Clinical and Experimental Ophthalmology
0$xK 2006;
b!4N)t>gl 34
(aDb^(]> : 880–885
vi[#?;pkF doi:10.1111/j.1442-9071.2006.01342.x
>G-8FL © 2006 Royal Australian and New Zealand College of Ophthalmologists
2y9:'c| xQNw&'|UU Correspondence:
msA' 5> Dr Garry Brian, 5 Hazelmere Parade, Sherwood, Qld 4075, Australia. Email:
grbrian@tpg.com.au (xk.NZnF Received 11 April 2006; accepted 19 June 2006.
u"`5 Original Article
b lRY7 Cataract and its surgery in Papua New Guinea
%|: ;Ti Jambi N Garap
XPHQAo[(s MMed(Ophthal)
XysFwi ,
-:)DX++ 1,2
=&di4'` Sethu Sheeladevi
$l#v/(uFa MHM
@wd!&%yzO ,
-kG3k> by_ 3
dIoF ~8V Garry Brian
QRsqPh&- FRANZCO
Y5nz?a ,
>X;xIyRL 2,4
Si#"Wn?| BR Shamanna
X4d Xm>*?= MD
Ivz+Jjw ,
@PYW|*VS 3
ShC_hi Praveen K Nirmalan
7ZS>1 MPH
jK3giT
3
lr9=OlH and Carmel Williams
?"()>PJx MA
4 hL`=[AB 4
Bj;\mUsk 1
<\>+~p, The Fred Hollows Foundation – Papua New Guinea Eye Care Program,
R
^HohB 2
J$1j-\KS Department of Ophthalmology, School of Medicine and Health
t[%x}0FP-F Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea;
/m97CC#+ 3
}16&1@8 International Center for Advancement of Rural Eye Care,
A ?#]s L.V. Prasad Eye Institute, Hyderabad, India; and
6a7vlo 4
:lgHL3yl The Fred Hollows Foundation (New Zealand), Auckland, New Zealand
2K3MAd{ Key words:
7rH'1U blindness
yPSVwe|g ,
Po1hq2-U8 cataract
):/,w!1 ,
Vre=%bGw Papua New Guinea
(RExV?: ,
IDj_l+?c surgery
cvhlRI%6 ,
5
f8"j$Az vision impairment
<} &7 a s .
w2k<)3 g~ I
w
nWgy4: NTRODUCTION
pG(Fz0b{ Just north of Australia, tropical Papua New Guinea (PNG)
vuXS/ d has more than five million people spread across several major
`Uv)Sf{ and hundreds of other smaller islands. Almost 50% of the
A1Ka(3" land area is mountainous, and 85% of inhabitants are rural
\N? 7WQ dwellers. Forty per cent of the population is age 14 years or
5!tb$p#z younger, and 9% is 50 years or older.
<3lUV7! 1
n"iNKR>nW Papua New Guinea was administered by Australia until
NaF(\j 1975, when independence was granted. Since that time, governance,
B "*`R!y particularly budgetary, economic performance, law
\<X2ns@Tf and justice, and development and management of basic
W,DZ ;).% health and other services have declined. Today, 37% of the
MO-!TZ+6 population is said to live below the poverty line, personal
@^'$r&M and property security are problematic, and health is poor.
BMdSf(l There are significant and growing economic, health and education
t}VwVf<K disparities between urban and rural inhabitants.
5Q|sta! Papua New Guinea has one referral hospital, in Port
*!Y-! Moresby. This has an eye clinic with one part-time and two
iTu0T!4F full-time consultant ophthalmologists, and several ophthalmology
jQ?LHUE training registrars. There are also two private ophthalmologists
1+a@k in the city. Elsewhere, four provincial hospitals
Z["BgEJ have eye clinics, each with one consultant ophthalmologist.
PS$k >_=t One of these, supported by Christian Blind Mission and
&L%Jy #= based at Goroka, provides an extensive outreach service.
VRF6g|0; Visiting Australian and New Zealand ophthalmology teams
a8zZgIV and an outreach team from Port Moresby General Hospital
L<=) @7 provide some 6 weeks of provincial service per year.
4%J|D cY2 Cataract and its surgery account for a significant proportion
> ws!5q of ophthalmic resource allocation and services delivered
[Tp%"f1 in PNG. Although the National Department of Health keeps
+I@cO&CY| some service-related statistics, and cataract has been considered
NI.`mc6Xd in three PNG publications of limited value (two district
m2 O&2[g service reports
8+>\3j 2,3
Xu#:Fe}: and a community assessment
('4wXD]C 4
1"YpO"Rh ), there has
K&dT(U been no systematic assessment of cataract or its surgery.
+/y]h0aa A
Xa,\EEmQ BSTRACT
g<a<*)& Purpose:
|dk[cX> To determine the prevalence of visually significant
J633uH}} cataract, unoperated blinding cataract, and cataract surgery
M{E{N K for those aged 50 years and over in Papua New Guinea.
utH%y\NMF| Also, to determine the characteristics, rate, coverage and
[l*;E
f, outcome of cataract surgery, and barriers to its uptake.
