Cataract and its surgery in Papua New Guinea

Clinical and Experimental Ophthalmology
2006;
34
: 880–885
doi:10.1111/j.1442-9071.2006.01342.x
© 2006 Royal Australian and New Zealand College of Ophthalmologists

Correspondence:
Dr Garry Brian, 5 Hazelmere Parade, Sherwood, Qld 4075, Australia. Email: grbrian@tpg.com.au
Received 11 April 2006; accepted 19 June 2006.
Original Article
Cataract and its surgery in Papua New Guinea
Jambi N Garap
MMed(Ophthal)
,
1,2
Sethu Sheeladevi
MHM
,
3
Garry Brian
FRANZCO
,
2,4
BR Shamanna
MD
,
3
Praveen K Nirmalan
MPH
3
and Carmel Williams
MA
4
1
The Fred Hollows Foundation – Papua New Guinea Eye Care Program,
2
Department of Ophthalmology, School of Medicine and Health
Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea;
3
International Center for Advancement of Rural Eye Care,
L.V. Prasad Eye Institute, Hyderabad, India; and
4
The Fred Hollows Foundation (New Zealand), Auckland, New Zealand
Key words:
blindness
,
cataract
,
Papua New Guinea
,
surgery
,
vision impairment
.
I
NTRODUCTION
Just north of Australia, tropical Papua New Guinea (PNG)
has more than five million people spread across several major
and hundreds of other smaller islands. Almost 50% of the
land area is mountainous, and 85% of inhabitants are rural
dwellers. Forty per cent of the population is age 14 years or
younger, and 9% is 50 years or older.
1
Papua New Guinea was administered by Australia until
1975, when independence was granted. Since that time, governance,
particularly budgetary, economic performance, law
and justice, and development and management of basic
health and other services have declined. Today, 37% of the
population is said to live below the poverty line, personal
and property security are problematic, and health is poor.
There are significant and growing economic, health and education
disparities between urban and rural inhabitants.
Papua New Guinea has one referral hospital, in Port
Moresby. This has an eye clinic with one part-time and two
full-time consultant ophthalmologists, and several ophthalmology
training registrars. There are also two private ophthalmologists
in the city. Elsewhere, four provincial hospitals
have eye clinics, each with one consultant ophthalmologist.
One of these, supported by Christian Blind Mission and
based at Goroka, provides an extensive outreach service.
Visiting Australian and New Zealand ophthalmology teams
and an outreach team from Port Moresby General Hospital
provide some 6 weeks of provincial service per year.
Cataract and its surgery account for a significant proportion
of ophthalmic resource allocation and services delivered
in PNG. Although the National Department of Health keeps
some service-related statistics, and cataract has been considered
in three PNG publications of limited value (two district
service reports
2,3
and a community assessment
4
), there has
been no systematic assessment of cataract or its surgery.
A
BSTRACT
Purpose:
To determine the prevalence of visually significant
cataract, unoperated blinding cataract, and cataract surgery
for those aged 50 years and over in Papua New Guinea.
Also, to determine the characteristics, rate, coverage and
outcome of cataract surgery, and barriers to its uptake.
Methods:
Using the World Health Organization Rapid
Assessment of Cataract Surgical Services protocol, a population-
based cross-sectional survey was conducted in
2005. By two-stage cluster random sampling, 39 clusters of
30 people were selected. Each eye with a presenting visual
acuity worse than 6/18 and/or a history of cataract surgery
was examined.
Results:
Of the 1191 people enumerated, 98.6% were
examined. The 50 years and older age-gender-adjusted
prevalence of cataract-induced vision impairment (presenting
acuity less than 6/18 in the better eye) was 7.4% (95%
confidence interval [CI]: 6.4, 10.2, design effect [deff]
=
1.3).
That for cataract-caused functional blindness (presenting
acuity less than 6/60 in the better eye) was 6.4% (95% CI:
5.1, 7.3, deff
=
1.1). The latter was not associated with
gender (
P
=
0.6). For the sample, Cataract Surgical Coverage
at 6/60 was 34.5% for Eyes and 45.3% for Persons. The
Cataract Surgical Rate for Papua New Guinea was less than
500 per million population per year. The age-genderadjusted
prevalence of those having had cataract surgery
was 8.3% (95% CI: 6.6, 9.8, deff
=
1.3). Vision outcomes of
surgery did not meet World Health Organization guidelines.
Lack of awareness was the most common reason for not
seeking and undergoing surgery.
