|Year : 2015 | Volume
| Issue : 1 | Page : 9-13
Epidemiological study of patients availing free cataract services of national programme of control of blindness
Mita V Joshi
Department of Ophthalmology, Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India
|Date of Submission||13-Sep-2013|
|Date of Acceptance||28-Jul-2014|
|Date of Web Publication||14-Jan-2015|
Mita V Joshi
Assistant Professor, Department of Ophthalmology, Sri Aurobindo Medical College and Postgraduate Institute, Indore - 453 555, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Purpose: To find the proportion of patients who are blind or have low vision prior to undergoing free cataract surgery at a tertiary referral center, selected from free eye camps. To evaluate which patient groups are more in need of free cataract surgery, a series of consecutive cases of cataract that attended free eye camps and were operated during three years, 2008-2010, were evaluated. Materials and Methods: Using computerized assessment systems, we congregated data on pre-operative visual status, diagnosis, condition of other eye, age, gender, caste, and locality for 2507 patients. Visual status was defined as per World Health Organisation (WHO) classification. Results: A total of 2507 (15.06%) operations were performed out of 16,637 cases who attended eye camps, 63.3% were blind (V.A.<3/60) patients, 19.2% were with low vision (V.A. <6/60). Five hundred and seventy-eight (23.1%) patients were between 60-64 years of age followed by 491 (19.6%) in 70-74 years of age, and 456 (18.2%) in 65-69 years of age group. About 74.9% operations were performed on patients above 60 years of age. Females outnumbered males in ratio 1.3: 1.0 and operated cases of backward caste were 86.59% in comparison to general population (13.4%). Conclusion: The demand for free surgery amongst blind patients is still high for underprivileged urban as well as rural population. Backward caste, females, and citizens of age groups 71-80 and 81-90 are most in need of services of cataract programs because of lack of awareness and affordability.
Keywords: Blindness, backward class, cataract surgery, eye camp, national programme of control of blindness
|How to cite this article:|
Joshi MV. Epidemiological study of patients availing free cataract services of national programme of control of blindness. J Clin Ophthalmol Res 2015;3:9-13
|How to cite this URL:|
Joshi MV. Epidemiological study of patients availing free cataract services of national programme of control of blindness. J Clin Ophthalmol Res [serial online] 2015 [cited 2019 Feb 20];3:9-13. Available from: http://www.jcor.in/text.asp?2015/3/1/9/149341
The National Programme for Control of Blindness (NPCB) India was initiated in 1976 as an entirely central government supported scheme with the target of reducing the prevalence of blindness from 1.4% to 0.3%. According to surveys done in 2001-02 and 2006-07 the prevalence of blindness was estimated at 1.1% and 1%, respectively. 
Over a quarter of the century, the causes of blindness have changed in proportion and actual number in different communities. Cataract has remained the major cause of bilateral blindness in India where vision less than 6/60 in the better eye on examination is defined as blindness. ,,, Cataract has been reported to be responsible for 50-80% of the bilaterally blind in the country. ,,,
Private hospitals and ophthalmologists manage a case of cataract with cost ranging from Rs. 3000 to Rs. 60,000, depending on locality, quality of intraocular lens (IOL) implanted, and standing of surgeon, whereas government hospitals do the same without any emoluments. With the idea that "if a blind cannot come to the hospital, let the hospital arrive at his door0" free of cost, diagnostic, and operative eye camps are organized for mass clearance of backlog of cataract patients. It is a common practice in every part of India for the under privileged population in the form of eye camps organized by charity organizations in collaboration with NPCB.
The scheduled castes (SCs), also known as "Dalit", and the scheduled tribes (STs) are two groups of historically disadvantaged people that are given express recognition in the Constitution of India. SCs and STs make up to 15% and 7.5%, respectively, of the population of India, or around 24% altogether, according to the 2001 Census.  They are socioeconomically weak and a large number of them live below poverty line.  Females are traditionally disadvantaged natives with limited freedom of money and movement. They also have a higher prevalence of blindness compared to their better half.  The present study was conducted to evaluate prevalence of blindness in different groups based on factors such as age, sex, caste, poverty, and locality, and the communities most benefited by NPCB.
| Materials and Methods|| |
We studied preoperative clinical and social data of patients examined and performed operations during 3 years, namely 2008-2010. Camps were conducted as a part of government NPCB in a 30-kilometer radius around our tertiary care center, which includes urban under-privileged zones and rural community.
