Clinical and Experimental Ophthalmology
P
hs4]! 2006;
y4PR&^l?g 34
}A\s`Hm : 880–885
z
Rd^Uks doi:10.1111/j.1442-9071.2006.01342.x
<
^c?M[j © 2006 Royal Australian and New Zealand College of Ophthalmologists
9E5Ec~l "j;"\i0 Correspondence:
@E
%:ALJ Dr Garry Brian, 5 Hazelmere Parade, Sherwood, Qld 4075, Australia. Email:
grbrian@tpg.com.au sG[v vm Received 11 April 2006; accepted 19 June 2006.
E #q
gt9 Original Article
}^U7NZn<" Cataract and its surgery in Papua New Guinea
r"sK
@ Jambi N Garap
?f f !(U MMed(Ophthal)
W=:4I[a6Q ,
XVr>\T4 1,2
h\| ~Q.kG Sethu Sheeladevi
> Dy<@e MHM
{9:[nqX ,
v;m`d{(i2 3
2[
!#Xf Garry Brian
PxfWO1S( FRANZCO
HYU-F_|N=
,
t|-TG\Q X 2,4
:5|'C BR Shamanna
7QV@lR<C2R MD
m}Xb #NAF8 ,
p[oR4 HWr 3
v~E\u Praveen K Nirmalan
:kU#5Aj gK MPH
X 4L"M%i 3
[0c7fH`8V and Carmel Williams
QguRU|y MA
@}9*rWJIE 4
qZQB"Q.* 1
*<r\:g
The Fred Hollows Foundation – Papua New Guinea Eye Care Program,
@M( hyS&on 2
*<HA])D, Department of Ophthalmology, School of Medicine and Health
U$,-F** Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea;
iA.:{^_)09 3
+az=EF International Center for Advancement of Rural Eye Care,
O q3aboAt L.V. Prasad Eye Institute, Hyderabad, India; and
\B/!}Tn; 4
IKo,P$
PE The Fred Hollows Foundation (New Zealand), Auckland, New Zealand
vw~=z6Ka Key words:
B`<a~V blindness
7a0T] ,
]v2%h X cataract
idzc4jR6BT ,
Pk?M~{S Papua New Guinea
i<\WRzVT ,
F ?N+ __o surgery
w;b;rHAZ\ ,
z( !K8
T vision impairment
c)`=wDi .
<nvzNXql I
X_HU?Q_N NTRODUCTION
sq rY<@% Just north of Australia, tropical Papua New Guinea (PNG)
QnJd}(yN has more than five million people spread across several major
|S6L[Uo and hundreds of other smaller islands. Almost 50% of the
T)#e=WcP] land area is mountainous, and 85% of inhabitants are rural
OC6v%@xa dwellers. Forty per cent of the population is age 14 years or
2}uSrA7n] younger, and 9% is 50 years or older.
L#k`>Qn2 1
P=<>H9
p:o Papua New Guinea was administered by Australia until
6DuA 1975, when independence was granted. Since that time, governance,
Xmny(j)g particularly budgetary, economic performance, law
"}Oj N\ and justice, and development and management of basic
RW`+F|UbE health and other services have declined. Today, 37% of the
wh2Ljskda8 population is said to live below the poverty line, personal
"'3QKeM1 and property security are problematic, and health is poor.
fB=j51Lw There are significant and growing economic, health and education
ZH)thd9^b disparities between urban and rural inhabitants.
gP2<L5&Z, Papua New Guinea has one referral hospital, in Port
g1{2E<b5 Moresby. This has an eye clinic with one part-time and two
kInU,/R* full-time consultant ophthalmologists, and several ophthalmology
{d '>J<Da training registrars. There are also two private ophthalmologists
rI#,FZ in the city. Elsewhere, four provincial hospitals
"Z]z9( have eye clinics, each with one consultant ophthalmologist.
^&7gUH*v One of these, supported by Christian Blind Mission and
y=&^=Zh[ based at Goroka, provides an extensive outreach service.
z3p
TdUt Visiting Australian and New Zealand ophthalmology teams
9j>LU<Z and an outreach team from Port Moresby General Hospital
,5}")T["u provide some 6 weeks of provincial service per year.
RjxFlKs8 Cataract and its surgery account for a significant proportion
!BDJU of ophthalmic resource allocation and services delivered
Gt$PBlq0 in PNG. Although the National Department of Health keeps
z9
$1jC some service-related statistics, and cataract has been considered
J+u z{ in three PNG publications of limited value (two district
FO:k
>F service reports
534DAhpD=. 2,3
cD'|zH] and a community assessment
2CRgOFR 4
<O3,b:vw ), there has
"?>hQM1R been no systematic assessment of cataract or its surgery.
e"cvo(}g A
;Dp<|n BSTRACT
a{\<L/\ Purpose:
yk/BQ|G To determine the prevalence of visually significant
.zo>,*:t cataract, unoperated blinding cataract, and cataract surgery
qS[KB\RN1 for those aged 50 years and over in Papua New Guinea.
