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Prevention of BlindnessDr. B. Subba Rao, M.D. (Ophth) A.I.I.M.S (New Delhi)Eye SurgeonEx. Sr. Residential Eye Surgeon & RegistrarA.I.I.M.S. New DelhiTrained in Japan Under one of the world famous Eye Surgeon Dr. Akira Mamose, JapanS.K. Super Speciality Laser Eye Hospital, Kaleswara Rao Road, Suryaraopet, Vijayawada-2, A.P. IndiaPh : 0866-2433791, Cell : 9441364655*Blindness is one of the major Public Health Problem through out the World*Females are affected more than males*64% of blind people are women*Blindness not only affects the quality of life directly but also indirectly affects the family and also the society and country also.*On ethical & humanitarian grounds prevetion of blindness is must*Nearly 40 million people are blind and 290 million people are visually impaired through out the world

*1.4 million children are blind in the world*Blindness is more in poor people and also more in poor countries than in developed and rich countries*Trachoma affects 84 million people world wide*85% to 90% of blindness can be cured or prevented*River Blindness (Onchocerciasis) affects 37 million people*If you have a good organisation poverty is not a hurdIe to control blindness*Health expenditure is becoming catastrpohic in many countries. *Direct & Indirect benefits are enormous by controlling blindness*Live healthy long & productive life is the basic Human Right*Cataract is the commonest cause of blindness in almost all countries in the world.*In Sub-sahara Africa "Trachoma" is the leading cause of blindness in children*In Children, in Latin America R.O.P. is the commonest cause of blindness*2.5 lakh to 5.0 lakh children are becoming blind due to Vitamin 'A'defeciency in the world every year*In developing countries Vit A deficiency infections, Congenital Cataract are leading causes of blindness in children*2/3rd of illeterate population is women in the world*Childhood blindness is 5 times more common in developing countries than in developed countries*The Quality of life and socioeconomic conditions will improve tremendously by controlling, treating and preventing blindness

*The (GDP) Gross domestic product increases by preventing and treating blindness*Govt. should work at national level, state level and district level and community (Local) level to eradicate blindnessTop 3 blinding conditions are (1) Cataract (2) Glaucoma (3) Macular degeneration*Top 3 visual impairment conditions are (1) Refractive error (2) Cataract (3) Glaucoma*Nearly 30 billion dollars (US) are required Globally to eliminate Blindness yearly*Nearly 600 billion dollars (US) are spending on Eye care health Globally*Nearly 85% of money is used in developed countries ie about 397 billion (US) dollars

*Rehabilitation of blind people into main stream of population is very important.*90% blindness is in developing countries (ie low and middle income countries)*16% of (developed coutries) population use nearly 68% of Global halth money*Only 32% of Global health money is used by 84% of Global population*Developing countries are alloting very small amount of money from their GDP for prevention of blindness, than developed countries.*Cataract, Glaucoma, Trachama, Onchocercias is corneal opacity blindness, childhood blindness are more in developing countries.*Opticnervediseases, Retinal diseases diabetic retinopathy, age related macular degeneration, are main causes of blindness in developed countries.*Presently all information & Statistics are derived from rapid assessment method of servey*The cost effectiveness of treating and preventing blindness is many times more than the sum spend on the health programmes.*Globally by spending 5 to 8 billion dollars (Us) yearly 100 billion dollars (US) can be saved by countries ie. more than 10 times profitable.*The affected persons, the families, the society and country also improves economically by these programmes.*Non communicable cable diseases are also becoming problem.*Every effort should be made to do the health program ie "prevention of blindness" inthe world.*IAPB (International Agency for prevention of blindness) and who combine started "Vision 20-20", the right to sight program in 1999 for prevention of blindness world wide.

VISION 20-20 THE RIGHT TO SIGHTThe Service Should be :(1) Affordable (2) Accessible (3) Acceptable (4) Appropriate(Aim of Vision 20-20 : To integrate sustainable, comprehensive, high quality, equitable eye care system in to national helath care system, main focus is on (1) Cataract (2) Glaucoma (3) Refractive Errors (4) Trachoma (5) Childhood blindness (6) AMD (7) DBR ect.,

Out of 195 countries in WHO - 178 countries agreed for survey on low vision service, and survey results available only 114 countries (64%). Person providing service is also very important.It contains (1) Good Listening(2) Good behaviour(3) Empathy(4) Good Communication(5) Good advise and good education about the problem

Such type quality Eye care is needed for patient satisfactionVision lessthan 6/60 is taken as blindnessVision less than 6/12 is taken as visual impairmentVision not improved by optical, Contactlens, Medical and Surgical methods is called "Low vision"Just a pair of spectacle costing about Rs. 250 to Rs. 300/- can cure visual impairmentIndia is the first country in the world to start prevention of blindness program ie NSPB (National society for prevention of blindness).

