Rapid Assessment of Avoidable Blindness in Western Rwanda: Blindness in a Postconflict Setting

Abstract

Background

The World Health Organization estimates that there were 37 million blind people in 2002 and that the prevalence of blindness was 9% among adults in Africa aged 50 years or older. Recent surveys indicate that this figure may be overestimated, while a survey from southern Sudan suggested that postconflict areas are particularly vulnerable to blindness. The aim of this study was to conduct a Rapid Assessment for Avoidable Blindness to estimate the magnitude and causes of visual impairment in people aged ≥ 50 y in the postconflict area of the Western Province of Rwanda, which includes one-quarter of the population of Rwanda.

Methods and Findings

Clusters of 50 people aged ≥ 50 y were selected through probability proportionate to size sampling. Households within clusters were selected through compact segment sampling. Visual acuity (VA) was measured with a tumbling “E” chart, and those with VA below 6/18 in either eye were examined by an ophthalmologist. The teams examined 2,206 people (response rate 98.0%). The unadjusted prevalence of bilateral blindness was 1.8% (95% confidence interval [CI] 1.2%–2.4%), 1.3% (0.8%–1.7%) for severe visual impairment, and 5.3% (4.2%–6.4%) for visual impairment. Most bilateral blindness (65%) was due to cataract. Overall, the vast majority of cases of blindness (80.0%), severe visual impairment (67.9%), and visual impairment (87.2%) were avoidable (i.e.. due to cataract, refractive error, aphakia, trachoma, or corneal scar). The cataract surgical coverage was moderate; 47% of people with bilateral cataract blindness (VA < 3/60) had undergone surgery. Of the 29 eyes that had undergone cataract surgery, nine (31%) had a best-corrected poor outcome (i.e., VA < 6/60). Extrapolating these estimates to Rwanda's Western Province, among the people aged 50 years or above 2,565 are expected to be blind, 1,824 to have severe visual impairment, and 8,055 to have visual impairment.

Conclusions

The prevalence of blindness and visual impairment in this postconflict area in the Western Province of Rwanda was far lower than expected. Most of the cases of blindness and visual impairment remain avoidable, however, suggesting that the implementation of an effective eye care service could reduce the prevalence further.

Abstract

A survey of 2,250 people aged 50 y or over in Rwanda, based on clusters of 50 people, found a much lower prevalence of blindness than expected.

Editors' Summary

Background.

VISION 2020, a global initiative that aims to eliminate avoidable blindness, has estimated that 75% of blindness worldwide is treatable or preventable. The WHO estimates that in Africa, around 9% of adults aged over 50 are blind. Some data suggest that people living in regions affected by violent conflict are more likely to be blind than those living in unaffected regions. Currently no data exist on the likely prevalence of blindness in Rwanda, a central African country that is rebuilding following the 1994 genocide and civil war. Parts of the country, such as the Western Province, currently have no eye care services at all, but the government is trying to plan what services are necessary for this part of the country.

Why Was This Study Done?

These researchers wanted to collect data that would help them estimate the number of people suffering from avoidable blindness in Western Province, Rwanda, and to find out the main causes of blindness in this region. The approach they adopted is known as the Rapid Assessment of Avoidable Blindness (RAAB).

What Did the Researchers Do and Find?

This research project used survey methods based on the 2002 Rwandan national census. The researchers used the census to produce a list of settlements in Western Province, together with the number of individuals living in each settlement. Settlements were randomly picked from the list using a technique that was more likely to pick out bigger settlements than smaller ones. Each settlement was then divided into “cells,” with each cell containing around 500–700 people. One cell was randomly chosen from each settlement. Then, the researchers visited households within the cells, making sure that they visited 50 people aged over 50 y within each cell. They followed a standard procedure for collecting information from each person included in the survey. Each individual was examined by a nurse to measure their clearness of sight (“visual acuity”), using a Snellen chart (a chart with several rows of letters, where the size of the letters gets smaller as you go down the rows). The people being surveyed were examined by an ophthalmologist and the main cause of blindness was recorded, as well as general information on age, sex, details of any cataract operations, and why a cataract operation had not been done if one was needed.

Around 2 million people live in Western Province. The researchers included 2,250 people in the survey, for whom detailed examinations were done for 2,206 survey participants. Overall, 1.8% of the individuals examined were blind in both eyes. The main causes of blindness in the individuals surveyed were avoidable, and included cataract (clouding of the lens), focusing problems, and scarring of the cornea. Although 65% of cases of blindness were caused by cataract, and the availability of cataract surgery for those who needed it was reasonable, the outcomes of surgery were judged to be poor.

What Do These Findings Mean?

>The overall proportion of individuals in this survey who were found to be blind was quite low—1.8% instead of the expected prevalence of 9%. The researchers estimated that the overall proportion of blind people in all age groups in this region of Rwanda would be around 0.2%, and they calculated that 365 cataract surgeries would be needed in the region every year to meet international targets for correcting cataracts. It is not clear why the prevalence of blindness was lower than expected in this survey; one factor might be the low proportion of people in the 50 y age group in the Rwandan population. However, this survey suggests that most of the cases of blindness in this population are avoidable, and the data produced here are important in planning future eye care services within Rwanda.

PLoS Medicine, as a leading general medical journal, would not usually publish the results of a survey of blindness (or any other medical condition) in just one part of one country. The editors felt this one was of particular interest for several reasons. There has previously been very little information about blindness prevalence in Rwanda. The idea of Rapid Assessment of Avoidable Blindness (RAAB) is also fairly new. Furthermore, the results are a striking contrast with what was found in two studies that we recently published from the southern Sudan (see below for references), another part of Africa that has experienced devastating conflict. The Sudan studies found a very much higher prevalence of blindness. However, it must be noted that the fighting in the Sudan continued over a much longer period (several decades) and the Sudanese environment is different in many respects; for example, it is much drier (which raises the risk of blindness due to trachoma) and many people live in extremely remote locations.

Additional Information.

Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040217

• World Health Organization Health Topics maintains a minisite on blindness that includes links to fact sheets, statistics, official publications, and other information

• Wikipedia has an entry on visual acuity (clearness of sight), including details of how acuity is measured (note: Wikipedia is an internet encyclopedia anyone can edit)

• The World Health Organization publishes detailed country health profiles, including one for Rwanda (click on the relevant country name to download a PDF fact sheet)

• VISION 2020 is a global initiative aiming to eliminate avoidable blindness by the year 2020. Its Web site provides information on the main causes of avoidable blindness

• Two papers recently published in PLoS Medicine about blindness in the war-afflicted southern Sudan dealt with overall blindness prevalence (Ngondi J, Ole-Sempele F, Onsarigo A, Matende I, Baba S, et al. [2006] Prevalence and causes of blindness and low vision in southern Sudan. PLoS Med 3: e477) and blindness due to trachoma (Ngondi J, Ole-Sempele F, Onsarigo A, Matende I, Baba S, et al. [2006] Blinding trachoma in postconflict southern Sudan. PLoS Med 3: e478)