A team comprising of an ophthalmologist, an optometrist, and 6 paramedics per expected 150 patients were sent to makeshift clinics at a convenient and hygienic place such as a school or primary health center. The camps were organized by the public relation department in collaboration with local social organizations. Detailed history of patients including age, gender, caste, and locality of camp, and presenting complains were recorded. Preliminary clinical examination including distant vision recording, anterior segment examination by diffuse light, and direct ophthalmoscopy was done at the site of eye camp.
Cases in need of cataract operation were selected and transported to our tertiary center. Meticulous examination of each patient including distant vision, clinical examination by slit lamp, fundus examination, condition of other eye, and presence of any associated pathology was done. Hemoglobin estimation, total and differential blood cell count, complete urine examination, and test for Human Immunodeficiency Virus and Australia antigen were performed in every patient prior to surgery. Cataract operations, small incision extra-capsular lens extraction with posterior chamber IOL implant, were done after due investigations, which included tonometry, ocular biometry, IOL power calculation, and controlling systemic ailments such as hypertension and diabetes. Patients were conveyed back to their homes next day with requisite medicine and dark goggles. Financial aid of Rs. 750 per operation is provided by government NPCB. Hospital stay, surgical cost, IOL, medicines, meals, and to-and-fro transportation is borne by the Institute. Consent was obtained from the Ethics Committee to carry out this survey.
| Results|| |
During 3 years, 2008-2010, ninety-eight diagnostic and cataract operation camps were organized [Table 1], in destitute urban areas and contiguous villages to centre in which 16,637 patients were examined and 15.06% (n = 2507) of them were operated for cataract.
Vision in two eyes varies and multiple probabilities may occur from 6/6 in both eyes to no vision in both or either eye. [Table 2] provides the details of visual acuity of the patients examined.
|Table 2: Number of patients operated for cataract having different grades of vision |
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One thousand five hundred and eighty-eight (63.3%) operated cases were blind having V.A.<3/60 in better eye and 481 patients (19.2%) were having low vision with V.A.<6/60 in better eye, thus reducing backlog of blind persons in society by 2068 (82.5%). Of these, 977(39.0%) required assistance for ambulation as they had 1/60 or less vision in better eye. Merely 11 (0.4%) patients were having vision 6/18. One-eyed, having no vision in other eye, patients were 199 (7.9%), who required extra attention, while uniocular cataract cases with good vision in other eye were 437 (17.5%).
It is a known fact that cataract develops 10 years earlier in tropical countries,  at around 50 years of age. There is difference of opinion regarding time of surgery in patients as well ophthalmologist and all cases do not get operated at optimum time even in most favorable circumstances; we found that majority of cases were delayed in accessing surgery.
Between age 45-59 years 494 (19.7%) patients were operated in comparison to 1877 (74.9%) patients who were above 60 years of age; out of which 1299 (51.9%) were above 65 years, 842 (33.6%) above 70 years, and 73 (2.9%) above 80 years. Maximum operations 578 (23.1%) were performed in the 60-64 years age group, followed by 491 (19.6%) and 456 (18.2%) in 70-74 and 65-69 age group, respectively. Congenital and traumatic cataracts below 45 years comprised only 134 (5.3%) cases. Chart 1 describes the distribution of patients according to age group.
Females outnumbered males in outpatient department as well as cataract operations. In total 16,637 attended the camps, 6962 (41.85%) males and 9675 (58.15%) females. Chart 2 classifies the patients according to gender.
Out of total 2507 operations performed, 1426 (56.84%) were women and 1081 (43.16%) were men showing that 1317 females benefitted for every 1000 males.
