ORBIS International & Lions NAB E H it l Mi jNAB Eye Hospital, MirajOperational Research Project, AED/USAID Cycle VI July 25, 2011July 25, 2011

Partnership – ORBIS & Lions NAB Eye Hospitalp

ORBIS & Lions NAB Eye Hospital (LNEH) partnered under AED/USAID Child Blindness Fund Cycle VI to implement operational research project (November 2010 – July 2011)

• ‘Post-operative continued follow-up leads to better visual outcomes which leads toPost operative continued follow up leads to better visual outcomes, which leads to better patient quality of life’

ORBIS direct partner of AED & LNEH the implementing sub-partner• ORBIS India & HQ – responsible for technical assistance, monitoring & reporting

2

Q p , g p g• LNEH implementing arm

– Principal Investigator, Parikshit Gogate, MS DNB FRCSEd MSc IPS– Director, Research & Education, Shailbala Patil, Lions NAB Eye Hospital

Acknowledgement

ORBIS International: Dr. Joan McLeod, Kerry St l D G V R Ri hi R j BStalonas, Dr. G V Rao, Rishi Raj Bora

AED/FDI Development 360: Kelly Josiah

Lions NAB Eye Hospital, Miraj, India: Prof. A N Kulkarni, Dr. A H Mahadik, Dr. Mitali Shah, Dr.Kulkarni, Dr. A H Mahadik, Dr. Mitali Shah, Dr. Mohini Sahasrabudhe, Rahin Tamboli, Rekha Mane,

3

Project Objectives

T d t i th f li t f ll• To determine the causes of poor compliance to follow-up of eye care for children after cataract surgery

• To assess the visual acuity/outcomes of children who• To assess the visual acuity/outcomes of children who received pediatric cataract surgery

• To better understand the impact of pediatric cataract interventions on the quality of life and vision function of a child

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Childhood Blindness Situation in IndiaC d ood d ess S tuat o d a 320,000 children are blind; 9.2 million children are visually

impaired (Gogate P, Gilbert CE. Blindness in children – a world wide perspective: Journal of Community Eye Health 2007; 20 (62): 32-33 )

50% of pediatric eye conditions are treatable or t blpreventable

Main causes: cataract, refractive errors, corneal ulcer/opacity, retinopathy of prematurity, glaucoma, trauma, strabismus

Life expectancy of a blind child is about 48 years (BR Shamanna

et.al.; Economic burden of blindness in India; Ind J Ophthalmol 1998;46 :169-172) , thus disproportionate burden of blindness

5

disproportionate burden of blindness (Rahi J, et.al. Measuring the burden of childhood blindness. Br J Ophthalmol 1999;83:387–388)

ORBIS India Childhood Blindness Initiative (ICBI)( )

ORBIS in coordination with the Government of India, identified a need for 100 pediatric eye care facilitiesidentified a need for 100 pediatric eye care facilities by 2020.

The ORBIS Initiative intends to: Establish 50 well equipped & staffed pediatric

eye care centers around the country by 2020 . Key Components of the model include:

1.Introduce child-friendly pediatric eye care services2. Build institutional capacity3 T i di t i t3. Train pediatric eye care teams4. Conduct outreach in local communities to identify &

refer children with eye problems5. Educate parents & caregivers

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p g

Before Initiation of ICBI : 4 pediatric centers for nearly 400 million childreny

R P C t N D lhiR P Centre, New Delhi

L V Prasad Eye Institute, Hyderabad

Sankara Nethralaya, ChennaiA i d E

7

y ,Aravind Eye Hospital, Madurai

Current Partners: Pediatric Eye Care Centers Established & In DevelopmentEstablished & In Development

National Training and Research Partners

Aravind Eye Hospital, Madurai, Tamil NaduSankara Nethralaya, Chennai, Tamil NaduL. V. Prasad Eye Institute, Hyderabad, A. P.

