Is the International Eye Care Community Blind to Couching?

couch’er n. Middle English couche, from Old French culche, couche, from couchier, to lay down, lie down, from Latin collocāre(American Heritage Dictionary of the English Language, 2009).

Couching is an ancient practice. The coucher, literally, one who causes the crystalline lens to “lie down,” is traditionally taught the craft by those who have practiced this ancient manipulation of the human crystalline lens. Knowledge of couching techniques, both internal and ab externo, have been carefully protected, sequestered through generations of traditional healers.

Many years ago in a city in the Horn of Africa, I was invited by a trained ophthalmic health care worker to observe a coucher and his operation. I was interested because we were seeing many blinding complications of couched eyes in our clinic. When I arrived at the place where it was to be performed, the coucher refused to demonstrate his craft, possibly believing that I had the authority to stop his work.

Knowledge can be exercised as power. Power can be an incentive for material or financial gain. Thus couching persists in some of the world’s poorest societies.

But financial gain is not the only reason that this primitive atavistic procedure continues. There is adequate documentation that modern ocular surgical services in northern Nigeria and Mali are scarce, not sufficiently accessed, or both.^1,2,3

The lead article in this issue of Ophthalmic Epidemiology, Couching in Nigeria: prevalence, risk factors and visual acuity outcomes (Gilbert, Murthy, Selvaraj et al.) documents the harmful and blinding results of couching in a population-based study.

In this well designed prevalence survey, 15,373 people were randomly enumerated and 13,582 were interviewed and examined. Nearly 43% of eyes in that survey that had undergone cataract surgery had been couched (249 of 585). None were wearing aphakic correction, and 56% of people who presented and 73% of eyes were blind by the World Health Organization definition (visual acuity <3.60). Even after refraction and visual acuities were re-measured with aphakic correction, 43% of eyes remained blind by the same definition.

Couching and its attendant complications are well known⁴ and are familiar to many who have worked in some of the world’s poorest countries. Couching is by no means limited to Nigeria.⁵ Its practice is widespread geographically, but to what extent has yet to be determined because it is shrouded in secrecy. The cumulative contribution to ocular morbidity, pain, suffering, low vision and blindness is unknown.

This important paper articulates the need for comprehensive and sustained action to educate, advocate, and implement goals of Vision 2020 to reduce the prevalence rate of blindness and low vision from cataract.

IS THE INTERNATIONAL EYE CARE COMMUNITY BLIND TO COUCHING?

Those health care planners and practitioners who believe couching is extinct should take intelligent note of this scientific article. The take away message is a clarion call to increase practical, effective and safe surgery to the underserved cataract blind community.