Cataract and babies – Frontline
I first saw him just before the lockdown, in the second week of March 2020. Teju was about 18 months old when he came to our out patient department (OPD). Scared, he clung to his mother, as most visually impaired children do. They are anxious and diffident in a new environment. The family was from Raichur, about 400 kilometres from Bengaluru, requiring an overnight journey by train.
Teju’s father was a taxi driver who supplemented his income through agricultural work when it was available. His mother was a housewife. Teju belonged to a joint family that included his paternal uncle and grandparents. Teju’s mother noticed that her 14-month-old child was tripping over objects and could not see well for a few months. She had postponed talking to his father about it. She thought little Teju would just get better on his own. When things worsened, the family took a decision to consult the local paediatrician.
The doctor who examined Teju said that treatment for his condition was available only in cities—at tertiary eye-care centres. But this solution placed virtually impossible demands on the poor family, which did not have enough money to undertake a trip to the city. With great difficulty the family gathered money from friends and relatives and made the journey to Bengaluru. Meanwhile, the pandemic had hit Bengaluru, which reported its first COVID-19 case on March 9, 2020. The air in the city was thick with fear and anxiety. Suddenly, the Central government ordered a countrywide lockdown. Mine is a tertiary eye-care centre that is not directly involved in caring for COVID-19 patients. And, this was a new disease and nobody knew much about it. But we knew that the virus could infect the eye and spread through tears. Our hospital was closed from March 24 to April 30 for regular patients; only emergencies were entertained.
Little Teju was examined and found to have cataracts in both his eyes. The treatment for cataracts is surgical. There are no medicines to cure them. It was only in May 2020, after the lockdown had ended, that Teju was able to come to meet us again for the operation. Most ophthalmic surgeries are performed under local anaesthesia, but surgeries in children always have to be performed under general anaesthesia. There was much fear about general anaesthesia. Since general anaesthesia formed more aerosols, it was feared that it might be conducive for the spread of COVID-19 if the child was infected. Moreover, the severe shortage of test kits in the initial months of the pandemic prohibited us from getting an RT-PCR test done. It was a tough decision: to operate or not to operate? How long could we make such a young child wait? On the one hand, it did not look like the pandemic would end anytime soon, and on the other, the child had already suffered a delay of six weeks, a long time for a child of his age.
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Finally, we decided to go ahead with the surgery. We explained to the parents about the “lazy” eye that could plague Teju and impair his vision and development for the rest of his life if the surgery was not performed immediately. We also explained the risks involved in administering general anaesthesia and conducting a surgery in the middle of a pandemic and asked them to take a decision. Teju’s parents, already burdened by severe financial problems, were ill-equipped to take these decisions that they were forced to make. They could not afford the cost of the surgery. Luckily, our hospital had a policy that no child should be denied surgery merely because his/her parents could not afford it. We arranged a donor for Teju. The financial burden was shared between the donor, Teju’s parents and the hospital.
And so, on a bright Friday morning in the first week of May, we carried a screaming Teju into the operation theatre. Cataract surgery on children is routinely performed at our hospital, but this time there was a kind of hushed anxiety in the room because of the pandemic. Teju was anaesthetised with due precaution; the surgeon, the anaesthetist and the entire staff were in full personal protective equipment (PPE). The white, opaque cataract was removed and replaced with a glistening artificial lens made of acrylic material, which would serve him for the rest of his life. The surgery lasted about 30 minutes.
Cataracts occur when the lens inside the eye opacifies and does not allow light to enter. They can happen because of various reasons. Infection of the lens during pregnancy is one of the commonest causes for congenital cataract in India. This infection can occur because of the rubella virus if the mother is not vaccinated with the MMR vaccine in her childhood. It can also be inherited; the possibility of cataracts in babies is higher when the parents are in a consanguineous marriage, common in southern India. A study conducted by us revealed a 10.75 times higher risk of childhood cataract in children born of consanguineous wedlock1. Malnutrition in mothers during pregnancy is said to be another cause of congenital cataract.
Cataracts generally occur in adults, especially in old age. In India, about 60 per cent of the people above 60 have cataract. The prevalence of cataract in childhood is only about 0.06 per cent (6/10,000 children); yet it is important to address the problem because a little child blinded by cataracts lives sightless for about 60 years, unable to contribute to or participate in society fully and effectively. When you take into account the “blind years” (number of years that a person lives with blindness), childhood blindness is second only to adult cataract blindness. Moreover, 80 per cent of a child’s development depends on vision. Visual impairment affects cognitive development, behaviour, language skills, communication and education. Continued neglect of the problem of childhood blindness translates into a waste of national talent and human capacities. It is important to screen and detect childhood cataract at the earliest.