Low vision problems are (1) Phychological depression (2) Emotional instability (3) Decreased quality of life (4) Loss of independent life (5) Difficulty in caring himself (6) Decreased mobility (7) Increasedrisk of falls & fractures (8) loss of Job & Income (9) Reduced education and professional skills etc.,Due to vision 20-20 and other programs implementation, presentlyThe blindness is decreased through out the worldIn India blindness prevalence is decreased from 1.8% to 0.8%The causes for decrease in blindness are 1 vision 20-20 program

2NSPB Program3Health awareness in the society4Education improvement5Socio economic condition improvement6Accessibility of medical services by Govt. Hospitals, Private Hospitals, NGOs New Medicines & New TechnologyEx. Azithromycin - For TrachomaIvermectin - For onchocercias is Phaco and SICS - For Cataract Surgery7New approches in implementing blindness control Programs8Practical & Effective collabaration through out the world in various organisations in prevention of Blindness.9Govt. Funding rise ad integrating eye care program in to other health programmes at community and district & regional level10 Availability of more ophthalmic nurses, optometrists, ophthalmic technicians & Ophthalmologists.Comprehensive & Holistic approach is needed to tackle this problemEach & every patient needs comprehensive eye checkup to detect and treat all the causes of avoidable blindness.

Blindness in India-Cataract is the main cause of blindness in India.-Surgery is the only treatment for cataract-Every year 3 million new cataract cases are added in the country.-Every year 6 million cataract surgeries are done in India ie in 2011-In the year 2000 - only 3 million cataract surgeries were done-In the year 1980 - only 1/2 million cataract surgeries were done

IN URBAN AREAS CATARACT IS DECREASED BUT IN RURAL AREAS CATARACT IS STILL A MAJOR PROBLEM.BLINDNESS DECREASED FROM 1.4% TO 0.8%.VIT - A - DRUG GIVING ORALLY TWICE A YEAR ELIMINATED THE XEROPHTHALMIA CONDITIONGIVING THE DRUG AZITHROMYCIN-ELIMINATED THE TRACHOMA IN MAJORITY PARTS OF INDIA.PUBLIC AND PRIVATE AGENCIES ARE DOING VERY GOOD WORK IN THE PREVENTION OF BLINDNESSTELEOPHTHALMOLOGY HELPED IN DETECTING DIABETIC RETINOPATHY CASES AND REFERING THEM TO THE HIGHER CENTERS FOR TREATMENT.TELEMEDICINE IN OPHTHALMOLOGY CONTAINS LATEST EQUIPMENT(1) FUNDUS CAMERA (PORTABLE)(2)SLITLAMP(3) TELEMEDICINE EQUIPMENT(4) CONTROL OF V.SAT CONNECTION (LINK)IN INDIA ARAVIND EYE HOSPITAL, SANKARA NETHRALAYA, NARAYANA NETHRALAYA ARE DOING TELE MEDICINE WORK IN OPHTHALMOLOGYROP (RETINOPATHY OF PREMATUITY) IS ALSO INCLUDED IN TELEMEDICINE ALONG WITH THE CO-OPERATION OF PAEDIATRICIANS AND CHILD SIGHT FOUNDATION.DEVELOPING PRIMARY EYE CARE CENTRES THROUGH OUT INDIA IS IN PROGRESS.60% OF RURAL POPULATION IS WITHOUT ACCESS FOR PROPER EYE CARE

-THE DISTRIBUTION OF BLINDNESS (ROUGHLY)CATARACT - 60%GLAUCOMA - 15%DBR - 7%CORNEAL BLINDNESS - 6%ARMD - 6%REF-ERRORS - 6%-R.O.P. IS LEADING CAUSE OF BLINDNESS IN CHILDREN IN LATIN AMERICA, AND IN INDIA ALSO IT IS BECOMING IMPORTANT CAUSE OF BLINDNESS IN CHILDREN.50% OF LATIN AMERICAN POPULATION IS BELOW POVERTY LINEINCOME TO PRIMARY EYE CARE CENTRES IS MAINLY 65% CATRACT SURGERIES - SUBSIDY RATE, 15 TO 20% ARE PAYING PATIENTS, 15 - 20% ARE FREE SURGERIES, SPECTACLES AND OTHER MEDICATIONSMANUAL SMALL INCISION CATARACT SURGERY IS THE MAIN METHOD OF SURGERY IN INDIA AND IN MANY COUNTRIES COST OF E.C.S. - IS ABOUT 100 TO 400 US DOLLARSSURGERY MSICS - 500 DOLLAR, AND PHACO IS - 1000 DOLLARS IN LATIN AMERICA L.V. PRASAD EYE INSTITUTE PYRAMID STRUCTURE OF PREVENTION OF BLINDINESS