5@^['S4%8* Also, to determine the characteristics, rate, coverage and
H{g&y
o outcome of cataract surgery, and barriers to its uptake.
Su]p
6B Methods:
O^r,H,3S Using the World Health Organization Rapid
I(va;hG<o Assessment of Cataract Surgical Services protocol, a population-
zXGi based cross-sectional survey was conducted in
zhVkn]z~* 2005. By two-stage cluster random sampling, 39 clusters of
vt(cC)) 30 people were selected. Each eye with a presenting visual
?@H/;hB[| acuity worse than 6/18 and/or a history of cataract surgery
qsHjqK@( was examined.
Rv|X\W
m Results:
u5A$VRMN Of the 1191 people enumerated, 98.6% were
vJsx_i\i examined. The 50 years and older age-gender-adjusted
>?(}F': prevalence of cataract-induced vision impairment (presenting
`|e3OCU acuity less than 6/18 in the better eye) was 7.4% (95%
G$E+qk
nJL confidence interval [CI]: 6.4, 10.2, design effect [deff]
9Bi{X_.9 =
1{?5/F \ + 1.3).
kB=\
a( That for cataract-caused functional blindness (presenting
/EV _Y|(- acuity less than 6/60 in the better eye) was 6.4% (95% CI:
frUO+ 5.1, 7.3, deff
#_'|
TT>p# =
qx`)M3Mu|< 1.1). The latter was not associated with
AZfW gender (
l g*eSx>M P
N.?)s.D( =
e#s-MK-Q 0.6). For the sample, Cataract Surgical Coverage
'L8B"5|> at 6/60 was 34.5% for Eyes and 45.3% for Persons. The
&nfG
Rb Cataract Surgical Rate for Papua New Guinea was less than
X*e<g= 500 per million population per year. The age-genderadjusted
0
![ prevalence of those having had cataract surgery
@Q%<~b[y was 8.3% (95% CI: 6.6, 9.8, deff
[)t1" =
#?fKi$fS;L 1.3). Vision outcomes of
i]}`e>fF surgery did not meet World Health Organization guidelines.
PEPf=sm Lack of awareness was the most common reason for not
?k+>~k{}a seeking and undergoing surgery.
:bu]gj4e Conclusion:
L<0eIw Increasing the quantity and quality of cataract
DgODTxiX surgery need to be priorities for Papua New Guinea eye
$n* wS, care services.
F-PQ`@ZNW Cataract and its surgery in Papua New Guinea 881
Q<T+t0G\O- © 2006 Royal Australian and New Zealand College of Ophthalmologists
1i/&t[ This paper reports the cataract-related aspects of a population-
~;yP{F8? based cross-sectional rapid assessment survey of
N'~l,{ those 50 years and older in PNG.
B;c2gu
M
k%%0"+y#a ETHODS
]La~Bh6
;m The National Ethical Clearance Committee of The Medical
^~7ouA Research Advisory Committee granted ethics approval to
x`Jh NAO> survey aspects of eye health and care in Papua New Guinea
f7?IXDQ>! (MRAC No. 05/13). This study was performed between
qaiR329fx December 2004 and March 2005, and used the validated
!z2 KQ
4C World Health Organization (WHO) Rapid Assessment of
Pd04 Cataract Surgical Services
4x|\xg(
l 5,6
bDjm:G protocol. Characterization of
S(PU"}vZy cataract and its surgery in the 50 years and over age group
5F$~ZDu was part of that study.
v4
vIcHDs As reported elsewhere,
uYCWsw/ 7
Jsf"h-)P the sample size required, using a
1C+d&U prevalence of bilateral cataract functional blindness (presenting
v\dP visual acuity worse than 6/60 in both eyes) of 5% in the
A.cNOous| target population, precision of
.O6(QI*
±
jJyS^*.X 20%, with 95% confidence
&vN^*:Q intervals (CI), and a design effect (deff) of 1.3 (for a cluster
'+v[z=.8] size of 30 persons), was estimated as 1169 persons. The
T&^b~T(y sample frame used for the survey, based on logistics and
S`pB EM security considerations, included Koki wanigela settlement
97vQM in the Port Moresby area (an urban population), and Rigo
Ogu";p( coastal district (a rural population, effectively isolated from
;k
(M4? Port Moresby despite being only 2–4 h away by road). From
}///k]_Sh this sample frame, 39 clusters (with probability proportionate
zKfY0A R to population size) were chosen, using a systematic random
yq12"Rs sampling strategy.
9k;%R5( Within each cluster, the supervisor chose households
o^W.53yX using a random process. Residency was defined as living in
+}iuTqu5 that cluster household for 6 months or more over the past
!md1~g$rN year, and sharing meals from a common kitchen with other
oAgU rl;R members of the household. Eligible resident subjects aged
q9(Z9$a(\ 50 years and older were then enumerated by trained volunteers
xE-
_Fv9 from the Port Moresby St John Ambulance Services.