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Research on childhood blindness is sparse in India 2-8. Most of the studies have been in the southern part of the country. The prevalence of childhood cataracts varies widely across States (0.03 to 0.1 per cent of the population). Possible reasons for the huge variation could be the difference in methodology of collecting data, difference in age groups chosen, and the differences in the under-five mortality rates. Incidentally, childhood blindness is directly proportional to the under-five mortality rate because the causes of under-five mortality (malnutrition, preterm births) are also the causes for childhood blindness.
The eye in adults and children
A child’s eye is very different from an adult’s. The diameter of the eye at birth is about two-thirds of an adult eye. The axial length of the eye is around 17 mm at birth, which increases to approximately 24 mm in adulthood. A newborn baby is hyperopic (long sight) with approximately +3.5 dioptres of hyperopia (illustration on page 66). This hyperopia gradually decreases when the child is eight or nine years old. About four-fifths of the growth of the eye happens in the first two years of life; the rest continues up to the age of eight to nine years. A newborn baby has very little vision.
For further development of the visual system, the child requires a constant input of visual stimuli. For a clear, focussed image, visual inputs from both the eyes ought to reach the brain. This is necessary for proper visual development to take place. If this does not happen, a condition called amblyopia or “lazy eye” develops (illustration on page 68). That is why it is very important that a child should see well during the first few years of life. Amblyopia is a condition where eye-to-brain connections do not occur. Most eye diseases in children, if not treated early enough, have the possibility of the development of amblyopia. That is why amblyopia is best treated during childhood. The younger a child, the better the chances of recovery. There is hence a certain amount of urgency in the treatment of eye diseases in children. This is also the reason why eye surgeries should not be postponed for too long.
Cataract surgery in children
Cataract surgery in a child is challenging and technically more difficult than in adults. The entire surgery is done through an opening as small as 2.8 mm. The lens in the human eye has an anterior (front) and a posterior (back) capsule. An opening is made in the anterior capsule (this is called continuous curvilinear capsulotomy or CCC) and the opaque lens matter is removed. This creates a bag into which the artificial intra ocular lens (IOL) is folded and gently pushed into place, with the posterior capsule supporting the IOL. Cataract surgery in children is also different from that in an adult because the anterior capsule is very elastic and the sclera (outer white coat of the eye) is less rigid and easily collapsible. In adults, the posterior capsule is left intact. But in children, a small opening, called the primary posterior capsulotomy (PPC), has to be made in the posterior capsule, taking care to see that the IOL is not displaced. This is done to ensure that the visual axis remains clear for the rest of the child’s life. If the PPC is not made, a white opacity starts appearing just behind the IOL within six months, especially in younger children, thus hampering vision. Any surgery in a child requires the administering of general anaesthesia, which necessitates a fully equipped anaesthesia unit with a paediatric anaesthetist. There are fewer than a thousand ophthalmologists in India who are trained to perform cataract surgery in little children. Most of the facilities offering services for children are concentrated in urban centres, and in tertiary eye-care hospitals.
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Social factors affecting treatment
Little Teju was lucky. His parents did not wait too long to get him to a tertiary eye-care centre. However, most parents, illiterate or with poor means, do not know the importance of early treatment. Assuming that their children are too young to cooperate for an eye examination and to undergo any kind of treatment, they do not consult an eye specialist. A study conducted by us in 2012 regarding the barriers in accessing eye care in children revealed that 70 per cent of Indian parents were unaware that their child was visually impaired 9. The other reason for not accessing eye care is the fatalistic attitude adopted by caregivers—that it is by God’s will that their child is visually impaired. Poor people in remote villages are usually daily wage earners. Their daily meal depends on their ability to work. Taking the child for a consultation means loss of a day’s wage. There are also many who are misled by ill-informed health care professionals or by traditional “healers”. People usually live in large joint families and the child’s grandparents often take decisions in the family. Indian children have a submissive social existence. At the bottom of the social structure, in a family with limited resources, this can mean that priority is assigned to older persons when medical care is needed.