Depressed class or backwards caste is maximally benefitted by these free eye camps. In total, 2171 (86.59%) operations done were of the backward classes. Of these, 984 (39.1%) patients were from SC, 828 (33.0%) from schedule tribes, and 359 (14.3%) belonged to other backward classes (OBC). General class patients were 131 (5.23%) males and 205 (8.23%) females, aggregating to 336 (13.40%) out of total 2507 operative cases. [Table 3] shows the number of operations done in different castes.
In total, 1081 (43.16%) backwards caste males and 1426 (56.84%) females were operated for cataract.
| Discussion|| |
A blind man will not thank you for a looking glass. Proverb, English.
It is estimated that there is an annual incidence of 2 million subjects with cataract-induced blindness in India. According to surveys on the magnitude and causes of blindness and surgical outcomes of cataract conducted in 1999-2002 and in 2003, the estimated prevalence of blindness was found to be 1.1% in the major states and 1.38% in the north-eastern states.
Cataract is the most common cause of blindness (62.6%).  Eye camps are organized to reduce burden of blindness of individual and society and to improve quality of life.
Two thousand five hundred and seven of 16,637 total patients attending the camp, required cataract surgery. In each camp, average 170 patients were examined, ranging from 32 to 1128 patients. Success of eye camps depends on selecting proper place, adequate publicity by print and electronic media, transportation, cooperation of local social and charitable groups, dedicated skilled workers, convenient time, and appropriate season. Traditionally, summer and rainy season are not preferred for any elective surgery by Indians on the ground that the journey is arduous and odds of infection are more. Mostly eye camps are organized between September and March.
Decline in cataract blindness has been possible due to enhanced cataract operations along with fewer complications with advent of advanced equipments, microscopes, IOLs, instruments, and trained, skilled surgeons. Percentage of IOL implantation surgeries has increased from 20% in 1997-98 to 83% in 2003-04. 
Cataract is a condition of senility, which is major cause of reversible or treatable blindness, accounting up to 62% blindness; therefore, prevalence of blindness in population of 50 years and above is bound to be high, which was estimated to be 8.5% in comparison to 1.1% in general population in 2001 National Survey of blindness.  The 50+ population has increased from 13% in 1991 to 13.7% in 2001  while prevalence of cataract blindness in persons above the age of 50 years was 7.6% in 1989,  which dropped down to 5.3% in 2001.  Improved medical facility, literacy, awareness, and purchasing capacity are some of the aspects accountable for increased life expectancy and cataract.
Despite increase in number of cataract operations, the cataract surgery rate remain low as there is a rapid increase in number of new cataract cases as result of growing population, the number of unoperated cases are accumulating each year. Cataract surgery rate is 3400 per million populations per year in India. 
In our study, 1877 (74.9%) of patients operated for cataract were above the age of 60 years while 842 (33.6%) and 73 (2.9%) were above 70 years and 80 years of age, respectively. Only 391 (15.6%) cases were between 50-60 years of age, which is strong evidence that majority (75%) of patients receive delayed eye care and come in advanced stages of cataract.
Higher attendance of aged people at camp was mostly because of their dependence on negligent offspring, poor affordability, financial dependence, and inconvenient transport to reach medical services and get operated at optimum time. Delayed treatment is evident by the fact that they present at older age and with advanced stage of cataract with much diminished vision than 6/60. In India, all cataract surgeries are not sight-restoring surgeries as nearly 40-50% surgeries are performed in individuals with a vision >6/60 in the better eye,  but in our series, only 11 (0.4%) patients operated for cataract had vision 6/18.
Vision 2020 targets the bilaterally blind as the immediate priority and eye camps are worthwhile in their role in every respect to eliminate cataract blindness, particularly for poor people. In the present study, blind persons having vision <3/60 in better eye were 1588 (63.3%) and low vision <6/60 in better eye were 481 (19.2%), making an aggregate of 2068 (82.5%) persons that were operated and whose sight was restored. About 437 (17.5%) were uniocular blind, had vision less than 6/60 in to be operated eye although other side vision was normal as against 199 (7.9%) cases that were one-eyed, having no vision in other eye. Loss of sight of one eye in past due to any etiology put patients in a noteworthy position because the other eye is precious and its surgery becomes critical, requiring a highly skilled, competent surgeon as there is no margin for error. Uniocular cataract with normal other eye are mostly traumatic cataract occurs without exempting any age.
