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Childhood Blindness

As the causes of blindness in children differ from those in adults, different control measures are needed. In low-income countries like Nepal, high proportions of children are blind from preventable causes, which require community-based interventions. In all regions, children with treatable diseases, principally cataract, can have their sight restored. Children’s eyes cannot, however, be considered smaller versions of adults’ eyes, and specific expertise and equipment are required. Unlike adults, children require long term follow-up after surgery, to manage complications and to prevent amblyopia (‘lazy eyes’). The understanding and involvement of parents is critical. In all areas, children with irreversible visual loss must be assessed for low-vision services, early visual stimulation, rehabilitation or special education, depending on their age and level of residual vision.

Current situation

It has been estimated that there are 1.4 million blind children in the world, 1 million of whom live in Asia and 300,000 in Africa. The prevalence ranges from 0.3/1000 children aged 0–15 years in affluent countries to 1.5/1000 children in very poor communities. Although the number of blind children is relatively low, they have a lifetime of blindness ahead, with an estimated 75 million blind-years (number blind × length of life), second only to cataract. The same report showed that 500,000 children become blind each year (nearly one per minute). Many die in childhood from the underlying cause, such as measles, meningitis, rubella, prematurity, genetic diseases and head injuries. Most blind children are either born blind or become blind before their fifth birthday. Owing to demographic differences, the number of children who are blind per 10 million population varies from approximately 600 in affluent countries to approximately 6000 in very poor communities. About 40% of the causes of childhood blindness are preventable or treatable.

The causes of childhood blindness vary among countries. The most recent estimation based on childhood mortality rate has estimated that there is 0.4/1000 prevalence rate of childhood blindness in Nepal and the main avoidable causes are:

  • Cataract
  • Glaucoma
  • Retinopathy of prematurity is emerging in major cities
  • Refractive errors
  • Low vision, which encompasses visual impairment and blindness from untreatable causes.

The main causes of blindness in children change over time. As a consequence of child survival programmes (for example, integrated management of childhood illness), corneal scarring due to measles and vitamin A deficiency is declining so that the proportion due to cataract is increasing. Retinopathy of prematurity is emerging as an important cause in the middle-income countries and is likely to become an important cause in Nepal over the next decade. The prevalence of refractive errors, particularly myopia, is increasing in school-age children, especially in urban population.

Achievements:

  • Vitamin A deficiency: The Government of Nepal has incorporated the Vitamin A capsule distribution to all children aged 6 months to 5 years in Nepal twice a year. It has contributed for reduction of Vitamin A deficiency cases seen in hospital in recent years.
  • Measles: Measles immunization coverage continues to improve in the country, resulting in a lower incidence of measles and measles-related deaths. Reducing the prevalence of measles will also reduce the number of children with measles-related corneal ulceration and scarring.
  • Retinopathy of prematurity: Programmes for detecting and treating severe retinopathy in premature infants at risk are expanding in major cities of the country.
  • Child eye-care centres: Training in pediatric ophthalmology is becoming more prevalent, and tertiary level child eye-care centres are being set up in major eye hospitals in all development regions.
  • Consumables for children: Low vision devices suitable for children as well as other consumables are available through resource centres in Hong Kong, China, and Durban, South Africa.

Limitations:

  • Inadequate population-based data on the prevalence and causes of blindness in children;
  • Lack of awareness among parents and the community about preventive measures and that the vision of children who are blind can often be improved or maximized;
  • Barriers to accessing services, including lack of awareness, distance, cost, fear and competing demands for scarce resources within the family;
  • Shortage of pediatric eye-care professionals and inadequate opportunities for training in pediatric ophthalmology in most low-income countries;
  • Lack of international exchanges in human resource development for pediatric ophthalmology and insufficiently developed postgraduate curricula for training pediatric ophthalmologists in country;
  • Fragmentation of pediatric eye-care services in many countries, so that children who need specialist expertise are managed by general ophthalmologists; and inadequate provision of special education for children with irreversible visual loss, particularly in low-income countries to eliminate avoidable causes of blindness in children.
  • Inadequate provision of special education for children with irreversible visual loss.

Aim:

  • To eliminate avoidable cause of childhood blindness in the country

Objective:

  • To promote programmes that reduce corneal scarring and visual loss from vitamin A deficiency and measles and to implement interventions against harmful traditional practices,
  • neonatal conjunctivitis and eye injuries;
  • To provide services to treat children with cataract, glaucoma, retinopathy of prematurity and corneal ulcer or scarring;
  • To provide optical services for children with refractive errors, for instance in school eye-health programmes; and
  • To provide services for children with low vision.