50% OF AFFECTED POPULATION NOW LIVES IN CITIES GLOBALLYWOMEN SPEND TIME ON CARING CHILDREN, CARING OLD PEOPLE, CARING SICK PEOPLE, TIME ON KITCHEN 3 HRS/DAY IS ALL AFFECTED BY POOR VISIONGDP GROWTH RATE OF NEARLY 5% TO 10% IS ALSO AFFETED BY POOR VISION63% OF DISEASES ARE NOW A DAYS DUE TO NON COMMUNICABLE TYPE LOW VISION PROBLEMS ARE VERY SEVERE DISEASES AND PSYCHOLOGICAL DEPRESSION IS PRESENT IN LOW VISION PEOPLEHEALTH & EDUCATION, JOB CREATION, INDUSTRILISATION, ECONOMIC DEVELOPMENT ALL ARE AFFECTED BY BLINDNESSPREVENTION OF BLINDNESS PROGRAM SHOULD BE INCLUDED IN SOCIAL WELFARE PROGRAMLOW VISION CARE SERVICE, REHABILITATION SERVICE SHOULD BE INCLUDED IN EYE CARE IN EVERY HOSPITAL-Lowvision : It is a Chronic significant vision loss and vision cannot be corrected by spectacles, contact lenses, medicines or surgery is called "Low vision"-Presently in the world one ophthalmologist per one million population present but one ophthalmologist for every one lakh population is needed, Low vision cases should be referred to higher centers.-Human resources, infrastructure development, health education, multi disciplinary low vision services, strengthening existing primary & secondary health care centers by Govt & Private agencies is important Globally 85% of visual impairment is preventable training, funding, continuation in service is important Globally 55% to 85% blindness is preventable.

Training of ophthalmologist is very important it includes (1) Basic Training(2) Standard Training(3) Advanced training(4) Very advanced training (ie fellowships)Majarity Ophthalmologists are in (1) USA (2) China (3) India (4) Brazil (5) Japan (6) Russia and distribution is un equal in the world.Role of Ophththalmologist in vision 20 - 201) He is the main eye care Health Provider2) Manager in eye care service delivery3) Indentifying and priotising local eye care needs4) Advisory to Govt. & Non Govt. Policy makers in alloting funds for vision 20 - 205) Giving training to ophthalmic nurses, Technicians etc

Activities in community eye care (public health applied in ophthalmology)1) Epidemological research at community level2) Eye health promotion3) Identification of main eye disease causing blindness4) Implement appropriate strategies to reduce barriers to eye care services5) Providing equitable service for theraphy and prevention of blindness6) Include community Eye Health in P.G. Residency program7) Reduce the burden of visual impairment in the communityby Using appapriate technology & Resources 8) Locally planning & Maintaining for regular eye care services9) Providing accessibility according to local needs and make service affordable to poor peopleSOCIAL INEQUALITIES IN BLINDNESS VISUAL IMPARIRMENT AND BLINDNESS PREVALENCE DEPENDS ON VARIOUS FACTORSIN EQUALITY IN HEALTH IS AVOIDABLE UNFAIR, UNTOLERABLE & UNNECESSARY 1)GENDER : WOMEN ARE AFFECTED MORE THAN MEN2)ETHNICITY - AFRICAN COUNTRIES, ASIAN NATIONALITY COUNTRIES AND SOUTH AMERICAN COUNTRIES ARE MORE AFFECTED3)RACE - BLACKS ARE AFFECTED MORE4)GENETIC BIOLOGICAL - WOMEN ARE AFFECTED MORE DUE TO HARMONAL CAUSES5)AGE - OLD PEOPLE ARE AFFECTED MORE6)EDUCATION : LOW EDUCATION & LOW SOCIO ECONOMIC CONDITION, ECONOMICALLY POOR PEOPLE ARE MORE AFFECTED7)RURAL PEOPLE ARE AFFECTED MORE THAN URBAN PEOPLE8)OCCUPATION :- FARMERS ARE AFFECTED MORE9)ACCESS TO SERVICE :- SERVICE AVAILABITY REDUCES BLINDNESS10) INSURANCE STATUS IN BLINDNESS : PEOPLE WHO ARE HAVING INSURANCE ARE LESS AFFECTED11)Higher Income & Higher Education :- Low prevalence of blindness 12)Political context :- Stable political countries are less affected by blindness13)Greater Awareness - Less affected by blindness 14)Class people : Less affected and less incidence of blindnessEX : 1. ONCHOCERCIASIS IS MORE IN SUB-SAHARA AFRICA2.Angle closure glaucoma is more in china3. Tropical areas - Cataract is more common Ex. India4. Trachoma is more common in Africa5. Diabetic retinopathy and macular degeneration and retinal diseases - morecommon in europeans and North Americans

