Couching

In sub-Saharan Africa, (1),(2), (3), Sudan (4), Morocco (5), India (6), Nepal (7), China (8), and Yemen(9), couching, a method of traditional cataract treatment, is employed. As shown in the figure below, it typically involves the use of a sharp or blunt instrument to dislocate the cataract lens and push it back into the posterior chamber of the eye.(10).

Couching is the oldest traditional technique documented to treat cataracts. It was first documented and practiced in the 6th century B.C. by the Hindu surgeon Sushruta and was later adopted from India by the Greeks and Romans as well as the Egyptians, Arabs and Europeans.  It was the only method of cataract treatment until the 19th century. (11), (12)  Couching is normally performed by traditional healers, although not by most community-based healers. Couchers are observed as dominantly male and itinerant, providing minimal follow-up care.(13) ,(14)

Most literature on couching has examined the visual acuity of couched eyes and the risk factors associated with the procedure.  Studies show that couched eyes have significantly poorer vision post-operatively and are associated with a much higher incidence of complications and subsequent blindness when compared with eyes which undergo biomedical cataract surgery. Most ophthalmologists report a complete loss of sight for at least 50% of couched patients – defined as visual acuity less than 3/60 according to WHO Categories of Visual Impairment (15) – and complications such as corneal scarring, retinal detachment, secondary glaucoma, uveitis, optic nerve atrophy, and endophthalmitis. (16),(17),(18),(19) As a result, couching has been dismissed by most ophthalmologists, who have concluded that it is highly unsafe and ineffective.

However, studies suggest that in some cases, if couching is performed carefully, it can present a somewhat viable alternative to cataract surgery.(20),(21) Schrader examined 65 eyes from 48 patients from northeast Nigeria which had been treated for cataract by couching. Refractive correction for optimal vision of between -2.00 to +10.00 D was provided. Forty two of the 65 eyes examined had a corrected visual acuity of between 20/20 and 20/40 and sixteen eyes were corrected to between 20/40 and 20/200. The remaining seven eyes had a visual acuity of less than 20/200 and were associated with previous or concomitant pathology. In addition, in a prospective study which lasted 5 years, Belyaev and Barachkov reported on 68 eyes couched in a clinical setting. In 26 eyes with no previously existing pathology, vision was 20/20, whereas eyes with previous pathology had a mean visual acuity of 20/50. Complications, including capsule rupture, and secondary glaucoma occurred in only three cases.

Cases when couching is associated with good vision and few complications can be explained by Girard’s findings.(22) He completed an experiment which investigated a modified method of couching that relocated the lens using a frozen probe and zonulolytic agents like alpha-chymotrypsin. In this technique, the lens capsule and the anterior vitreous hyaloid remain intact. He showed that when the entire lens, including the capsule, is dislocated downwards and the anterior vitreous hyaloid membrane is not damaged, complications are unlikely to occur and good vision is possible.(23) Thus, one can infer from Girard’s experiment that eyes with no previous pathologic conditions that are couched carefully without damaging the anterior vitreous hyaloid can be restored to good vision after receiving refractive correction with spectacles.  Despite these observations, the number of successful couching procedures compared with successful cataract surgeries is remarkably low. The complications outweigh the possible benefits and couching is not advised as a method of treatment for cataracts.

Footnotes

(1) Gilbert C.E., Murthy, G.V.S.,  Sivasubramaniam S., Kyari F., Imam A., Rabiu M.M., Abdull M., Tafida, A. “Couching in Nigeria: Prevalence, Risk Factors and Visual Acuity Outcomes.” Ophthalmic Epidemiology. 17.5 (2010): 269-275. Accessed 11 Nov. 2010.
< http://journals1.scholarsportal.info.subzero.lib.uoguelph.ca/tmp/13642830978751295193.pdf>

(2) Ntim-Amponsah C.T. “Traditional Methods of Treatment of Cataract seen at Korle-Bu
Teaching Hospital.” West African Journal of Medicine. 14.2 (1995): 82-87.

(3) Schémann, J.F., Bakayoko, S., Coulibaly, S. “Traditional couching is not an Effective Alternative Procedure for Cataract Surgery in Mali.” Ophthalmic Epidemiology. 7.4(2000): 271-283. Accessed on 20 Nov. 2010. <http://journals1.scholarsportal.info.subzero.lib.uoguelph.ca/tmp/9175130753440011938.pdf>

(4) Ahmed Siddig, Mohamed and Ali Mohamed Ali, Nadir. “Complications of Couching and
Visual Outcome After IOL Implantation – a study of 60 patients in Sudan.”Sudanese Journal of Opthamology, 1.1 (2009): 33-36. Accessed 11 Nov. 2010. http://indexmedicus.afro.who.int/iah/fulltext/SJO/vol.1%20n1/Complications%20couching%2033-36.pdf

(5) Negrel, A.D., Chami Khazraji, Y., Azelmat M.“Cataract-related Blindness in Morocco. The Moroccan Group of Epidemiologic Evaluation of Blindness.” Medecine Tropicale” revue du Corps de santé Colonial 55.4 (1995): 421-424.