SW7AG;c= This continued until 30 subjects were enrolled. If the
Rw^X5ByJE required number of subjects was not obtained from a particular
X*t2h3"} cluster, the fieldworkers completed enrolment in the
\G2PK&)F nearest adjacent cluster. Verbal informed consent was
Y%^qt]u.8 obtained prior to all data collection and examinations.
%ZX3:2 A standardized survey record was completed for each
eC`G0.op participant. The volunteers solicited demographic and general
6*:U1{Gl) information, and any history of cataract surgery. They
q<Y#-Io%3 also measured visual acuity. During a methodology pilot in
yM*_"z!L the Morata settlement area of Port Moresby, the kappa statistic
H@'u$qr$: for agreement between the four volunteers designated
84/#,X!=s to perform visual acuity estimations was over 0.85.
=g$%jM>35 The widely accepted and used ‘presenting distance visual
%[on.Q'1]2 acuity’ (with correction if the subject was using any), a measure
KebC$g@W of ocular condition and access to and uptake of eye care
s#FX2r3=Fg services, was determined for each eye separately. This was
yC[Q-P *rG done in daylight, using Snellen illiterate E optotypes, with
{?Cm four correct consecutive or six of eight showings of the
I "HEXsSe smallest discernible optotype giving the level. For any eye
t@jke with presenting visual acuity worse than 6/18, pinhole acuity
L=&}s[5 was also measured.
n&8SB'-r An ophthalmologist examined all eyes with a history of
1cD cataract surgery and/or reduced presenting vision. Assessment
ucFfxar" of the anterior segment was made using a torch and
Tr,
zV loupe magnification. In a dimly lit room, through an undilated
tNljv >vI pupil, the status of the visually important central lens
<MJ-w1A was determined with a direct ophthalmoscope. An intact red
3-BC4y/ reflex was considered indicative of a ‘normal’ clear central
[0lO0ik>G lens. The presence of obvious red reflex dark shading, but
Ehq
[4} transparent vitreous, was recorded as lens opacity. Where
Se>v|6 present, aphakia and pseudophakia with and without posterior
,3Nna:~f capsule opacification were noted. The lens was determined
C)ic;!$Qhb to be not visible if there were dense corneal opacities
gSkY c{b or other ocular pathologies, such as phthisis bulbi, precluding
Dlz1"|SF any view of the lens. The posterior segment was examined
} wx(P3BHD with a direct ophthalmoscope, also through an
sU/vXweky" undilated pupil.
9]:F!d/ A cause of vision loss was determined for each eye with
nGxG! a presenting visual acuity worse than 6/18. In the absence of
GjbOc any other findings, uncorrected refractive error was considered
[Xww`OUsh to be that cause if the acuity then improved to better
\zhCGDm1_ than 6/18 with pinhole. Other causes, including corneal
f{h2>nEj\ opacity, cataract and diabetic retinopathy, required clinical
1^2]~R9,9 findings of sufficient magnitude to explain the level of vision
ysFp$!9Ux loss. Although any eye may have more than one condition
lXXWQ= contributing to vision reduction, for the purposes of this
o
l}}c6 study, a single cause of vision loss was determined for each
,m M7g eye. The attributed cause was the condition most easily
{Rn*)D9 treated if each of the contributing conditions was individually
izLB4pk$ treatable to a vision of 6/18 or better. Thus, for example,
n<ecVFft when uncorrected refractive error and lens opacity coexisted,
O;.DQ refractive error, with its easier and less expensive treatment,
Yn>FSq^Wp- was nominated as the cause. Where treatment of a condition
!ZY1AhGZ present would not result in 6/18 or better acuity, it was
O6ltGtF determined to be the cause rather than any coincident or
n!U1cB{ associated conditions amenable to treatment. Thus, for
IiV]lxiE] example, coincident retinal detachment and cataract would
6t gq.XL^n be categorized as ‘posterior segment pathology’.
?8)k6:
Participants who were functionally blind (less than 6/60
Gz2\&rmN in the better eye) because of unoperated cataract were interrogated
7wHd*{^9N about the reasons for not having surgery. The
$|VdGRZ1 responses were closed ended and respondents had the option
K{XE|g of volunteering more than one barrier, all of which were
,M
:j5 recorded in a piloted proforma. The first four reasons offered
c/%GfB[w0 were considered for analysis of the barriers to cataract
TRr%]qd{Hr surgery.
u ^M'[<{ Those eyes previously operated for cataract were examined
J\Tu=f) to characterize that surgery and the vision outcome. A
mqDI'~T9 u detailed history of the surgery was taken. This included the
^~s!*T)\ age at surgery, place of surgery, cost and the use of spectacles
2B+qS'OT afterward, including reasons for not wearing them if that was
NKiWt
Z" the case.
<slrzc_>& The Rapid Assessment of Cataract Surgical Services data
&t
d entry and analysis software package was used. The prevalences
QFFFxaeJg of visually significant cataract, unoperated blinding
-4obX cataract and cataract surgery were determined. Where prevalence
v3wq- estimates were age and gender adjusted for the population
!PgwFJ of PNG, the estimated population structure for the
+mYK 882 Garap
Rpj{!Ia et al.