Pediatric Eye Care Centers Established

1 Dr. Shroff’s Charity Eye Hospital, Delhi2 Sadguru Netra Chikitsalaya, Chitrakoot, M. P.3 H. V. Desai Eye Hospital, Pune, Maharashtra 4 Lions NAB Eye Hospital, Miraj, Maharashtra5 Little Flower Hospital, Angamaly, Kerala 6 West Lions Eye Hospital, Bangalore, Karnataka7 Lotus School of Optometry, Mumbai, Maharashtra8 Sankara Eye Center, Guntur, Andhra Pradesh 9 Srikiran Institute of Ophthalmology, Kakinada, A. P.10 Sri Sankaradeva Nethralaya, Guwahati, Assam11 Drashti Netralaya, Dahod, Gujarat 12 Shri Ganapati Nethralaya, Jalna, Maharashtra13 Regional Institute of Ophthalmology (RIO) – R P Center, New Delhi14 RIO – Kolkata, West Bengal15 Global Hospital, Mount Abu, Rajasthan16 Kalinga Eye Hospital, Dhenkanal, Orissa17 Ramakrishna Mission Hospital, Itanagar, Arunachal18 Medical College, Dehradun, Uttaranchal19 Christian Medical College, Ludhiana, Punjab20 MGM Eye Hospital, Raipur, Chattisgarh21 Khairabad Eye Hospital, Kanpur, Uttar Pradesh22 Suraj Eye Institute, Nagpur, Maharashtra23 MM Joshi Eye Hospital, Hubli, Karnataka24 Shri Sadguru Sewa Sangh Trust, Anandpur, M. P.25 Sahai Hospital and Research Center, Rajasthan26 Alakh Nayan Mandir, Rajasthan27 Choitram Nethralaya, Madhya Pradesh

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28 Gandhi Eye Hospital, Aligarh, Uttar Pradesh 29 Netra Niramoy Niketan, Haldia, West Bengal

Pediatric Eye Care Centers in Development

30 Siliguri Greater Lions Eye Hospital, West Bengal

Future Locations of Pediatric Eye Care Centers

Pediatric Eye Care Centers to be Developed

31 Partner to be identified, Uttar Pradesh32 Partner to be identified, Karnataka33 Partner to be identified, Madhya Pradesh34 Partner to be identified, Uttar Pradesh35 Partner to be identified, Bihar36 Partner to be identified, Bihar37 Partner to be identified, Jharkhand38 Partner to be identified, Orissa39 Partner to be identified, Madhya Pradesh40 Partner to be identified, Uttar Pradesh 41 Partner to be identified, West Bengal42 Partner to be identified, West Bengal43 Partner to be identfied, Assam44 Partner to be identified, Gujarat45 Partner to be identified, Gujarat46 Partner to be identified, Haryana47 Partner to be identified, Himachal Pradesh48 Partner to Be identified, Uttar Pradesh49 Partner to be identfied, Kerala50 Partner to be identified, Rajasthan

Focusing on central and northern India

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ICBI Progress thru 2010

29 centres across 16 states have been established

More than 5 5 million children screenedMore than 5.5 million children screened

More than 978,000 children treated medically or for glasses

Over 81,500 pediatric surgeries have been performed (out of which approximately 40% were pediatric cataract)

% A hi t f ICBI

74.11% 25.89%

% Achievement of ICBI

76.70%

88.99%

23.30%

11.01%

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0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

Already Achieved To be Achieved

ORBIS & LNEH Initial Partnership

As part of the ICBI ORBIS partnered with LNEH toAs part of the ICBI, ORBIS partnered with LNEH to establish a pediatric eye care center from 2005 –2008

More than 1,000 children operated on for various diseases, including 374 children (520 eyes) thatdiseases, including 374 children (520 eyes) that received pediatric cataract surgery

Today the center fully functioning unit that servesToday the center fully functioning unit that serves child pop of 3.5 million in southern Maharashtra (southwest India)

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( )

Significance of Pediatric Cataract

Pediatric cataract is the leading cause of avoidable or treatable blindness in most developing countriesor treatable blindness in most developing countries

Three large studies on causes of blindness and i l i i t i hild diff tsevere visual impairment in children across different

Indian states has put un-operated cataract & uncorrected aphakia as a significant and increasinguncorrected aphakia as a significant and increasing cause of visual impairment

1 Gogate P et al Changing pattern of childhood blindness in Maharashtra1.Gogate P, et. al. Changing pattern of childhood blindness in Maharashtra, India. Br J Ophthalmol. 2007;91(1):8-12.2. Bhattacharjee H, Borah RR, Guha K, Gogate P, et al. Causes of childhood blindness in the north-eastern states of India. Indian J Ophthalmol.

