<8;,cjYR  
Ambulance Services (Port Moresby) volunteers and staff for dt@c,McN|Q  
their invaluable contribution to the fieldwork. This survey +or <(%o @  
was funded in part by a program grant from New Zealand UimofFmI%  
Agency for International Development (NZAID) to The K:jn^JN$  
Fred Hollows Foundation (New Zealand). Axns  
REFERENCES vpf.0!zh  
1. National Statistical Office, Government of the Independent $pAJ$0=sw  
State of PNG. Papua New Guinea 2000 Census. Port Moresby: U;WwEta ]  
PNG Government, 2000. jc)7FE  
2. Parsons G. Ophthalmic practice in Papua New Guinea. PNG ,dTmI{@O  
Med J 1975; 18: 79–82. lH`TF_  
3. Parsons G. A decade of ophthalmic statistics in Papua New aQ $sn<-l  
Guinea. PNG Med J 1991; 34: 255–61. te2vv]W1  
4. Dethlefs R. The trachoma status and blindness rates of selected \u{4=-C.  
areas of Papua New Guinea in 1979–80. Aust J Ophthalmol 1982; xx>h J!  
10: 13–18. 'nGUm[vh  
5. WHO. Rapid assessment of cataract surgical services. In: Vision -JF^`hBD-  
2020: The Right to Sight: Developing an Action Plan Version 2 CDROM. Ad>81=Z  
World Health Organization and International Agency m N}szW,  
for the Prevention of Blindness, 2004. Available from: http:// t4#gW$+^?H  
www.who.int/ncd/vision2020_actionplan/documents/raccs/ L55 UeP\  
installation_racss.htm s$>n U  
6. Amansakhatov S, Volokhovskaya ZP, Afanasyeva AN, Limburg YIg43Av  
H. Cataract blindness in Turkmenistan: results of a national PBb&.<   
survey. Br J Ophthalmol 2002; 86: 1207–10. PjEJ C@n  
7. Garap JN, Sheeladevi S, Shamanna BR et al. Blindness and zaHZ5%{LQD  
vision impairment in the elderly of Papua New Guinea. Clin Jg[Ao#,==  
Experiment Ophthalmol 2006; 34: 335–41. vuPNru" 2  
8. Limburg H, Foster A. Cataract surgical coverage: an indicator )S%t) }  
to measure the impact of cataract intervention programmes. 3._ ep  
Community Eye Health J 1998; 11: 3–6. LZe)_9$  
9. Lewallen S, Courtright P. Gender and use of cataract surgical y0mND ze  
services in developing countries. Bull World Health Organ 2002; E|f[ #+:+  
80: 300–3. vHpw?(]  
10. Bassett KL, Noertjojo K, Liu L et al. Cataract surgical coverage \6&Ml]1  
and outcome in the Tibet Autonomous Region of China. Br J ":Tm6Nj  
Ophthalmol 2005; 89: 5–9. X%5eZ"1{x  
11. WHO. State of the World’s Sight: Vision 2020: The Right to Sight: X n!md R  
1999–2005. Geneva: World Health Organization, 2005. -  /\qGI  
12. WHO. How to plan cataract intervention in a district. In: Vision 70c]|5  
2020: The Right to Sight: Developing an Action Plan Version 2 CDROM. k(dakFaC^  
World Health Organization and International Agency Uv *A a7M  
for the Prevention of Blindness, 2004. Available from: http:// Cr7Zi>sd<!  
www.who.int/ncd/vision2020_actionplan/contents/4.1.htm D:/ n2_  
13. WHO. Informal Consultation on Analysis of Blindness Prevention Outcomes. fx_#3=bXi  
WHO/PBL/98.68. Geneva: World Health Organization, #%p44% W  
1998. Lkm-<  
14. Brian G, Ramke J, Szetu J et al. Towards standards of outcome S"Cz. bv  
quality: a protocol for the surgical treatment of cataract in ;3cbXc@]  
developing countries. Clin Experiment Ophthalmol 2006; 34: 383– }R['Zoh4I  
7. I1E9E$m5\<  
15. Yorston D, Gichuhi S, Wood M et al. Does prospective monitoring a'i Q("  
improve cataract surgery outcomes in Africa? Br J Ophthalmol >s{I@#9  
2002; 86: 543–7. tbRW 6  
16. Limburg H. Monitoring cataract surgical outcomes: methods /YvXyi>^"%  
and tools. Community Eye Health J 2002; 15: 51–3.
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