4r#4h4`y| © 2006 Royal Australian and New Zealand College of Ophthalmologists
&,* ILz year 2000
ssl.Y! 1
|3>%(4
OS was used, and 95% CI were derived around these
spWo{ point estimates. Additional analysis for potential associations
'f8'|o) of cataract, its surgery and surgical outcomes employed the
N(P2Lo{JF STATA (version 8.0; StataCorp LP, TX, USA). Fisher’s exact
*hh9
K test and the chi-square test for bivariate analysis and a multiple
1!
5VWF0 logistic regression model for multivariate analysis were
r(rT.D& used. Odds ratios (OR) and 95% CI were estimated. A
uvi&! )x P
yi2F#o 'K -
WwUHHm<v value of
tjQ6[`
<
KGmAnN 0.05 was taken as significant for this analysis.
/x\~5cC The Cataract Surgical Coverage (Eyes) (CSC(Eyes)) was
D'#,%4P,e\ calculated. This is a surgical service impact indicator. It measures
3E}j*lo the proportion of cataract that has been operated on
5uJ!)Q in a defined population at a particular point in time, being
AEUR`. the eyes having had cataract surgery as a percentage of the
:k2J
&@8 combined total of all of those eyes operated with those
h-U]?De5\ currently blind (less than 6/60) from cataract (CSC(Eyes) at
):fu]s
" 6/60
=Z..&H5i =
"BIhd*K[~ 100
)S}.QrG a
^ Z3y /(
2>f3nW a
qHPinxewx +
]ZH6
.@| b
4\j1+&W
), where
@\+UTkl8 a
W,:j>vg =
N|8^S pseudophakic
IR32O,) +
4L r,}tA aphakic eyes,
w:](F^<s, and
,^jQBD4={ b
IDdu2HNu =
i_nUyH%b eyes with worse than 6/60 vision caused by cataract).
Z7 ++c<|p 8
3h6,x0AG The Cataract Surgical Coverage (Persons) (CSC(Persons))
6=x]20 was determined. This considers people with operated
Fxn=+Xgg cataract (either or both eyes) as a proportion of those having
<~e*YrJ?- operable cataract. (CSC(Persons) at 6/60
Hi U/fi` =
2#8PM-3" 100(
^P`I"T
d x
^c"\%!w"O +
COd~H y
U^-RyE!} )/
K3&k+~$ (
9h<iw\$' x
|1Nz8Vr. +
#nKGU"$+ y
TLg 9`UA +
$H6n gL z
[?da BXS ), in which
[mF=<G" x
\;+b1 =
#Zn+-Ih persons with unilateral pseudophakia
]ij:>O@{$ or unilateral aphakia and worse than 6/60 vision
_HAr0R8BY caused by cataract in the other eye,
vVo# nzeZ5 y
QdIoK7J 9 =
NNRKYdp, persons with bilateral
0IsnG?" previously operated cataract, and
5=!
aq\
5 z
x
o72JJ =
DyQvk persons with bilateral
1i Q(q\% cataract causing vision worse than 6/60 in each).
|8\et 8
eT8h:+k The Cataract Surgical Rate, being the number of cataract
aIN?|Ch operations per year per million of population, was also
uJ,I6P~9 estimated.
> 'JWW*Y! R
`UkPXCC\1 ESULTS
%5<t3H" Of the 1191 people enumerated, 5 subjects were not available
utw@5 during the survey and 12 refused participation. Data
G"
"=`@ from these 17 were not considered in the analysis. Of the
|>nVp:t^ remaining 1174 (98.6%), 606 (51.6%) were female, and 914
l3kBt-m (77.9%) were domiciled in rural Rigo.
}$s._)a Cataract caused 35.2% of vision impairment (presenting
a#,lf9M vision less than 6/18) and 62.8% of functional blindness
!|#1z}( (presenting vision less than 6/60) in the 2348 eyes sampled
f&Meiu+ (Table 1). It was second to refractive error (45.7%)
;[-y>qU0 7
DVRbTz3V in the
hC2Ra "te) former, and the leading cause of the latter.
6z+*H7Qz For the 1174 subjects, cataract was the most prevalent
BP@Lhii cause of vision impairment (46.7%) and functional blindness
]F,v#6qi (75.0%) (Table 1). On bivariate analysis, increasing age
rjT!S1Hs (
e
+O0l P
C8
2lT_7" <
*:V"C\`^n 0.001), illiteracy (
%g%#=a;]q P
jhSc9 <
`LCxxpHi| 0.001) and unemployment
9Vv&\m!0 (
WqRg/ P
:. a
}pgh <
gj Ue{cb5 0.001) were associated with cataract-induced functional
eVbaxL!Q^ blindness. Gender was not significantly associated (
D'+kzb@ P
| (a<b =
p)=Fi}#D\ 0.6).
l]
o&D))R In a multivariate model that included all variables found
R%N&Y~zH significant in bivariate analysis, increasing age (reference category
?I.<mdhN#t 50–59 years; OR: 2.6, 95% CI: 1.6, 5.9 for persons
A?
