Pediatric ophthalmology and strabismus in India: Wake-up call and the way forward!

India has 407 million children below the age of 16 years. This accounts for 40% of the Indian population.[1] Mahatma Gandhi said, “The greatness of a nation can be judged by the way its animals are treated.” The way women, children, the elderly and differently abled people are treated also contributes equally in defining the above. India is a country in transition and needs to simultaneously address preventable and treatable causes of childhood blindness (CB). Children require support in recognizing eye problems and hence screening becomes essential. Moreover, their eye issues need to be tackled at the earliest for treatment to be effective.

There is a marked regional variation in the major causes of blindness in children in different parts of the world. Under-5 mortality rate is a surrogate measure for the prevalence and causes of CB in any region. The prevalence of CB in India is estimated to be five times that seen in the developed world.[2345] In certain parts of India, the causes are similar to those seen in poor countries of the world and predominantly include preventable causes (mainly corneal blindness). In urban areas, conditions such as retinopathy of prematurity, cerebral visual impairment, retinal dystrophy, etc., are seen, which are similar to those prevalent in middle-income countries. Apart from this, other treatable conditions such as pediatric cataract and glaucoma are also seen. Overall, approximately 60%–70% of blindness in children is avoidable and/or treatable. The remaining 30% of children may require low vision and rehabilitation care to improve their quality of life.

Children do not know how to show their gratitude for treatment received and may or may not be able to express themselves, irrespective of whether the treatment provided was excellent or poor. Hence, the onus of optimum and efficient care, purely lies in our hands. To make sure that each and every child receives appropriate treatment, pediatric eye care professionals need excellent training. Teachers and mentors play a very crucial and pivotal role here.

In the current issue of the journal, the article titled “Is Pediatric Ophthalmology a popular subspecialty in India – present scenario and future remedies,”[6] states that close to 70% residency (postgraduate) programs do not have a structured rotation and surgical training in pediatric ophthalmology. In addition, surveys always underestimate the ground reality.

According to an earlier survey, Murthy et al.[7] reported that only 192 of 668 (28.7%) ophthalmic setups provided pediatric eye care services. Eighty-three percent of advanced eye care centers and 72.4% of nongovernmental organization hospitals had an anesthesiologist for pediatric eye service. Refractive error was the most common reason for seeking service. The most common surgical procedure was pediatric cataract surgery, followed by squint surgery.

As per WHO, one children's eye care center is required for every 10 million people, where at least one specialty-trained or oriented ophthalmologist should be available.[8] This warrants immediate doubling of the number of dedicated children's eye care units across India. In the current scenario, pediatric ophthalmologists (PO), pediatric “oriented” general ophthalmologists or subspecialists (POO), optometrists (including orthoptists), field workers, and ophthalmic nurses, etc., collectively provide eye care to children. Currently, only 11 ophthalmic institutions in India offer fellowship training in pediatric ophthalmology and strabismus (POS).[6] Roughly 28–30 POS fellows are trained every year, which is far below the required number. POOs can play a major role in a big country like India. Quality POs and POOs can be created by good mentorship. Continuing medical education programs, short-term fellowships, and/or observerships, etc., might help improve the skill set of government sector eye care professionals and are equally important.

POS practice is invariably a branch of Ophthalmology, where school teachers, anganwadi workers, pediatricians, anesthetists, etc. contribute in their own way working in tandem with Ophthalmologists to ultimately provide comprehensive eye care to children. Currently, referrals come from fellow ophthalmologists. In addition, we also need referrals from pediatricians thereby ensuring children who need to be seen by ophthalmologists receive the timely care and attention they require. An essential change of this kind in practice patterns will eventually result in appropriate and well-timed eye care for children. POS practice will be more sustainable and financially viable for private practitioners. The levels of eye care provided can be at primary, secondary, and tertiary centers with pediatric eye surgeries being performed only at tertiary centers. The linkage system connecting these levels, in terms of referral and transport of patients is important. At all levels, more screening programs should be planned and implemented. The national society, despite being one of the oldest ophthalmology subspecialty societies, is currently more focused on strabismus and should be engaging itself equally if not more in pediatric ophthalmology as well. The society should be instrumental in bringing out guidelines with regards to preferred practice patterns for ophthalmologists attending to children's eyes and other related issues that parents may have. Private hospitals, institutes, and government sector hospitals should create more children's eye care units and competitive POS training programs. The trainees who pass out from these programs will help bridge the gap in terms of current deficit of POs and POOs.

In conclusion, good fellowship programs, inspiring role models in POS, and the massive demand for children's eye care in India should motivate future ophthalmology residents/postgraduates to join this subspecialty in the years to come thereby making a positive impact on the current status of POS specialty in India.

About the author

Dr. Ramesh Kekunnaya, completed his MBBS from KMC, Hubli postgraduation from GMC, Mysore. He then went on to do a Comprehensive and Pediatric Ophthalmology fellowship at LV Prasad Eye Institute, Hyderabad followed by a Pediatric Ophthalmology and Strabismus Fellowship at Jules Stein Eye Institute, University of California, Los Angeles, USA. Dr. Kekunnaya is currently the Head of Pediatric Ophthalmology and Adult Strabismus and Neuroophthalmology services at the Child Sight Institute at LV Prasad Eye Institute, Hyderabad. He is an Executive Bureau member of the World Society of Pediatric Ophthalmology and Strabismus and an Administrative Council member of International Strabismological Association. His academic honors include Achievement awards from American Academy of Ophthalmology (AAO), Asia-pacific Academy of Ophthalmology, Honor award from American Academy of Pediatric Ophthalmology and Strabismus, and International Scholar Award from AAO. He is a Section Editor for British Journal of Ophthalmology and has authored more than 85 publications in peer-reviewed journals. Dr. Kekunnaya's clinical interests include Complex Strabismus, Pediatric Cataract, Vision Development, Amblyopia and Neuroophthalmology.