INDUSTRALISED COUNTRIES - LESS VISUAL IMPAIRMENT90% OF BLINDNESS PEOPLE LIVE IN LOW AND MIDDLE INCOME COUNTRIESHABITS - TOBACCO SOMKING, ALCOHOL USAGE HIGHER IN INDENCE OF VISUAL IMPAIRMENTSOLDIERS ARE MORE AFFECTED BY OCULAR TRUAMAIN INDIA TRACHOMA IS MORE COMMON IN NORTH INDIAPOVERTY EXPLOITATION, VIOLENCE INJUSTICE DISCRIMINATION, UN EMPLOYMENT, INFLUENCE, LESS POLITICAL VALUES I.E. IN THESE IS CONDITIONS BLINDNESS PREVALENCE IS MORE

21.LONG VITY OF LIFE - WOMEN LIVE LONGER THAN 80 YEARS AND AMD IS MORE COMMON IN WOMEN22.DEMOCRATIC COUNTRIES : VISUAL IMPAIRMENT IS LESS23.HIGHER CULTURAL VALUES - HIGHER POLITICAL VALUES LESS PREVALENCE24.MORE HOSPITALS BOTH GOVT. AND PRIVATE LESS PREVALENCE OF BLINDNESS 25.SOUTH AMERICANS AFFECTED MORE THAN NORTH AMERICANS26.PEOPLE WITH OTHER SYSTEM IS DISEASESPREVALENCE IS MORE27.PSYCHOLOGICAL DEPRESSION - MORE PREVALENCE OF VISUAL IMPAIRMENTPREVENTION OF BLINDNESSADVOCACY FOR EYE CARENearly four crore people are blind and by 2020 it may increase to 8 crores blind people285 million people are visually impairedAdvocasymeans - It is the way to improve eye care by better service delivery with necessary resources at every level by service providers and policy makersEye care will improve quality of life, education and productivity of countryRehabitation of blind people is not included in vision 20 - 20 program, but it is also very important1)EYE CARE FOR BELOW 20 YEARS AGE : 1/3 RD OF TOTAL PUPULATION IS BELOW 20 YEARS THIS WILL BE REACHED IN EDUCATION INSTITUTIONS2)EYE CARE FOR 20 TO 60 YEARS AGE : THIS IS THE MOST PRODUCTIVE AGE GROUP AND 50% OF TOTAL POPULATION IS IN THIS GROUPEX. : EMPLOYEE, FARMERS, OFFICERS ETC.,3)EYE CARE PROVIDER SHOULD TAKE THE SUPPORT OF A) COMMUNITY LEADERSB) VILLAGE ELDERSC) LOCAL INDUSTRIALISTSD) LEADERS OF SERVICE OGRARISATIONS EX. LIONS CLUB, ROTARY CLUB ETC.,4)Majority eye conditions are not self diagnosed by pantient except Cataract, many eye Conditions like Refractive errors, Glaucoma, Diabetic Retinopathy, Macular Degeneration should be detected by Eye specialists only5)Help from other health care providers is also importantEx. DBR : Physicians, Diabetologists, Endocrinologists, these people should refer patients to ophthalmologists ; Cong. Cataract, Squint, Nystagmus, Cong Glaucoma Paediatricians, Neonatologist, obstestricians should refer the patient to Eye specialist-Papillitis - Papilledema, Head ache cases - Neurologists should refer the cases to ophthalmologists

CORNEAL DISEASES : - REFER TO OPTHALMOLOGIST BY GENERAL PHYSICIANS AND TIMELY USE OF ANTIBIOTICS WILL HELP INREDUCING BLINDNESSTRADITIONAL LOCAL MEDICINES SHOULD NOT BE USED IN COERNAL INFECTIONS7)EDUCATION & AWARENESS CREATION AT PRIMARY LEVEL WILL REDUCE EYE MORBIDITY8)THERE IS A HUGE VARIATION IN THE SERVICE PROVIDED BY OPHTHALMOLOGISTS AND OPTHALMIC TECHNICIANS IN EYE CARE9)EYE CARE PROGRAMMES SHOULD REHABILITATE LOW VISION PEOPLE, AND BLIND PEOPLE TO LEAD NORMAL LIFE, FOR THIS THEY SHOULD BE REFERRED TO HIGHER CENTERS BY OPHTHALMOLOGISTS AND OPHTHALMIC TECHNICIANS10)BY SHARING INNOVATICE IDEAS AND METHODS YOU CAN COLLECT DATA, AND THEN DEPENDING ON DATA YOU CAN DISSIMINATE SERVICES IN THE BETTER WAY