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2008;56(6):495-9.3. Gogate P, et al. The pattern of childhood blindness in Karnataka, South India. Ophthalmic Epidemiol. 2009 Jul-Aug;16(4):212-7.

Standard Follow-Up Protocol

1st Follow-up 1 week after surgery

2nd Follow up Month after first follow up (52nd Follow-up Month after first follow-up (5 weeks after surgery) -Prescription of glasses, Patching to start

3rd Follow-up 3 Months (12 weeks) from surgeryUp to 16 years follow up every six months (biUp to 16 years follow-up every six months (bi-

annual) After 16 years till child follow-up once a year (annual)

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yattains adulthood

p y ( )

Outcomes of Pediatric Cataract Surgery

Very few reports of outcomes pediatric cataract surgery from India and Nepalsurgery from India and Nepal Most focus on short term outcome 6 weeks to 3

month follow-upAs the child grows, the eye too develops and

changes; and a long term follow-up is recommended by experts to maintain and if neededrecommended by experts to maintain and if needed restore vision

1. Thakur J,et al. Pediatric cataract surgery in Nepal. J Cataract Refract Surg2004;30:1629 16352004;30:1629–1635.2. Khandekar R, et. Al. Pediatric cataract and surgery outcomes in Central India: a hospital based study. Indian J Med Sci. 2007 ; 61(1):15-22.3. Gogate P, et.al. Cataracts with delayed presentation- Are they worth operating upon? Ophthalm Epidemiology 2010; 17(1): 25 33

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Epidemiology 2010; 17(1): 25-33.

Assumptions/Rationale

• Pediatric cataract surgery is just one crucial step in the process to rehabilitate a cataract blind childprocess to rehabilitate a cataract blind child

• Proper post-operative follow-up, repeated checking of refraction and anti-amblyopia services are essential to y prestore and maintain the child’s vision

• Studies from Africa shown follow-up rates of pediatric t t d ff t th hild’ lti tcataract surgery are poor and affect the child’s ultimate

visual recovery 1

• Unfortunately no such studies exist from India or AsiaUnfortunately no such studies exist from India or Asia (which houses largest number of blind children globally)

1. Erickson JR, Bronsard A, Mosha M, Carmichael D, Hall A, Courtright P. Predictors of poor

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1. Erickson JR, Bronsard A, Mosha M, Carmichael D, Hall A, Courtright P. Predictors of poor follow-up in children that had cataract surgery. Ophthalmic Epidemiology 2006; 13:237-243

Rationale

To determine the impact that cataract intervention has on the quality of life of a childhas on the quality of life of a child

• LNEH performed hundreds of sight restoring surgeries during ORBIS project period unfortunately little data on how theORBIS project period, unfortunately little data on how the intervention impacts a child’s life

A ti b k bli d ti l th t th• Assumption by many key blindness prevention players that the intervention doesn’t just improve the child’s vision but also assists in social and educational development

• Few studies available however to corroborate this

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Project Objectives Summary

Project studied long term outcomes of pediatric cataract surgery & evaluated the barriers to the child and his/hersurgery & evaluated the barriers to the child and his/her parents for not accessing follow-up eye care services

Study addressed the knowledge gap about the impact of Study addressed the knowledge gap about the impact of pediatric cataract surgery on the child’s life, growth, mobility, education & general development

Results to assist in planning of future childhood blindness amelioration initiatives so future programs can be more effective by ensuring better follow-upeffective by ensuring better follow up

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Study Methodology & Planning

Study was completed between Oct 2010 June 2011 but Study was completed between Oct 2010-June 2011, but planning began in July 2011

Approved by the ethical committee of Lions NAB Eye Hospital Miraj (LNEH) was obtained in August 2011Hospital, Miraj (LNEH) was obtained in August 2011

Case records of all 520 pediatric cataracts (on 374 children) operated on from 2005-2008 obtained from the medical records unitrecords unit

Addresses of each child, along with phone #s recordedChildren grouped according to talukas (sub districts in IndianChildren grouped according to talukas (sub-districts in Indian

administration) & villages

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Study Methodology - Case Mapping