Conclusion:
Increasing the quantity and quality of cataract
surgery need to be priorities for Papua New Guinea eye
care services.
Cataract and its surgery in Papua New Guinea 881
© 2006 Royal Australian and New Zealand College of Ophthalmologists
This paper reports the cataract-related aspects of a population-
based cross-sectional rapid assessment survey of
those 50 years and older in PNG.
M
ETHODS
The National Ethical Clearance Committee of The Medical
Research Advisory Committee granted ethics approval to
survey aspects of eye health and care in Papua New Guinea
(MRAC No. 05/13). This study was performed between
December 2004 and March 2005, and used the validated
World Health Organization (WHO) Rapid Assessment of
Cataract Surgical Services
5,6
protocol. Characterization of
cataract and its surgery in the 50 years and over age group
was part of that study.
As reported elsewhere,
7
the sample size required, using a
prevalence of bilateral cataract functional blindness (presenting
visual acuity worse than 6/60 in both eyes) of 5% in the
target population, precision of
±
20%, with 95% confidence
intervals (CI), and a design effect (deff) of 1.3 (for a cluster
size of 30 persons), was estimated as 1169 persons. The
sample frame used for the survey, based on logistics and
security considerations, included Koki wanigela settlement
in the Port Moresby area (an urban population), and Rigo
coastal district (a rural population, effectively isolated from
Port Moresby despite being only 2–4 h away by road). From
this sample frame, 39 clusters (with probability proportionate
to population size) were chosen, using a systematic random
sampling strategy.
Within each cluster, the supervisor chose households
using a random process. Residency was defined as living in
that cluster household for 6 months or more over the past
year, and sharing meals from a common kitchen with other
members of the household. Eligible resident subjects aged
50 years and older were then enumerated by trained volunteers
from the Port Moresby St John Ambulance Services.
This continued until 30 subjects were enrolled. If the
required number of subjects was not obtained from a particular
cluster, the fieldworkers completed enrolment in the
nearest adjacent cluster. Verbal informed consent was
obtained prior to all data collection and examinations.
A standardized survey record was completed for each
participant. The volunteers solicited demographic and general
information, and any history of cataract surgery. They
also measured visual acuity. During a methodology pilot in
the Morata settlement area of Port Moresby, the kappa statistic
for agreement between the four volunteers designated
to perform visual acuity estimations was over 0.85.
The widely accepted and used ‘presenting distance visual
acuity’ (with correction if the subject was using any), a measure
of ocular condition and access to and uptake of eye care
services, was determined for each eye separately. This was
done in daylight, using Snellen illiterate E optotypes, with
four correct consecutive or six of eight showings of the
smallest discernible optotype giving the level. For any eye
with presenting visual acuity worse than 6/18, pinhole acuity
was also measured.
An ophthalmologist examined all eyes with a history of
cataract surgery and/or reduced presenting vision. Assessment
of the anterior segment was made using a torch and
loupe magnification. In a dimly lit room, through an undilated
pupil, the status of the visually important central lens
was determined with a direct ophthalmoscope. An intact red
reflex was considered indicative of a ‘normal’ clear central
lens. The presence of obvious red reflex dark shading, but
transparent vitreous, was recorded as lens opacity. Where
present, aphakia and pseudophakia with and without posterior
capsule opacification were noted. The lens was determined
to be not visible if there were dense corneal opacities
or other ocular pathologies, such as phthisis bulbi, precluding
any view of the lens. The posterior segment was examined
with a direct ophthalmoscope, also through an
undilated pupil.
A cause of vision loss was determined for each eye with
a presenting visual acuity worse than 6/18. In the absence of
any other findings, uncorrected refractive error was considered
to be that cause if the acuity then improved to better
than 6/18 with pinhole. Other causes, including corneal
opacity, cataract and diabetic retinopathy, required clinical
findings of sufficient magnitude to explain the level of vision
loss. Although any eye may have more than one condition
contributing to vision reduction, for the purposes of this
study, a single cause of vision loss was determined for each
eye. The attributed cause was the condition most easily
treated if each of the contributing conditions was individually
treatable to a vision of 6/18 or better. Thus, for example,
when uncorrected refractive error and lens opacity coexisted,
refractive error, with its easier and less expensive treatment,
was nominated as the cause. Where treatment of a condition
present would not result in 6/18 or better acuity, it was
determined to be the cause rather than any coincident or
associated conditions amenable to treatment. Thus, for
example, coincident retinal detachment and cataract would
be categorized as ‘posterior segment pathology’.
