Eastern Mediterranean Health Journal | All issues | Volume 31 2025 | Volume 31, issue 4 | Challenges in providing ophthalmic care to children in Gaza

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Challenges in providing ophthalmic care to children in Gaza

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Amena Masrur1,2, Yousef Atef Yousef Yasin1,2, Eyad OA Alhalis1 and Enas Abdelraof A Abu Muaileq1

1Children Not Numbers, United Kingdom (Correspondence to Amena Masrur: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ). 2Islamabad Medical and Dental College, Pakistan.

Abstract

Background: There are several challenges in providing ophthalmic services to children in Gaza due to the conflict.

Aim: To document the challenges in providing ophthalmic care to paediatric patients in Gaza and offer possible solutions.

Methods: Between March and September 2024, we interviewed 23 children in 4 hospitals in Gaza, aged < 20 years and diagnosed with traumatic and non-traumatic ophthalmic disorder. We assessed their visual acuity, adnexal, anterior and posterior segments, and ocular motility and analysed the data using SPSS version 20. We discussed their cases during the weekly meetings and devised a management plan for each of them.

Results: Eleven (48%) of the children (95% CI 27.42–68.92%) presented with ocular trauma and 12 (52%) with non-traumatic ocular disorders (95% CI 31.08–72.58%). The most common challenge in managing these patients was ineffective communication; it was difficult to obtain relevant clinical information for 52% of the cases. Other challenges included the degraded infrastructure, limited number of trained personnel and inefficient evacuation corridors.

Conclusion: The conflict in Gaza and the lack of facilities to adequately cater to their ophthalmic needs expose children to the risk of developing amblyopia and long-term vision loss. Multifaceted actions are needed to increase access to specialized eye care for the children, including permanent ceasefire, opening of safe evacuation corridors, timely and safe provision of aid, and enhanced medical training for service providers.

Keywords: ophthalmic disorder, ophthalmic care, paediatric, conflict zone, ocular trauma, Gaza

Citation: Masrur A, Yasin YAY, Alhalis EOA, Abu Muaileq EAA. Challenges in providing ophthalmic care to children in Gaza. East Mediterr Health J. 2025;31(4):262–267. https://doi.org/10.26719/2025.31.4.262. Received: 27/10/2024; Accepted: 04/03/2025

Copyright © Authors 2025; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Background

Healthcare workers are often one of the first casualties during conflicts, while children are the most vulnerable victims who bear the disproportionate consequences of war (1,2). The recent conflict in the Gaza Strip has caused the destruction of health care facilities and left Gaza in urgent need of specialized facilities with trained personnel who can cater to conflict-associated injuries and other health needs, including ocular health needs of the paediatric patients. The absence of these is a great challenge to the provision of ophthalmic care for Gaza’s children.

Children Not Numbers (CNN) is one of several non-government organizations (NGOs) operating in the Gaza Strip. Its mission is to provide immediate support and long-term rehabilitation for children affected by conflict, ensuring that they have access to medical care, education and advocacy. CNN works with its international multidisciplinary team of experts, including paedia-tricians, surgeons and ophthalmologists located within and outside Gaza, to provide the best possible health care related solutions. This paper highlights the challenges faced by ophthalmologists working for CNN to provide ophthalmic care to paediatric patients in Gaza and some of the solutions.

Methods

This was a multicentre, observational, cohort study conducted among paediatric patients who presented at 4 hospitals (Al Aqsa Hospital, European General Hospital, Kamal Adwan Hospital, and Nasser Medical Complex) in the Gaza Strip. It was conducted from March 2024 to September 2024 among patients who registered with CNN for further assistance and were diagnosed with an ophthalmic disease after initial management and stabilization. Twenty-three paediatric patients met the inclusion criteria, which was age less than 20 years, diagnosed with an ophthalmic disorder and registration with CNN. The age was 0.4 to 19 years, median 7 years, interquartile range (IQR) 1–13.

After registration with CNN, remote case workers contacted and interviewed the parents or legal guardians of the patients using secure, digital, free, cross-platform messaging service. They collected data on their demographics and the nature and duration of their ocular injury or disease. They obtained and examined records of their hospital assessment and investigations through standardized patient examination charts, including scanned copies of the hospital records and investigations. Professional interpreters were used when there was language communication barrier. The charts included data on visual acuity estimation, adnexal examination, anterior and posterior segment examination, and ocular motility analysis for ophthalmology cases.

