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Table of Contents
Year : 2020  |  Volume : 2  |  Issue : 1  |  Page : 34

Pediatric ocular disease in an ophthalmic surgical mission trip to belize: A 7-year review

1 Department of Ophthalmology, Johns Hopkins University, Wilmer Eye Institute, Baltimore, Maryland, USA
2 Department of Ophthalmology and Pediatrics, Medical University of South Carolina, Storm Eye Institute, Charleston, South Carolina, USA

Date of Submission20-Jul-2020
Date of Acceptance24-Sep-2020
Date of Web Publication10-Dec-2020

Correspondence Address:
Dr. Courtney L Kraus
625 N Wolfe Street, Baltimore, MD 21287
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/PAJO.PAJO_36_20

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Purpose: The purpose is to identify the various causes of ocular disease and surgical interventions undertaken in children (0–18 years of age) seen during an annual ophthalmic surgical trip to Belize.
Methods: A retrospective, cross-sectional review of records from seven annual surgical trips conducted by the World Pediatric Project providing pediatric ophthalmologic clinical and surgical care to Belize from 2013 to 2019 was performed.
Results: The charts of 313 patients who received care during the surgical mission trips were examined. From these 313 patients, there were 545 independent clinical encounters, yielding 405 diagnoses. Patients aged 6–10 years were most commonly seen (32.1%) followed by those 2–5 years old (28.1%). The most common pathophysiology seen was strabismus/ocular motility disorder (151 diagnoses; 37.4%), followed by refractive issues (69 diagnoses; 17.1%), eyelids and/or lacrimal system disorders (53 diagnoses; 13.1%), disorders of the retina/vitreous (30 diagnoses; 7.4%), lens abnormalities/cataract (28 diagnoses; 6.9%), amblyopia (23 diagnoses; 5.7%), disorders of the cornea/conjunctiva (23 diagnoses; 5.7%), trauma (13 cases; 3.2%), conditions affecting the globe/orbit (7 diagnoses; 1.7%), other (6 diagnoses; 1.5%), and glaucoma (1 diagnoses, 0.2%).
Conclusion: This study identified the most frequently diagnosed ocular conditions encountered during annual surgical mission trips to Belize. The most prevalent pathophysiology encountered was strabismus/ocular motility disorders, followed by refractive issues. The most common refractive issues encountered were myopia and astigmatism. This is the first study detailing pediatric ocular disease in Belize.

Keywords: Belize, Latin America, ophthalmology, pediatrics, strabismus, surgery

How to cite this article:
Xue GF, W. Peterseim MM, Kraus CL. Pediatric ocular disease in an ophthalmic surgical mission trip to belize: A 7-year review. Pan Am J Ophthalmol 2020;2:34

How to cite this URL:
Xue GF, W. Peterseim MM, Kraus CL. Pediatric ocular disease in an ophthalmic surgical mission trip to belize: A 7-year review. Pan Am J Ophthalmol [serial online] 2020 [cited 2021 Dec 5];2:34. Available from: https://www.thepajo.org/text.asp?2020/2/1/34/303000

  Introduction Top

World Pediatric Project (WPP) (Richmond, VA, USA), a 501©(3) tax-exempt nonprofit organization, in partnership with the Belize Council for the Visually Impaired (BCVI) provides annual surgical and clinical care for pediatric eye disease in Belize. Annual trips included surgical outreach and patient care. In this study, we report the incidence and causes of ocular diseases seen during annual ophthalmic surgical mission trips to Belize with the goal of identifying the distribution of ocular disease to inform public health interventions to decrease the rates of visual impairment, ocular morbidity, and blindness for children in Belize.

  Methods Top

This study was adherent to the guidelines of the Declaration of Helsinki. The institutional review board (IRB) at Johns Hopkins classified the study as IRB exempt. A retrospective, cross-sectional review of records was performed. Seven 1-week surgical trips providing pediatric ophthalmologic clinical and surgical care to Belize were conducted by WPP from 2013 to 2019. Mission work was conducted at a local eye clinic with an associated ambulatory surgical center in Belize City (BCVI Eye Clinic). The majority of patients presented in a walk-in fashion resulting from radio, television, and internet advertisements. Local providers also referred patients with surgical needs to the mission surgeons. A smaller subset represented internal referrals from other subspecialty missions conducted by WPP physicians and surgeons. Patients were examined and triaged by mission practitioners, which included teams of fellowship-trained pediatric ophthalmologists and orthoptists, for operative or nonoperative management. Clinic appointments included complete eye examinations, including visual acuity (VA) testing, strabismus examinations, dilated fundus examinations, cycloplegic refractions, and when possible, Goldmann tonometry. Glasses prescriptions were dispensed as indicated to be filled by BCVI. Appropriate patients underwent surgery.