Participants who were functionally blind (less than 6/60
in the better eye) because of unoperated cataract were interrogated
about the reasons for not having surgery. The
responses were closed ended and respondents had the option
of volunteering more than one barrier, all of which were
recorded in a piloted proforma. The first four reasons offered
were considered for analysis of the barriers to cataract
surgery.
Those eyes previously operated for cataract were examined
to characterize that surgery and the vision outcome. A
detailed history of the surgery was taken. This included the
age at surgery, place of surgery, cost and the use of spectacles
afterward, including reasons for not wearing them if that was
the case.
The Rapid Assessment of Cataract Surgical Services data
entry and analysis software package was used. The prevalences
of visually significant cataract, unoperated blinding
cataract and cataract surgery were determined. Where prevalence
estimates were age and gender adjusted for the population
of PNG, the estimated population structure for the
882 Garap
et al.
© 2006 Royal Australian and New Zealand College of Ophthalmologists
year 2000
1
was used, and 95% CI were derived around these
point estimates. Additional analysis for potential associations
of cataract, its surgery and surgical outcomes employed the
STATA (version 8.0; StataCorp LP, TX, USA). Fisher’s exact
test and the chi-square test for bivariate analysis and a multiple
logistic regression model for multivariate analysis were
used. Odds ratios (OR) and 95% CI were estimated. A
P
-
value of
<
0.05 was taken as significant for this analysis.
The Cataract Surgical Coverage (Eyes) (CSC(Eyes)) was
calculated. This is a surgical service impact indicator. It measures
the proportion of cataract that has been operated on
in a defined population at a particular point in time, being
the eyes having had cataract surgery as a percentage of the
combined total of all of those eyes operated with those
currently blind (less than 6/60) from cataract (CSC(Eyes) at
6/60
=
100
a
/(
a
+
b
), where
a
=
pseudophakic
+
aphakic eyes,
and
b
=
eyes with worse than 6/60 vision caused by cataract).
8
The Cataract Surgical Coverage (Persons) (CSC(Persons))
was determined. This considers people with operated
cataract (either or both eyes) as a proportion of those having
operable cataract. (CSC(Persons) at 6/60
=
100(
x
+
y
)/
(
x
+
y
+
z
), in which
x
=
persons with unilateral pseudophakia
or unilateral aphakia and worse than 6/60 vision
caused by cataract in the other eye,
y
=
persons with bilateral
previously operated cataract, and
z
=
persons with bilateral
cataract causing vision worse than 6/60 in each).
8
The Cataract Surgical Rate, being the number of cataract
operations per year per million of population, was also
estimated.
R
ESULTS
Of the 1191 people enumerated, 5 subjects were not available
during the survey and 12 refused participation. Data
from these 17 were not considered in the analysis. Of the
remaining 1174 (98.6%), 606 (51.6%) were female, and 914
(77.9%) were domiciled in rural Rigo.
Cataract caused 35.2% of vision impairment (presenting
vision less than 6/18) and 62.8% of functional blindness
(presenting vision less than 6/60) in the 2348 eyes sampled
(Table 1). It was second to refractive error (45.7%)
7
in the
former, and the leading cause of the latter.
For the 1174 subjects, cataract was the most prevalent
cause of vision impairment (46.7%) and functional blindness
(75.0%) (Table 1). On bivariate analysis, increasing age
(
P
<
0.001), illiteracy (
P
<
0.001) and unemployment
(
P
<
0.001) were associated with cataract-induced functional
blindness. Gender was not significantly associated (
P
=
0.6).
In a multivariate model that included all variables found
significant in bivariate analysis, increasing age (reference category
50–59 years; OR: 2.6, 95% CI: 1.6, 5.9 for persons
aged 60–69, OR: 9.8, 95% CI: 4.6, 20.6 for persons aged
70–79, and OR: 18.6, 95% CI: 8.3, 41.9 for persons aged
80 years and older) and illiteracy (OR 2.2, 95% CI 1.3, 3.8)
were associated with functional cataract blindness.
The survey sample included 97 people (8.3%) who had
previously undergone cataract surgery, for a total of 136 eyes
(5.8%). On bivariate analysis, increasing age (
P
=
0.02), male
gender (
P
=
0.02), literacy (
P
<
0.001) and employed status
(
P
=
0.03) were associated with cataract surgery. Illiteracy
was significantly associated with reduced uptake of cataract
surgery (adjusted OR 0.43, 95% CI: 0.20, 0.91) in a multivariate
model that adjusted for age, gender and employment
status.