A Snellen’s visual acuity chart was used to assess vision in verbal patients, while preverbal patients were assessed using their ability to follow and fixate light. The anterior segment was assessed via either slit lamp examination (Topcon SL-D2) or a binocular indirect ophthalmoscope (Topcon ID 5) using a 20 dioptre lens for magnification. Posterior segment examination was performed using a binocular indirect ophthalmoscope with a 20 and 30 dioptre lens after dilation with cyclopentolate eye drops. The intraocular pressure was assessed using a Schiotz tonometer (Riester) after administration of general anaesthesia. For patients requiring spectacles, cycloplegic refraction was done using cyclopentolate eye drops and either a handheld streak retinoscope (Hongdae, SR 24-B) or automated refractometer (Topcon, KR1).

Patients’ cases were discussed during meetings of the multidisciplinary team of clinicians and ophthalmology cases were discussed during the weekly meetings of the multidisciplinary team of surgeons. Following the discussions, a management plan and treatment options were decided for each patient. Children who could not be treated in Gaza due to the lack of either equipment or expertise were recommended for evacuation. The ophthalmologists recorded and communicated recommendations of the multidisciplinary team to the case workers, who liaised with the parents or legal guardians to set up appointments with the ophthalmologists. Any gaps, such as the unavailability of surgical and/or medical supplies were communicated through CNN logistics team by the case workers. All records were maintained on Microsoft SharePoint as ‘case files’ for each patient.

Ethics consideration

All patient information was stored in Microsoft SharePoint and accessible only to authorised staff members of CNN, with adherence to the tenets of the Declaration of Helsinki.

Statistical analysis

Statistical analysis was performed using SPSS version 20. Patient age was expressed as median with interquartile range and patient gender and presentation (either traumatic or non-traumatic ophthalmic cases) were expressed as percentages. Challenges associated with the management of the cases were divided into categories (Table 3) and presented as percentages.

Results

This study was conducted from 11 March to 30 September 2024. It included 23 paediatric ophthalmic patients: 13 (57%) female and 10 (43%) male, age range 4 months to 19 years (median 7 years, IQR 1–13). Eleven cases (48%) (95% CI 27.42–68.92%) presented with ocular trauma and 12 cases (52%) (95 CI 31.08% to 72.58%) with non-traumatic ocular disorders (Tables 1–3).

The most common challenge encountered in the management of the patients was ineffective communication (Table 3); acquiring relevant clinical information was a challenge in 52% of the cases, liaising with other teams to urgently evacuate cases 5%, and exploring locally available treatment options 5%.

Discussion

This study highlights the challenges faced in providing ophthalmic care to paediatric patients from the Gaza Strip and the solutions. There were very few trained personnel and limited specialized equipment, both for diagnosis and treatment of the patients. Other challenges were language barrier and inadequate knowledge about ocular diseases among the medics. Almost equal numbers of the children presented with traumatic visual loss (n = 11) and non-traumatic causes (n = 12), which is a proof that providing general ophthalmic services is as important as providing emergency services in conflict zones.

The health implications of armed conflict are more extensive than the direct harm caused by violence; loss of infrastructure invariably leads to impoverishment, and mortality and morbidity continue to increase even after the crisis (3). Due to the war, most ophthalmic care centres in Gaza were closed (4-6), and the border closures caused a shortage of medical supplies, especially those used for ophthalmology. In a conflict zone, saving lives takes precedence over saving an eye, therefore, patients requiring ophthalmic care face the threat of visual loss, which may eventually lead to poor self-esteem, limited social interactions and a decrease in their quality-of-life (5,7). The impact is worse on children because they have to struggle in all aspects of development due to visual loss.

To cater to the increasing medical needs of children affected by the conflict in the Gaza Strip, CNN created a community using a free cross-platform messaging service for communication. This service enabled communication within the global CNN community, even where there was low internet bandwidth, using easily accessible hardware such as mobile phones and laptops (8).

Ophthalmology is an instrument-intensive specialty that requires the use of delicate equipment by highly skilled personnel. Due to the absence of specialized equipment most ophthalmic patients were initially evaluated with a pen torch. Then the ophthalmology team began using cell phones to photograph the anterior segment to diagnose, triage and formulate a management plan for each patient. This helped in the evaluation of patients suffering from trauma (cases 1-11, Table 1), and evisceration with ocular prosthesis was offered to patients with hypotonus and collapsed eyes. It then became easy to monitor and document the efficacy of treatment with glasses in patients who presented with ocular deviation (cases 20 and 23, Table 2).

