Socio-Demographic Characteristics and Presenting Visual Acuity of Beneficiaries of a Free Cataract Surgical Intervention in Ekiti State, South-Western Nigeria

Cataract is the leading cause of blindness worldwide accounting for approximately 47.8% of all blindness [1] more than 90% of cataract blinded patients’ lives in low and middle-income countries [2]. In Nigeria its accounts for 43.0% of blindness with the prevalence of blindness in South Western Nigeria where Ekiti state is located to be 2.8% with cataract constituting about 45.3% of the causes [3]. 

Blindness from cataract can be reversed by simple extraction and replacement with an intraocular lens but unfortunately many people are needlessly blind from it because they fail to utilize routine surgical services available for it. Many studies have shown that finance is the major reason for not utilizing such services [4-8]. 

Consequently many low and middle income countries do conduct free eye screening and surgery for their citizens to lessen the burden of blindness in order to achieve vision 2020: the right to Sight [9], these free to patient surgical interventions are usually sponsored by either Government or some Non-Governmental Organizations (NGO) and at times by some philanthropists. 

Anecdotal experience by the Authors have shown that the screening stage to select beneficiaries for such free surgical intervention are usually jam packed and overwhelming for both participants and the Health workers, as such many needy patients may not be selected while some selected ones would be  those who could afford to pay for routine cataract surgery. It will therefore be worthwhile to look into the Socio-demographic characteristics and the level of Blindness of beneficiaries of such programmes in order to develop a protocol that will help to prioritize the needy ones   especially when the sponsorship is for a target number.

To analyse the socio-demographic characteristics and presenting visual acuities of beneficiaries of a well attended  free to patient cataract surgical intervention in Ekiti State and use it  to justify the need for such intervention and develop a protocol that will ensure that the most needy patients are given priority.

This is a retrospective study of cataract patients that benefited from a well attended free surgical intervention sponsored by a Non-Governmental Organization (Mobile Telecommunication Nigeria Limited -MTN) in Ekiti State in July 2017. Prior to the time of surgery, a screening exercise was conducted at the Local Government headquarters by primary eye care workers including optometrists to select all cases of operable cataracts which were then given specific dates for their surgery which was scheduled to take place at the Ekiti State Teaching hospital, Ado- Ekiti the capital city of the State for logistic reasons. 

Records of their Bio-data, Socio-demographic characteristics, presenting visual acuity of the operated eye were extracted from available records.   

The data obtained were coded and input for analysis using the Statistical Package for Social Sciences (SPSS) version 21. Patients with incomplete data were excluded from the analysis. The socio-demographic characteristics, presenting visual acuities of the operated eye were presented in form of text, frequency tables and percentages. The test for significance of some of the categorical variables were also carried out and a p value of <0.05 was considered significant.   

Approval for the study was obtained from the Research and Ethical Committee of Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti.

A total of 243 patients with complete data were analysed for the study. They comprised of 131males (53.9%) and 112 females (46.1% ), M: F ratio 1.2:1 Their Age range was 11-97 years with a mean of 65.3 years ± SD 15.0 Most of the patients were within the age group of 70-79yrs (Table 1). They were predominantly Christians, 229(94.2%) as against 14(5.8%) that were Muslims, almost all the patients were married or widowed (97.5%) as against 2.5% that were single. 

Table 1: Socio-demographic characteristics of patients. 

Many of the patients 74(30.5%) were traders, while others were farmers, artisans, drivers and retirees (Table 2). Of the 243 patients, 128(52.7%) had surgery to their right eye while 115(47.3%) had surgery to left eye. The presenting visual acuity of the operated eye ranged  from light perception to count finger in 81.5%  while the remaining 18.5% had visual acuity ranging from 6/24 to 3/60 (Table 3). Of the 243 patients 115(47.3%) were bilaterally blind while 128(52.7%) had uniocular blindness. 

Table 2: Occupation of the patients. 

Table 3: Presenting visual acuity of the operated eye. 

The greatest majority of the patients (43.6%) were based in Ado - Ekiti Local Government where the surgeries were done while others were scattered over the other local Government Areas in the state with 3 of them not having any beneficiary (Table 4).   

There was no statistical significance between being a beneficiary and their gender P-value =0.605 but the presenting visual acuity was a significant factor P-value = 0.000. 

Table 4: Local Govt. area of patients.

Routine cataract surgery is usually a costly procedure, as such any free to patient cataract surgical intervention is usually patronized by a good number of patients. Anecdotal experience by the Authors have shown that there are usually no guideline in the selection process of the would be beneficiaries of such intervention with some very needy patients not benefitting because of restricted number. 

In this study, there were slightly more males than females m:f = 1:2:1,this is in consonance with some other studies [10-13] that showed slight male preponderance but different from  some other studies that showed slight female preponderance [4,14,15]. 

