EyeWorld India September 2016 Issue

53 EWAP CATARACT/IOL September 2016 by Liz Hillman EyeWorld Staff Writer Gender inequality in some pediatric cataract surgery cases Study suggests gender is a factor that could lead to fewer bilateral cataract surgeries for girls in some regions around the world, but expert says this disparity on the whole has gotten better T he fact that gender inequity can exist for patients seeking eyecare is well documented in peer-reviewed literature, but most papers focus on adults. According to a systematic review recently published in Ophthalmology , gender differences had not previously been reported for surgery among children with bilateral cataract. 1 Clare Gilbert, MD , professor of international eye health, London School of Hygiene & Tropical Medicine, said she is interested in equal eyecare opportunities for both adults and children, but children especially “as they do not have a voice.” The study by Gilbert et al. comprised 38 published papers that included 6,854 children who had undergone surgery in one or both eyes for bilateral cataract in developed and developing countries from the year 2000 onward. “In some regions of the world, the proportion of girls accessing surgery for bilateral cataract is lower than anticipated,” the study authors found. Higher income countries as well as some lower income settings saw relatively equal proportions of boys and girls receiving bilateral cataract surgery. Other regions, such as sub-Saharan Africa, East Asia, South Asia, and the Pacific including China, however, appeared to show more bilateral cataract surgeries for boys than girls. Dr. Gilbert said she expected lower proportions of females receiving the surgery in low income regions and in cultures that traditionally favor boys, but she did not expect to see such a gender difference in Asia. The literature on cataract surgeries in India and Nepal, for example, found that 29.1% of cases were girls, while in China 36% were girls. “It was good to see that differences were not significant in studies from Africa and the Eastern Mediterranean region, but I did not expected the difference in Asian countries to be as great,” Dr. Gilbert said. One of the contributing factors for the gender disparity in these countries, the study authors wrote, could be lower female birth rates, genetic factors, and girls possibly having a higher mortality rate. The most likely explanation though, according to the study authors, is that in some regions “families have different health- seeking behavior for their sons than for their daughters.” After looking at this paper, Kalpana Narendran, MD , chief of pediatric ophthalmology, Aravind Eye Hospital, Coimbatore, India, said she reviewed data within her own pediatric department. While the numbers showed surgeons at this location performed more cataract surgery on boys than girls, Dr. Narendran doesn’t necessarily think gender preference was a factor. Dr. Narendran’s larger review of data from four Aravind Eye Hospital locations revealed that males in the 0- to 15-year-old age group received about 63% of cataract surgeries from 2003 through April 2016. Females in this age group and time frame composed about 37% of the cataract surgeries. “I can’t very strongly say that it is the gender inequality,” Dr. Narendran said, noting previous research about pediatric cataracts in Western India published in 2004 in the Indian Journal of Medical Sciences that found males were twice as likely to have cataracts compared to females. 2 This, Dr. Narendran said, suggests that boys could be more likely to have cataract surgery than girls because they’re more likely to get cataracts in general. Dr. Narendran said gender might factor into access to cataract surgery in some more rural areas, but from her experience, this is not happening very much overall. “It’s not that way now,” she said. Gilbert et al. wrote in areas where there was a significant gender disparity, “the overall explanation […] is likely to reflect a complex interplay of social, economic, and attitudinal factors, with poverty, low levels of maternal education, and cultural norms being key factors.” As for addressing gender inequality for children with bilateral cataract, Dr. Gilbert said there needs to be an emphasis on changing attitudes and increasing knowledge through health education. Dr. Narendran agreed, saying “when the education level goes up, when your literacy rate goes up, this problem gets solved.” Dr. Gilbert said that providers could do their part by making sure there is enough infrastructure to provide cataract surgery to children and waive the costs for such services. “I hope this paper will reach some of the key decision makers so they can consider reducing or waiving their costs,” she said. If these disparities are not addressed, Dr. Gilbert said it could have life-long consequences for children living without the surgery, which can lead to blindness. “Delayed cataract surgery can lead to amblyopia, which cannot be reversed if surgery is delayed,” Dr. Gilbert said. “If girls do not access surgery at all, they obviously remain blind; if they access surgery late, this compromises their visual outcome. “We know that good vision early in life is vitally important for children’s development—motor, social, emotional, and cognitive— and if girls do not receive high quality surgery at the same rate as boys and at the most opportune time, this will have an impact on the whole of the rest of their lives,” she said. Further research, according to the study authors, could include gaining a better understanding of the general attitudes toward debilitating vision loss in children. The study authors also encouraged future studies of surgery for bilateral cataract in children to be disaggregated by gender to provide more data on equity in access. EWAP References 1. Gilbert CE, et al. Gender inequalities in surgery for bilateral cataract among children in low-income countries: a systematic review. Ophthalmology . 2016;123:1245–51. 2. Johar SR, et al. Epidemiology based etiological study of pediatric cataracts in western India. Indian J Med Sci. 2004;58:115–121. Contact information Gilbert: Clare.Gilbert@lshtm.ac.uk Narendran: kalpana@cbe.aravind.org