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Publications Cataract blindness in Chakwal district 1)- Cataract blindness in Chakwal District, Pakistan: Results of a survey: Sajjad Haider, FRCS, Arif Hussain, DOMS, Hans Limburg, MD PhD: Cataract blindness in Chakwal District, Pakistan: Results of a survey - Ophthalmic Epidemiology - 2003, Vol. 10, No. 4, pp. 249-258 Munawwar Memorial Hospital, Chakwal, Pakistan. drsajjadhaider@yahoo.co.uk AIM: To present the results of a rapid assessment of cataract surgical services in Chakwal District, Pakistan. METHODS: 40 clusters of 40 persons of 50 years and older (1600 eligible persons) were selected by systematic random sampling from the entire Chakwal district. A total of 1505 persons were examined (coverage 94%). RESULTS: Cataract is the major cause of bilateral blindness (46.5%). The age and sex adjusted prevalence of bilateral cataract blindness (VA < 3/60) in people of 50 years and older was 2.0% (95% CI: 1.2-3.2%), with a cataract surgical coverage of 92% for males and 73% for females, a significant difference. The prevalence of bilateral cataract and VA < 6/60 in persons of 50 years and older was 5.1% (95% CI: 3.6-6.9), an estimated total of 8833 persons. In this last group, the surgical coverage was 66% (persons) and 50% (eyes). Of the patients operated with IOL implantation, 12% could not see 6/60, while 36% of those operated without IOL could not see 6/60. 'No services' (18%) and 'cannot afford' (18%) were mentioned most as reasons why surgery had not been done, followed by 'no information' (13%), 'waiting for maturity' (12%) and 'old age, no need for surgery' (12%). CONCLUSION: The number of cataract operations in Chakwal District can be increased by reducing the threshold for cataract surgery to VA < 6/60 or less. A special approach to operate more females may be required. Results from this survey can be used for a planning exercise to optimize eye care services in the district. Sustained efforts have to be made to increase the number of IOL surgeries, through making IOL surgery available locally at an affordable cost. 2)- Gender & use of Cataract Services Gender and use of cataract surgical services in developing countries – Some Practical experience in a Pakistani district: Sajjad Haider , Arif Hussain , Hans Limburg ----------------- Sajjad Haider FRCS ----------------- Munawwar Memorial Hospital Chakwal Pakistan Arif Hussain DOMS ----------------- Munawwar Memorial Hospital Chakwal Pakistan Hans Limburg MD PhD ----------------- Consultant International Centre for Eye Health London School of Hygiene and Tropical Medicine Keppel Street London WC1E 7HT UK The corresponding author: Sajjad Haider Munawwar Memorial Hospital
Key words: female cataract blindness, gender and cataract, Pakistan , Chakwal It is estimated that roughly 63.3 % of blind adults are females 1 . It is likely that the excess blindness in females is due to a combination of different factors, including slightly higher prevalence of blinding diseases in females, and perhaps increased survival in blind females compared to blind males. (The latter has not been well studied) 1 . In the industrialised countries, women undergo cataract surgery at rates roughly 20-60% higher than males 1 . In contrast, women in developing countries are less likely to be operated on for cataract although the cataract blindness burden is higher for females 2,3 . Quite clearly, for an eye care programme to be more effective in reduction of blindness, and to be equitable to both sexes, it needs to more focussed on females and be gender sensitive. There is need for further operational research, into this issue. So called barriers to surgery have been described as fear, family/work responsibilities, treatment costs (indirect costs must not be forgotten) , lack of escort (family support), lack of transport and distance from treatment facility etc 4 . The same barriers may reduce uptake of services by females more than males, especially in societies, where females are dependent on younger family members for economic and social reasons. We would like to share our experience from Munawwar Memorial Hospital in District Chakwal, Pakistan . The facility was opened in 1999 and in the year 2000 a survey of Cataract Blindness was conducted 5 . The age and sex adjusted prevalence of bilateral cataract blindness (VA<3/60) in people of 50 years and older was 1.8% (95% CI: 1.0-3.0%). An estimated 3095 people were bilaterally blind due to cataract in the district, 647 males and 2,448 females (79%). In the sample, the average age for the cataract blind men was 70.3 years, and 75.3 years for the cataract blind women. The barriers table (Table 1) for bilateral cataract blindness <3/60 shows the differences in barriers for males and females. Although the numbers, especially for males, are small, it may provide a direction for future intervention strategies directed at increasing the uptake of cataract surgery by females. The cataract surgical coverage for persons at VA<3/60 was 93% for males and 74% for females - a significant difference. At the <6/60 and the <6/18 level the differences were not significant.  