EX. SINGLE WINDOW METHOD11)CONSISTENT AND SUSTAINED PROMOTION OF SERVICE IS NEEDED TO IMPROVE QUALITY OF LIFE12)CREATING GOOD ENVIRONMENT FOR SERVICE IS MUST - MAN POWER - RESOURCES- INFRASTRUCTURE- POLICIES - ETC13)MARKET DEVELOPMENT : ROAD CONDITIONS SHOULD BE IMPROVED BY GOVT TO REACH EYE CARE CENTRE- BARRIERS TO EYE CARE SHOULD BE REMOVED- IMPROVE HEALTH SEEKING BEHAVIOUR OF PEOPLE14)HUMAN RESOURCES IN EYE CARE IS VERY IMPORTANT- RECRUIT COMPUTER EYE CARE PROVIDERS- QUALITY OF TRAINING SHOULDBE IMPROVED- ALLOCATION OF SPECIALISTS TO RURAL AREAS SHOULD BE IMPROVEDMORE TRAINING INSTITUTES, SHOULD BE THEREEYE CARE SUPPLIER : WILL PROVIDE I.O.LS, EYE DROPS SPECTACLES, MEDICINES, DISPOSABLES, THESE SHOULD BE AVAILABLE ROUND THE TIME IN EVERY CENTRE.MOBILISING RESOURCES : NOW A DAYS 80% OF PATIENTS ARE PAYING THEMSELVES FOR THEIR SERVICE AND SUPPLIES, GOVT & NGOS SHOULD FUND THE EYE CARE PROGRAMMESRESEARCH SHOULD BE DONE ON EYE CARE SCREENING AND TRAINING PROGRAMS POLITICALLY, FINANCIALLY, TECHNICALLY, EDUCATIONALLY, GENERAL HEALTH CARE PERSONS, NGOS, HUMAN RESOURCE DEVELOPMENT : THESE ALL SHOULD BE CO-ORDINATED TO GIVE BETTER SERVICE IN EYE CAREEX : NCPB NATIONAL SOCIETY FOR CONTROL OF BLINDNESS PROGRAM IS A SUCESSFUL EYE CARE PROGRAM. BY THIS PREVALENCE OF BLINDNESS DECREASED FROM 1.4% TO 0.8% IN INDIA AND 6 MILLION CATARACT OPERATIONS ARE DONE IN 2010 & 2011TELL & SHOW THE BURDEN OF BLINDNESS TO GOVERNMENT AND INFLEUNCE THE POLITICAL & GOVT. PEOPLE TO ALL OFF MORE FUNDS FOR PREVENT BLINDNESS PROGRAMMESGLOBAL INITIATION OF VISION-20-20--- A/C to Global census 4.2% to 5% of total population is having visual impairment.--- Out of 38 million blind people 11 million people are with low vision.--- Since 1999 vision 20-20 program, prevented atleast 100 million people to become blind.--- Attention by individual Govt. of each country and corporate resources and efforts and integrating health into total health care system achieved this result.

Blind persons 39 millions +}---- 285 millions are visually impaired Low vision 246 millions --- Severe low vision means 3/60 to 6/18--- Moderate low vision means 6/60 to 6/18 Less than 3/60 vision is called blindness.Cataract is the cause for 50% of blindness and for 1/3rd of visual impairment.

Uncorrected refractive error -- 42%Cataract -- 33%Glaucoma -- 2%AMD -- 1%Corneol opacities -- 1%Trachoma -- 1%Childhood blindness -- 1%Undetermined causes -- 18%45 million blind +} to 314 million people VI

269 million low vision Presbyopia is 4 times more common than refractive error.Aged people means more than 50 years of age.Even though aged people increased by 18% , the blindness decreased by 2010.Reduced cost of I.O.L. free service , consistent and quality service reduced the cataract incidence in the world.Low vision is taken as presenting vision, instead of Best corrected vision by WHO.Refractive error and presbyopia are easily corrected by a pair of spectacles.Vision technician can examine 50 thousand people per year.