Second eye surgery
Two weeks after the surgery in his right eye, Teju underwent surgery in his left eye. Usually, the operation on the second eye is done a week after the first. Since we were in a pandemic and the incubation period of the disease was about two weeks, we decided to operate after two weeks. Teju’s mother had to be very careful with him. She did not let him go outside to play physical games. She had to administer various eye drops to facilitate healing of the wound. The sutures that were in the wound were absorbable and did not need removal. The difference in Teju’s world was apparent immediately after the first eye surgery. On the day after the first eye surgery, as I climbed up the stairs to the paediatric OPD, I watched transfixed as I saw little Teju playing on a small slide in the play area.
This sight—when a child begins to open his eyes to the unseen and starts seeing this beautiful planet, is magical and is a paediatric ophthalmologist’s moment of ecstasy. After the second eye surgery he became very talkative. His mother asked me: “Doctor, is the anaesthesia ‘gas’ that you made him inhale making him so talkative and mischievous?” “No, dear lady,” I said, “your son has started to see this world and learn from seeing.”
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Teju’s cataracts prevented him from having a clear view of the world, which in turn prevented an overall sensory and motor development. About three weeks after his second surgery, we gave him bifocal glasses—glasses that have different segments for distance and near vision. We then taught him vision stimulation exercises to try and strengthen the eye-brain connections that had gone limp because of the cataracts. Teju will need frequent change of glasses. As the length of the eye increases, there will be a change in the power of his glasses. His vision immediately after surgery was only about 30 per cent of what is normal. With glasses and exercises it improved to 60 per cent by about four months of surgery. After several months of exercises, he had about 80 per cent of the vision that a normal child of his age would have. He needs constant monitoring of his eye pressure. Initially, for a year, I will see him every three months, after which I need to see him biannually, and if everything goes well, I can see him once every year until he is 18.
Most of the children with cataract we see in our OPD are like Teju; they come from areas that are backward in educational and socio-economic standards. Their parents live a hand-to-mouth existence, and general awareness of health-related issues is poor. They live in remote villages where facilities for the treatment of paediatric cataracts are unavailable.
Since rubella virus infection is still the commonest cause of cataract in children in India, it is a good idea to improve vaccination coverage against rubella. Nearly 45 per cent of the women of reproductive age in India are susceptible to rubella infection during pregnancy10, leading to congenital cataract in offspring. The MMR vaccine is not a part of the national immunisation schedule of India. However, the Ministry of Health and Family Welfare has initiated measles-rubella (MR) vaccination campaign in the age group of nine months to under 15 years in a phased manner across the nation. The first phase was completed in 2017, wherein children in five States were vaccinated 11. This may help reduce cases of rubella and, hence, congenital cataract. Maternal malnutrition is one other cause of congenital cataract. Regular ante-natal check-ups with emphasis on prevention of anaemia and malnutrition will go a long way in good maternal and child health. It is also imperative to create awareness on the consequences of consanguineous marriages.
There is a need to develop awareness among parents on various common eye diseases. Educating teachers and community workers in screening of eye diseases would help in early detection. The staff in the primary health centres should be trained in the early detection of eye diseases. It would be a good idea to include eye examinations every time the child comes for vaccination. Children with blinding eye diseases need to be referred to tertiary eye-care centres without delay.
According to the World Health Organisation (WHO), every 10 million of the population should be serviced by one paediatric ophthalmology service centre, with at least one specially trained ophthalmologist 12. India has 69 such centres for a population of 1.3 billion. This means that we need a doubling of such centres 13. Many of these centres are not fully equipped (diagnostic and surgical infrastructure, human resources) to provide complete eye care to children. Also, these centres are not equally distributed across the country; the southern and western regions are better off 14. Most of these centres are located in urban areas. Hence increasing the present infrastructure is a huge task confronting the governing bodies. The treatment is also costly, and most patients cannot afford the cost of the surgery. The government should bear the expenses for the treatment of sight-giving surgeries in economically backward sections.
A year after the surgery, Teju is now almost three. He is walking and talking and has normal milestones. The lag in his development has been eliminated. He has 75-80 per cent of vision with glasses. He will be able to go to a regular school. I shudder to think what might have happened if his parents had not come to us. He might have become blind. If he had been operated on at an older age, he would not have gained the vision he now has. Teju is no ordinary child. He can now see and the world is his to conquer.
Dr Vasudha Kemmanu is a consultant paediatric ophthalmologist at Narayana Nethralaya, Bengaluru.