8TPN#" Methods:
ARWZ; GX Using the World Health Organization Rapid
vv+J0f^ Assessment of Cataract Surgical Services protocol, a population-
h1f8ktF based cross-sectional survey was conducted in
!d8A 2005. By two-stage cluster random sampling, 39 clusters of
10O$'` 30 people were selected. Each eye with a presenting visual
URw5U1 acuity worse than 6/18 and/or a history of cataract surgery
&{z<kmc$6 was examined.
@Y-TOCadT Results:
:=fvZA WD Of the 1191 people enumerated, 98.6% were
Uf$i3 examined. The 50 years and older age-gender-adjusted
/S~m)$vu prevalence of cataract-induced vision impairment (presenting
SaO3zz@L acuity less than 6/18 in the better eye) was 7.4% (95%
u
#~;&D*q confidence interval [CI]: 6.4, 10.2, design effect [deff]
&&7r+.Y =
Phs-(3 1.3).
j *3}1L4P That for cataract-caused functional blindness (presenting
LM"y\q ] acuity less than 6/60 in the better eye) was 6.4% (95% CI:
euQ.ArF 5.1, 7.3, deff
d,9`<1{9 =
b$-e\XB! 1.1). The latter was not associated with
(
u`W!{1\ gender (
J/ W{/E>; P
FxRXPt
FK =
*b)Q5dw@1 0.6). For the sample, Cataract Surgical Coverage
Zyy
e%Ly at 6/60 was 34.5% for Eyes and 45.3% for Persons. The
2Z/K(J"&J Cataract Surgical Rate for Papua New Guinea was less than
<Q5Le dN 500 per million population per year. The age-genderadjusted
]RIVc3?;$ prevalence of those having had cataract surgery
||eAE) was 8.3% (95% CI: 6.6, 9.8, deff
(^n*Am;zlH =
Qa`hR 1.3). Vision outcomes of
'&yeQ surgery did not meet World Health Organization guidelines.
lE5v-z? &| Lack of awareness was the most common reason for not
:c]`D> seeking and undergoing surgery.
pq!%?m] Conclusion:
x\@*60o Increasing the quantity and quality of cataract
L,]=vba'$ surgery need to be priorities for Papua New Guinea eye
vqNsZ 8|` care services.
QIU,!w-3X Cataract and its surgery in Papua New Guinea 881
;4#D,z lO^ © 2006 Royal Australian and New Zealand College of Ophthalmologists
C)RBkcb This paper reports the cataract-related aspects of a population-
,FQK;BU!lh based cross-sectional rapid assessment survey of
uCP>y6I those 50 years and older in PNG.
o>lmst%< M
[=%YV# O ETHODS
D'[Uc6 The National Ethical Clearance Committee of The Medical
C+V*
Fh3 Research Advisory Committee granted ethics approval to
=VP=|g survey aspects of eye health and care in Papua New Guinea
'mM jjG9 (MRAC No. 05/13). This study was performed between
qE7R4>5xjO December 2004 and March 2005, and used the validated
.ln8|;% World Health Organization (WHO) Rapid Assessment of
USPTpjt8R Cataract Surgical Services
0E/:|k 5,6
`
,>wC+} protocol. Characterization of
kBEmmgL cataract and its surgery in the 50 years and over age group
n!ok?=(kQ was part of that study.
FG-L0X As reported elsewhere,
_^t-9 7
W{"XJt_ the sample size required, using a
sd0r'jb prevalence of bilateral cataract functional blindness (presenting
,^s visual acuity worse than 6/60 in both eyes) of 5% in the
40P) 4w target population, precision of
w
YNloU ±
rR{,)fX; 20%, with 95% confidence
":W%,`@$ intervals (CI), and a design effect (deff) of 1.3 (for a cluster
)@g;j> size of 30 persons), was estimated as 1169 persons. The
sq0 PBEqq sample frame used for the survey, based on logistics and
:14i?4Fd security considerations, included Koki wanigela settlement
":;@Hnb/ in the Port Moresby area (an urban population), and Rigo
7^e + coastal district (a rural population, effectively isolated from
`s
HuM* Port Moresby despite being only 2–4 h away by road). From
m6n!rRQ^U this sample frame, 39 clusters (with probability proportionate
U9d:@9Y to population size) were chosen, using a systematic random
j|_E$L A\ sampling strategy.
(k"_># % Within each cluster, the supervisor chose households
v> z@ using a random process. Residency was defined as living in
VHUW]8We that cluster household for 6 months or more over the past
MBr:?PE7 year, and sharing meals from a common kitchen with other
*TdnB'Gd members of the household. Eligible resident subjects aged
!dcwq;Ea 50 years and older were then enumerated by trained volunteers
o>D from the Port Moresby St John Ambulance Services.
\' li This continued until 30 subjects were enrolled. If the
'?*g%Yuz required number of subjects was not obtained from a particular
dKhA$f~ cluster, the fieldworkers completed enrolment in the
!Jfs?Hy nearest adjacent cluster. Verbal informed consent was
hZ\+FOx; obtained prior to all data collection and examinations.