A i i A mapping exercise conducted using various colour stickers to visualize location of the caseslocation of the cases

Result was a clear idea of village-wise distribution of children & minimizedchildren, & minimized effort/time of community workers to find the childrenchildren

Daily plans generated for community workers to visit the area & identify

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the area & identify children

Barriers to Follow-Up Questionnaire - Design & Training on its Administration

A questionnaire to record barriers to pediatric follow-up required for development

Inputs taken from the RAAB India study [1] & additional questions added, considering pediatric population

Questionnaire translated into local language, Marathi, by two independent translators

Marathi translations translated Marathi translations translated back into English to verify if any content changed or lost during translation, & upon satisfaction printedprinted

Community workers were again oriented to questionnaire & trained on various methods to

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trained on various methods to administer it (direct questioning, catching information during individual or group discussions)

1. John N, et.al. Rapid assessment of avoidable blindness in India. PLoS ONE 2008;3(8):e2867

Kuppusamy scale for judging socio-economic status

To determine if parents’ education & socio-economic status had any effect on follow-up, Kuppusamy scale of measuring socio – economic status included in the questionnaire [Kumarsocio economic status included in the questionnaire. [Kumar N, et. al. Kuppuswamy's socioeconomic status scale-updating for 2007. Indian J Pediatr. 2007 Dec;74(12):1131-2.]

Community workers also trained on administering theCommunity workers also trained on administering the Kuppusamy scales which depended on fathers occupation, fathers education, mother’s education, mother’s occupation and family income These 5 parameters were used to scoreand family income. These 5 parameters were used to score and divide the family into 5 socio-economic classes.

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Child Vision Function Questionnaire - Design & Training on its Administration

L V Prasad’s Functional Vision Questionnaire for children L.V. Prasad s Functional Vision Questionnaire for children was adopted for determining the impact of pediatric cataract surgery on the quality of life of the child 1

Questionnaire was translated into local language by two independent translators, & back-translated to English to check for validity & upon satisfaction was printedcheck for validity, & upon satisfaction was printed

Children over 12 years answered questions on their own (and responses corroborated with parents); for younger ( p p ); y gchildren, parents were interviewed1. Gothwal VK, et.al. The development of the LV Prasad-Functional Vision Questionnaire: a measure of functional vision performance of visually

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Questionnaire: a measure of functional vision performance of visually impaired children. Invest Ophthalmol Vis Sci. 2003 Sep;44(9):4131-9.

Community/Social Worker Training

Training schedule developed & stressed:Importance of childhood blindness & pediatric cataract• Importance of childhood blindness & pediatric cataract

• Training on use & completion of both questionnaires• Potential problems & pitfalls in its completion discussed• Potential problems & pitfalls in its completion discussed• How to assist pediatric ophthalmologists in collecting

patient history & capturing data• Entering data to excel sheets & ways to maintain data

accuracy & validity

Following the training, a pilot study conducted in nearby Savli village with 37 children - sample size of 10% identified & counseled

23A fortified training later conducted with Pediatric Ophthalmologist & Principal Investigator

Development of Clinical Protocol

D l d b D P ik hit G t ( i i l i ti t )Developed by Dr. Parikshit Gogate (principal investigator)

Validated by Professor Clare Gilbert (London School of Hygiene and Tropical Medicine/International Centre for EyeHygiene and Tropical Medicine/International Centre for Eye Health (ICEH)

Valuable inputs provided by: Dr Joan McLeod (USA); Dr Valuable inputs provided by: Dr. Joan McLeod (USA); Dr. Rupal Trivedi (USA); Dr. H. Kishore (Oman); Dr. Millind Killedar (India)

Approved by Dr. G.V.Rao, Prof. A.N.Kulkarni, Rishi Raj Bora, Dr. Lutful Husain with Dr. Mitali Shah and Dr. Mohini Sahasrabudhe of LNEH

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Sahasrabudhe of LNEH

Data collection

Daily program scheduled for community workers & ycounselors to go into the field & identify children

‘Barriers to follow–up’Barriers to follow up questionnaire was completed; and children & parents counseled about i t f limportance of regular follow-up

‘Vision function questionnaire’ completed at time of clinical examination at the hospital & during the