Strategies:

  • Provide comprehensive services for children at all levels of service delivery.
  • Capacity building of eye hospitals for pediatric eye care services
  • Increase awareness in the community and encourage primary health care, including specific preventive measures at the primary level, through primary eye care, including:
  • Measles immunization, to prevent corneal scarring;
  • Vitamin A supplementation, nutrition education, food supplementation and fortification of commonly eaten foods with vitamin A, to control vitamin A deficiency;
  • Avoidance of harmful traditional practices, to prevent corneal scarring;
  • Ocular prophylaxis of newborns, to prevent neonatal conjunctivitis;
  • Rubella immunization with strategies appropriate to the setting (e.g. schoolgirls aged 12–13 years).
  • At the secondary level, strengthen diagnosis and management of less complex cases.
  • At the tertiary level, provide specialist training and services for the management of surgically remediable visual loss from cataract, congenital glaucoma and corneal scarring, including long term follow up. Examine premature infants at risk of retinopathy of prematurity, treat those with severe disease and promote oxygen monitoring.
  • As children with cataract often do not present or present late, undertake active case finding, particularly for girls.
  • Provide each child eye-care centre with a well-trained team (e.g. pediatric or child-centred ophthalmologist, optometrist, anesthetist, counsellor, low vision therapist, mid-level personnel), appropriate equipment and infrastructure and access to consumables for infants and children (e.g. small spectacle frames, high-power intraocular lenses).
  • Ensure the availability of ophthalmologists experienced in indirect ophthalmoscopy to identify premature infants in intensive neonatal care who require treatment for retinopathy of prematurity.
  • Ensure that infants at risk have fundus examinations starting 4–6 weeks after birth and that infant with severe disease are treated immediately by laser or cryotherapy.
  • Develop low vision services for children with irreversible visual loss at secondary and tertiary levels.
  • Promote school eye-health programmes:
  • Promote the diagnosis and management of common conditions, such as refractive errors, and trachoma and vitamin A deficiency in endemic areas;
  • To promote a healthy environment; and
  • To educate children in looking after their eyes as part of the normal school curriculum.
  • In areas where significant uncorrected refractive errors affect more than 2% of schoolchildren aged 11–15 years, ensure that children undergo a simple vision screening examination, ideally as part of the school health programme, with provision of spectacles to those who will benefit.
  • Ensure that all children in special education establishments are examined by an ophthalmologist and receive medical, surgical, optical or low-Vision services to maximize their Vision.
  • Ensure good linkages between eye-care services and those providing education and rehabilitation services for incurably blind children.

Targets:

  • National plan will include the control of blindness in children, with achievable targets, as shown below.

For Disease Control:

  • Reduction in the prevalence of blindness in children from 0.4/1000 to 0.3/1000 by the year 2020;
  • Reduction in corneal scarring caused by vitamin A deficiency, measles, neonatal conjunctivitis and the use of traditional eye remedies;
  • Reduction in the proportion of blindness due to retinopathy of prematurity, particularly in countries where it is responsible for more than 10% of blindness in children; and
  • Appropriate management of children with cataract, with immediate, effective optical correction in suitably equipped specialist centres.

For Human Resource Development:

  • Prevention of blindness in children an explicit aim of primary health care programmes and included in all primary eye-care training curricula;
  • Adopt the policy to train and retain the pediatricAnesthesiologist in eye care
  • Personnel in secondary-level eye clinics with knowledge and skills necessary to manage less complex eye conditions in children; and
  • At least one child eye-care center with a well-trained team for every 5 million population by the year 2020.
  • Develop indigenous pediatric ophthalmologist learning and training center one in capital and outside capital.

For Infrastructure and Technology:

  • All child eye-care centers have adequate supplies of consumables for children, e.g. pediatricaphakic spectacles and low-power, small-diameter intraocular lenses; and
  • Secondary-level eye clinics have facilities to provide appropriate spectacles for children with refractive errors.

Indicators:

  • Prevalence of childhood blindness
  • Prevalence of avoidable childhood blindness, by cause;
  • Number of child eye-care centers per at least 5 million population;
  • Number of pediatric eye care team
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