Data were collected and maintained in accordance with the WPP policy in a de-identified fashion. Children aged 0–18 years were included in the analysis. The data included medical health records from clinic visits, as well as operative records. Limited demographical information (age, gender, and year of visit) was available, as well as results from ophthalmological examinations, intra-/postoperative diagnoses, and treatment recommendations. For some patients, multiple diagnoses were recorded. Postoperative complications of surgical procedures were excluded from the data set.

Statistical analysis was performed using Microsoft Excel. 95% confidence intervals were calculated to determine the likely percentages of different pathology seen in the data set.

  Results Top

There were 313 patients who received care over 7 years of consecutive, annual mission trips. Of these patients, 168 were male (51.8%) and 156 were female (48.1%). Mean (standard deviation) age was 6 years (4.77). One hundred and four patients (32.1%) were 6–10 years; 91 (28.1%) were 2–5; 58 patients (17.1%) were 0–1 years old; 43 patients (13.3%) were 11–14; and 17 patients (5.25%) were 15–18 years old. There were 545 independent clinical encounters, 395 (72.5%) were consultations with medical management, and 150 (27.5%) received surgical treatment. Of the 313 patients, 115 were seen at least twice during subsequent mission trips.

The majority of cases had an unknown referral source (271 patients; 83.6%), followed by patients known to or referred through the WPP program (22 patients; 6.7%). Other sources included referral from a Belizean national source (Belizean physicians, community advocates) (12 patients; 3.7%), patients referred through the consortium team (11 patients; 3.4%), patients referred directly from BCVI (7 patients; 2.2%), and patients referred by a family friend (1 patient; 0.3%).

A total of 405 diagnoses were extrapolated from the data, which were then classified into 11 groups according to the anatomical location of the disease process and pathophysiology. The most common pathophysiology seen was strabismus/ocular motility disorder (151 diagnoses; 37.4%), followed by refractive issues (69 diagnoses; 17.1%), eyelids and/or lacrimal system disorders (53 diagnoses; 13.1%), disorders of the retina/vitreous (30 diagnoses; 7.4%), lens abnormalities/cataract (28 diagnoses; 6.9%), amblyopia (23 diagnoses; 5.7%), disorders of the cornea/conjunctiva (23 diagnoses; 5.7%), trauma (13 cases; 3.2%), conditions affecting the globe/orbit (7 diagnoses; 1.7%), other (6 diagnoses; 1.5%), glaucoma (1 diagnoses, 0.2%).This distribution of diagnoses is demonstrated in [Table 1].
Table 1: Absolute number and percentage of different pathologies seen during the world pediatric project ophthalmic surgical mission trip from 2013 to 2019

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Of the 151 cases of strabismus, 75 (49.6% of all cases) underwent surgical repair through the mission.

Forty-five patients with esotropia underwent surgical realignment (66.2% of esotropes). Thirty-six (80.0%) of these underwent bilateral medial rectus recessions, 3 (6.7%) unilateral medial rectus recession with lateral rectus resection, 3 (6.7%) unilateral medial rectus recession, 2 cases (4.4%) of bilateral medial rectus recession with a unilateral lateral plication, and 1 case (2.2%) of bilateral medial rectus recessions combined with inferior myectomy. Of the 45 patients undergoing surgery for esotropia, 12 required reoperations (18.4% of cases). Of these 12 reoperations, 6 required repeat surgery for overcorrection of the esotropia and 6 required repeat surgery for under correction of the esotropia.

Twenty-four patients with exotropia underwent surgery (66.7%% of exotropes). Twenty patients (83.3%) had bilateral lateral rectus recessions, 2 (8.3%) unilateral lateral rectus recession and medial rectus resection, and 2 (8.3%) unilateral lateral rectus recession. Of these 24 surgical cases, none underwent reoperation by the surgical team.

The four patients with dissociated strabismus complex were operated upon (100% of dissociated strabismus complex patients). One each of these underwent bilateral superior rectus recessions, unilateral lateral rectus recession, unilateral medial rectus recession and superior rectus recession, and bilateral lateral rectus recession and unilateral superior rectus recession.