*_14& aged 60–69, OR: 9.8, 95% CI: 4.6, 20.6 for persons aged
Nbnu
QPb' 70–79, and OR: 18.6, 95% CI: 8.3, 41.9 for persons aged
fhp][)g; 80 years and older) and illiteracy (OR 2.2, 95% CI 1.3, 3.8)
9*}?0J8 were associated with functional cataract blindness.
O)!MWmr The survey sample included 97 people (8.3%) who had
f^f{tOX previously undergone cataract surgery, for a total of 136 eyes
C.$`
HGv (5.8%). On bivariate analysis, increasing age (
3M{/9rR[ P
0UvN ws =
P=V=\T<4_ 0.02), male
!fcr3x|Y~M gender (
~Xg@,?Zr P
N8|
;X =
.q1OT> 0.02), literacy (
j6KGri P
*a7&v3X <
Q1Sf7) 0.001) and employed status
Y&k6Xhuao (
;$\d^i{N P
`\:92+ =
wU#79:h
0.03) were associated with cataract surgery. Illiteracy
0 ej!!WP was significantly associated with reduced uptake of cataract
L+PrV y surgery (adjusted OR 0.43, 95% CI: 0.20, 0.91) in a multivariate
+_HPZo model that adjusted for age, gender and employment
4#Fz!Km status.
sSC yjS'T The CSC(Eyes) at 6/60 for the survey sample was
~/6m|k 34.5%, and the CSC(Persons) at the same vision level was
8#w}wGV* 45.3%.
b<B|p| Most cataract surgery occurred in a government hospital
L
"L@4B (
"|S \J5-% P
hmOhXE[a& <
aU3
m{pE 0.001), more than 5 years ago (
)Aa98Eu?2 P
qHfs*MBJ% <
EAcJ> 0.001). Also, most
X 5LI of the intracapsular extractions were performed more than
50oNN+;=R 5 years ago (
Lnnl++8Y P
'._8 <
y(B~)T~e@ 0.001). Patients are now more likely to
%Ysu613mz receive intraocular lens surgery (
^.F@yo2} P
`wI<LTzXS <
O^I~d{M 5I 0.001). Although most
<L@0w8i` surgery was provided free (
}> k9]Y P
SI3ek9|XU =
zPU&
}7 0.02), males, who were more
W?!(/`J] likely to have surgery (
2f>lgZ! P
EN()dCQHr =
!mrB+<: 0.02), were also more likely to
ZGa>^k[: pay for it (
t<9oEjk[" P
w*r.QzCu,5 =
|HJdpY>Uu 0.03) (Table 2).
)+Wx!c,mb As measured by presenting acuity, the vision outcomes of
k/O|ia6 both intracapsular surgery and intraocular lens surgery were
y@'8vOh` poor (Table 3). However, 62.6% of those people with at least
+/7UM x1 Table 1.
T{bM/?g Vision impairment and blindness by eye and person; Koki and Rigo, Papua New Guinea (2005)
e|+U7=CK Category 2348 eyes/1174 people surveyed
X^#48*"a Vision impairment Blindness
ePK^v_vBD Eye (presenting
F'W{\4 visual acuity less than 6/18)
D,d mlv Person (presenting visual
3'O+ acuity less than 6/18 in the
&@c=$+#C better eye)
I)V2cOrXM Eye (presenting visual
qiiX49}{ acuity less than 6/60)
R{5Qb?&wOp Person (presenting visual
M5HKRLt acuity less than 6/60 in the
B cd6~ better eye)
]<A|GY0q1 Total Cataract Total Cataract Total Cataract Total Cataract
$.(%7[ n
g}@_
@ %
j./3 ) n
X3#|9 %
aAF:nyV~~0 n
MQ5#6vJ
%
mfQQ<Q@ n
Ku*@4#<L6h %
:
Sk0?WU n
t=NPo+fm %
XL >Vwd n
K_bF)6" %
a9mLPP n
*L%HH@] %_ %
G$}\~dD n
VZ'[\3J %
8n?qm96 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
+^Eruv+F 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
6E{HNP
Mb> 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
D3$PvX[f 80
$IA(QC_]AO +
#Z)e]4{!l years 136 14.3 74 22.1 57 15.5 42 24.4 85 20.6 60 23.3 30 25.0 28 31.1
S=~[ 6;G Male 467 49.1 157 46.9 180 48.9 77 44.8 203 49.4 123 47.7 59 49.2 41 45.6
RmY5/IYR|: Female 485 50.9 178 53.1 188 51.1 95 55.2 208 50.6 135 52.3 61 50.8 49 54.4
rQ(Aj All cases 952 100 335 35.2 368 100 172 46.7 411 100 258 62.8 120 100 90 75
d^mw&F)S Cataract and its surgery in Papua New Guinea 883
EeG7 %S
5( © 2006 Royal Australian and New Zealand College of Ophthalmologists
4Pe%*WTX one eye operated on for cataract felt that their uncorrected
0z #'=XWk vision, using either or both eyes, was sufficiently good that
tisSj ?+ spectacles were not required (Table 3).
ci0)kxUBF ‘Lack of awareness of cataract and the possibility of surgery’
a$yAF4HR< was the most common (50.1%) reason offered by 90
s]50Y-C cataract-induced functionally blind individuals for not seeking
^90';ACFy and undergoing cataract surgery. Males were more likely
C$(US8:{ to believe that they could not afford the surgery (P = 0.02),
U<gMgA and females were more frequently afraid of undergoing a
/W1!mih cataract extraction (P = 0.03) (Table 4).
