Developing pediatric eye care program in Nepal: Insurmountable Mountains can be reduced to mole hills. The Orbis experience in Nepal.

doi:10.21203/rs.3.rs-4267006/v1

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Developing pediatric eye care program in Nepal: Insurmountable Mountains can be reduced to mole hills. The Orbis experience in Nepal.

https://doi.org/10.21203/rs.3.rs-4267006/v1

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Background: Nepal straddles the Himalayas mountains and its geography has posed a challenge to delivering eye care in children. This manuscript describes the pediatric eye care facilities developed, and children examined and treated under the Orbis International’s childhood blindness initiative.

Methods: Between 2010-2017 Orbis International had supported the Nepal Netra Jyoti Sangh (NNJS) and Tilganga Institute of Ophthalmology (TIO) to develop pediatric eye care centers in major hospitals, along with their outreach. This manuscript looks at the impact of that intervention. Reports of Nepal Netra Jyoti Sangh, Tilganga Institute of Ophthalmology and Orbis International were studied, along with publications on ophthalmology from Nepal. Eight child friendly pediatric eye care centers were set-up in eight hospitals and their pediatric eye care teams were trained under this project. An outreach program was designed especially for children’s eye problems in the form of health promotion and screening. The project monitored outcomes and promoted research.

Results: Between the years 2010–17, a total of 1,281,153 children had been examined in eight pediatric eye centres (an average of 20,018 per centre per year, range 10,729 –39,485) and the average outpatient per month per centre was 1668 (range 894 - 3,290). Between the years 2010 – 2017, a total of 42,430 children had been operated upon in eight hospitals (an average of 663 children per hospital per year, range from 96 – 1,465) and the average pediatric eye surgery per month per hospital was 55 (ranged from 8 to 122).

In the years 2018 & 2019 (21 months) post-project, all the 8 hospitals had operated on 14,252 children (average of 1,782 per hospital, range 185 - 4438) and the average pediatric eye surgery per month per hospital was 85 (range 9 to 211). Nineteen publications on pediatric eye care were published in indexed journals.

Conclusion: Orbis childhood blindness amelioration initiative in Nepal resulted in more than a million children examined, and >50,000 children underwent eye surgeries in the 8 pediatric eye care centres and the good service continued after the project was over.

Childhood blindness

visual impairment

Nepal

pediatric eye care centre

refractive errors

pediatric cataract

Nepal was the world’s only Hindu kingdom that became a secular republic in 2008, after a decade-long Maoist insurgency. Nestled in the mighty Himalaya mountains, it has one of the most dramatic landscapes, from near sea level to over 29000 feet within a few hundred kilometers. One of the poorer parts of Asia, due to its terrain and remote landlocked location, it was also wracked by internal strife. [1] Nepal is mainly divided into three physiographic areas: Mountain, Hill and Terai. These ecological belts run east-west and are vertically intersected by Nepal's major, north to south flowing river systems. Himalayan mountain region constitutes 15 per cent of the country's total land and is covered with snow-capped mountains in the northern part. Its altitude ranges from 4,877 to 8,848 meters, including the world's highest peak Mount Everest (8,848m). The Hilly region, covers 68 per cent of the country's total land in the central part of Nepal. The altitude varies from 610 to 4,877 meters in this region. In the southern part is the plain area of the Terai region that covers 17 per cent of the country's total land, but has nearly half the population. Nepal's gross domestic product (GDP) for 2021 was estimated at over $36 billion.

Nepal has had a steady improvement in per capita income and health care indices in the past four decades. [1, 2] Nepal Netra Jyoti Sangh (NNJS), an umbrella non-governmental organization for providing eye care under the aegis of Government of Nepal had helped set up large hospitals in each zone of the country. [3] Most service was for adults, but children too needed care, as 40% of populace was < 18 years old. A nation-wide prevalence of blindness survey was conducted in Nepal in 1980s. [4]. A total of 17,423 children aged 0–15 were examined during the National Blindness Survey in 1981 and the prevalence of bilateral blindness in 10–19 year olds was 0.14 per hundred. [4]