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hospital & during the home visits

Clinical Examination

Children identified were transported by vehicle to LNEHtransported by vehicle to LNEH along (along with parents) for eye examination

Children underwent complete ocular examination – slit lamp examination, orthoptic

l ti f d &evaluation, fundoscopy & cycloplegic refraction

Clinical data was recorded IfClinical data was recorded. If any treatment required, they were informed, & relevant treatment provided. Also

26

ea e p o ded socounseled during the visit about importance of follow-up

Patient Home Visit

In spite of home visits & counseling, 74 children did not g,visit LNEH

Developed schedule for home visits of these children by Pediatric Ophthalmologist along with optometrist & g pcommunity workers

Home visits were conducted with required equipments (portable visual acuity charts, portable slit lamp,

27

p p,Keratometer, A-Scan) & children were examined

Summary: Project outputs

374 children (520 eyes) were operated for pediatric t t t Li NAB E H it l Mi jcataract surgery at Lions NAB Eye Hospital, Miraj

from 2005 to 2008. Out of these,

328 children (88%) were identified and completed the Barriers to Follow-Up Questionnaire

262 children -70% (393 eyes) were examined• All but 19 required some form of intervention

262 children/parents completed the Vision Function Questionnaire

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Questionnaire

Result: Age Group

Demographic Data – Age wise Distribution

AgeFrequency %

0 – 5 12 4.6

6 – 10 59 22.5

11 – 15 94 35.9

16 – 20 97 37.0

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Total 262 100.0

Result: Gender & Laterality

Frequency PercentGender

Frequency PercentMale 150 57.3Female 112 42.7

Total 262 100.0Laterality

Frequency PercentBoth Eyes 131 50.0yLeft Eye 64 24.4Right Eye 67 25.6

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Total 262 100.0

Number of children in the family

Boys GirlsBoys  Girls

Frequency Percent Frequency PercentOne 106 40.5 102 38.9One 106 40.5 102 38.9

Two 118 45.0 60 22.9

Three 17 6 5 30 11 5Three 17 6.5 30 11.5

Four 4 1.5 11 4.2

Five 1 0 4 2 0 8Five 1 0.4 2 0.8

None 16 5.8 57 21.8

T t l 262 100 0 262 100 0

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Total 262 100.0 262 100.0

Study Variables, Result: Ordinal Status of the child

Frequency PercentEldest 92 35.1

Middle 65 24.8

Youngest 105 40.1

Total 262 100.0

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Result: Any other similarly affected child in family

Frequency PercentYes 39 14.9

No 223 85.1

Total 262 100.0

Frequency PercentNo 223 85.1Yes, one child 29 11.1

Yes-2 children 10 3.8

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Total 262 100.0

Result: Mother's Occupation

Mother's occupation Number of patients Percentage (%)

U l d 1 117 44 7Unemployed 1 117 44.7

Unskilled worker/ home maker 2

62 23.7

Semi-skilled 3 11 4.2

Skilled 4 6 2.3

Clerical/Shop owner / farmer 5

56 21.4

Semi profession 6 1 0 4Semi-profession 6 1 0.4

Profession 7 2 0.8

Missing 7 2 7

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Missing 7 2.7

Total 262 100

Kuppusamy Score for Socio economic class

SocioSocio economic class Frequency

Percentage (%)

I (Hi h t) 2 0 8I (Highest) 2 0.8

II 13 5.0

III 75 28.6

IV 161 61.5

V (Lowest) 11 4.2

Total 262 100.0

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Total 262 100.0

Compliance for Follow-up

N b f P tN Number of patients

Percentage (%)

Compliance 53 20.2Compliance 53 20.2

Non 209 79 8Non compliance

209 79.8

T t l 262 100 0Total 262 100.0

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Compliance to follow-up: Regular (compliant) or not regular (Non-compliant)g ( p )

PercentageFollow-up Total

p-

Percentage (%)

Non- Non-valueComp. comp. Comp. comp.

