and Socio-economic Profile of Cataract Patients from Rural Areas of Eastern Rajasthan

Introduction: Blindness due to cataract is a global health problem. In India also it is the major cause of blindness in 62.4%. The prevalence of cataract is more in rural population owing to lack of infrastructure and manpower as well as illiteracy and poverty. There is a paucity of data on the subject from rural Rajasthan especially the eastern region. In order to optimize limited health care facilities for the target population, it is necessary to know the clinico-epidemiological and socio-economic factors associated cataract; thus, the study was conceptualized. Materials and Methods: This cross-sectional study was conducted in the National Institute of Medical Sciences, a tertiary care center situated in the rural area of Jaipur from January 2018 to December 2019. Patients having cataract and giving consent to participate in the study were included. Results: Eight hundred and eleven cataract patients were included in the study. The majority (53.3%) of cataract patients were aged and males (55.9%). Most patients were illiterate (68.5%) and belonged to low socio-economic status (88.7%). Diabetes and hypertension were common. In our setting, senility was the most frequent cause (91.1%) followed by trauma (5.3%); Congenital cataract was least common (1.7%). Sixty-four percent of total cataract patients had bilateral affection. Majority of patients (45%) had immature cataract, 39.9% had mature and 15% had hyper-mature cataract. Conclusion: Socioeconomic and clinico-epidemiological profile of patients living in the rural population of eastern Rajasthan share similarities with people living in other rural areas of our country.


Introduction
As per the World Health Organization (WHO), the estimated number of visually impaired population in the world is 285 million. There are 39 million blind people and as high as 246 million people who are having low vision. Sixty-five percent of people who are visually impaired and 80% of all blind people all are above 50 years of age. Cataract is the leading cause of blindness worldwide which is related to aging in most of the cases. Cataract account for more than half of all causes of blindness [1].
The proportion of vision impairment attributable to cataract is higher in low-and middle-income countries than high-income countries. In high-income countries, diseases such as diabetic retinopathy, glaucoma, and age-related macular degeneration are more common. To estimate the incidence of blindness in India, the first survey by the central government was conducted in the year 1971-1974. The survey showed that 1.4% of the Indian population is blind, and in total 12 million blind people live in India. The National Program for the control of Blindness was started in 1976; later the name of this organization was changed to National Program for the Visual impairment and Blind (NPCB) [2]. A scientific study was conducted in the year 1999-2001 to assess the work undertaken by the NPCB.
The study showed that the incidence of treatable blindness was reduced from 1.4% to 1.1%. Cataract emerged as the major cause of blindness in 62.4% followed by refractive errors (19.65%), glaucoma (5.83%), corneal blindness (0.89%), and posterior segment diseases (4.72%). This survey was conducted on people above 50 years of age; cataract was the cause of bilateral blindness in 50%-80% of patients [3]. Cataract as a cause of blindness is not only limited to rural areas of India but also becoming more common in urban Population [4]. Rajasthan state of India has the second highest prevalence of blindness in the country after Tamilnadu. As per the national census of India in 2011, 2.5% people out of 68.6 million people of Rajasthan are affected by blindness [5].
In India, due to lack of infrastructure and trained personals, the government alone cannot meet the health demands of all. To add, number of other hindrances like poverty, illiteracy and the growing number of elderly populations also lead to inaccessibility of available resources.
A lot of private organizations and international nongovernmental organizations (NGO) are fighting against blindness due to cataract by supporting free camps. The things are better, but there is still a long way to go to achieve the WHO goal of eliminating blindness by the year 2020, which is unfortunate as most blindness which is due to cataract is curable.
To eradicate blindness, it is important to know its stature especially in a rural population where health resources are largely scarce and inaccessible. In order to mobilize the resources and effectively manage blindness especially cataract, it is important to have the knowledge of clinico-epidemiological and socioeconomic factors associated with the disease. There is a paucity of data on the subject from the rural area of eastern Rajasthan. Such information will be helpful for optimizing limited health care facilities. Therefore, the present study was conducted in cataract patients visiting the Ophthalmology department of a tertiary health care center situated in a rural area of eastern Rajasthan to study the clinico-epidemiological and socio-demographic profile of cataract patients.