His duties are - Primary eye care - Refraction - Dispencing spectacles - Detecting sight threatening diseases and referring to higher centers.SAFE is the treatment plan for TrachomaS = Surgery for Trichiasis - 4.2 to 8 million surgeries are neededA = Antibiotics - AzithromycinF = Facial wash E = Environment improvementCATARACT --> 94 MILLION PEOPLE ARE PRESENT.TRACHOMA --> 110 TO 320 MILLION PEOPLE ARE AT RISK 150 MILLION DOSES OF AZITHROMYCIN ARE DISTRIBUTED ONCHOCERCIASIS --> 100 MILLION PEOPLE ARE AT RISK BY THIS DISEASE 3 LAKHS PEOPLE BECAME BLIND AND IVERMECTIN IS THE DRUG OF CHOICE6 LAKHS ARE VISUALLY IMPAIRED BY ONCHOCERCIASIS80 MILLION PEOPLE RECEIVED IVERMECTIN DRUG IN 1985 --1285 CATARACT SURGERIES ACCURED / MILLION POPULATIONIN 2010 -- 5300 CATARACT SURGERIES / MILLION POPULATIONUN CORR.REF.ERROR --- 120 MILLION PEOPLEUN CORR.PRESBYOPIA -- 410 MILLION PEOPLEDBR --- 3 MILLION PEOPLE TRACHOMA --- 6 MILLION PEOPLE AMD --- 3 MILLION PEOPLE A/C 2009 --- 40 MILLION PEOPLE ARE INFECTED BY TRACHOMA IN 57 COUNTRIES.- 8.2 MILLION PEOPLE ARE SUFFERING WITH TRICHIASIS.- 1.2 MILLION PEOPLE ARE BLIND DUE TO TRACHOMA.- 1.7 MILLION PEOPLE ARE VISUALLY IMPAIRED BY TRACHOMA -> INTERNATIONAL TRACHOMA INITIATION IS DISTRIBUTING AZITHROMYCIN DRUG.

VITAMIM A - BLINDNESS - DECREASED ROP - BLINDNESS - DECREASED VISION 20-20 -AIM IS - TREAT AVOIDABLE BLINDNESS AND VISUAL IMPAIRMENT BY 2020IN 2004 - DIRECT COST OF TREATMENT IS - 1.8 BILLION DOLLARS (U.S.)INDIRECT COST OF TREATMENT IS - 3.2 BILLION DOLLARS (U.S.)GLOBALLY -> 5 BILLION USD I.E., 0.6% GDPLOSS OF PRODUCTIVITY BY VISUAL IMPAIRMENT AND BLINDNESS IS 200 BILLION DOLLARS AND IT INCREASES TO 300 BILLION DOLLARS BY 2020.BY SPENDING 1.5 MILLION DOLLARS ON CATARACT AND TRACHOMA 4.5 MILLION USD CAN BE SAVED I.E., RATE OF RETURN IS 10% TO 20%.- --Allign all health programmes at country level. - Globally health workers are at shortage.Nearly 4 million people are needed.Staff recruitment, retention, motivation, deployment at rural areas, braindrain are important problems.Funding to Eye care programs.5% from NGOs5% Official development assistance25% from Government65 to 70% from patient himself.PREVENTION OF BLINDNESS:MILLENIUM DEVELOPMENT GOALS AND EYE HEALTHAim: Equitable, prosperous, healthy, safer world by 2015 Reduction of poverty and reduction of blindness:Vision 20-20 started in 1999 by WHO and IAPB i.e., the right to sight to eliminate avoidable blindness. Millenium development goals are :1. Eradicate hunger and poverty.2. Achieve universal primary education3. Empower awareness and promote equality. 4. Reduce child mortality 5. Improve maternal health 6. Combat - HIV/AIDS and malaria and T.B7. Ensure environmental sustainability 8. Develop global partnership and development Improve quality of life and quality of service Reduce global poverty Reduce global disparity between various countriesCAUSES FOR POVERTY: 1. Low income2. Less education 3. Lack of employment 4. Lack of land ownership5. Social and psycological impact6. DISABILITYDISABILITY IS THE CAUSE AND CONSEQUENCE OF POVERTY. 90% OF DISABLE PERSONS LIVE IN POVERTY.BLINDNESS IS ASSOCIATED WITH POVERTY.FOR MANY BLIND PERSONS THE ACCESS TO SERVICE IS LESSVISUAL DISABILITY IS LINKED WITH LOSS OF ECONOMIC PRODUCTIVITYANY MONEY SPENT ON VISUAL RESTORATION IS MONEY SPENT ON PRODUCTIVITY.STIGMATISATION POOR SELF ESTEEM ALL THESE CAN OCCUR DUE TO POVERTY.DISCRIMINATIONLESS SOCIAL STATUSFACIAL APPEARANCEFUNCTIONAL LIMITATION