Age 0 - 5 8 4 12group 66.7 33.3

6 - 10 19 40 59 32.2 67.8

< 0 001

11 -15 11 83 94 11.7 88.3≥ 16 15 82 97 15 5 84 5

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0.001 15.5 84.5Total 53 209 262

Barriers to Follow-Up

Th t b i dThe most common barriers emerged as –We cannot afford to travel, visit the hospital -25.3%

38

The hospital is too far - 20.6%

Barriers to Follow–Up

Did not find time/ I had more urgent things to do -26.9%26.9%

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Barriers to Follow-Up

The child was seeing fine.- 24.5%Did not feel the need - 14 8%Did not feel the need - 14.8%

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Barriers to Follow-Up

No one told to visit us again - 20.6%

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Barriers to Follow-Up

I thought whatever I d ill tdo will not improve the child’sthe child s vision -0.4%

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Barriers to Follow-Up

Some of the other reasons:

• The surgery made no difference to child’s vision – 3.9%

• Doctors or staff kept me waiting for a longtime - 1.2%

I th ht diti ill i b it lf 0 4%• I thought condition will improve by itself - 0.4%

• Unaware of complications & risk of cataracts – 0.8%

• Others - 2%

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Summary Findings on Barrier to Follow-Up:

20.6% Children complied with regular follow-up

Only 1 2% respondents felt that the doctors or staff inOnly 1.2% respondents felt that the doctors or staff in the pediatric unit kept them waiting for a long time. (So child friendly atmosphere worked & was maintained)

14.8% respondents did not feel the need for follow-up.

20.6% respondents cited that no one told them to visit h h i l i Education &the hospital again

26.9% respondents said that didn’t find time to take their children to the hospital 24.5% respondents felt that th hild i fi

Education & Awareness Issues

the child was seeing fine

20 6% respondents said that the hospital is too farAccess & Affordability

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20.6% respondents said that the hospital is too far

25.3% respondents said that they can not afford to travel to the hospital

Affordability Issues

Compliance to follow-upP-value Significance

Age group <0.001 Significant

Gender 0 676 Not significantGender 0.676 Not significant

Ordinal status 0.818 Not significant

Number of boys in family 0.860 Not significant

Number of girls in family 0.391 Not significant

Any other affected child 0.365 Not significant

Mother’s education 0 012 SignificantMother s education 0.012 Significant

Mother’s occupation 0.327 Not significant

Father’s education 0.256 Not significant

Father’s occupation 0.031 Significant

Social strata 0.492 Not significant

Accompanied by parent/ other 0 062 Not significant

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Accompanied by parent/ other 0.062 Not significant

Money spent on travel 0.033 Significant

Paid / Free 0.001 Significant

Vision Function: Before and After surgery

1. Do you have any difficulty in making out whether the personmaking out whether the personyou are seeing across the room is a boy or a girl, during the day?Pre op Score Ave(SD)-2 62 (0 8)Pre op Score Ave(SD)-2.62 (0.8)Post op Score Ave(SD)-0.95(1.0)

2 Do you have any difficulty in2. Do you have any difficulty in seeing whether somebody is calling you by waving his or her hand from across the road?hand from across the road?Pre op Score Ave(SD)- 2.57 (0.9)Post op Score Ave(SD )-0.95 (1.0)

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Vision Function: Before and After surgery

3. Do you have difficulty in walking alone in the corridor at school withoutb i i t bj t l ?bumping into objects or people?Pre op - 2.34 (1.0)Post op - 0.77 (1.2)

4. Do you have any difficulty in copying from the blackboard whilesitting on the first bench in your class?Pre op - 2.44 (0.9)Post op - 0.96 (1.0)

5 Do you have any difficulty in5. Do you have any difficulty in reading your textbooks at an arm’slength?Pre op - 2.47 ( 0.8)

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p ( )Post op - 0.96 (1.1)

Vision Function: Before and After surgery

6. Do you have difficulty in

surgery

y yreading the bus numbers?Pre op - 2.57 (0.8)Post op - 1 03 (1 0)Post op 1.03 (1.0)

7. Do you have any difficulty i di th th d t ilin reading the other details on the bus (such as its destination?)Pre op - 2.53 (0.8)Post op - 0.99 (0.9)

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Vision Function: Before and After surgery

8. Do you have any difficulty in writing along a straight line?P 2 32 (0 9)

surgery

Pre op - 2.32 (0.9)Post op - 0.70 (1.0)

