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      Cataract blindness: challenges for the 21st century Translated title: Ceguera por catarata: retos para el siglo XXI Translated title: Cécité due à la cataracte: les enjeux pour le XXIe siècle

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          Abstract

          Cataract prevalence increases with age. As the world’s population ages, cataract-induced visual dysfunction and blindness is on the increase. This is a significant global problem. The challenges are to prevent or delay cataract formation, and treat that which does occur. Genetic and environmental factors contribute to cataract formation. However, reducing ocular exposure to UV-B radiation and stopping smoking are the only interventions that can reduce factors that affect the risk of cataract. The cure for cataract is surgery, but this is not equally available to all, and the surgery which is available does not produce equal outcomes. Readily available surgical services capable of delivering good vision rehabilitation must be acceptable and accessible to all in need, no matter what their circumstances. To establish and sustain these services requires comprehensive strategies that go beyond a narrow focus on surgical technique. There must be changes in government priorities, population education, and an integrated approach to surgical and management training. This approach must include supply of start-up capital equipment, establishment of surgical audit, resupply of consumables, and cost-recovery mechanisms. Considerable innovation is required. Nowhere is this more evident than in the pursuit of secure funding for ongoing services.

          Translated abstract

          La prevalencia de la catarata aumenta con la edad. A medida que envejece la población mundial, aumentan también los casos de disfunción visual y ceguera por catarata. Se trata de un problema mundial importante, que nos desafía a prevenir o retrasar la formación de cataratas y a tratar todos los casos que aparezcan. A la formación de la catarata contribuyen factores tanto genéticos como ambientales. Sin embargo, la reducción de la exposición a la radiación UV-B y el abandono del tabaco son las únicas medidas que permiten reducir la influencia de factores que inciden en el riesgo de catarata. La curación se consigue sólo con tratamiento quirúrgico, pero no todo el mundo puede acceder a él, y las intervenciones quirúrgicas disponibles tienen resultados dispares. Es necesario que todas las personas necesitadas, cualesquiera que sean sus circunstancias, puedan acceder fácilmente a servicios quirúrgicos aceptables, capaces de restablecer debidamente la vista. Para establecer y sostener estos servicios se requieren estrategias amplias que no se detengan en la simple técnica quirúrgica. Hay que introducir cambios en las prioridades de la Administración y la educación de la población, y enfocar de forma integrada la capacitación en el manejo y el tratamiento quirúrgico de esta dolencia. Forman parte de ese enfoque el suministro de bienes de equipo iniciales, el establecimiento de sistema de control de las intervenciones quirúrgicas, la reposición del material fungible y los mecanismos de recuperación de costos. Se requiere para ello una innovación considerable, lo que resulta especialmente evidente a la hora de buscar fondos para los servicios en marcha.

          Translated abstract

          La prévalence de la cataracte augmente avec l’âge. A mesure que la population mondiale vieillit, les dysfonctionnements visuels et la cécité dus à la cataracte augmentent, ce qui représente un problème important partout dans le monde. Les enjeux consistent donc à prévenir ou à retarder l’apparition de la cataracte et à la traiter lorsqu’elle survient. Des facteurs génétiques et environnementaux contribuent à l’apparition de la cataracte. Les seules interventions susceptibles de réduire les facteurs de risque consistent à diminuer l’exposition oculaire aux rayonnements UV-B et à cesser de fumer. La cataracte s’opère très bien, mais l’opération n’est pas à la portée de tous et les méthodes chirurgicales ne donnent pas les mêmes résultats partout. Des services chirurgicaux capables de garantir une bonne récupération de la vision doivent être accessibles à tous ceux qui en ont besoin quelle que soit leur situation, et acceptables par tous. La mise en place durable de ces services suppose des stratégies complètes qui aillent audelà des simples techniques chirurgicales. Il convient en effet aussi de modifier les priorités gouvernementales, d’éduquer la population et d’adopter une approche intégrée de la formation à la prise en charge et à la chirurgie. Cette démarche doit comprendre la fourniture de matériel de base, l’établissement d’un contrôle sur le plan chirurgical, le réapprovisionnement en fournitures renouvelables et des mécanismes de récupération des coûts. Des innovations considérables s’imposent, particulièrement en ce qui concerne la recherche d’un financement durable des services.

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          Most cited references132

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          Effect of ultraviolet radiation on cataract formation.

          To investigate the relation of ultraviolet radiation and cataract formation, we undertook an epidemiologic survey of 838 watermen (mean age, 53 years) who worked on Chesapeake Bay. The annual ocular exposure was calculated from the age of 16 for each waterman by combining a detailed occupational history with laboratory and field measurements of sun exposure. Cataracts were graded by ophthalmologic examination for both type and severity. Some degree of cortical cataract was found in 111 of the watermen (13 percent), and some degree of nuclear cataract in 229 (27 percent). Logistic regression analysis showed that high cumulative levels of ultraviolet B exposure significantly increased the risk of cortical cataract (regression coefficient, 0.70; P = 0.04). A doubling of cumulative exposure increased the risk of cortical cataract by a factor of 1.60 (95 percent confidence interval, 1.01 to 2.64). Those whose annual average exposure was in the upper quartile had a risk increased by 3.30 (confidence interval, 0.90 to 9.97) as compared with those in the lowest quartile. Analysis using a serially additive expected-dose model showed that watermen with cortical lens opacities had a 21 percent higher average annual exposure to ultraviolet B (t-test, 2.23; P = 0.03). No association was found between nuclear cataracts and ultraviolet B exposure or between cataracts and ultraviolet A exposure. We conclude that there is an association between exposure to ultraviolet B radiation and cataract formation, which supports the need for ocular protection from ultraviolet B.
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            Genetic and environmental factors in age-related nuclear cataracts in monozygotic and dizygotic twins.

