Pediatric ophthalmology slowly gaining ground

Issue: July 2008

The field of ophthalmology in India has been expanding quickly in the past few decades, but the pediatric ophthalmology subspecialty remains small despite a relatively high rate of preventable blindness among children.

G. V. Rao

“There is a dearth of infrastructure and trained manpower to combat this issue,” Ramesh Kekunnaya, FRCS, of Jasti V. Ramanamma Children’s Eye Care Centre at L.V. Prasad Eye Institute, told Ocular Surgery News in an e-mail interview. “As of now, only a few tertiary eye care centers are able to treat these conditions. We need many more of these [centers] and a lot more awareness among the public.”

About 320,000 children in India are blind, resulting in a prevalence of 0.08%, according to the Web site of Orbis International, a nonprofit agency dedicated to eliminating unnecessary blindness by increasing access to and improving eye care.

The leading causes of pediatric blindness in India are corneal scarring, cataracts, glaucoma and optic atrophy. About 50% to 70% of such issues are preventable, according to G.V. Rao, PhD, director of India operations for Orbis. Corneal scarring due to vitamin deficiency is still a major concern, he said, although the incidence has decreased slightly over time. Additionally, measles infections and congenital rubella syndrome are responsible for many cases of childhood blindness.

Combating these issues will require an expansion of public health initiatives, with more emphasis on prevention and care in the area of the field of pediatric ophthalmology in terms of increased access to pediatric eye care specialists and increased awareness among parents and children, he said.

Traditional medicines, myths

One obstacle faced by many ophthalmologists in India involves ocular complications because of the use of harmful traditional medicines, according to Dr. Rao.

“[Children and their parents] still go to local traditional healers who too often use harmful traditional medicines in the eye,” he said.

In addition, some still believe that certain conditions, specifically strabismus, are lucky, said R.D. Thulasiraj, of the Lions Aravind Institute of Community Ophthalmology.

“They don’t recognize that it will lead to amblyopia and loss of vision,” Mr. Thulasiraj said.

The solution is education, he explained. Parents must learn that ophthalmologists can help their children, and they must be encouraged to take their children to see specialists early on.

Education efforts

“Through educational and awareness programs, we are able to inform parents, as well as teachers and health workers, how to recognize cases at the early stage,” Dr. Rao said.

“We are trying to involve everyone — the health workers, villagers, the community — to educate themselves and report the cases on time,” he said. “They should know where to go and when to go.”

Aravind Eye Hospital in Coimbatore carries out a yearly school screening program in association with the District Blindness Control Society, said Kalpana Narendran, DO, DNB, chief of the Pediatric Ophthalmology & Strabismus Clinic there.

“Some of the schools have 3,000 children, so it’s not practical for us to be there to screen all 3,000 children,” she said. Instead, the hospital sets up a 1-day training program for local teachers.

“We educate them with slides on eye care problems in children and how valuable it is to refer them early,” Dr. Narendran said. The teachers return to the schools with vision charts to evaluate the children. Once they have identified children who may have refractive errors or other ophthalmic issues, an ophthalmic assistant re-examines the children and decides the appropriate care.

“That way we are able to screen more children, and we also identify them at an earlier age,” she said.

According to T.S. Surendran, vice chairman of Sankara Nethralaya and director of the pediatric ophthalmology department there, similar educational programs sponsored by Orbis have increased pediatric patient traffic at his hospital from about 3,000 in 2003 to an estimated 29,000 in 2008.

“That’s almost 10 times the number of children being examined in the department,” he said.

Mr. Thulasiraj said recent increases in school attendance will help. With more children in school, systematic screening becomes easier, he said.

Working toward more access

Even when parents are agreeable to bringing their children to ophthalmologists, the issue of access often remains.

The three major eye care centers in India offering pediatric services are L.V. Prasad, Aravind Eye Hospital and Sankara Nethralaya. Rural areas lack the appropriate care within 100 miles.

Organizations such as Orbis are helping to establish eye care centers run by trained specialists in more areas of the country. Dr. Rao said the organization has established 15 children’s eye care centers since it started work in India. He said they are on schedule to create another seven by the end of 2008. The goal is to have developed 50 centers offering pediatric care by 2010.