Bha#=>4FU DISCUSSION
uf]SPG#/D The limitations of the standardized rapid assessment methodology
njtz,qt_;G used for this study are discussed elsewhere.7 Caution
6=U81 should be exercised when extrapolating this survey’s
yhv(KI Table 2. Circumstances of cataract surgery; Koki and Rigo, Papua New Guinea (2005)
c[J?`8 Category 136 cataract surgeries
`ltc)$ Male Female Aphakia
$s+/OgG4H (n = 74)
#%N v\g; Pseudophakia
N;4bEcWjp (n = 60)
@&?E3?5ll Couched
k>E^FB= (n = 2)
/4/'&tY Male, n (%) 83 (61.0) 45 (60.8) 38 (63.3) 0 (0.0)
pMB!I9q Female, n (%) 53 (39.0) 29 (39.2) 22 (36.7) 2 (100)
-{`8Av5)E% Undergone surgery in the last 5 years, n (%) 19 (22.9) 20 (37.7) 10 (13.5) 29 (48.3) 0 (0.0)
.a2b&}/.d Range of age at the time of surgery, years 39–84 40–87 39–87 45–85 52
<|Srbs+ Age at the time of surgery, years, mean ± SD 61.3 ± 9.7 60.5 ± 11.6 60.8 ± 10.6 63.4 ± 10.9 52 ± 0.0
5;'(^z-bL Surgery in a government hospital, n (%) 72 (86.7) 44 (83.0) 63 (85.1) 53 (88.3) 0 (0.0)
01=nS? Surgery in a private hospital, n (%) 10 (12.1) 7 (13.2) 10 (13.5) 7 (11.7) 0 (0.0)
|y9(qcKn$ Surgery in an eye camp, n (%) 1 (1.2) 0 (0.0) 1 (1.4) 0 (0.0) 0 (0.0)
-]el_:H Surgery by traditionalist, n (%) 0 (0.0) 2 (3.8) 0 (0.0) 0 (0.0) 2 (100)
%"-bG'Yc Totally free surgery, n (%) 32 (38.6) 26 (49.1)
@<kY,ox@~ Paid full price asked for surgery, n (%) 25 (30.1) 14 (26.4)
\ vn!SO7 Paid partial price asked for surgery, n (%) 26 (31.3) 13 (24.5)
9gq+,g>E_ Totally free surgery in a government hospital, n (%) 55 (47.4)
GWFF.Mo^ Full price surgery in a government hospital, n (%) 23 (19.8)
j9gn7LS Partially paid surgery in a government hospital, n (%) 38 (32.8)
SU,G0. Table 3. Characterization of cataract surgery outcomes; Koki and Rigo, Papua New Guinea (2005)
Z$?(~ln (a) 136 cataract surgeries
,w`g+ 9v (b) 97 people with at least one eye operated on for cataract
"DaE(S& (c) 67 (69.1%) cataract operated people not currently using distance correction: 38 (56.7%) male; 29 (43.3%) female
37apOK4+ Aphakia Pseudophakia Couched
fGZ56eH: n % n % n %
0N;~(Vt2 Total 74 54.4 60 44.1 2 1.5
$%BI8_ Presenting vision 6/18 or better 27 36.5 24 40 0 0.0
o|:c{pwq Presenting vision worse than 6/60 40 54.1 11 18.3 2 100
U
#V&=~- Aphakia Pseudophakia‡ Couched
-pmb-#`M Unilateral† Bilateral n % n %
Emy=q5ryl n % n %
X)e#=w!fi3 Total 28 28.9 17 17.5 51 52.6 1 1.0
vf&_
N Presenting vision 6/18 or better in better eye 15 53.6 11 64.7 35 68.6 0 0.0
U$yy7}g Presenting vision worse than 6/60 in better eye 13 46.4 3 17.6 9 17.6 1 100
x~Y{
{ Reason n %
Mj&G5R~_ Never provided 20 29.9
=yF]#>Ah
Damaged 2 3.0
}y%c. Lost 3 4.5
fmq''1u Do not need 42 62.6
Um}f7^fp^l †Unilateral aphakes with an unoperated contralateral eye. ‡Bilateral pseudophakes (n = 9) + those with one eye aphakic and the other
=oBl
UE pseudophakic (n = 12) + unilateral pseudophakes with an unoperated contralateral eye (n = 30).
1:JwqbZKJ 884 Garap et al.
