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     Volume 5 Issue 110 | September 1, 2006|

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View from the Bottom

From Darkness to Light Working to Beat Childhood Blindness

Muhammad Rajib Hossain

Photo: Sayed Zakir Hossain

Sometimes it's hard to be thankful for what should be taken for granted. Life's simple pleasures, like a magnificent sunset, or watching a child's eyes light up with delight, are just a few wonders that sighted people take for granted all the time. But for four-year-old Maya living in the outskirts of Chittagong and blind since birth, such basic joys of life are non-existent. Her parents thought it was her fate and left it at that. They would not let her go out much and she was left out of most social activities living in a dark, isolated world. She lives in a village in the outskirts of the city of Chittagong. A local doctor saw the girl and made a decision that changed her life. The doctor took her into Chittagong Eye Infirmary and Training Complex. When they came to Chittagong Eye Infirmary, she was diagnosed with congenital cataract (present from birth). The doctors said that it might be too late. But Maya proved to be one of those lucky ones who, after surgery, was able to see the world for the very first time in her life.Like Maya, there are many children who go blind from avoidable causes. Many people don't know that in most of cases it is preventable or curable. They unnecessarily delay in bringing the children to eye specialists or eye hospitals.

Every minute a child goes blind. One and half million children in the world suffer from blindness and every year hundreds or thousands of children are born blind or become blind in the course of their early childhood. In developing countries like Bangladesh, blindness carries a big stigma. It deprives them of being an active member of the community; it often excludes them from education, and condemns them to a life of suffering and even early death. Without any interventions, children who are blind face a high risk of death. Over half of children who go blind die within one or two years.

Photo: Sayed Zakir Hossain

A national study by International Centre for Eye Health, U.K and Child Sight Foundation in children revealed that around 40,000 people are blind in Bangladesh. Two thirds of blind children have lost their sight because of conditions that could either have been prevented or they have conditions where surgery could restore sight. Other studies suggest that there are almost 10,000 children with some degree of visual impairment in every million population, and most of them just need glasses to be able to see clearly again.

The facilities for child eye care in Bangladesh are inadequate. We are far behind to provide proper eye care due to extreme scarcity of doctors specialising in child eye care (paediatric ophthalmologists). There are only 7 paediatric ophthalmologists working in Bangladesh. Most of them live in the capital city and the rural people have no access to simple eye care services even for refraction correction. Training in quality eye surgery or eye care has become an urgent need. A number of NGO's are trying to educate people about avoidable blindness. But they face many barriers from society and from the families of blind children. "A child with blindness often stays at home as parents are unaware that the child is in a treatable condition. They don't allow the blind child to play with other children or participate in social affairs. During conducting the National study among 64 districts we faced the difficulty to find out blind children", says Dr Muhammad Muhit, Clinical Research Fellow of International Centre of Eye Health (ICEH). After finding a blind baby who needs surgery in both eyes, parents are reluctant to let their babies go through surgery thinking that the risks are too high. Without appropriate counselling, many parents do not accept referral for surgery even when surgery is offered free of cost, he adds.

Increase in awareness may not be enough as old beliefs and attitudes persist informs Farida Akhter, Project Manager of Child Sight Foundation (CSF). "We should disseminate the information among key informants of the society like school teachers, imams, chairmen, local leader and make them able to identify the blind children" she says. "They can act as Change agents by changing community attitude and beliefs about childhood blindness. CSF adopted this strategy and currently it has been running 3 major projects for blind and visually impaired children."

Photo: Zobaer Hossain Sikder

"ORBIS has undertaken long-term projects to provide quality child eye care" says Anindita Roy, Program Officer of ORBIS international, Bangladesh Country Office. "We will continue our ongoing programme and expand the programme with government district hospitals".

The Eye Infirmary and Training Complex in Chittagong with the support of ORBIS established the Paediatric ophthalmology service, the first of its kind in our country in 2002. They have sophisticated eye ward for children and provides special eye care service for children in their outdoor care. Bangladesh Eye Hospital, Islamia Eye Hospital, Khulna BNSB Eye Hospital, National Institute of Ophthalmology, Dinajpur BNSB Eye Hospital, Moulvibazar BNSB Eye Hospital, Serajgonj BNSB Eye Hospital, ORBIS flying eye hospital also provide special paediatric eye care at present. Besides other organisations named Sight Savers International, Assistance for Blind Children (ABC), Helen Keller International, World Vision and Bangladesh Blind Mission (BBM) have been working to eliminate blindness in children.

Photo: Zobaer Hossain Sikder

We can do a lot to reduce blindness in children from these preventable and treatable causes. There are specific preventive measures that can be undertaken by health care workers as well as by parents themselves. The following key activities are critically important for controlling blindness in children:

The best way to prevent blindness is to try to keep children well fed, clean, and healthy. We should clean the babies' eyelids at birth properly. When they get infected or have pus, clean them often with a clean wet cloth with clean water, and immediately consult with a physician.

If a woman becomes short of vitamin A during pregnancy her breast milk will be low in vitamin A. Some women who are low in vitamin A complain of difficulty seeing at night ("night blindness"). However, this is not always the case, and all women who live in communities where vitamin A deficiency in children is common should be assumed to be deficient in vitamin A. It is required to give high dose vitamin A supplements to mothers within one month of delivering a baby.