Orbis is a non-aligned, non-profit global development organization whose mission is to preserve and restore sight by strengthening the capacity of local partners in their efforts to prevent and treat blindness. [5] Through the Childhood Blindness Initiative, Orbis is working with not-for-profit organizations in the eye care sector to establish well-equipped children’s eye centers across the globe with a particular emphasis on under-served rural areas. It aims to provide access to quality eye care to millions of children, in each of the country it works, by setting up pediatric eye care centres with its partners; and once established and operational, these child eye care centers would continue to serve future generations. Till the year 2000, blindness prevention interventions in Nepal had been cataract centric and the whole country did not have a single dedicated pediatric eye care center to treat children. In July 2004, under ORBIS India program, Shree Rana Ambika Shah Eye Hospital (SRASEH) at Bhairawa near Lumbini (Buddha’s birthplace) in Terai region, one of the high-volume eye hospitals of Nepal, was identified for establishing a dedicated child eye care center. Currently it is named as Lumbini Eye Institute and Research Center (LEI).

ORBIS had commissioned a national survey in Nepal in the year 2007 to identify gaps in current availability of infrastructure and trained human resources related to pediatric eye care services. As per the survey, there were a total of 6 trained pediatric ophthalmologists in Nepal, one trained pediatric ophthalmologist for every 4.3 million population. The program was then extended to establish seven more pediatric eye centres in Nepal.

There have been few studies that have documented the change in health care delivery status in developing countries. Thomas et al (2005) provided a review of eye care in India.[6] Durkin (2008) reviewed the literature available on eye health care programs in Australia for aboriginals.[7] Faal et al reported the prevalence of blindness in Gambia, a small West African country after a ten year intervention in terms of a national eye care program.[8] Aghaji et al (2018) described the strengths, challenges and opportunities of implementing primary eye care in Nigeria.[9] There have been no such publications documenting eye care from Nepal.

This manuscript reports the results and outcomes of the decade plus interventions aimed to improve eye care service delivery for children in Nepal from 2004 to 2019, during the project period and after completion, to understand the sustainability of the implemented interventions.

Permission & ethics approval: Permission was obtained from the ethics committee of Nepal Netra Jyoti Sangh, Kathmandu, Nepal.

Source of data: Annual reports of Orbis International, India country office, Nepal Netra Jyoti Sangh and Tilganga Eye Institute (later renamed Tilganga Institute of Ophthalmology) were studied as were the project reports, quarterly reports and midterm and final evaluation reports. No individual medical records, either of adults or children, were directly accessed for this study.

Orbis International, India country office had initially supported Shri Rana Ambika Shah Eye Hospital (SRASEH, later called Lumbini Eye Institute & Research Center) in Bhairava, Lumbini in the Terai region of Nepal, from 2004–2008. Orbis helped refurbish the outpatient department, train human resource, purchase equipment and shore up outreach activities.

Human resource training: Orbis first trained a pediatric eye care team, an ophthalmologist, optometrist, anesthetist, orthoptist, pediatric oriented nurse and counselors. [10] They were existing team members who were trained for pediatric orientation at a center of excellence in India (Aravind Eye Care System, Madurai, Tamil Nadu). A paramedic and/ or technician was trained in basic equipment maintenance at the same institute. This was supplemented by short training programs abroad the Orbis Flying Eye Hospital which visited Kathmandu and hospital based programs (HBPs) where volunteer faculty visited, stayed and taught trainees in their own hospitals for a week. The management and team of the eye hospital were trained in gender sensitization, and to ensure equal access and care to patients irrespective of their gender, ethnicity and socioeconomic status. Numerous meetings and conferences for continual medical education were conducted for ophthalmologist and optometrists.

Infrastructure strengthening or capacity building: A child friendly pediatric eye care center was developed with a dedicated children’s play area, breast feeding area, toilets for children and a pediatric ward. [10] Facilities were created for general anesthesia in the operating rooms.

The strategies to improve pediatric eye care used first in the SRASEH, Lumbini region from 2004–2007 were followed by six other hospitals operated by the Nepal Netra Jyoti Sangh (NNJS) and the Tilganga Eye Institute in Kathmandu, the national capital from 2010–2017. Their details are given in Table 1. Together they covered all the five zones of Nepal. Figure 1 shows the map of Nepal with its 5 zones and the location of the hospitals in 2007. Figure 2 shows the map of Nepal with the newly constituted 7 provinces and the location of the eight pediatric eye care centers in 2019.