2HUw^ *3 © 2006 Royal Australian and New Zealand College of Ophthalmologists
F r!FV4 results to the entire population of PNG. However, this
JM1O7I study’s results are the most systematically collected and
:8K}e]!c1 objective currently available for eye care service planning.
@ ]40xKF Based on this survey sample, the age-gender-adjusted
ph}%Ay$ prevalence of vision impairment from all causes for those
:YQI1 q[6 50 years and older in PNG is 29.2% (95% CI: 27.6, 35.1,
tr5
j<O deff = 2.3), with 13.1% (95% CI: 11.3, 15.1, deff = 1.2) due
FDFwx| to uncorrected refractive error.7 Cataract (7.4% [95% CI:
"OwK
- 6.4, 10.2, deff = 1.3]) is the second most frequent cause. The
s+~GQcj<T adjusted prevalence for functional blindness from all causes
e|?eY)_ in people aged 50 years and older is 8.9% (95% CI: 8.4, 12.0,
Gx
%=&O deff = 1.2),7 with cataract the leading cause at 6.4% (95%
&|j0GP& CI: 5.1, 7.3, deff = 1.1). This is typical of developing countries.
HKr}"`I. However, atypically, it would seem that cataract blindness
^2H; in PNG is not associated with female gender.9
U?an\rv Assuming that ‘negligible’6 cataract blindness (less than
(i L*1f 5% at visual acuity less than 3/60,8 although it may be as
?JG^GD7D much as 10–15% at less than 6/6010) occurs in the under
c7~R0nP 50 years age group, then, based on a 2005 population estimate
,f{w@Er of 5.545 million, PNG would be expected to currently
Pz34a@%" have 32 000 (25 000–36 000) cataract-blind people. An
Ui!l3_O additional 5000 people in the 50 years and older age group
Q-<Qm ? will have cataract-reduced vision (6/60 and better, but less
BPa,P_6( than 6/18), along with an unknown number under the age of
u7^(
?"x 50 years.
WQ 2{`'z The age-gender-adjusted prevalence of those 50 years
'da
'WZG and older in PNG having had cataract surgery is 8.3% (95%
)
[?xT CI: 6.6, 9.8, deff = 1.3). Prevalences for males and females,
rrr_{d/
respectively, are 10.2% (95% CI: 7.7, 12.7) and 6.4% (95%
)
l$}plT4 CI: 4.5, 8.4), with the expected9 association with male gender
E_En"r)y (age adjusted OR 1.6, 95% CI: 1.2, 2.1). Assuming negligible
yq49fEgc@U cataract surgery is performed on those under age
m3BL 50 years (noting mean age and age range of surgery in
|ZE^'e*k Table 2), there would be about 41 400 people in PNG today
a/\{NHs6"5 who have had this surgery. In the survey sample, 28.7% of
.=9WY_@SZ surgery occurred in the last 5 years (Table 2). Assuming that
}04mJY[ there have been no deaths, annual surgical numbers have
!ig&8: been steady during this time, and a population mean of the
JC%&d1
2000 and 2005 estimates, this would equate to about 2400
|mE;HvQ
F people per year, being a Cataract Surgical Rate (CSR) of
QOo'Iv+EL approximately 440 per million per year.
ZaU8eg7 Unfortunately, no operation numbers are available from
')!X1A{ the private Port Moresby facility, which contributed 12.5%
MNWI%*0LO (Table 2) of the surgeries in this study. However, from
y7M{L8{0 records and estimates, outreach, government and mission
4[@YF@_=M hospital surgical services perform approximately 1600 cataract
cu($mjC@T surgeries per year. Excluding the private hospital, this
#'q7 x equates to a CSR of about 300 per million population per
V-}}?c1 F year.
1'\QD`M9^ Whatever the exact CSR, certainly less than the WHO
@2/|rq estimate of 716,11 the order of magnitude is typical of a
3}<U'%sd country with PNG’s medical infrastructure, resourcing and
#G77q$ bureacratic capability.11 With the exception of the Christian
WN+i 3hC
Blind Mission surgeon, who performs in excess of 1000 cases
d]]z ) per year, PNG’s ophthalmologists operate, on average, on
&jHsFS fewer than 100 cataracts each per year. This is also typical.6
\~ChbPnc It will be evident that the current surgical capability in
'ZW(Hjrd PNG is insufficient to address the cataract backlog. The
Mg.%&vH\ CSC(Persons) of 45.3%, relating directly to the prevalence
nf0u:M"fm of bilateral cataract blindness, and CSC(Eyes) of 34.5%,
)pH+ibR relating to the total surgical workload, are in keeping with
b$7]cE
other developing countries.6,8,10 If an annual cataract blindness
3NgXM incidence of 20% of prevalence12 is accepted, and surgery
FKTF?4+\U is only performed on one eye of each person, then 6400
&rBe -52 (5000–7200) surgeries need to be performed annually to meet
f\<r1 this. While just addressing the incidence, in time the backlog
VTu#)I7A^@ will reduce to near zero. This would require a three- or
&/? C
t!_ fourfold increase in CSR, to about 1200. Despite planning
RW L0@\ for this and the best of intentions, given current circumstances
K:a8}w>Up in PNG, this seems unlikely to occur in the near future.