In addition to increasing the number of centers offering pediatric eye care, Dr. Surendran emphasized the value of “teleconnectivity,” commonly known as telemedicine. With this technique, ophthalmologists can interact with colleagues and patients in other locations, combating the lack of specialized facilities in some areas.

Part of the Orbis initiative involves broadcasting surgeries to hospitals throughout India. The organization also introduced Cyber-Sight, a telemedicine initiative that uses the Internet to connect doctors throughout the world with Orbis volunteer specialists for professional mentoring, patient care consultation and online continuing medical education. Through Cyber-Sight, qualified physicians can consult with specialists on their patients’ conditions via the Web for free.

Pediatric ophthalmic training

Another essential part of increasing access to pediatric eye care is training new pediatric ophthalmologists.

“Not many pediatric ophthalmologists are available in the country,” Dr. Narendran said.

Up until recently, “pediatric ophthalmology was not a known specialty in India,” Dr. Surendran said. “Very few people were doing full-time work.

“The main problem is lack of manpower,” he said. “One out of every 100,000 is an ophthalmologist. So the pediatric ophthalmologist may be one in 10 million.”

Both Aravind and L.V. Prasad train teams of pediatric eye care specialists with support from organizations such as Orbis and Sightsavers, another international nongovernmental organization. These teams include ophthalmologists, anesthesiologists, orthoptists, optometrists, nurses, counselors, outreach representatives and clinic managers, all of whom coordinate service at a particular location after training.

The team training programs last 12 to 15 months, whereas normal fellowship training for pediatric ophthalmologists in India lasts about 18 months.

The training programs at Aravind Eye Hospital in Coimbatore and Sankara Nethralaya are conducted on a smaller scale, resembling traditional fellowship programs. At Sankara Nethralaya, Dr. Surendran assists new ophthalmologists in surgery and overseeing patient care in the outpatient clinic. He said they have trained 16 ophthalmologists and that their own pediatrics staff has increased from one to five members.

At Aravind Eye Hospital, Dr. Narendran trains about two to three pediatric ophthalmologists at a time. “It has to be done with close monitoring and supervision because you’re handling children,” she said.

During the first 6 months, trainees remain in general ophthalmology, moving into pediatric ophthalmology for the last year. “Based on their skills, they would probably start surgery from the second month onward,” she said.

Areas of focus

Pediatric ophthalmology training in India focuses on the most problematic conditions. The more exposure new ophthalmologists get to such conditions, the better they are able to help prevent blindness and low vision in children.

At Sankara Nethralaya, pediatric ophthalmologists are primarily trained to treat strabismus and congenital cataracts, according to Dr. Surendran. He also said refractive error is a common ocular issue among children, affecting about 2.5 million people.

At Aravind Eye Hospital, Dr. Narendran said trainees perform strabismus evaluations, refractive error corrections and surgeries for pediatric cataracts and strabismus. She said they typically get to perform about 30 to 50 strabismus surgeries and about 20 to 30 pediatric cataracts during their fellowship.

“They get some exposure to retinopathy of prematurity,” Dr. Narendran said.

For more information:

Ramesh Kekunnaya, FRCS, can be reached at Jasti V. Ramanamma Children’s Eye Care Centre, Kallam Anji Reddy Campus, L.V. Prasad Eye Institute, Hyderabad 500 34, Andhra Pradesh; 40-30612345; fax: 40-23548271; e-mail: rameshak@lvpei.org.

Kalpana Narendran, DO, DNB, can be reached at Aravind Eye Hospital, Avinashi Road, Coimbatore 641 014, Tamilnadu; 42-24360400; fax: 42-22593030; e-mail: kalpana@cbe.aravind.org.

G.V. Rao, PhD, can be reached at Orbis India, All India Ophthalmic Society Building, A-8 Institutional Area, Karkardooma, Delhi, 110092; 11-22376301; fax: 11-22376304; e-mail: g.rao@in.orbis.org.

T.S. Surendran can be reached at Sankara Nethralaya, 18 College Road, Chennai 600 006; 44-28271616; fax: 44-28254180; e-mail: drtss@snmail.org.

R.D. Thulasiraj can be reached at the Lions Aravind Institute of Community Ophthalmology, Aravind Eye Care System, 72 Kuruvikaran Salai, Gandhi Nagar; 452-4356500; fax: 452-2530984; e-mail: thulsi@aravind.org.