PARENTS MUST BE PARTNERS IN PAEDIATRIC CARE

As the epidemiology of paediatric blindness in the developing world continues to change, so the ophthalmic profession must alter its strategy and foster a multisectoral approach if the burden of blindness in these countries is to be reduced, Parikshit Gogate MD told delegates attending the World Ophthalmology Congress.

'We need ultimately a multisectoral team effort engaging ophthalmologists, general practitioners, optometrists, paediatricians, teachers, educationists, ophthalmic assistants, healthcare assistants and community medicine specialists in order to combat childhood blindness and visual impairment,' he emphasised.

Dr Gogate, an ophthalmologist in practice in Maharashtra, India, said that paediatric blindness was not just a public health issue. 'A child is a veritable asset and represents a nation's and a community's future. Blindness and visual impairment in children does not just affect a child's vision but also his or her mobility, education and development and it has immense social and economic costs. That is why childhood blindness has always been a priority because the causes are different from adults and many are preventable at the community level,' he said.

Dr Gogate said that the pattern of childhood blindness has changed since Vision 2020 set out its initial roadmap for the prevention of paediatric blindness over a decade ago. 'Now that we are at the midpoint of Vision 2020 a lot of things have changed on the ground. This is partly because of the success of Vision 2020 in reducing the global prevalence of blindness from 0.75 per 1,000 population to 0.4 per 1,000 by seeking to eliminate corneal scarring, congenital rubella and by introducing prompt surgery for childhood cataract. Vision screening in schools to detect and treat refractive errors has also played an important role,' he said.

The upshot of such targeted campaigns is that eye conditions that were not considered a priority before are increasingly implicated in childhood blindness, said Dr Gogate. Refractive error is now responsible for visual impairment in an estimated 9.2 million children worldwide. Trauma is implicated in 20 per cent to 40 per cent of unilateral blindness, while conditions such as strabismus and amblyopia also represent a major cause of social suffering and visual impairment. Another change is that congenital anomalies are also appearing more frequently in developing countries, he said.

Dr Gogate said that the most striking changes have occurred in developing countries over the past decade. 'General economic growth and improved healthcare planning have resulted in an increasing number of eye care providers in these countries, and we are now seeing doctors setting up private practice in rural areas. In the last 20 years, Africa has seen a four- to five-fold increase in the number of ophthalmologists with increased distribution of services outside the capital cities. Programmes have been put in place to reduce the use of harmful traditional eye medicines and practices, further decreasing the risk of corneal conditions,' he said.

Economic development
The rapid pace of economic development in countries such as India and other developing countries is underpinning many of these changes, said Dr Gogate. 'India, for instance, has significantly improved its primary healthcare infrastructure and NGO hospitals are providing high-quality low-cost eye care across the country. There is also easier and cheaper availability of antibiotics and better managed procurement and distribution systems. And while ocular injuries have not been eliminated, trauma and infection are less likely to lead to blindness than previously. ORBIS International has done yeoman's work for combating childhood blindness in India,' he said.

In terms of primary healthcare, screening programmes for disease and refractive errors in kindergartens and primary schools have had a positive effect on the paediatric blindness rates in certain regions. Other measures such as programmes to target vitamin A deficiency, measles immunisation, and treatment of ocular infections and trauma have also played a role, he said.
Significant advances have also been made at the tertiary level, said Dr Gogate, citing measures such as improved paediatric cataract and glaucoma surgery, screening and treatment of retinoblastoma and ROP, squint and ptosis correction and genetic counselling.
Nevertheless the cost of establishing dedicated healthcare facilities remains a brake on progress in many developing countries.

'Setting up a paediatric eye centre costs an enormous amount of money. Surgical services are an expensive proposition in terms of equipment, instrumentation and trained human resources. The World Health Organisation (WHO) recommends that there be at least one paediatric eye centre per 10 million population, which is far from being the case in some regions,' he said.

Some progress is being made, however. India has added at least 20 paediatric eye centres in the past decade and there are now around 26 centres in 10 countries of sub- Saharan Africa, said Dr Gogate. In developed countries, central nervous system lesions, congenital anomalies and retinal disorders are among the main causes of paediatric blindness and visual impairment. In middle-income countries, congenital cataract, glaucoma and ROP are the primary culprits.

Dr Gogate also pinpointed what he called the 'life versus sight' paradox associated with retinopathy of prematurity in developing countries. 'As more neonatal units are springing up, we see paradoxically that the healthcare system which saves a premature baby's life may see that same baby develop ROP if the clinic does not monitor and follow up the baby properly,' he said.

Looking to the future, Dr Gogate said that much remains to be done to achieve the Vision 2020 targets in terms of childhood blindness. He concluded that one costeffective way to improve the current situation would be to engage parents more directly in the ocular care of their children.
'We should remember to make parents our partners because they have the biggest stake in their children and are finally the ones who will implement the medicine or follow-up care that is needed to prevent blindness in children,' he said.