Paediatric Eye Services in KATH and Northern Ghana P. Osei- Bonsu, MD Komfo Anokye Teaching Hospital

Childhood Blindness –Global Magnitude 37 million people are blindworldwide -Only 1.4 million are children(0-15 years) -Why is the elimination of avoidable blindness in children a Vision 2020 a top issue? Vision for Children.WHO & IAPB C,FosterA.Bull World Health Org 2001;79:

Incidence and prevalence of blindness in children Estimated at 500,000 new cases / year One per minute Over 50% die within 1-2 years of becoming blind Prevalence under-estimates the magnitude of the problem of childhood blindness, as this only takes account of children who survive Blind years

Childhood blindness in Ghana - Ghana – population 24million Population of children 0-15 years is approximately 8,000,000 (33% of population) Childhood Blindness prevalence estimate 0.8/1000 ( based on U 5 mortality rate) Estimated number of blind children 6,400 ( excluding refractive errors) Paediatric ophthalmologist 2 Paediatric eye care centres 2 Excellent Vitamin A and Measles programme

Northern Ghana Made of 5 regions occupying about 2/3 of land mass of the country. Population 11 million Three regions most deprived& poor No of opthalmologist 12 Only 4 outside the Ashanti region 1 paediatric ophthalmologist.

Country, year (references)Number of children in surveyPrimary causes of blindness Malawi, Kenya, Tanzania, Uganda, 2009 ( Njuguna M., Msukwa et al) 701 Cornea = 19% Whole globe = 15.7% Retina = 15.4% Lens = 13.1% Nigeria, 2011 ( Onakpoya O.H et al 30 Lens = 26.7% Glaucoma = 20% Retinitis pigmentosa = 16.7% Ghana, 2008 ( Ntim-Amponsah C.T., Amoaku W.M.K ) 201 Cornea = 59.3% Lens = 23% Glaucoma = 15.6% Cameroon, 2010 ( Noche C.D., Bella A.L. 56 Cornea = 32.1% Optic lesion = 26.8% Lens = 19.6% Nigeria 2009 ( Okoye O.I. et al ) 45 Glaucoma = 22% Cornea = 20% Lens = 13.3% Findings from recent schools for the blind surveys in Africa.

KATH records Cataract / uncorrected aphakia 30% Glaucoma 20%

Corneal lesions injuries

Other causes Refractive errors Retinal diseases Cortical blidness

Why are they blind Most of the causes are avoidable – so why ? GOOD NEWS- good EPI has reduced corneal cause of blindness

Nationwide no properly organized school screening Current school screening is cumbersome and the yield is poor with lot of false positives Need to streamline current methods- simple but effective tools needed Case Finding- School screening

Case finding At the community level Identification and referral No Community based programme to look for cases – A study has shown that only 33% of CEHTF in Africa had active case finding programmes in 2008, World Health Organization. Preventing blindness in children: Report of a WHO/IAPB Scientific Meeting. WHO/PBL/00.77; Agarwal P.K., Bowman R., Courtright P. Child eye health tertiary facilities in Africa. JAAPOS. 2010;14:263– 266. Transport- Not all cases identified or referred will travel to KATH Poor awareness Childrens’ issues especially chidren eye issues- not top priority. Cost- paediatric surgery is much more expensive than adult surgery

Community level Late presentation

Surgery- Late presentation

Why are they blind Chlidhood glaucoma is the second most impotant cause of visual impairment. Juvenile glaucoma- 80% of cases present already legally blind

Why are the children blind Blind HOSPITAL LEVEL The Provider factor - non availability of critical staff- “The Doctor is not there”-. Dr is attending a meeting Doctors/ Nurses on strike ---- not very good news for parents

Why are the children blind HOSPITAL LEVEL Limited theatre time- No electricity, No water, no consumables, No drapes?, another programme is running in the theatre Appropriate equipment- vitrector, frequent breakdown of essntial equipment like operating microscope, inappropriate size IOL,biometry, vitrectomy Consecutive refractive error-

Why are they blind HOSPITAL LEVEL_ Anaesthesia Paediatric anaesthesia is still a considerable risk Currently -Provider of anaesthetic services are mainly nurses Rate determining step of Surgery Maximum no per day 4 cases Preoperative assessment is cumbersome and expensive, though necessary- investigationsnot covered by NHIS Anaesthesia is not covered by NHIS

Low Vision services HOSPITAL LEVEL Low vision service is still very infantile expecially in the northern sector. Few Low Vision Aids.

Paediatric eye care at KATH- The Moran Eye Centre / HCP factor Paediatric HBT from 2009 And 3 months observership Mentorship Infrastructure Equipment

ORBIS support Aim Develop Komfo Anokye Teaching Hospital as a Childhood Tertiary Eye Health Training Facility (CTEHTF) with fully deloveloped Infrastructure, equipment and adequately trained paediatric team

Orbis support-What we seek to achieve To develop human resource for paediatric eye care Training primary health care workers/ key informants. Delveop and desseminate approprite awareness and public information materials. Annual surgical output of 400+ cases when programme is well established. Prevention of childhood blindness activities are integrated into primary health care programmes in Ghana.

Orbis support-What we seek to achieve To establish a database of paediatric ophthalmology Establish low vision and optical services to provide affordable spectacles and low vision aids for children Establish a functioning school screening programme and screen of children in the programme area for refractive errors and amblyopia and other treatable diseases.

Current state- Infrastructure and equipment Child eye clinic with 2 consulting rooms, nurses room, orthoptist room. One dedicated theatre with Anaesthetic machine Hand held autorefractor/keratometre Mobile fundus camera Vitrectome Mobile A/B scann Basic vision assessment tools Tonopens Hand held slit lamp Phoropter

Current state-HR Ophthalmologist Second ophtalmologist being trained Paediatric ophthalmic nurse Optometrist Paediatric eye care coordinator

Current State- Service delivery 2 Surgery days a week Fully dedicated theatre 2 clinic days per week School screening started actively from 2013 Child Friendly Environment Ward For Kids Equipment for more efficient service delivery

Plans for 2014 and after Human resources development Hospital Based Training Paediatric Ophthalmology,2 HBTs Paediatric Anaesthetists,2HBTs Ophthalmic Nurses,2HBTs Orthoptist, 1HBT Fellowships Paediatric ophthalmologist Paediatric Anaesthetists Non-clinical training courses Child Eye Health Coordinator Child Eye Health Counselors

Provision equipment and consumables Procurement of equipment Prioritise outstanding equipment for procurement in years 1& 2 Procurements of consumables Once yearly procurement of child spectacle frames Twice yearly local purchase of toys Refurbishment to ensure child-friendly Programme Technology Computer literacy training for Eye Department Staff Expansion fo KATH’s electronic medical record system Local training

Future plans Community Based programmes Visits to school for the blind Train key informers Train teachers

Twins with cataract. Referred by school teacher (before SURGERY)

Same twins

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