The CSC(Eyes) at 6/60 for the survey sample was
34.5%, and the CSC(Persons) at the same vision level was
45.3%.
Most cataract surgery occurred in a government hospital
(
P
<
0.001), more than 5 years ago (
P
<
0.001). Also, most
of the intracapsular extractions were performed more than
5 years ago (
P
<
0.001). Patients are now more likely to
receive intraocular lens surgery (
P
<
0.001). Although most
surgery was provided free (
P
=
0.02), males, who were more
likely to have surgery (
P
=
0.02), were also more likely to
pay for it (
P
=
0.03) (Table 2).
As measured by presenting acuity, the vision outcomes of
both intracapsular surgery and intraocular lens surgery were
poor (Table 3). However, 62.6% of those people with at least
Table 1.
Vision impairment and blindness by eye and person; Koki and Rigo, Papua New Guinea (2005)
Category 2348 eyes/1174 people surveyed
Vision impairment Blindness
Eye (presenting
visual acuity less than 6/18)
Person (presenting visual
acuity less than 6/18 in the
better eye)
Eye (presenting visual
acuity less than 6/60)
Person (presenting visual
acuity less than 6/60 in the
better eye)
Total Cataract Total Cataract Total Cataract Total Cataract
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
50–59 years 266 27.9 49 14.6 84 22.8 23 13.4 74 18.0 37 14.3 17 14.2 10 11.1
60–69 years 298 31.3 93 27.8 121 32.9 50 29.1 119 29.0 67 26.0 31 25.8 18 20.0
70–79 years 252 26.5 119 35.5 106 28.8 57 33.1 133 32.4 94 36.4 42 35.0 34 37.8
80
+
years 136 14.3 74 22.1 57 15.5 42 24.4 85 20.6 60 23.3 30 25.0 28 31.1
Male 467 49.1 157 46.9 180 48.9 77 44.8 203 49.4 123 47.7 59 49.2 41 45.6
Female 485 50.9 178 53.1 188 51.1 95 55.2 208 50.6 135 52.3 61 50.8 49 54.4
All cases 952 100 335 35.2 368 100 172 46.7 411 100 258 62.8 120 100 90 75
Cataract and its surgery in Papua New Guinea 883
© 2006 Royal Australian and New Zealand College of Ophthalmologists
one eye operated on for cataract felt that their uncorrected
vision, using either or both eyes, was sufficiently good that
spectacles were not required (Table 3).
‘Lack of awareness of cataract and the possibility of surgery’
was the most common (50.1%) reason offered by 90
cataract-induced functionally blind individuals for not seeking
and undergoing cataract surgery. Males were more likely
to believe that they could not afford the surgery (P = 0.02),
and females were more frequently afraid of undergoing a
cataract extraction (P = 0.03) (Table 4).
DISCUSSION
The limitations of the standardized rapid assessment methodology
used for this study are discussed elsewhere.7 Caution
should be exercised when extrapolating this survey’s
Table 2. Circumstances of cataract surgery; Koki and Rigo, Papua New Guinea (2005)
Category 136 cataract surgeries
Male Female Aphakia
(n = 74)
Pseudophakia
(n = 60)
Couched
(n = 2)
Male, n (%) 83 (61.0) 45 (60.8) 38 (63.3) 0 (0.0)
Female, n (%) 53 (39.0) 29 (39.2) 22 (36.7) 2 (100)
Undergone surgery in the last 5 years, n (%) 19 (22.9) 20 (37.7) 10 (13.5) 29 (48.3) 0 (0.0)
Range of age at the time of surgery, years 39–84 40–87 39–87 45–85 52
Age at the time of surgery, years, mean ± SD 61.3 ± 9.7 60.5 ± 11.6 60.8 ± 10.6 63.4 ± 10.9 52 ± 0.0
Surgery in a government hospital, n (%) 72 (86.7) 44 (83.0) 63 (85.1) 53 (88.3) 0 (0.0)
Surgery in a private hospital, n (%) 10 (12.1) 7 (13.2) 10 (13.5) 7 (11.7) 0 (0.0)
Surgery in an eye camp, n (%) 1 (1.2) 0 (0.0) 1 (1.4) 0 (0.0) 0 (0.0)
Surgery by traditionalist, n (%) 0 (0.0) 2 (3.8) 0 (0.0) 0 (0.0) 2 (100)
Totally free surgery, n (%) 32 (38.6) 26 (49.1)
Paid full price asked for surgery, n (%) 25 (30.1) 14 (26.4)
Paid partial price asked for surgery, n (%) 26 (31.3) 13 (24.5)
Totally free surgery in a government hospital, n (%) 55 (47.4)
Full price surgery in a government hospital, n (%) 23 (19.8)
Partially paid surgery in a government hospital, n (%) 38 (32.8)
