Strategies may eliminate issues impeding Tunisian pediatric care

Tunis, Tunisia-–Delayed patient presentation, compounded by problems relating to insufficient resources and lack of follow-up, explain why pediatric cataract remains an important cause of visual impairment in Tunisia. 

Thorough understanding of these existing challenges is providing a framework for developing solutions, according to Lamia El Fekih, MD.

“It is important that strategies for managing congenital cataract be developed and adopted according to regional conditions,” said Dr. El Fekih, faculty of medicine, University of Tunis-El Manar, Tunisia. “In Tunisia, we are working together to eliminate surgical disequalities, and we have to focus on improving public and physician education, access to good quality care, and patient follow-up.”

Dr. El Fekih suggested that maldistribution of services is the principal reason why children with cataract do not receive the surgical care and follow-up they need for successful vision rehabilitation. She noted there are few centers in Tunisia where pediatric ophthalmology and pediatric anesthesiology services are available. Consequently, families are faced with the need to travel long distances to procure care for their child, and they may lack a means of transportation.

In addition, there are multiple other factors limiting access to care. For example, although surgery is available at no charge for the poor in Tunisia, inability to pay for other necessary services remains an important barrier, considering the low socioeconomic level of the population in some regions of the country.

Hereditary component

“Moreover, congenital cataract in Tunisia appears to have a hereditary component,” Dr. El Fekih said. “When a family has more than one child needing treatment, the financial impact increases. In addition, these children with congenital cataract often have other medical and physical issues that can make it difficult for families to bring them for care.”

Even if children undergo surgery, their visual prognosis depends on proper follow-up care. In Tunisia, there is also a scarcity of practitioners who can provide contact lenses for aphakic refractive correction.

Furthermore, compliance with amblyopia therapy among families in Tunisia is poor. Dr. El Fekih noted that a review of a series of children operated for congenital cataract at her institution showed that about half of those who needed occlusion therapy to prevent amblyopia did not receive it.

Children who develop amblyopia need low vision training, but there are only two low vision centers in Tunisia, and even when physical access to these services is not an issue, a financial obstacle can exist.

“Children may need more than one low vision device or there may be a need to replace devices that get broken. Low vision aids, however, can be expensive,” Dr. El Fekih said.

Solutions

Solutions

Dr. El Fekih said that overcoming these challenges requires a multipronged approach. The development of health education targeting parents and health providers is important to raise awareness about pediatric cataract and its management so more children are presented for ophthalmic care. Increasing parental knowledge also leads to improved compliance with postoperative follow-up and amblyopia treatment protocols.

Focusing on education and other strategies to increase patient access, Dr. El Fekih and others are working with the government to strengthen programs for early detection for all causes of childhood blindness and to implement or improve referral systems.

In addition, they are mapping and identifying tertiary eye care centers that have facilities for pediatric patients. They also are trying to encourage young ophthalmologists to train in pediatrics.

“Although there are about 600 ophthalmologists in Tunisia serving our country’s population of about 12 million people, there are few pediatric ophthalmologists,” Dr. El Fekih said. “And, new trainees are showing little interest in specializing in pediatric ophthalmology.

“We hope by 2020, we will have prepared equipped specialist centers and be able to provide surgery to all of our children with congenital cataract along with immediate and effective optical correction.”

Lamia El Fekih, MD

e. elfekihlamia@yahoo.fr

Dr. El Fekih has no relevant financial interests to disclose.