A7XnHPIw A standardized survey record was completed for each
!sSQQo2Sv participant. The volunteers solicited demographic and general
SS.jL) information, and any history of cataract surgery. They
xyHejE} also measured visual acuity. During a methodology pilot in
g^>#^rLU the Morata settlement area of Port Moresby, the kappa statistic
h rN% for agreement between the four volunteers designated
2h^WYpCm to perform visual acuity estimations was over 0.85.
,Fqz e/ The widely accepted and used ‘presenting distance visual
#&!G"x7 acuity’ (with correction if the subject was using any), a measure
y>VcgLIB of ocular condition and access to and uptake of eye care
:K.4 n services, was determined for each eye separately. This was
QGnxQ{ko done in daylight, using Snellen illiterate E optotypes, with
?h\mk0[ four correct consecutive or six of eight showings of the
D #2yIec smallest discernible optotype giving the level. For any eye
w2gf&Lc\ with presenting visual acuity worse than 6/18, pinhole acuity
25{ uz was also measured.
")#<y@Rv
An ophthalmologist examined all eyes with a history of
/ONV5IkPy cataract surgery and/or reduced presenting vision. Assessment
8|1^|B(l of the anterior segment was made using a torch and
5rxA<Gs loupe magnification. In a dimly lit room, through an undilated
JHV)ZOO pupil, the status of the visually important central lens
CX/(o] was determined with a direct ophthalmoscope. An intact red
0`#(Toe{B reflex was considered indicative of a ‘normal’ clear central
'w/qcD- lens. The presence of obvious red reflex dark shading, but
"u^EleE! transparent vitreous, was recorded as lens opacity. Where
$+=
<(* present, aphakia and pseudophakia with and without posterior
K\!#4>yd capsule opacification were noted. The lens was determined
42) mM# to be not visible if there were dense corneal opacities
qojXrSb"y or other ocular pathologies, such as phthisis bulbi, precluding
Va<HU:< any view of the lens. The posterior segment was examined
OmMX$YID with a direct ophthalmoscope, also through an
_ *(bmJM undilated pupil.
GY!C|7kN A cause of vision loss was determined for each eye with
mNmUUj9z a presenting visual acuity worse than 6/18. In the absence of
>=,uau7 any other findings, uncorrected refractive error was considered
T.&7sbE_ to be that cause if the acuity then improved to better
7_jE[10 than 6/18 with pinhole. Other causes, including corneal
;<Q
dy`
T opacity, cataract and diabetic retinopathy, required clinical
Pi6C/$
K findings of sufficient magnitude to explain the level of vision
5mB]N%rfW% loss. Although any eye may have more than one condition
a' FN 3 contributing to vision reduction, for the purposes of this
Pe7e?79 study, a single cause of vision loss was determined for each
J\co1kO9/ eye. The attributed cause was the condition most easily
]?l{j treated if each of the contributing conditions was individually
[[L-jq.' treatable to a vision of 6/18 or better. Thus, for example,
>9K//co"of when uncorrected refractive error and lens opacity coexisted,
*:"^[Ckc refractive error, with its easier and less expensive treatment,
I<\
'% was nominated as the cause. Where treatment of a condition
19u =W( present would not result in 6/18 or better acuity, it was
gT52G?- determined to be the cause rather than any coincident or
ur%$aX) associated conditions amenable to treatment. Thus, for
)/t6" " example, coincident retinal detachment and cataract would
7nE"F!d+0 be categorized as ‘posterior segment pathology’.
pa/9F[ Participants who were functionally blind (less than 6/60
:[7lTp
in the better eye) because of unoperated cataract were interrogated
n'w,n1z7 about the reasons for not having surgery. The
-;c responses were closed ended and respondents had the option
e1(h</M U2 of volunteering more than one barrier, all of which were
nfE@R."A recorded in a piloted proforma. The first four reasons offered
BSUPS+@+ were considered for analysis of the barriers to cataract
'1+.t$"/tU surgery.
Wr%7~y*K Those eyes previously operated for cataract were examined
,@CfVQz to characterize that surgery and the vision outcome. A
H'Qo\L4H detailed history of the surgery was taken. This included the
x7ATI[b[ age at surgery, place of surgery, cost and the use of spectacles
3VO:+mT afterward, including reasons for not wearing them if that was
/=T"=bP#/ the case.
A" !n1P The Rapid Assessment of Cataract Surgical Services data
#BJ\{"b_}z entry and analysis software package was used. The prevalences
*@M3p}',M of visually significant cataract, unoperated blinding
Da,Tav%b cataract and cataract surgery were determined. Where prevalence
7 `Du5>b8 estimates were age and gender adjusted for the population
5P+YK\~ of PNG, the estimated population structure for the
&=w|vB)(p 882 Garap
P[i\e7mR et al.
f1cl'; © 2006 Royal Australian and New Zealand College of Ophthalmologists
Q<