Table 3. Characterization of cataract surgery outcomes; Koki and Rigo, Papua New Guinea (2005)
(a) 136 cataract surgeries
(b) 97 people with at least one eye operated on for cataract
(c) 67 (69.1%) cataract operated people not currently using distance correction: 38 (56.7%) male; 29 (43.3%) female
Aphakia Pseudophakia Couched
n % n % n %
Total 74 54.4 60 44.1 2 1.5
Presenting vision 6/18 or better 27 36.5 24 40 0 0.0
Presenting vision worse than 6/60 40 54.1 11 18.3 2 100
Aphakia Pseudophakia‡ Couched
Unilateral† Bilateral n % n %
n % n %
Total 28 28.9 17 17.5 51 52.6 1 1.0
Presenting vision 6/18 or better in better eye 15 53.6 11 64.7 35 68.6 0 0.0
Presenting vision worse than 6/60 in better eye 13 46.4 3 17.6 9 17.6 1 100
Reason n %
Never provided 20 29.9
Damaged 2 3.0
Lost 3 4.5
Do not need 42 62.6
†Unilateral aphakes with an unoperated contralateral eye. ‡Bilateral pseudophakes (n = 9) + those with one eye aphakic and the other
pseudophakic (n = 12) + unilateral pseudophakes with an unoperated contralateral eye (n = 30).
884 Garap et al.
© 2006 Royal Australian and New Zealand College of Ophthalmologists
results to the entire population of PNG. However, this
study’s results are the most systematically collected and
objective currently available for eye care service planning.
Based on this survey sample, the age-gender-adjusted
prevalence of vision impairment from all causes for those
50 years and older in PNG is 29.2% (95% CI: 27.6, 35.1,
deff = 2.3), with 13.1% (95% CI: 11.3, 15.1, deff = 1.2) due
to uncorrected refractive error.7 Cataract (7.4% [95% CI:
6.4, 10.2, deff = 1.3]) is the second most frequent cause. The
adjusted prevalence for functional blindness from all causes
in people aged 50 years and older is 8.9% (95% CI: 8.4, 12.0,
deff = 1.2),7 with cataract the leading cause at 6.4% (95%
CI: 5.1, 7.3, deff = 1.1). This is typical of developing countries.
However, atypically, it would seem that cataract blindness
in PNG is not associated with female gender.9
Assuming that ‘negligible’6 cataract blindness (less than
5% at visual acuity less than 3/60,8 although it may be as
much as 10–15% at less than 6/6010) occurs in the under
50 years age group, then, based on a 2005 population estimate
of 5.545 million, PNG would be expected to currently
have 32 000 (25 000–36 000) cataract-blind people. An
additional 5000 people in the 50 years and older age group
will have cataract-reduced vision (6/60 and better, but less
than 6/18), along with an unknown number under the age of
50 years.
The age-gender-adjusted prevalence of those 50 years
and older in PNG having had cataract surgery is 8.3% (95%
CI: 6.6, 9.8, deff = 1.3). Prevalences for males and females,
respectively, are 10.2% (95% CI: 7.7, 12.7) and 6.4% (95%
CI: 4.5, 8.4), with the expected9 association with male gender
(age adjusted OR 1.6, 95% CI: 1.2, 2.1). Assuming negligible
cataract surgery is performed on those under age
50 years (noting mean age and age range of surgery in
Table 2), there would be about 41 400 people in PNG today
who have had this surgery. In the survey sample, 28.7% of
surgery occurred in the last 5 years (Table 2). Assuming that
there have been no deaths, annual surgical numbers have
been steady during this time, and a population mean of the
2000 and 2005 estimates, this would equate to about 2400
people per year, being a Cataract Surgical Rate (CSR) of
approximately 440 per million per year.
Unfortunately, no operation numbers are available from
the private Port Moresby facility, which contributed 12.5%
(Table 2) of the surgeries in this study. However, from
records and estimates, outreach, government and mission
hospital surgical services perform approximately 1600 cataract
surgeries per year. Excluding the private hospital, this
equates to a CSR of about 300 per million population per
year.