The Cataract Surgical Rate for Chakwal District was quite high at 2530 in 1999, against the average CSR of 1050 for Pakistan as a whole. 1460 cataract operations were performed in the district and 1070 (42%) through screening camps by hospitals outside the district. These screening camps stopped in later years, reducing the CSR over the following years. It was not possible to provide an exclusive or priority service to females. A series of measures were therefore taken to raise awareness, improve detection rate, streamline referrals, improve access, reduce costs, and to make the programme “more friendly” to the patients' family members, to make some difference. We were able to increase the acceptance of surgery considerably in the last four years. This became possible through combined effect of 1. 1. A resident facility being available in the area, so the family can reach home for the evening. 2. 2. Making day case surgery available to reduce effort and indirect costs. 3. 3. Making service available over the weekends, when a younger member of family may be more easily available to accompany the elderly female patients 4. 4. Cost reduction through subsidy 5. 5. Making transport available to reduce indirect costs and improve access. 6. 6. Training female primary health care workers and family planning services workers (females) to raise awareness among female blind, and to detect and refer female blind. These workers are available at the community level. In total 1650 Primary Health Care workers within this district were trained in Primary Eye Care in 34 one-day long training workshops during last 2 and a half years. They were given a brief introduction to common sight threatening conditions, given an instruction manual, basic diagnostic tools, and on the job training in methods of detection and a procedure for referral. This was all made possible through a support grant from SSI. The table below mentions the numbers of cataract surgeries referred by them (community detection). Following were the outcomes in successive years in MMH  Following is the breakdown of the cataract volume in the last four years in MMH  Graphic representation of gender and cataract surgery  The rate of cataract surgery in females has remained consistently higher than males. Volume of cataract surgery has doubled but distribution male/female remains roughly the same. Increasing the coverage in females with bilateral cataract further may require more focussed interventions. Year on year increase before the programme started was around 5 to 10%. Towards the end of the three years, the cataract surgical volume has increased by > 250 %. It also appears that any measures taken, can take up to at least a year to show a substantial effect. Improving access has made a difference. References 1. Blindness and Gender in the Industrialized Countries: a review of the literature with special attention to Canada Susan Lewallen MD http://www.interchg.ubc.ca/bceio/gender_paper.htm 2. Susan Lewallen and Paul Courtright Gender and use of cataract surgical services in developing countries Bulletin of the World Health Organisation 2002, 80 (4) :300-3. 3. Sex inequalities in cataract blindness burden and surgical services in south India . Nirmalan PK , Padmavathi A, Thulasiraj RD. Br J Ophthalmol. 2003 Jul;87(7):847-9. 4. Review Article: People Who Don't Use Eye Services: 'Making the Invisible Visible' Martine Donoghue BSc MSc: http://www.jceh.co.uk/journal/31_3.asp 5. Cataract blindness in Chakwal District , Pakistan : results of a survey. Sajjad Haider, Arif Hussain, Hans Limburg. Ophthalmic Epidemiology 2003, Vol.10, No.4, pp. 249-258 Prevalence of Non Vision impairing condition 3)- Prevalence of non-vision-impairing conditions in a village in Chakwal district,Punjab , Pakistan: Arif Hussain, Haroon Awan, Prof. Mohammed Daud Khan: Prevalence of non-vision-impairing conditions in a village in Chakwal district, Punjab, Pakistan - Ophthalmic Epidemiology - 2004, Vol. 11, No. 5, pp. 407-420 Munawwar Memorial Hospital, Rawalpindi Road, Chakwal Pakistan. drarifhussain@yahoo.com PURPOSE: To determine the prevalence of non-vision-impairing ocular conditions (NVIC) and estimate the number of primary eye care treatments per 1000 population per month. METHODS: A cross-sectional study in a random sample of 1670 people was done to determine the load of NVIC in a village in Chakwal district. RESULTS: The prevalence of NVIC was 30.6% (306 per 1000 population). NVIC with the exclusion of presbyopia accounted for 14.6%. The main NVIC were allergic conjunctivitis (3.7%), bacterial conjunctivitis (3.5%), pterygium/pinguicula (2.6%) and acute/chronic dacryocystitis (1%). The average Complaint Frequency (CF) per month/1000 population was 55, excluding complaints of near vision and watery eyes. CONCLUSIONS: The foundation of a comprehensive district eye care strategy in the light of VISION 2020 - the Right to Sight - remains an effective primary eye care service whose elements are treatment of NVIC, detection and referral of cataracts and refractive errors, and promotion of eye health. Under process of publication 1. Effectiveness of School Children vision screening programme – Experience form a rural Pakistani District
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