js<d"m* Increasing the output of surgical services of itself will be
CaJ-oy8 insufficient to reduce cataract-related blindness. As measured
.J)TIc__|A by presenting acuity, the outcome of cataract surgery is poor
iYSt
l (Table 3). Neither the historical intracapsular or current
'dwT&v]@ intraocular lens surgical techniques approach WHO outcome
s$R /!,c guidelines of more than 80% with 6/18 and better
^HSxE presenting vision, and less than 5% presenting functionally
fY!?rZ)$ blind.13 Better outcomes are required to ensure scarce
0SIC=p=J Table 4. Reasons that cataract-blind (worse than 6/60) people do not seek or undergo cataract surgery; Koki and Rigo, Papua New Guinea
5l6/
5 (2005)
zFq%[ X 90 people functionally blind due to cataract
Tn}`VW~ Responses by 41
r%PWv0z_c males (45.6%)
xol%\$| Responses by 49
zuvPV{
X females (54.4%)
fjRVYOG# Responses by all
G)Gp}4gV} n % n % n %
{]HiT pn Lack of awareness of cataract and the possibility of surgery 18 43.9 28 57.1 46 50.1
:jiuu@< Too old to do anything about vision 7 17.1 6 12.2 13 14.4
nje7?Vz Believes unable to afford surgery 10 24.4 7 14.3 17 18.9
f^$,; No time available to attend surgery 4 9.8 6 12.2 10 11.1
TpKAdrY Waiting for cataract to mature 4 9.8 5 10.2 9 10.0
+/ukS6>gr None available to accompany person to surgery 4 9.8 2 4.1 6 6.7
"I.6/9 Fear of the surgery 2 4.9 6 12.2 8 8.9
F0:]@0>r Believes no services available 2 4.9 2 4.1 4 4.4
UBaXS_c\ Cataract and its surgery in Papua New Guinea 885
A[Mke © 2006 Royal Australian and New Zealand College of Ophthalmologists
z#tIa resources are well used.14 Routine monitoring of surgical
YN8x|DLi? activity and outcome, perhaps more likely to occur if done
8rsc@]W manually, may contribute to an improvement.15,16 So too
L/8oqO| would better patient selection, as many currently choose not
k~>(XG[x& to wear postoperation correction because they see well
@nktD. enough with the fellow eye (Table 3). Improving access to
OIblBQ! refraction and spectacles will also likely improve presenting
"V|Rq]_+% acuities (Table 3).
`OfhzOp Of those cataract blind in the survey, 50.1% claimed to
J>Ar(p be unaware of cataract and the possibility of surgery
l]]NVBA]) (Table 4). However, even when arrangements, including
8}'iEj^
e transportation, were made for study participants with visually
?H=YJK$k significant cataract to have surgery in Port Moresby, not
*qpu!z2m|| all availed themselves of this opportunity. The reasons for
E|@C:ghG this need further investigation.
R]"Zv'M(AM Despite the apparent ignorance of cataract among the
,?GwA@~$k: population, there would seem little point in raising demand
t!?`2Z5 and expectations through health promotion techniques until
s%jB
Ieh such time as the capacity of services and outcomes of surgery
^z
*0 have been improved. Increasing the quantity and quality of
{<-s&%/r cataract surgery need to be priorities for PNG eye care
@M'k/jl services. The independent Christian Blind Mission Goroka
mY 1l2 and outreach services, using one surgeon and a wellresourced
EavBUX$O support team, are examples of what is possible,
K?l|1jez(# both in output and in outcome. However, the real challenge
g0,~|. is to be able to provide cataract surgery as an integrated part
{Ydhplg{ of a functioning service offering equitable access to good eye
Oc)n,D)0 health and vision outcomes, from within a public health
3p#UEH3 system that needs major attention. To that end, registrar
kepuh%KY[
training and referral hospital facilities and practice are being
RZz?_1' improved.
Y9abRrK It may be that the required cataract service improvements
r]e{
~v/ are beyond PNG’s under-resourced and managed public
^A ]4 health system. The survey reported here provides a baseline
AH,?B*zGj against which progress may be measured.
:V9Q<B^ ACKNOWLEDGEMENTS
11PL1zzH The authors thankfully acknowledge the technical support
(u?s@/e:`/ provided by Renee du Toit and Jacqui Ramke (The International
V
FM[- Centre for Eyecare Education), Doe Kwarara (FHFPNG
s.z)l$ Eye Care Program) and David Pahau (Eye Clinic, Port
LNL}R[1( Moresby General Hospital). Thanks also to the St Johns
P}6#s'07~ Ambulance Services (Port Moresby) volunteers and staff for
Md6u4
c their invaluable contribution to the fieldwork. This survey
l&H-<Z.8m was funded in part by a program grant from New Zealand
@;EQ{d Agency for International Development (NZAID) to The
v=^^Mr"Z^ Fred Hollows Foundation (New Zealand).
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