            Age-related cataracts are a major public health problem. The relative importance of genes and environment in the causation of nuclear cataracts, the most common form of age-related cataracts, is not known. We studied 506 pairs of female twins (226 monozygotic and 280 dizygotic) who were 50 to 79 years old (mean, 62). The amount of nuclear cataract in the right and left eyes was determined objectively by analysis of Scheimpflug lens photographs (yielding three measures) and subjectively with use of the Oxford Clinical Cataract Classification and Grading System (yielding one measure). All eight measures (four in each eye) were subsequently combined in one summary measure of nuclear cataract for each woman. A univariate maximum-likelihood model was used to estimate the variance of the genetic and environmental contributions to each of the measures. The different measures of cataract formation were highly correlated (correlation coefficients, 0.71 to 0.94). The mean scores were similar for the right and left eyes and for monozygotic and dizygotic twins. Quantitative genetic modeling of each of the nuclear-cataract scores invariably resulted in a best-fitting model that involved additive genetic effects, unique environmental effects, and age. The common environmental and dominant genetic effects could be removed from the models without significant loss of fit. The overall heritability in the combined nuclear-cataract score (the proportion of the variance explained by genetic factors) was 48 percent (95 percent confidence interval, 42 to 54 percent); age accounted for 38 percent of the variance (95 percent confidence interval, 31 to 44 percent) and unique environmental effects for 14 percent (95 percent confidence interval, 12 to 18 percent). Genetic effects are important even in such a clearly age-related disease as nuclear cataract, explaining almost 50 percent of the variation in the severity of this disease.
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              Use of inhaled corticosteroids and the risk of cataracts.

              The use of systemic corticosteroids is a risk factor for the development of posterior subcapsular cataracts, but the association between inhaled corticosteroids and cataracts is uncertain. We conducted a population-based, cross-sectional study of vision and common eye diseases in an urban area of the Blue Mountains, near Sydney, Australia. We recruited 3654 people 49 to 97 years of age; the participation rate was 82 percent. We collected information by questionnaire on potential risk factors for cataracts, including the current or prior use of inhaled corticosteroids (beclomethasone or budesonide). Photographs of the subjects' lenses were graded, without information on the subjects, to determine the presence and severity of cortical, nuclear, and posterior subcapsular cataracts. Three hundred seventy subjects reported using inhaled corticosteroids, 164 currently and 206 previously. Among these subjects, after adjustment for age and sex, there was a higher prevalence of nuclear cataracts (relative prevalence, 1.5; 95 percent confidence interval, 1.2 to 1.9) and posterior subcapsular cataracts (relative prevalence, 1.9; 95 percent confidence interval, 1.3 to 2.8) than among the subjects with no inhaled-corticosteroid use, but the prevalence of cortical cataracts was not significantly higher (relative prevalence, 1.1; 95 percent confidence interval, 0.9 to 1.3). Higher cumulative lifetime doses of beclomethasone were associated with higher risks of posterior subcapsular cataracts (P for trend <0.001); the highest prevalence (27 percent) was found in subjects whose lifetime dose was over 2000 mg (relative prevalence, 5.5). Adjusting for the use of systemic corticosteroids and other potential confounders had little effect on the magnitude of the associations. The associations with posterior subcapsular cataracts, but not those with nuclear cataracts, were less marked when the analyses were restricted to subjects who had never used systemic corticosteroids. The use of inhaled corticosteroids is associated with the development of posterior subcapsular and nuclear cataracts.
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                Author and article information

                Journal
                bwho
                Bulletin of the World Health Organization
                Bull World Health Organ
                World Health Organization (Genebra, Genebra, Switzerland )
                0042-9686
                2001
                : 79
                : 3
                : 249-256
                Affiliations
                [01] New South Wales orgnameFred Hollows Foundation Australia
                [02] orgnameCentre for Eye Research Australia
                Article
                S0042-96862001000300015 S0042-9686(01)07900315
                ec96c47a-d40f-4886-a322-5586fca9aeaf

                History
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 84, Pages: 8
                Product

                SciELO Public Health

                Self URI: Full text available only in PDF format (EN)
                Categories
                Round Table

                Lenses, Intraocular,Health care rationing,Health services accessibility,Aging,Cataract extraction,Cataract,Cristallin artificiel,Gestion ressources santé,Accessibilité service santé,Vieillissement,Extraction cataracte,Cataracte,Lentes intraoculares,Asignación de recursos para la atención de salud,Accesibilidad a los servicios de salud,Envejecimiento,Extracción de catarata,Catarata

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