Figure 1: Map of Nepal showing the 5 zones and location of eye centers in 2007. This map was created using freely available country boundary base map GADM.org, rendered in ArcGIS. The base map was downloaded from https://geodata.ucdavis.edu/gadm/gadm4.1/shp/gadm41_NPL_shp.zip under a CC BY license

Figure 2: Map of Nepal showing the 7 Province and location of 8 centers in 2019. This map was created using freely available country boundary base map opendatanepal.com, rendered in ArcGIS. The base map was downloaded from https://opendatanepal.com/dataset/new-political-and-administrative-boundaries-shapefile-of-nepal under a CC BY license.

The network of 106 primary eye care centers working under aegis of NNJS, located in the 77 districts of Nepal added as a feeder to the secondary eye centers and helped screen children with visual impairment and refer them to secondary and tertiary centers which were equipped with general anaesthesia facilities. Twenty-eight such primary centres were upgraded for delivering pediatric eye care. They were strengthened by donating pediatric visual acuity testing equipment, emphasizing school eye screening and developing pediatric outpatient facilities. [10] The REACH project helped strengthen the outreach by examining school children by teaming up with the primary eye clinics attached to the hospitals. [11]

The partner hospitals were encouraged to use electronic medical record systems and measure the outcome of pediatric eye surgeries performed.

Ensuring follow-up and promoting research: The project encouraged the hospitals to have regular follow-up after paediatric ocular surgery as regular follow-up by itself improved outcome as shown by a publication from Nepal in JAAPOS and the Orbis supported Miraj paediatric cataract study in Maharashtra, India.[12, 13] The project made measuring outcomes of visual acuity and refraction mandatory and ensured documentation of follow-ups. The teams were encouraged to conduct clinical and operational research. The scientific publications that ensured from the data were also documented. The hospitals also collected data on the number of patients they served from Nepal and neighbouring Indian states.

Health promotion: The project also had a health promotion and education component. Efforts were made by Orbis to raise awareness on eye health among parents and care givers: Counsellors in Orbis partner hospitals were trained to strengthen counselling of children and parents visiting the hospitals. The Training Center for pediatric ophthalmology established at Lumbini Eye Institute had a refresher course for counsellors to improve counselling in children’s eye care.

Outcome measures: The number of out-patient visits in pediatric eye clinic and the number of surgeries performed on children’s eyes by all the eight hospitals annually were collated ; before, during and after the project period and their mean and standard deviation was calculated. The type of pediatric eye surgeries were also recorded as aslp the publications on pediatric eye care in reputed journals. The number and cadre of eye care team members trained was also studies.

Data collection and management: The data was collected in excel software (Microsoft Inc.).

Lumbini Eye Institute, the first hospital to set up a dedicated pediatric eye unit was examining 5,189 children before Orbis intervention in the year 2003 (432 per month) and with the Orbis support had improved their capacity to examine about 15,556 children by the year 2007 (1296 per month). The overall children examined between 2004–2007 were 51,887 (avg 12,972 per year). The other 7 hospitals had a pediatric eye care centre in 2010. Table 1 shows the geographic coverage by each partner hospital.

Table 1

shows the geographic coverage, population and area covered by each hospital.
Sl.No.	Orbis Partner Hospital	Geographic coverage	Total Population as per 2011 census	Estimated Pediatric Population 0–18 years – 40%	Area in square kilometer
1	Tilganga Eye Institute, Kathmandu, Nepal	Bagmati Province	5529452	2211781	20300
2	Lumbini Eye Institute & Research Center, Bhairava, Lumbini, Nepal	Lumbini Province	3028800	1211520	14971
3	Geta Eye Hospital, Dhangadi, Nepal	Sudurpashchim Province	2552517	1021007	19515
4	Himalaya Eye Hospital, Pokhara, Nepal	Gandaki Province	2403757	961503	21504
5	Mechi Eye Hospital, Birtamode, Nepal	Province 1	4534943	1813977	25905
6	Sagarmatha Chaudhary Eye Hospital, Lahan, Nepal	Madhesh Province – Siraha; Saptari; Mahottari; Dhanusha; Sarlahi; Sindhuli districts	3694487	1477795	5992
7	R M Kedia Eye Hospital, Birgunj, Nepal	Madhesh Province – Bara; Parsa; Rautahat districts	1709658	683863	3669
8	Fateh-Bal Eye Hospital, Nepalgunj, Nepal	Lumbini Province – BARDIYA; BANKE; Dang districts	1470472	588189	7317

Except Tilganga Eye Institute and Himalaya Eye Hospital (both in hills region) all other hospitals were in Terai region and catered to patients from India, as they were very close to the border.