The use of smart phone camera in emergency departments to capture and send ophthalmic images for review, although relatively new, has been documented (9,10). A study in Afghanistan concluded that teleophthalmology using mobile apps may improve and extend ophthalmic care in combat zones and reduce the need for medical evacuations (11). In our case, we used a commercially available but free messaging service, which was improved for ophthalmic care in a combat zone.

Cultural and language barriers can complicate medical decision-making in war zones (12). Many of the patients and available medics did not speak the same language and most of the medics provided consultation remotely. This posed a communication challenge for the doctors and patients, however, we had to make use of interpreters who were fluent in both Arabic and English to bridge the gap. This proved very helpful for consultation and the acquisition of relevant clinical information.

The ophthalmology team faced another challenge as most of the doctors who were physically present in Gaza were not confident to perform ocular examination and record their findings because they had limited exposure to ophthalmology during their training (13). Often the results of a basic examination, such as the ability of a patient to perceive light, can change the management plan (14). This was of paramount importance for patients who presented with ocular trauma (cases 1-11, Table 1). Therefore, we created simple clinical examination videos in English and Arabic, which provided basic information on how to do these. Two ophthalmologists based in Gaza also provided technical support to the other medics, highlighting the importance of having a trained personnel who could be present to provide clinical ophthalmology support. This helped improve the quality of care delivered to the patients, as medics were able to conduct their examinations using specialized equipment instead of pen torches and mobile phone cameras. It reduced the need to evacuate patients. Two patients (Cases 18 & 19, Table 2) successfully underwent glaucoma filtration surgery locally, thereby avoiding the need for evacuation and preserving their vision. Case 7 (Table 1), a 19-year-old (classified as child) (15) successfully underwent penetrating keratoplasty thereby retaining vision in the only functional eye. Another child (Case 22, Table 2), who was initially diagnosed as a case of congenital cataract, was evaluated under general anaesthesia and found to have total retinal detachments in both eyes because of retinopathy of maturity. This required early detection and treatment and the creation of a retinopathy of maturity team. Creation of the team enabled at-risk neonates to be examined and treated promptly, thereby saving vision and avoiding the need for urgent evacuation.

Another difficulty in medical decision-making in this conflict zone was the chaotic and unpredictable environment, which complicated logistics and resource allocation. As of the time of writing this paper, only 12 of the 36 hospitals in Gaza were partially operational and they all struggled with the shortage of medical supplies (16). Once a management plan was decided, the ophthalmology team identified the supplies needed and these were procured by CNN and sent to Gaza through the aid convoys. Such supplies included spectacles, specialized surgical equipment such as corneal trephines (for Case 7, Table 1), etc. The team devised innovative solutions when convoys were delayed. For example, a patient suffering from ichthyosis and ectropion was given edible olive oil to moisten the periocular skin and prevent his condition from worsening (Case 10, Table 2). A torch with blue light was used, in the absence of a portable slit lamp biomicroscope, to evaluate a bedridden polytrauma patient with non-healing corneal epithelial defect (Case 7, Table 1, Figure 1). This enabled the team to save eyes that would have been otherwise lost to corneal ulceration, thereby preventing lifetime morbidity for the patients.

Conclusion

Children in Gaza strip have been severely affected by the recent conflict, making them more susceptible to trauma and at risk of developing amblyopia. Addressing their needs requires a multifaceted approach that includes a permanent ceasefire, opening of evacuation corridors, timely and safe availability of aid, enhanced training on ophthalmic care for medics, and increased access to specialized eyecare. By prioritizing paediatric ocular health amidst conflict, we can prevent lifelong visual loss and improve the quality-of-life of Gaza’s children.

Funding: None.

Conflict of interest: None declared.

Défis liés à la prestation de soins ophtalmologiques aux enfants de Gaza

Résumé

Contexte : Le conflit pose de nombreux obstacles à l'accès aux soins ophtalmologiques pour les enfants de Gaza.

Objectifs : Documenter les défis liés à la prestation de soins ophtalmologiques aux patients pédiatriques à Gaza et proposer des solutions appropriées.