9 Do you have any difficulty in9. Do you have any difficulty in finding the next line while readingwhen you take a break and then resume reading?resume reading?Pre op - 2.40 (0.9)Post op - 0.94 (1.0)

10. Do you have any difficulty in locating dropped objects (pen,pencil, eraser) within the

49

classroom?Pre op - 2.34 (1.0)Post op - 0.69 (1.0)

Vision Function: Before and After surgery

11. Do you have any difficulty in threading a needle?Pre op - 2 55 (0 8)

surgery

Pre op - 2.55 (0.8)Post op - 1.25 (1.2)

12. Do you have any difficulty in walking home at night (from tuition or a friend’s house) without assistance when there arestreetlights?Pre op - 2.41 (1.0)Pre op 2.41 (1.0)Post op - 0.74 (1.0)

13. How much difficulty do you have indistinguishing between 1 rupee and 2distinguishing between 1 rupee and 2 rupee coins (without touching)?Pre op - 2.44 (0.9)Post op - 0.80 (1.0)

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Vision Function: Before and After surgery

14. Do you have difficulty in lacing your shoes?Pre op 2 13 (1 1)

surgery

Pre op - 2.13 (1.1)Post op - 0.53 (1.0)

15. Do have difficulty in locating a ball while y gplaying in the daylight ?Pre op - 2.34 (0.9)Post op - 0.68 (0.9)

16. Do you have difficulty in climbing d t i ?up or down stairs?

Pre op - 2.22 (1.0)Post op - 0.49 (0.9)

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Vision Function: Before and After surgery17. Do you have difficulty in applying paste on your toothbrush?Pre op - 1 93 (1 2)

surgery

Pre op - 1.93 (1.2)Post op - 0.27 (0.8)

18 D h diffi lt i l ti18. Do you have difficulty in locating food on your plate while eating?Pre op - 1.87 (1.2)Post op - 0.32 (0.8)

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Post op 0.32 (0.8)

Vision Function: Before and After surgery

19 Do you difficulty in19. Do you difficulty in identifying colours (e.g., while colouring) ?Pre op - 2.17 (1.0)p ( )Post op - 0.54 (0.9)

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Vision Function: Before and After surgery

20 Do you think your20. Do you think your vision is as good as your friend,? A bit less? A lot less? Pre op – 1.75 (0.5)Post op - 0.81 (0.5)

54

Summary: Vision Function: Before and After surgery

On every question, children fared better after the i t ti th b fintervention than before

Even if visual recovery was not dramatic by visual acuity measurement, it made an immense difference to the child’s functioning

Children reported more confidence in negotiating with their environment, peers & community at large

Intervention was worth it

55

Visual Acuityy

Post-operative vision >6/18 in 40 7%

Post-operative vision >6/60 in 57 8%>6/18 in 40.7% >6/60 in 57.8%

56

Visual acuity

>= 6/18 <6/18 >=6/60 <6/60 Total

Complicated4 (36.4%) 7 (63.6%) 8 (72.7%) 3 (27.3%)

11

Congenital 34Congenital 7 (20.6%) 27 (79.4%) 15 (44.1%) 19 (55.9%)

34

Developemental51 (45 5%) 61 (54 5%) 72 (64 3%) 40 (35 7%)

11251 (45.5%) 61 (54.5%) 72 (64.3%) 40 (35.7%)

Subluxlated4 (100%) 0.00 4 (100%) 0.00

4

Total cataract 148Total cataract55 (37.2%) 93 (62.8%) 76 (51.4%) 72 (48.7%)

148

Traumatic 38 (46 3%) 44 (53 7%) 51 (62 2%) 31 (37 8%)

82

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38 (46.3%) 44 (53.7%) 51 (62.2%) 31 (37.8%)

Visual Acuity

P-value (>6/18)

P-value (>6/60)

Gender 0.053 0.094 Not significantAge-group 0.125 0.002 SignificantType of surgeon 0 419 0 999 Not significantType of surgeon 0.419 0.999 Not significant

Type of surgery 0.041 SignificantType of cataract 0 011 0 042 SignificantType of cataract 0.011 0.042 SignificantPost-operative uveitis 0.097 0.013 Not significantSecondary glaucoma 0.627 0.883 Not significantPost cap opacification <0.001 <0.001 SignificantDelay between diagnosis & surgery 0.067 Not significantPhaco used / not used 0.052 Not significant