Table 2 shows the out-patient children visits and pediatric eye surgeries before (2010), during (2010-17) and after (2018-19) the project. The 2018-19 figures are for 21 months.

Table 2

Overall pediatric eye clinic out-patient visits (OPD) and pediatric eye surgeries (surgeries) before, during and after the project period.
All eight centres	2010		2018-19
OPD (Total)	94,114	1,281,153	366,377
OPD (Average) annual per hospital	11,764	20,018	26,170
OPD (Range) annual	0 to 28,419	10,729 to 39,485	13,558 to 47,737
OPD (Average) monthly per hospital	980	1,668	2,181
OPD (Range) monthly per hospital	0 to 2,368	894 to 3,290	1,130 to 3,978
Surgeries (Total)	2,715	42,430	14,252
Surgeries (Average) annually	339	663	1,782
Surgeries (Range) annually	0 to 1019	96 to 1465	185 to 4438
Surgeries (Average) monthly per hospital	28	55	85
Surgeries (Range) monthly per hospital	0 to 91	8 to 122	9 to 211

The number of paediatric surgeries performed had more than doubled on average. Among the total pediatric surgeries performed, cataract was the highest (42%, ranging from 24% − 62%), followed by oculoplastic/ptosis/lid surgery (11%, ranging from 0.3–25%) and corneal tear repair/transplant (10%, ranging from 7–17%). The above data was only from the base hospital’s pediatric eye care centres. More children had been examined at the 28 upgraded Primary Eye Care Centres/ Child Eye care Centres. In 2010, in these centers children accounted for only 2% of the total out-patients which increased to > 10% in 2019. Children were also referred from outreach camps, school screening program and through Female Community Health Volunteers (FCHV).

The dedicated pediatric ophthalmology units had the highest OPD load amongst all ophthalmic subspecialties like cornea, retina, glaucoma and oculoplastic, again reaffirming the fact that there was a great need for setting up such a service. Hospitals too had set up a dedicated low vision service.

The different types of surgeries performed between 2010–2019 by all hospital are shown in the following Table 3.

Table 3

Types of pediatric eye surgeries performed
Type of surgery	Proportion of total surgeries	Range
Cataract	41.8%	24–62%
Strabismus/Squint	2.9%
Pterygium	0.5%
DCR/DCT	1.5%
Glaucoma	1.6%
Cornea Repair/Transplant	10.2%	7–17%
Oculoplastic/Ptosis/Lid Surgery	10.9%	0.3–25%
Vitreous/Retina	8.4%
LASER	0.1%
Others	22.5%
Total Children Operated	100%

# LASER was done under general anesthesia and thus counted as surgical procedure.

Others include lid tear repair, conjunctival tear repair, corneal foreign body removal, probing and syringing for nasolacrimal duct obstruction, detailed evaluation of peripheral retinal under general anesthesia. They were included under ‘surgeries’ as they were performed in the operation theatre with requisite consent.

Anaesthesia services: There were hardly any general anaesthesia and paediatric eye surgery facilities in most large eye hospitals before the Orbis childhood blindness project. In 2004 at LEI and also in 2007 at the 7 hospitals, ketamine anaesthesia was being used, which was not the best preferred technique both for open globe surgeries and for strabismus surgeries. With the development of clinical protocols, training of staff, anaesthesiology support had improved and safe anaesthetic agents were used now in the 8 hospitals. Intubation inhalation anesthesia service and use of laryngeal masks for paediatric general anaesthesia had become common. Surgery on infants (age < 1 year) had been started.

In 2007, there were no anesthetists oriented with ophthalmic pediatric surgery. However, 6 anesthesiologists and 6 anesthesia assistants/technicians had been trained through the flying eye hospital program and Hospital-Based Programs (HBPs). Due to the high demand for anesthetists, all the hospitals excluding those in Kathmandu, were not able to get anesthetists every day. Very small children and infants were rarely taken for surgery earlier, but this changed during the project period.

Human resource development: The 2007 study had indicated the lack of pediatric teams available in the hospitals and the available resources were unevenly distributed, with most services concentrated in the big urban areas and the capital city of Kathmandu. In 2007, there were a total of 6 trained paediatric ophthalmologists in Nepal. Out of the 6, one was trained under Orbis project from LEI. There were no paediatric oriented ophthalmologists in the country, though many other ophthalmologists regularly attended to paediatric patients. Figure 3 shows the pediatric eye care teams available in Nepal.