Méthodes : Entre mars et septembre 2024, nous avons interrogé 23 enfants âgés de moins de 20 ans et atteints de troubles ophtalmologiques traumatiques et non traumatiques, dans quatre hôpitaux de Gaza. Nous avons évalué leur acuité visuelle, les segments annexes, antérieurs et postérieurs, ainsi que la motilité oculaire. Ces données ont ensuite été analysées à l'aide du logiciel SPSS version 20. Leurs cas ont été abordés lors de réunions hebdomadaires et un plan de prise en charge a été élaboré pour chacun d'entre eux.

Résultats : Onze des enfants (48 %) (IC à 95 % : 27,42-68,92 %) présentaient un traumatisme oculaire alors que 12 (52 %) étaient atteints de troubles oculaires non traumatiques (IC à 95 % : 31,08-72,58 %). Le principal défi dans la prise en charge de ces patients résidait dans l'inefficacité de la communication ; il a été difficile d'obtenir des informations cliniques pertinentes pour 52 % des cas. Parmi les autres défis figurent les infrastructures dégradées, le nombre limité de personnels formés et l'inefficacité des couloirs d'évacuation.

Conclusion : Le conflit à Gaza et le manque d'infrastructures adaptées pour répondre à leurs besoins ophtalmologiques exposent les enfants au risque de développer une amblyopie et de perdre leur vision sur le long terme. Des mesures multidimensionnelles sont nécessaires pour améliorer l'accès aux soins ophtalmologiques spécialisés pour les enfants de Gaza, notamment un cessez-le-feu permanent, l'ouverture de couloirs d'évacuation sûrs, l'acheminement sécurisé et rapide de l'aide, ainsi qu'un renforcement de la formation médicale des prestataires de services.

تحديات تقديم رعاية العيون للأطفال في غزة

آمنة مسرور، يوسف عاطف يوسف ياسين، عیاد الحلیس، إيناس عبد الرؤوف، أحمد أبو معيلق

الخلاصة

الخلفية: يوجد العديد من التحديات في تقديم خدمات العيون للأطفال في غزة بسبب النزاع.

الأهداف: هدفت هذه الدراسة الى توثيق التحديات التي تواجه إتاحة رعاية العيون للأطفال المرضى في غزة، وطرح الحلول الممكنة.

طرق البحث: في الفترة بين مارس/ آذار وسبتمبر/ أيلول 2024، أجرينا مقابلات مع 23 طفلًا في 4 مستشفيات في غزة، وجميع هؤلاء الأطفال أعمارهم أقل من 20 عامًا، وشُخِّصت إصابتهم باضطراب العين الرضحي وغير الرضحي. وأجرينا تقييمًا لحدة البصر، والملحقات، والقطاعات الأمامية والخلفية، وحركية العين، وحللنا البيانات بالإصدار 20 من برنامج SPSS. وناقشنا حالاتهم خلال الاجتماعات الأسبوعية، ووضعنا خطة إدارة حالة لكل منهم.

النتائج: من بين الأطفال الذين شملتهم الدارسة، كان 11 (48%) طفلًا مصابين برضوح بالعين (95% فاصل الثقة 27.42-68.92%)، و12 طفلًا (52%) مصابين باضطرابات عين غير الرضحية (95% فاصل الثقة 31.08-72.58%). وأما التحدي الأكثر شيوعًا في علاج هؤلاء المرضى، فهو عدم فعالية التواصل، وتجلَّى ذلك في صعوبة الحصول على المعلومات السريرية ذات الصلة في حالة 52% من الحالات. وشملت التحديات الأخرى تدهور البنى التحتية، ومحدودية عدد الموظفين المدربين، وعدم كفاءة ممرات الإجلاء.

الاستنتاجات: إن النزاع الدائر في غزة وعدم وجود مرافق تلبي احتياجات رعاية العيون بشكل كافٍ يعرضان الأطفال في غزة لخطر الإصابة بالغمش وفقدان البصر على المدى الطويل. ولذا ثمة حاجة إلى اتخاذ إجراءات متعددة الأوجه لزيادة فرص حصول الأطفال في غزة على رعاية العيون المتخصصة، ولا سيما وقف إطلاق النار الدائم، وفتح ممرات آمنة للإجلاء، وتوفير المساعدات في الوقت المناسب وبشكل آمِن، وتعزيز التدريب الطبي لمقدمي الخدمات.

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