Materials and Methods
This was a unicenteric, hospital based, cross sectional and non-interventional observational study conducted in department of Ophthalmology, National Institute of Medical Sciences, Jaipur from January 2018 to December 2018. All consecutive patients who visited the outpatient department of Ophthalmology, National Institute of Medical Sciences, Jaipur during the study period were screened for the presence of Cataract. A detailed history was taken using a structured questionnaire. Socioeconomic status was categorized according to the modified Kuppuswamy classification [6]. Diagnosis of cataract was made on the basis of detailed ophthalmic examination. Cataract was further classified as immature, mature and hypermature clinically.
Inclusion criteria: Patients of either sex diagnosed to have unilateral or bilateral cataract on ophthalmic examination; and giving consent to participate in the study were included.
Exclusion Criteria: Those patients who did not give consent were excluded from the study.
Ethical consideration: Ethical Guidelines laid down by ICMR (2006) and Helsinki declarations (2013) were followed in conducting the study. There were no ethical issues as identity or socio-economic status of the participants was not disclosed.Ophthalmic consultations and tests were conducted free of cost; and details of surgery/outcomes were not studied.
Data collection and analysis: Data were recorded in a detailed proforma. The categorical data were then tabulated and expressed as numbers and percentages.

Results
In this cross-sectional study, the data were analysed from 811 patients who visited our center having unilateral or bilateral cataract, and willing to be included in the study. Majority of patients (53.3%) of cataract were old (more than 64 years of age). Younger cataract patients (<15 years of age) were only few in numbers (1%).
The present study showed that in our setting, senility was the most frequent cause (91.1%) of cataract followed by trauma (5.3%). Congenital cataract was the least common variety of cataract and was seen in only 1.7% of patients [ Table 2]. It was seen only in children and young adults (<25 years of age). Our study demonstrated that 64% of total cataract patients had bilateral cataract. Majority of patients (45%) had immature cataract, 39.9% had mature and 15% had hyper-mature cataract [ Table 3]. Diabetes and hypertension were also seen in 10.9% and 26% of patients of cataract respectively.
Most of the patients were illiterate (68.5%). Only 1.2% patients were graduates. Again, majority of patients were poor and belonged to low socio-economic status (88.7%) [ Table 1].

Tropical Journal of Ophthalmology and Otolaryngology
Available online at: www.medresearch.in 116|P a g e   In the present study, male cataract patients visiting our center outnumbered females. This is in contrast to the higher prevalence of cataract in females than male patients as shown in a population study from village population of north and south India (the India-study of age related eye disease) [10]. Logically more females should visit a health care facility for the purpose of cataract surgery, however we have observed that more male patients visit a hospital for surgical options. Avachat et al. in their study from Maharashtra also showed that males visiting hospital constituted 61.7% of cataract cases [7].
The possible explanation for this difference lies in the fact that females are less privileged in rural areas and have less access to health care facilities. Mahajan et al. also commented that cataract extraction is 1.6 times more common among males although women are more commonly affected [11]. However, a study from a southern affluent state of India demonstrated, that among cataract patients more than 40 years of age who were operated, females outnumbered males (53.9% vs 46.1% respectively) [12].
We observed that senility was the most common cause of cataract (91.9%), other causes being less common. More than half of our patients had bilateral cataract. In the study by Avachat et al. age-related cataract was seen in 53.8% of cases, followed by metabolic cause (26.5%); 52.5% of their patients had bilateral cataract [7]. In our study, 45% of patients had immature cataract followed by mature (39.9%) and hyper mature (15%) variety. Shori [7,9]. The association between education and cataracts is unclear; possibly there is less awareness of treatment options and lower surgical coverage for people with less education. Major limitation of our study is lack of control population. Only some of the cataract patients had the means to visit our center and may not be the true representative of the rural population. A population-based study with a larger sample size with age-matched controls should be able to give the necessary information to fill the gaps in our current knowledge.

Conclusion
To conclude, the socioeconomic and clinicoepidemiological profile of patients living in the rural