One patient with Browns syndrome underwent bilateral lateral rectus recessions and unilateral superior oblique suture spacer with unilateral superior rectus recession. One patient with hypertropia underwent a unilateral superior rectus recession and inferior rectus plication.

Among the 18 patients with ptosis, 7 patients underwent surgical repair on 7 eyes (38.9% of ptosis cases). Of these surgeries, 5 underwent frontalis suspension (71.4%) and 2 underwent levator resection/advancement (28.6%). No patients required repeat surgery.

Of the 18 patients with nasolacrimal duct obstruction (NLDO), there were 8 patients and 12 eyes that underwent probing of the nasolacrimal duct (44.4% of NLDO cases) with reoperation needed in 3 eyes of 2 patients. Of the surgeries performed, 7 underwent probing (87.5%) and 1 underwent a Crawford tube placement (12.5%). Two of the patients who underwent probing required reoperations.

Of the 27 patients who had cataracts, 16 patients underwent surgical repair on a total of 20 eyes (59.2% of cataract cases). There were 4 cases of bilateral cataracts that required bilateral surgery. Ten eyes (50%) had cataract extraction with intraocular lens (IOL) placement, posterior capsulotomy, and vitrectomy. Seven eyes (35%) had cataract extraction with IOL implantation and no anterior vitrectomy (AV), 3 eyes (15%) had cataract extraction with AV and intentional aphakia. There were no significant adverse events. The patient ages, gender, laterality, and additional surgeries done at the time of cataract surgery are listed in [Table 2].
Table 2: Patient ages, gender, laterality, and additional surgeries done at the time of cataract surgery

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Other surgeries performed included 3 examinations under anesthesia, 2 chalazion incision and drainage, 3 lateral tarsorrhaphies (consecutive on the same patient), 2 dermoid cyst excisions, 1 lateral tarsal strip/wedge resection for floppy eyelid syndrome, 1 excision of a pyogenic granuloma, and 1 excision of a conjunctival nevus.

  Discussion Top

In 1999, a partnership between the World Health Organization and the International Agency for the Prevention of Blindness launched VISION 2020: Right to Sight, a global initiative to eliminate preventable blindness. While childhood blindness makes up a relatively small percentage of global visual impairment, it remains a priority as the number of “blind years” produced due to all causes of blindness in children are equivalent to the number of “blind years” caused by cataracts in adults.[1] Estimates suggest there are 1.4 million children who are blind across the world.[1] As many causes of childhood blindness are avoidable, this represents a sizable portion of global visual impairment that could be eradicated. Identification and prevention are two of the most valuable tools to address this mission. It has been estimated that in developing countries, 7%–31% of childhood blindness is avoidable, 10%–58% is treatable, and 3%–28% is preventable.[2] This represents an opportunity for primary, secondary, and tertiary prevention of disease.

Latin America is a region where the types and prevalence of pediatric eye disease have been underreported. Many reports come from schools for the blind and low vision services.[3] Some larger South American countries, such as Brazil, with a relatively large population, academic teaching hospitals, and universal healthcare, have more epidemiologic data. While reports are few and variable, many suggest Retinopathy of Prematurity (ROP) is the most common cause of blindness in Latin American children.[3] However, other reports suggest uncorrected refractive error accounts for as much as three-quarters of visual impairment.[4] There are much less data from Central America, and no reports detailing the demographics of the country of Belize.

According to the International Council of Ophthalmologists, there are only 10 practicing ophthalmologists in Belize. They serve a population of 359,288, which amounts to 28 ophthalmologists per million. In contrast, in Brazil, there are 14,679 ophthalmologists or 71 ophthalmologists per million population.[5] With no subspecialty pediatric ophthalmology care available in Belize, many children travel to neighboring Guatemala, Mexico, or receive care through surgical mission trips.

This study is the first on the prevalence of pediatric ocular diseases in Belize and provides important data on the types and extent of ocular pathology in Latin America. Data in this study were similar to previously published prevalence studies in children across the world.[6],[7],[8],[9] There were few notable exceptions.