A systematic review of global population-based blindness surveys carried out between 1980 and 2000 showed that in 50+ population, blindness is approximately 40% more frequent in women compared to that in men.  Women account for about 64% of the total number of blind persons globally (a summary value). In 1999-2002 survey, females were found to have a higher prevalence of blindness as compared to men, and rural residents as compared to urban respondents in India.
Ignorance, illiteracy, dependence on negligent off springs, lack of access to medical services, shortage of transport facility, financial affordability, and reliance on malpracticing quack are some of the factors responsible for prevalence of blindness in varied percentage among different localities. However, one thing is universal for all places that whatever may be the reasons, it affects females more than males. As if this were insufficient, females have restricted freedom of movement, do not have financial decision-making authority,  and medical attention is not considered as urgent or important as that of male family members in India and many developing countries.
There are also two significant biological reasons for higher incidences of cataract, namely hormonal differences and longer life expectancy than men These eye camps were great help to women as 16.3% more women (1426, 56.84%) were operated compared to 1081 (43.16%) men.
In many quarters, males are twice as likely as females to be able to utilize eye care facilities.  In developing countries, the cataract surgical coverage rate was 1.2-1.7 times higher for males than for females. In India, the sex ratio is 1000 males to 940 females,  but female patients outnumbered males as outdoor patients-6962 (41.85%) males and 9675 (58.15%) females as well as operative cases 1081 (43.16%) were men in comparison with 1424 (56.84%) women, forming male-female surgery rate ratio 1.0: 1.32. Considering both factors, for every 100 males 140 females need eye surgery facility.
Even though females have lower coverage rate, they comprise of 57% of all cataract cases in the study populations, and if they get surgical modality at the same rates as males, the prevalence of cataract blindness would be reduced significantly. 
The high castes are the elite of the Indian society; the other lower castes or depressed classes communities are SC 15%, ST 7.5%, and OBC about 50%. Since Independence, according to the central government 'Reservation' policy that is an integral part of the Constitution of India, these three categories defined together as Backward Classes, are entitled for positive discrimination. [Table 4] describes the population ratio below poverty line.
|Table 4: Percentage of population below poverty line by social groups, 2004-05 |
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In central India (Madhya Pradesh), 42.8% rural and 67.3% urban SC population is below poverty line (BPL). In OBC, 29.6% in rural area and 55.5% in urban region are BPL. Poverty is one of the many contributory significant factors for lower access to eye care services to them. To reduce blindness, strategies targeting poor people will be needed.  In our series, maximum operations 2169 (86.55%) done in Backwards Classes, 982 (39.1%) were from SC, 828 (33.0%) were from ST and 359 (14.3%) belonged to OBC. General caste patients were 5.23% males and 8.23% were females out of total 2507 operative cases. Total backward class females got operated 1424 (56.84%) were 13.68% higher than total backward class males 1081 (43.16%).
A combination of these three factors - female gender, poverty, and backward class - lays an individual in utmost undesirable position. These camps were an immense aid to them.
| Conclusion|| |
Because of constant increase of population and enhanced life span, the number of cataract cases is bound to amplify the burden of cataract blindness in community. Available eye care is still out of reach in remote areas to poor inhabitants, women and backward class's society. In spite of the number of free eye camps organized, we still find a large backlog of cataract cases in the community. Free eye camps are still a requisite in a vast part of country for backward classes, under-privileged, women, and senior citizens. They should be well organized in larger number by highly proficient workers to eliminate colossal burden of blindness, without this success of Vision 2020 will remain an illusion.
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[Table 1], [Table 2], [Table 3], [Table 4]