Figure 3: Pediatric teams available in Nepal − 2007 Nepal HR Report

As of 2019, it is estimated that there were about 22 paediatric ophthalmologists in the country and 12 of them were at Orbis partner facility, and of these 7 had been trained by Orbis support (6 in India and 1 in LEI, Nepal); and in addition 6 ophthalmologist have been trained at LEI. Of the 22, 18 paediatric ophthalmologists were either directly trained, serve at partner facility or trained at Orbis supported training facility.

Table 4

Trained paramedical personnel available for paediatric eye care
Type of care provider	2007	2017
Paediatric nurses	5 (1 trained by Orbis)	19 (trained by Orbis)
Paediatric counsellors	4 (1 trained by Orbis)	15 (trained by Orbis)
Paediatric Optometrist/Orthoptist	12 (3 trained by Orbis)	18 (trained by Orbis)
Ophthalmic assistants in outreach programs trained in paediatric care	0	11 (trained by Orbis)
Administrators/Project manager with paediatric eye care orientation	0	9 (trained by Orbis)
Bio-medical technicians	0	5 (trained by Orbis)

By 2019, except one hospital, all the hospitals had full-time paediatric ophthalmologists and had trained optometrists/orthoptists, paediatric nurses and counsellors. Even though few trained staff had left the organization, all the hospitals tried to maintain the paediatric team composition.

Each of the hospitals now have optometrist training programs and orthoptics is part of the curriculum. Hands-on training in pediaric eye care is imparted to the optometry students in each hospital.

At the beginning of 2018, LEI had organized the first national paediatric ophthalmology and strabismus conference, where most of the paediatric and paediatric oriented ophthalmologists in the country participated. SCEH and TIO in 2016 had started providing a one-year fellowship program owing to the rise in demand for paediatric ophthalmologists. Currently, five paediatric ophthalmologists are being trained each year in Nepal.

Research & publications: All these centres pursue research in childhood blindness and have notable publications in various journals. Manuscripts on children’s eye health in Nepal were published in PubMed indexed journals during and after the project. [10, 14–28] The hospital teams had publications on low vison services for children [14–17], refractive errors [18, 19] and ocular injuries in children [21, 22]. The publications of children’s eye health were nil before the project.

Geographic coverage: At LEI, during the years 2004–2007, Nepalese children accounted for 59% of the OPD and 40% of the surgeries. About 41% of OPD patients and 60% of the surgeries were Indian children whose parents had got them from across the border for treatment.

Between 2010 and 2019, paediatric referral had increased from remote and rural areas of Nepal and the 8 hospitals had covered the entire Nepal (77 districts) and 9 states of India Uttarkhand, Uttar Pradesh, Bihar, West Bengal, Jharkhand, Assam, Meghalaya, Arunachal Pradesh, Nagaland) in terms of service delivery. By 2019, 76% of the paediatric OPD and 56% of paediatric surgery were of the native Nepalese population. This had increased from 30% in 2010. 24% of the outpatient and 44% of the paediatric eye surgery in the 7 out of 8 (Excluding HEH) hospitals in the Terai region mostly came from the neighbouring Indian states of Uttar Pradesh, Bihar and West Bengal.

Health promotion: The teams used the concept of Bhaat Bhahdur – Saag Bahadur (भात बहादुर - साग बहादुर) in patient communication, especially for children in the Children's Eye Centers for raising awareness among children and parents visiting the center. Bhaat is rice, Saag is green leafy vegetables, Bahadur means brave and is a common gorkha-Nepali name amongst boys. Children who subsist only on rice were more likely to be Vitamin A deficient and malnourished, as compared to those who consume green leafy vegetables too. The project developed relevant information, education and communication materials (brochure, leaflets and posters) on child eye health and general eye health awareness and distributed these in the community during outreach activities and through the fixed facilities (Primary eye Care Centers and Hospitals). Biratnagar Eye Hospital has created dedicated infrastructure for patient counselling and education in the hospital to provide adequate emphasis on patient counselling and systematize it.

The intervention by Orbis with NNJS and TEI had greatly increased the volume and scope of pediatric eye care services in Nepal, and also benefitted the surrounding states of India. In 2004-8, Orbis International first supported the implementation of the pediatric eye care center and project in Lumbini. Its success led to the project with six other NNJS Eye Hospitals and the Tilganga Institute of Ophthalmology. More importantly, the volume of service rendered during the project duration of 2010-17 was maintained in 2018-19, after the project was over. Cataract and eye injuries in children were managed well. The increased number of primary and secondary eye centers providing eye care for children, coupled with increased school enrollment ratio and better roads, reduced the barriers of awareness (lack of) and distance.