The strength of this study is that it is the first account of the ophthalmic conditions seen in a population of Belizean children. Pediatric eye disease is underreported in Latin America. It also provides additional detail on the number and treatment of surgical eye disease. As the nation's primary eye care provider, BCVI performed 2469 eye examinations on children in 2016. In addition, BCVI offered school screenings for ophthalmic conditions throughout Belize. As the treatments offered are nonsurgical, those children identified with strabismus, cataracts, or NLDO may be referred preferentially to the surgical mission. As a result, the majority of patients during the annual mission trips presented with operative ophthalmic diagnoses. This does bias the dataset to more surgical diagnoses. An additional limitation of this study relates to the constraints of data reporting. The patient information containing diagnoses and treatments were recorded on paper charts. These were transcribed into electronic documentation and, therefore, prone to transcription error. As the surgical procedures were recorded directly into a computer document by the attending surgeon, they were less likely to be improperly recorded. Secondary diagnoses (e.g., amblyopia and refractive error) were not listed with the same consistency and detail throughout the document. This leads to a probable underreporting of nonsurgical diagnoses, such as refractive error and amblyopia.

Demographically, most children treated were age 0–10. In this age group, it is essential to treat preventable and treatable ocular diseases. Untreated or unidentified visual impairment or ocular morbidity will negatively affect a child's academic performance and social relationships.[10] In addition, it is crucially important to identify modifiable causes of visual impairment, such as strabismus, as early intervention can improve outcomes. Late identification and treatment of these conditions can adversely affect the visual prognosis and, ultimately the life course of the child. Given the abundance of young children presenting with ocular problems in Belize, efforts should be directed at educating and training key local informants to recognize signs of ocular disease.

The most prevalent disease type presenting to our surgical mission was strabismus and ocular motility disorders, followed by refractive error, and eyelid and lacrimal system disorders. This may be attributed to the mission trip being advertised as a surgical mission trip. In addition, misaligned eyes are visible to parents and caregivers, as well as key informants. Our analysis of the referral sources demonstrated that the majority of patients had an unknown referral source/self-referred. As the surgical mission trip was advertised with social media directly to parents, many children may have been brought to clinic by parents who observed an eye misalignment at home or were encouraged to attend by local, informed members of the community. Lower rates of more common ocular diseases such as infectious and/or allergic conjunctivitis can also be attributed to the focus of the mission being primarily surgical interventions.

While VA was assessed in all patients during the surgical mission trip, the results of VA testing were not available in the deidentified data set. As VA data were not available, determination of the presence/absence of amblyopia could not be done in the absence of a diagnosis code. Amblyopia was therefore likely underreported in our database, as many children had only a primary diagnosis on record, and a considerable percentage of these were amblyogenic diagnoses. A relatively small number of cases of amblyopia were found considering the numerous cases of strabismus, cataract, and refractive conditions.[11],[12],[13] This suggests there is potentially a greater prevalence than the 5.7% reported in our data.

It is notable that 17.4% of surgical cases were for cataract. Pediatric cataract surgery is a more complex operation, requiring additional materials, instruments, and machines. Cataract extraction, primary posterior capsulotomy (PPC), AV, with IOL implantation is recommended in children 8 years and younger. From 8 years old and above, PPC is often recommended, but AV is optional. This requirement of expensive surgical equipment along with trained ophthalmologists, technical support staff, anesthesiologists, and local physicians dictates that a monumental team effort must be coordinated to allow cataract surgery to be performed in a surgical mission.[14] Coordination of premission supply acquisitions, including IOLs, viscoelastic agents, sutures, and pre-, intra-, and postoperative medications, is crucial. Staff from BCVI were available to serve as surgical scrub nurses and allow the use of BCVI equipment. Finally, a local ophthalmologist, while unable to perform the surgery, was capable and willing to perform follow-up.

In coordination with BCVI, ongoing work by study authors (MMP) has focused on outreach and education efforts for key members of the community. Instruction on cycloplegic retinoscopy, strabismus evaluation, and spectacle prescribing guidelines were provided to 7 BCVI optometrists and “refractionists” that travel to many of the more remote areas of Belize. ROP prevention and care have been instituted at the primary public hospital, Karl Heusner Memorial, during this period. As the goal of any international outreach is to empower and advance the care provided by the local practitioners, it is our hope that future mission demographics will reflect the improved skills and screening of the community practitioners.

  Conclusion Top

The records of children treated during seven consecutive annual pediatric ophthalmology surgical trips to Belize conducted by WPP from 2013 to 2019 were used to identify the leading forms of eye disease in children under 18 years of age. The types of ocular diseases, surgical interventions undertaken, and the sociodemographic profile of the study population were identified for each patient who was seen during the mission trip.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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