70% OF BLINDING CASES OCCUR ABOVE 50 YEARS OF AGE.PEOPLE ABOVE 80 YEARS ARE DOUBLED SINCE 1980, BUT STILL BLINDNESS IS DECREASED DUE TO VARIOUS BLINDNESS CONTROL PROGRAMS.46% OF GIRLS HAVE NO ACCESS TO PRIMARY EDUCATION IN DEVELOPING COUNTRIES.IMMUNISATION IS 1.5 TIMES LESS IN DEVELOPING COUNTRIES THAN IN DEVELOPED COUNTRIES. WOMEN ACCESS TO HEALTH SERVICE IS 50% LESS THAN MEN.CHILDHOOD BLINDNESS CONTROL PROGRAM SHOULD BE INCLUDED IN IMMUNISATION, NUTRITION, WATER AND SANITATION AND HYGINE IMPROVEMENT PROGRAM.CRS ( CONGENITAL RUBELLA SYNDROME) AFFECTS CHILDREN 112000/YEAR/GLOBALLYWITH HEART AND OTHER SYSTEM IS PROBLEMS WITH CONG CATARACT, DEAFNESS ETC.,SO MEASLES AND RUBELLA VACCINE WITH SINGLE SHOT IS MUST TO EVERY CHILD.HIV/AIDS IS DECREASED WORLD WIDE BY 17% TO 20%.T.B IS VERY WELL CONTROLLED.TRACHOMA AND ON CHOCERCIASIS ARE VERY WELL CONTROLLED.GLOBALLY 2.6 BILLION PEOPLE ARE STILL LACK OF WATER AND SANITATIONIN 1985 - 360 MILLION PEOPLE ARE TRACHOMA PATIENTS BUT IN 2006 ONLY 86 MILLION ARE TRACHOMA PATIENTS

CATARACT GLAUCOMA THEY ALL FALL IN NON-COMMUNICABLE DISEASES.DBRAMD63% OF DEATHS ARE DUE TO NON-COMMUNICABLE DISEASES IN THE WORLD.PREVENTION OF BLINDNESSRAPID ASSESSMENT METHOD IN EYE CARE:- It is started in 1990.- For any planning, reliable information is needed especially in eye care management.- Classical methods i.e., total number of people are assessed, but this is costly method , but gives most accurate information, it is effective , reliable and this applies to all fields in life.Rapid methods are not substitute for classical method. - Rapid method is simple, less cost, reliable , usage of local sources method is needed.- Simple methods and cost effective method can be repeated every 5 to 10 years.- Why we need simple and cost effective method?Because 1. Need is high 2. Resources are little Rapid methods are complimentary to classical methods.Classical method is must in every survey For basic setup To know priority areas Time bound interventionsTo evaluate outcomesRapid methods should be logically applicable and feasible.Now a days rapid methods are used in vision 20-20 and in all health fields, presently all information and statistics are derived from rapid assessment method only.Principles of rapid assessment method :Examination is done in one day i.e., why it is called Rapid assessment method 1.Use local resources2.Simple method in sampling 3.Short and simple examination protocol 4.Less cost 5.can be repeated in 5 to 10 years.Various types of sampling methods:1.EPI (Extended Program of Immunisation ) walk method2.Random walk method 3. Compact segment sampling method.1.EPI METHOD: USED IN SMALLPOX VACCINATION NUMBER OF PEOPLE CLUSTER OF HOUSES RANDOM SELECTION OF CASESRANDOM INDIVIDUAL HOUSE UPTO EQUAL NUMBER SAMPLES DRAWBACKS: IT IS NOT TRUE METHOD - CENSUS MAY NOT BE CORRECT - SELECTION OF HOUSE IS BIAS - INSELECTED HOUSE, INDIVIDUALS MAY NOT PRESENT THOSE NOT EXAMINED MAY BE AT HIGHER RISK OR MAY BE DIFFERENT PEOPLE 2.COMPACT SEGMENT SAMPLING METHOD: This is improved cluster method than EPIselected by recent censusImportant landmark is selected with the help of local people cluster is divided into equal number of people In that one cluster is randomly selected All households in that segment are studied (so no bias in selection of house )when there is absent of people in that house revisit to that house.3. SELECTING LOCALLY RELEVANT RAPID ASSESSMENT METHOD:IT INCLUDES:1.PRIORITY CAUSES OF VISUAL IMPAIRMENT 2.AVAILABILITY OF HUMAN RESOURCES 3.AVAILABILITY OF EYE CARE SERVICES IN THAT REGION 4.NEED FOR EYE CARE SERVICE - COMPREHENSIVE EYE CARE SURVEY IS IMPORTANT- ETHICALLY NO SURVEY SHOULD BE DONE WITHOUT SERVICE PROVISION - TRAINED PEOPLE SHOULD BE USED - LONG TERM SUSTAINABILITY SHOULD BE THERE - NEW AND LOW COST EQUIPMENT SHOULD BE USED TELEMEDICINE IN DBR, GLAUCOMA, AMD ETCIN RAPID ASSESSMENT METHOD 1.VISION TEST 2.SLIT LAMP TEST BY OPHTHALMIC TECHNICIAN 3.DIRECT OPTHALMOSCOPE TEST BY TECHNICIAN TELEOPHTHALMOLOGY INCLUDES 1.SLIT LAMP 2.PORTABLE FUNDUS CAMERA3.TELE OPTHALMOLOGY EQUIPMENT