Pediatric ophthalmology had developed as a sub-specialty and fellowship training was started in three hospitals and publications had come out from the research conducted by them. [14–27] The hospitals had publications on low vision services for children, refractive errors and ocular injuries in children. [14–17, 18, 19, 21, 22] They tracked outcomes of pediatric cataract, strabismus and dacrocystorhinostomy surgeries. [20, 25, 27, 23]

The improved range of pediatric eye care service benefitted not just Nepal but neighboring Indian states of Uttar Pradesh, Bihar and West Bengal, which were the least developed parts of that country in terms of most socioeconomic indicators. [28]

The International Centre for Eye Health, London and the Ministry of Health in Gambia, a small country in West Africa, had documented the reduction in the prevalence of blindness before and 10 years after the national eye care program. [9] The prevalence of blindness in children in a part of Nepal in 2015-16 was 0.07% as compared to the prevalence of 0.14% in 11–20 year olds in 1980. [4, 29] The prevalence in UK for bilateral blindness was 6.3 per 10,000 children, that is 0.063% in 2007 [30] So the comprehensive effort over decades had almost halved the childhood blindness, and it was now closer to prevalence in a developed country. The figures of unilateral prevalence of blindness were higher due to trauma. [29, 30]

The REACH program of Orbis India, implemented in six Indian states, aimed at tackling refractive errors in school children. It was extended to Nepal in 2018. It standardized school screening and strengthened the partner hospital’s links with the community through the school eye program. [11] Better vision just does not make a child see better, it has implications in improving scholastic and sports performance and improving social interaction.

As Nepal prospers and develops, more preterm babies would be surviving, and retinopathy of prematurity would be there on the horizon, as it has been in neighbouring India. [31]

Training of anesthesiologists helped not just pediatric eye care but also pediatric orthopedic, otorhinolaryngology and general surgery. Though the turnover of the trained staff and relocation to other units was a concern, they work in other eye hospitals and continue to provide pediatric eye care services in the country.

Doing pediatric eye surgeries is a bit like tiger conservation. Tiger is a symbol. For the tiger to be saved and their numbers to increase, an entire ecosystem has to be protected. Similarly, for every pediatric cataract identified, nearly 10,000 children have to be screened. This widespread screening of ocular and visual problems in the community upgrades and strengthens not just eye care, but also health care and educational systems. Better vision in children leads to academic betterment, more socialization and prevents disability. [32, 33] A better sighted child has more career options.

The development and training of an eye care team would have far reaching consequences, not just for the pediatric ophthalmology department, but also for the entire hospital because the synergy created amongst doctors, paramedics, administrators and outreach team would have positive implications for efficient eye care service delivery. These experiences may be used for learning for other countries having population around 30 million.

All the hospitals showed a consistent increase in the volume of patient load and surgery performance of screening and surgical volume even after the end of the project. In addition to service delivery, many hospitals have stepped into clinical and operational research and were training mid-level ophthalmic personnel and medicos in children’s eye care.

‘Human Ethics and Consent to Participate declarations: not applicable’.

Study is not a clinical trial. Clinical trial registration number not applicable.

The research was conducted in accordance with the Declaration of Helsinki.

Permission & ethics approval: Permission was obtained from the ethics committee of Nepal Netra Jyoti Sangh, Kathmandu, Nepal.

Source of funding: There was no funding.

Data Availability declaration: The authors shall make all the data available as needed. It has been uploaded as supplementary materiel.

Conflict of interest: None There are no competing interests

Author Contribution

All authors reviewed the manuscript.RishiRaj Borah, Sailesh Mishra, Y D Sapkota and Reeta Gurung conceptualised the study with Parikshit Gogate and Saibaba Sarvanan. PG and SS wrote the main text with inputs from RR Borah.Srijana Adhiikari, Purushottam Joshi, Suresh Raj Pant, Kabindra Bachracharya, Hari Bikram Adhikari, Govind Gurung, Ranjan Shah helped in data collection, getting permission and collating the data

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Developing pediatric eye care program in Nepal: Insurmountable Mountains can be reduced to mole hills. The Orbis experience in Nepal.

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