58

g

Secondary glaucoma

P-valueType of cataract 0 001 SignificantType of cataract 0.001 SignificantType of surgeon 0.99 Not significantGender 0.51 Not significantAge 0.142 Not significant

59

Posterior capsular opacification

P-value

Type of cataract <0.001 Significant

Type of surgeon 0.452 Not significant

Gender 0.742 Not significant

Age <0.001 Significant

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Summary

Study showed that of the 262 children examined, all t 19 d d ki d f i t tiexcept 19 needed some kind of intervention

103 needed Nd:YAG LASER capsulotomy and 22 required surgery. Most needed a change of spectacles, 5 needed contact lenses and 4 required low vision aidslow vision aids

Demonstrates importance of regular follow-up as th hild’ d l & f tithe child’s eye develops, grows & refraction may change

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Summary

Visual outcomes were comparable to other studies ld id ( t l I di M i N l Chiworld wide (central India, Mexico, Nepal, China,

Tanzania & Kenya), but were lesser than those from the developed worldthe developed world

While differences are small, results are poorer compared to visual outcomes of adult cataractscompared to visual outcomes of adult cataracts

As the vision function questionnaires shows however, hild f d b tt ti it d dchildren performed better on every activity graded

after cataract surgery

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What gaps remain in this research or what new questions have been shown?

We need more information on the causation of cataract & how much rubella contributes to itcataract & how much rubella contributes to it

Outcomes in pediatric cataract vary with time – we have a cross section of results after 3-5 years,have a cross section of results after 3 5 years, perhaps for the first time in the developing world

More research is needed as to why less girlsMore research is needed as to why less girls compared to boys

Vision function scores may be affected by recall -Vision function scores may be affected by recall the questionnaire was completed by the children or parents and not the service providers

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What is the best modality for pediatric cataract treatment depending on age

Cost of pediatric cataract surgery (in rupees)rupees)

Minimum Maximum

Fixed 3,270 3,270facility

,($83.85)

,($83.85 )

Consum 1,452 15,267 ables ($37.23) ($391.46 )Total 4,722 18,537

Gogate P, et.al. Cost of pediatric cataract in Maharashtra, I di I t J O hth l l 2010 10(7) 1248 52

($122) ($ 475)

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India. Int J Ophthalmology 2010; 10(7): 1248-52

How can results inform planning for effective pediatric eye care services?p y

Need for effective follow-up mechanism in the outreach strategy - to address issues of affordability & accessibilitystrategy to address issues of affordability & accessibility among beneficiaries

Need for effective counseling - to increase awareness levels and motivate parents/guardians about the importance of timely examination, treatment & follow-up

Need for encouragement to undergo surgical interventionNeed for encouragement to undergo surgical intervention irrespective of age, for improvement in quality of life post cataract surgery

Need to encourage involvement of both parents during the course of the treatment of their child from identification to follow-up

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How can results be used to change policies and/or programs?p gCombine case identification & post-operative follow-up in

each of the outreach initiatives to enhance timely follow-upup

Sponsor an annual week for pediatric cataract follow-up if needed

More effort to strengthen IEC & BCC to increase awareness levels, especially among parents/guardians on the importance of child eye carep y

Continue development of child-friendly ambience of pediatric unit and child-friendly attitude of trained staff as enablers for greater acceptance of pediatricenablers for greater acceptance of pediatric ophthalmology services

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How can results be used to change policies and/or programs? – cont.p g

Insist on anterior vitrectomy and primary posterior Insist on anterior vitrectomy and primary posterior capsulotomy for all children till 7-8 years of age.

Need to design, develop and use appropriate tools to record and monitor post operative surgical outcomes & complianceand monitor post-operative surgical outcomes & compliance to follow-up of all beneficiaries on a continuous basis

Design outcome guidelines for pediatric cataract, like WHO f d l

g g pones for adult cataract

Presenting study findings to larger audience including Government, V2020, IAPB, other global blindness preventionGovernment, V2020, IAPB, other global blindness prevention stakeholders, etc.

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Thank you for a patient hearingAny questions???Any questions???