Whatever the exact CSR, certainly less than the WHO
estimate of 716,11 the order of magnitude is typical of a
country with PNG’s medical infrastructure, resourcing and
bureacratic capability.11 With the exception of the Christian
Blind Mission surgeon, who performs in excess of 1000 cases
per year, PNG’s ophthalmologists operate, on average, on
fewer than 100 cataracts each per year. This is also typical.6
It will be evident that the current surgical capability in
PNG is insufficient to address the cataract backlog. The
CSC(Persons) of 45.3%, relating directly to the prevalence
of bilateral cataract blindness, and CSC(Eyes) of 34.5%,
relating to the total surgical workload, are in keeping with
other developing countries.6,8,10 If an annual cataract blindness
incidence of 20% of prevalence12 is accepted, and surgery
is only performed on one eye of each person, then 6400
(5000–7200) surgeries need to be performed annually to meet
this. While just addressing the incidence, in time the backlog
will reduce to near zero. This would require a three- or
fourfold increase in CSR, to about 1200. Despite planning
for this and the best of intentions, given current circumstances
in PNG, this seems unlikely to occur in the near future.
Increasing the output of surgical services of itself will be
insufficient to reduce cataract-related blindness. As measured
by presenting acuity, the outcome of cataract surgery is poor
(Table 3). Neither the historical intracapsular or current
intraocular lens surgical techniques approach WHO outcome
guidelines of more than 80% with 6/18 and better
presenting vision, and less than 5% presenting functionally
blind.13 Better outcomes are required to ensure scarce
Table 4. Reasons that cataract-blind (worse than 6/60) people do not seek or undergo cataract surgery; Koki and Rigo, Papua New Guinea
(2005)
90 people functionally blind due to cataract
Responses by 41
males (45.6%)
Responses by 49
females (54.4%)
Responses by all
n % n % n %
Lack of awareness of cataract and the possibility of surgery 18 43.9 28 57.1 46 50.1
Too old to do anything about vision 7 17.1 6 12.2 13 14.4
Believes unable to afford surgery 10 24.4 7 14.3 17 18.9
No time available to attend surgery 4 9.8 6 12.2 10 11.1
Waiting for cataract to mature 4 9.8 5 10.2 9 10.0
None available to accompany person to surgery 4 9.8 2 4.1 6 6.7
Fear of the surgery 2 4.9 6 12.2 8 8.9
Believes no services available 2 4.9 2 4.1 4 4.4
Cataract and its surgery in Papua New Guinea 885
© 2006 Royal Australian and New Zealand College of Ophthalmologists
resources are well used.14 Routine monitoring of surgical
activity and outcome, perhaps more likely to occur if done
manually, may contribute to an improvement.15,16 So too
would better patient selection, as many currently choose not
to wear postoperation correction because they see well
enough with the fellow eye (Table 3). Improving access to
refraction and spectacles will also likely improve presenting
acuities (Table 3).
Of those cataract blind in the survey, 50.1% claimed to
be unaware of cataract and the possibility of surgery
(Table 4). However, even when arrangements, including
transportation, were made for study participants with visually
significant cataract to have surgery in Port Moresby, not
all availed themselves of this opportunity. The reasons for
this need further investigation.
Despite the apparent ignorance of cataract among the
population, there would seem little point in raising demand
and expectations through health promotion techniques until
such time as the capacity of services and outcomes of surgery
have been improved. Increasing the quantity and quality of
cataract surgery need to be priorities for PNG eye care
services. The independent Christian Blind Mission Goroka
and outreach services, using one surgeon and a wellresourced
support team, are examples of what is possible,
both in output and in outcome. However, the real challenge
is to be able to provide cataract surgery as an integrated part
of a functioning service offering equitable access to good eye
health and vision outcomes, from within a public health
system that needs major attention. To that end, registrar
training and referral hospital facilities and practice are being
improved.
It may be that the required cataract service improvements
are beyond PNG’s under-resourced and managed public
health system. The survey reported here provides a baseline
against which progress may be measured.
ACKNOWLEDGEMENTS
The authors thankfully acknowledge the technical support
provided by Renee du Toit and Jacqui Ramke (The International
Centre for Eyecare Education), Doe Kwarara (FHFPNG
Eye Care Program) and David Pahau (Eye Clinic, Port
Moresby General Hospital). Thanks also to the St Johns
Ambulance Services (Port Moresby) volunteers and staff for
their invaluable contribution to the fieldwork. This survey
was funded in part by a program grant from New Zealand
Agency for International Development (NZAID) to The
Fred Hollows Foundation (New Zealand).
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4. Dethlefs R. The trachoma status and blindness rates of selected
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