(6) Das B. “Couching: A Quackery in Cataract Surgery.” Journal of the Indian Medical Association, 52.4 (1969): 175-178. Accessed 20 Nov. 2010.
< http://www.ncbi.nlm.nih.gov/pubmed/5771210>

(7) Ahuja O.P., Kaothalkar M.S. “Bilateral Phaco-Anaphylaxis after Couching.” Journal of the All-India Ophthalmological Society. (1970): 18.4:185-186.

(8) Liu S.R., Su X.L. “Analysis of 10.686 cataract operations in Guangdong Province.”
Chuang Hua Yen Ko Tsa Chih. 28.5 (1992): 267-269.

(9)  Bamashmus, M.A. “Traditional Arabic technique of couching for cataract treatment in Yemen.” European Journal of Ophthalmology 20.2 (2010): 340:44.

(10) Merabet L.B., Wanye S. “Letter to the Editor, Eye Care in the Developing World: How soon
is now?”Optometry and Vision Science. 85.7 (2008): E608-E610. Accessed on 21 Oct. 2010. < http://journals.lww.com/optvissci/Fulltext/2008/07000/To_the_Editor__Eye_Care_in_the_Developing_World_.20.aspx>

(11) Schrader, W.E. “Traditional Cataract Treatment and the Healer’s Perspective: Dialogue with Western Sciences and Technology in Nigeria, West Africa.” Annals of African Medicine, 3.3 (2004), 1-12. Accessed 12 Dec. 2010. < https://tspace.library.utoronto.ca/bitstream/1807/4105/1/am04039.pdf>

(12) Schrader, W.E. “Traditional Cataract Treatment and the Healer’s Perspective: Dialogue with Western Sciences and Technology in Nigeria, West Africa.” Annals of African Medicine, 3.3 (2004), 1-12. Accessed 12 Dec. 2010. < https://tspace.library.utoronto.ca/bitstream/1807/4105/1/am04039.pdf>

(13) Ibid.

(14) Courtright, Paul. (2000). Collaboration with African Traditional Healers for the Prevention of Blindness. New Jersey: World Scientific Publishing.
< http://www.who.int/ncd/vision2020_actionplan/documents/cath.pdf>

(15) World Health Organization. “Change in the Definition of Blindness.” World Health Organization.  Accessed online on 20 Nov. 2010.
<http://www.who.int/blindness/Change%20the%20Definition%20of%20Blindness.pdf>

(16) Ademola-Popoola, D.S., Owoeye, J.F.A. “Traditional Couching for Cataract Treatment: A Cause of Visual Impairment.” West African Journal of Medicine. 23.3 (2004): 208-210. Accessed 23 Nov. 2010.
< http://www.ajol.info/index.php/wajm/article/viewFile/28122/21910>

(17) Gilbert C.E., Murthy, G.V.S.,  Sivasubramaniam S., Kyari F., Imam A., Rabiu M.M., Abdull M., Tafida, A. “Couching in Nigeria: Prevalence, Risk Factors and Visual Acuity Outcomes.” Ophthalmic Epidemiology. 17.5 (2010): 269-275. Accessed 11 Nov. 2010.
< http://journals1.scholarsportal.info.subzero.lib.uoguelph.ca/tmp/13642830978751295193.pdf>

(18) Schémann, J.F., Bakayoko, S., Coulibaly, S. “Traditional couching is not an Effective Alternative Procedure for Cataract Surgery in Mali.” Ophthalmic Epidemiology. 7.4(2000): 271-283.Accessedon 20 Nov. 2010. <http://journals1.scholarsportal.info.subzero.lib.uoguelph.ca/tmp/9175130753440011938.pdf>

(19) Ahmed Siddig, Mohamed and Ali Mohamed Ali, Nadir. “Complications of Couching and
Visual Outcome After IOL Implantation – a study of 60 patients in Sudan.”Sudanese Journal of Opthamology, 1.1 (2009): 33-36. Accessed 11 Nov. 2010. <http://indexmedicus.afro.who.int/iah/fulltext/SJO/vol.1%20n1/Complications%20couching%2033-36.pdf>

(20) Schrader, W.E. “Traditional Cataract Treatment and the Healer’s Perspective: Dialogue with Western Sciences and Technology in Nigeria, West Africa.” Annals of African Medicine, 3.3 (2004), 1-12. Accessed 12 Dec. 2010. < https://tspace.library.utoronto.ca/bitstream/1807/4105/1/am04039.pdf>

(21) Belyaev V., Barachkov V. "A Modern Experience with Couching for Cataract.” Annals of Ophthalmology (1982): 14.8 742-745.

(22) Girard L. “Dislocation of Cataractous Lens by Enzymatic Zonulolysis: A Suggested Solution to the Problem of the 18 Million Individuals Blind from Cataracts in Third-World Countries.” Ophthalmic Surgery. (1995): 26.4 343-345.

(23) Ibid.