In Economic terms, men are usually more financially empowered than their female counterparts and cost is one of the major barriers in the uptake of cataract surgery as documented in some studies [4,10,16-18].  For instance Courtright & Lawan [17] reported that women attend programmes that are usually supported. 

The slight increase of males over females in this study may be due to the mode of advocacy by the sponsors of the programme which was mainly through text messages to all their mobile telecommunication subscribers in addition to Television and Radio adverts, usually males are more likely to pay attention to their telephone messages than females that are usually engulfed with domestic duties. 

Their age range was 11-97 years with a mean of 65.3yrs SD + 15.0, majority of them (50.6%) were 70 years and above. This is in consonance with the age group that are usually affected by senile cataracts as documented by some other studies [12,13,19,20]. 

In this study, majority which constitutes 43.6% of the beneficiaries where based in Ado-Ekiti where the surgeries were carried out. This was followed by 13.2% from Ikere-Ekiti which is just 16 kilometres from Ado-Ekiti. 

Of the remaining 14 Local Government areas in the state, three did not have any beneficiary while four had less than 1% and the rest had less than 12% (Table 4). 

These are places that are beyond 150kilometer from the venue of the surgery, this shows that cost is not the only barrier in accessing Eye Care intervention more so that this is a free programme, It shows that distance is also a significant barrier as documented by some other studies both in Nigeria and elsewhere [4,10,17,21,22]. 

As regards the occupation of the beneficiaries in this study, majority were traders (30.5%) followed by retirees (22.2%) and then farmers (14.8%) (Table 2). These are group of people of low economic power because the so called traders in this study were petty traders and not in the business class category while the farmers were cash crop farmers; the retirees in the environment do not have any health and other welfare scheme benefits while their pensions are usually meagre; being barely sufficient for their daily living. 

As such one will expect them to constitute the majority of people that will patronize this kind of free intervention rather than routine surgery which will be at a cost; more so that cost is a notable barrier to uptake of routine cataract surgery by a good number of studies [4-8]. 

Almost all the beneficiaries in the study were Christians (94.2 %) as against (5.8%) who were Muslims; this is because most citizens in the state are predominantly Christians as there were no Muslim festivities during the time of the surgery that could have debarred them from attending. 

Virtually all the beneficiaries were married or widowed (97.5%), this is because most cataracts are senile and will be seen in adults usually above 65yers of age. 

Aside the congenital and developmental cataracts as well as the secondary types are usually not selected for such mass surgery because of need for General Anaesthesia and other technicalities. 

The Presenting Visual Acuity (PVA) of the operated eye ranged from counting finger to light perception in the greater proportion of the beneficiaries (81.5%) while the remaining (18.5%) had their PVA ranging from 3/60 to 6/24. 

This poor PVA of <3/60 is not unusual for most patients presenting with operable cataract in the environment, for instance Abdulsalam [23] reported poor PVA of <3/60 among 72% of patients in his study while Adio [24] and Nwosu [25] reported 93% and 88% respectively. 

This is unlike the PVA in high income countries whereby patients that present with poor PVA of <3/60 are quite low. In a multicenter study reported by Norregaard et al. [26] US & Denmark had 5%, Canada had 9% and Spain had 23%. This can be attributed to two main reasons; the method of cataract extraction in high income countries has revolutionized in the past two decades such that phacoemulsification and femtosecond laser surgery has become the gold standard of cataract surgery;  this method enables them to operate safely on soft immature cataracts that are not visually disabling unlike in low income countries where the method is at best manual small incision type of cataract surgery which makes it technically difficult to operate on soft immature cataracts that are not visually disabling. 

Asides some patients in the environment will not readily accept surgery to their seeing eyes until they are visually disabled due to fear of surgery and ignorance [4,10,27,28]. 

In this study 47.3% of the beneficiaries were bilaterally blind with their best corrected visual acuity to be less than 3/60 while the remaining 52.7% had uniocular blindness with best corrected visual acuity in their better eye being greater than 3/60 

This incidence of bilateral blindness is quite high when compared with the 9.5% reported by Mushbau¹⁹ and the 24.3% reported by Abdu [29] working in the same similar environment. 

This may be due to the fact that these other studies were hospital based and patients do their surgery at a cost unlike this free to patient surgical intervention that affords opportunity to all needy patients regardless of whether it is  uniocular or bilateral. 

The slightly higher proportion of uniocular cataract patients over bilatetral ones in this study may be due to the fact that most uniocular blinded patients will rather wait for free of cost surgery since they are not visually disabled, Also some cases of bilateral blindness may not get an aid to bring them for the programme while the uniocular blinded ones do not need such an aid.

This study showed that majority of beneficiaries were those residing within the environs of the surgical venue. 

Other important characteristics of the beneficiaries were their gender, age and occupation. There is need for organizers of such free interventions to conduct both the selection process simultaneously with the surgery in at least 3 locations in conformity with the 3 senatorial districts of the state vis a vis North, South and Central in order to make it accessible to all and sundry and also to prioritize the poorest in such communities especially elderly females.

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