A little girl with a red ribbon in her hair walks hesitantly into the Low Vision Assessment Room at Kitwe Central Hospital’s new Paediatric Eye Care Centre. She’s a village child, visiting this bustling city in the heart of Zambia’s Copper Belt. She’s clearly rather overwhelmed by the crowd of doctors, nurses and journalists who are waiting for her and her eyes dart nervously around the room.
That little movement of the eyes is the miracle this group of people has been waiting to see. We had previously visited the Paediatric Eye Care Centre’s surgical theatre, where we first saw Catherine Kantumoua, a small anaesthetised figure lying very still on the operating table, with just her face and one childish hand visible, tubes threaded into her veins.
In August the centre’s outreach service, headed by Ariel Phiri, found her at a screening clinic in a small rural village near Solwezi in the North West. Kantumoua had cataracts in both her eyes (children can be born with congenital cataracts or they can acquire them through trauma to the eye). Her vision deteriorated to the point where she could not see movement or even distinguish between dark and light and she hadn’t been to school for three years.
Her parents were told to bring her to the centre and they were given a subsidy to pay for transport. After an arduous 250 kilometres journey by bus and truck, she arrived with her father, Pity.
On September 13 she was in theatre, where her eyes were operated on by Larry Benjamin, a distinguished ophthalmologist and microsurgery expert from the United Kingdom. Dr Chileshe Mboni observed and ophthalmological nurse Ann-Marie Ablett from Wales trained the theatre nurses.
Skills transfer
Mboni is Kitwe Central Hospital’s paediatric ophthalmologist and was delighted to get the chance to learn first-hand from his mentor, with whom he’s been communicating for three months through Cyber-Sight, a telemedicine programme.
Benjamin has volunteered for the non-profit organisation Orbis for the past 10 years, working in many of the 88 countries in which the organisation operates, including India, Bangladesh, China and Vietnam. Orbis developed the Cyber-Sight programme to give doctors in far-flung regions access to advice and information.
Orbis is dedicated to saving sight and focuses on training ophthalmology doctors and nurses. It sponsored Mboni’s paediatric fellowship in Tanzania. Volunteers — such as Benjamin and Ablett — don’t simply fly in to perform medical magic, but leave skills behind, which will help many more people in the future.
Orbis provides equipment, such as the vitrector the surgeons used to operate on Kantumoua’s eyes, and the anaesthetic machine. In the past nine months the organisation worked with Dr Asiwome Seneadza, the inspiring head of the ophthalmology department at Kitwe Central Hospital, to ensure that this paediatric unit had all it needed to perform sophisticated surgery safely. Kantumoua was the first child to be operated on after the official opening of the Paediatric Eye Care Centre.
Immediate results
When Kantumoua emerged from her long drugged sleep that followed surgery, she was disappointed that she couldn’t see. Her father had to explain that it was dark because she woke up at night and that she would have to wait until daybreak to experience her miracle.
At dawn it happened: a tsunami of stimuli flooded her eyes, which had not seen for so long. When surgeons remove cataracts, it takes time for the patient to adjust. The best results are not expected for at least a fortnight but, even so, by mid-morning, when she was tested, Kantumoua was able to read the first line on the eye chart and part of the second.
Her case is complicated. She will need another corrective operation in a few weeks and will have to use spectacles and vision devices. Yet after taking this first step on her journey to sight, she was able to walk around by herself in an unfamiliar building. The immediacy of the results is one of the most rewarding aspects of eye surgery, said Seneadza.
Further evidence of this was provided by the next child being tested, toddler Grace Bwalya, crying in the arms of her mother Queen.
When she arrived, Bwalya won everyone’s hearts with her beautiful, happy face, marred only by a severe squint in one eye. Soon after she arrived two doctors operated on three tiny muscles around that eye, and on Monday, although Grace had a scratchy sensation in her eye and she plainly felt miserable, her eyes looked at you straight on, and they moved together properly as she focused on everyone in the room.
Kitwe’s Paediatric Eye Care Centre has just scored a win in the fight against two top causes of childhood blindness and visual impairment.
Blindness kills children
Blindness is not just a disability, it can be a killer. Fifty percent to 60% of children who go blind die within the following two years; they are more prone to accidents and injuries. They also die from illnesses related to poverty, such as malnutrition. Vitamin A deficiency is a leading cause of child blindness globally.
Sub-Saharan Africa has the world’s highest prevalence of blind children, which is why Orbis has focused on paediatric eye care on the continent. The region contains less than 10% of the world’s people, but it’s home to 23% of the world’s 39-million blind people (compare that with India at 19% and China at 13%). About 80% of adult blindness is avoidable and treatable, as opposed to only 50% of child blindness.
Why the huge difference? Benjamin said there’s a small window of opportunity, a time period in which the brains of babies and toddlers develop the ability to see, laying down appropriate pathways in the brain. The “wiring” from the retina to the occipital cortex develops in the first six weeks after birth. “By the age of six or seven, the vision sets for life,” he said. This means that if problems such as congenital cataracts are not detected and corrected early on, the child will remain blind, even if the physical obstacles to vision are removed.
Other conditions that commonly cause visual problems in children include strabismus (squints) and amblyopia (lazy eye): the child may fail to develop binocular vision (the ability to focus and see using both eyes to create the field of vision). If lazy eye is left untreated, it may result in blindness should the person lose the functioning eye as an adult.
Southern African children are also prone to conjunctivitis – inflammation of the outer layer of the eye and the inside of the eyelid caused by a viral or bacterial infection, an allergy or even exposure to a chemical. It is quickly cleared up with appropriate medication, but if not treated it can cause corneal ulcers or another condition called keratoconjunctivitis, both of which can result in blindness if left untreated.
Children may also have glaucoma, which leads to severely impaired vision and blindness. Uncorrected refractive errors, for example short-sightedness, are a major cause of visual impairment in children, which is why the Kitwe Paediatric Eye Care Centre provides free glasses for poor children.
Benjamin said parents, especially mothers, are usually aware of “something wrong” with their child’s eyes. What they may not realise is how urgent it is to treat the problem as soon as possible.
“Be aware of behaviour like sitting very close to the television, or holding things like toys and books very close,” he said.
New paediatric facility
One reason for the high incidence of blindness on the continent is the paucity of ophthalmologists. In sub-Saharan Africa there is about one ophthalmologist per one million people, mostly in urban areas.
The World Health Organisation recommends one paediatric ophthalmic centre, such as Kitwe, for every 10-million people. With a total population in excess of 800-million, sub-Saharan Africa has just 26 child eye health centres — and those are found in only 12 of 48 countries.
Even South Africa, with all its advanced medical care, has only two dedicated children’s facilities. Orbis has committed to opening 10 units like the one in Kitwe in the next 10 years. While each will be adapted to meet specific community conditions, they will offer a combination of sophisticated treatment options and outreach deep into the rural areas, training eye-care ambassadors in local communities to identify potential problems and to refer them to the tertiary facility.
On World Vision Day — October 13 — a paediatric centre, based at Inkosi Albert Luthuli Central Hospital in KwaZulu-Natal, will open. This will provide a much-needed service in an area characterised by far-flung rural villages and will boost South Africa’s ability to treat and prevent childhood blindness significantly.