Breast milk is a good source of vitamin A for babies, which is needed for growth, and so that the baby can fight infection. So breast feeding is necessary for the baby, and should continue until the baby is at least 18 months old.

Measles is a highly contagious infection, and it can be very serious causing blindness or death in children.

Immunisation is mandatory in this case. It is important that all children aged 6-9 months are immunised, not only to protect individual children, but also to prevent epidemics.

Vitamin A deficiency can lead to greater rate and severity of infection, blindness, and an increased risk of death. All children aged 6 months to 6 years should be given 200,000 IU of vitamin A every 6 months. This can safely be given at the time of immunisation.

Vitamin A deficiency can sometimes be diagnosed in children as they have difficulty seeing at night, or when their mother notices they are reluctant to move about in the evening (night blindness). Sometimes white spots develop in the eyes, near the brown part of the eye (Bitots spots). It is urgent to treat children who are immediate risk of blindness (i.e. those with clinical signs of vitamin A deficiency, measles infection, severe diarrhoea, or malnutrition) with 3 doses of vitamin A.

Any parent or concerned person who notices a white spot in their child's eye(s), or who thinks the child cannot see properly, should be taken to the nearest eye hospital or eye specialist. A delay in the correct diagnosis and the treatment could mean that the vision is less likely to recover after surgery. The commonest cause of poor vision in older children is a refractive error. The child's eyes will appear completely normal on examination.

CATARACT (the condition where the lens of the eye gradually becomes hard and opaque) is the commonest cause of child blindness in Bangladesh that is 31 percent. One in every three blind children have cataracts It may seem surprising but cataract can affect babies and children although most of us think it as a disease of the elderly. Around 12,000 children are needlessly blind from cataract and can be treated. A child may be born with cataracts (congenital cataract) or he or she may develop cataracts during the first few years. Cataracts can run in families, and more than one child in the same family can be affected. Treatment of cataract in children is a matter of urgency as early surgery increases the likelihood of better vision. The cataract does not need to mature. If treatment is delayed there is a risk of amblyopia (partial blindness, leading to blindness, for which no cause seems to exist) and irreversible visual impairment or blindness. All children with blindness should be referred to an eye doctor for detailed eye examination, diagnosis and treatment as soon as they are detected.
In Bangladesh the major preventable cause of blindness in children is vitamin A deficiency that leads to scarring and opacity of the cornea (transparent part of the front of eyeball). Vitamin A deficiency principally affects children under 6 years. Most of Vitamin A deficiency is the result of an inadequate diet, improper breast-feeding, severe diarrahoea, and measles infection. Children may also go blind due to other reasons such as trachoma , amblyopia and glaucoma.

Injuries are also an important causes of visual loss in children. Injuries from sharp objects, such as thorns or needles, can cause a lot of damage inside the eye, sometimes with little pain. Blunt injuries can lead to damage or bleeding inside the eye. A chemical injury, especially from alkalis, can cause very serious damage to the outer surface of the eyes, and often leads to blindness. All children who give a history of injury from blunt or sharp objects, or from chemicals, should be referred straight away to an eye doctor. Thus we should keep sharp and pointed objects, bullets, explosives, acids, and lye away from children. The children should be taught about their dangers and be warned about the danger of throwing closed bottles, cans or pointed instruments.

Some traditional medicines or remedies cause serious damage or infection. Use of traditional medicines, even those that are not harmful for themselves, can lead to a delay in the child receiving proper treatment. Some eye drops can cause damage to the eye (e.g. steroid drops). Out of date eye drops can also cause problems. Parents should be concerned about the date of medicine and not use traditional remedies or medicines, nor use eye drops or ointment prescribed by someone other than a clinician.

Vision 2020
The right to sight is now a world health agenda. WHO in collaboration with International Agency for the Prevention of Blindness (IAPB) launched blindness campaign styled Vision 2020 for the elimination of avoidable blindness by the year 2020. It has adopted strategies for disease control with a focus on five major eye diseases: Cataract, Refractive errors and low vision (treatable), Trachoma, Onchocerciasis and vitamin A deficiency (preventable). The World Bank states that the treatments available for prevention and cure for blindness are amongst the cheapest and most cost effective of all health care interventions, especially when measured against the cost in lost productivity and lifelong that is associated with the loss of sight.

Sight is the sense that people fear losing the most. The vast majority of blindness in children occurs before the age of five, a time when 75 percent of learning is through sight. It is not surprising that children who are born blind, or who become blind in infancy, suffer from delayed development. Diseases that don't exist anymore or are hardly ever heard of in devloped countries like the UK are causing children to lose their sight needlessly in our country. It's rare, for instance, to hear of cataracts in children in the UK, and trachoma is a disease associated with Victorian times. Yet these and other diseases are having a dramatic impact on the lives of children in our country despite the availability of cost effective and simple treatments. Finally, all citizens of Bangladesh should come forward and pro-actively participate in any form of child blindness programme, be it awareness raising or identifying a case of a blind child in their home or locality. Only with such a concerted effort will we be able to overcome this threat to our nation's future.


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