RAPID ASSESSMENT METHOD IN EYE CARE :i.)Cataract rapid assessment method results- 50% of world blindness is due to cataract- random cluster sampling method is used - universal occurence in all countries and in all races- cataract surgery is one of the most cost effective surgery - easy to recognise in the field test - First survey by Dr.Venkat Swamy in 1989 in India- information about outcome of survey and incidence.- software is used for data entry and analysisEXAMINATION PROTOCOL - SNELLEN E CHART IS USED- VISION 6/18 TO 6/60 IS CRITERIA- TORCHLIGHT IS USED FOR TESTING- UNDILATED FUNDUS EXAM - VISION LESS THAN 6/18 IS REFERRED TO HIGHER CENTER.DRAWBACKS:- BIAS IN SELECTION OF HOUSE- UNDILATED FUNDUS EXAMINATION- TORCHLIGHT TEST- AGE SELECTION - VISION CUTOFF LIMITIMPORTANT: SOFTWARE AVAILABLE FROM WHO, AUTOMATIC ANALYSIS AND NO NEED OF STATISTCIAN, LOCAL PEOPLE CAN USE THIS SOFTWAREII. RAPID ASSESSMENT OF AVOIDABLE BLINDNESS:It provides information about 1. cataract 2. un corrected refractive error3. Trachoma4. conchocerciasis5. corneal scarring 6. Glaucoma7. posterior segment diseasesinforms about - cataract surgical coverage - barriers for cataract surgery - Age of patienthigher in centre - opthalmologist will see referred casesRapid assessment method in refractive errors:It is used to see the prevalence and causes of visual impairment15 to 50 years age group is included.presmyopia is also included.visual acuity with pinhole and without pinhole is tested.standard snellen chart is used vision 6/60 to 6/18 is used for cutoffDrawbacks: over estimation of defectsposterior segment not assessed.Rapid assessment method in Trachoma:prevalence is estimated chlamydia Trachomatis is the organism for this disease. Inflammatory stage is present in childhoodnon inflammatory or scarred stage is present in adults Information is collected from hospitals, clinics and other sources.1 to 9 years children are selected crowding , lack of facial cleaning , environmental changes , poor socioeconomic conditions are common causes. Treatment is - Azithromycin.RAPID ASSESSMENT OF ONCHOCERCIASIS:presence of nodules in adult males cause - black fly - AfricaDrug of choice - invermectin(merck company)community distribution of drug in Loa parasite over reaction occurs by ivermectincomprehensive eye care is best method select priorities in public health39 million people are blind 246 million people are having visual impairmentIN VISUAL IMPAIRMENT 43% is due to refractive error 33% of VI is due to cataract Aim of vision -20-20 -- Eliminate avoidable blindness (in these eye diseases)cataract GlaucomaTrachomaun - corrected refractive error childhood blindnessonchocerciasis etc.,PREVENTION OF BLINDNESS CORNEAL BLINDNESS After cataract blindness , corneal blindness is the commonest cause of blindness in the world.5 million corneal blind people are present in the world World largest corneal blind people are in India.15 % to 30% cases are bilateral corneal blindness.20% of childhood blindness in developing countries is due to corneal blindness but in developed countries corneal blindness in childhood blindness is only 2%.80% of corneal blindness is avoidable Infections and inflammations are the commonest cause for corneal blindness.

Trauma is cause for 26% of corneal blindness Trachoma caused trichiasis, it is present in 4.5 million cases 2.5 to 5 lakh corneal blind people are added every year in the worldIn USA 150000 keratoplasty operations are performed every yearProfessional eye banking is not good, and success rate is less in IndiaMainly eight(8) eye banks are doing 31% of keratoplasty operations in India.Public awareness and donor selection should be improved Aim of vision - 2020 is to do one lakh (100000) keratoplasty operations per year in India.In DALK(Deep Anterior Lamellar Keratoplasty) Endotheteal rejection is less , results are good , followup is less, steroid induced glaucoma is less, future problems are less , maximum utilisation of cornea, storage upto one year in Glycerine media, Boston keratoprothesis is used in vascularised cornea .Future :- Infrastructure improvement , over all medical care improvement. From 1% deaths if cornea can be collected , donar problem solved and wide spread innovative sustainable methods are used to pravant and cure corneal blindnessWORLD WIDE EPIDEMIC OF DIABETIC RETINOPATHYA/C - To 2010 census 126 million diabetic people are present globally .Visual loss due to DBR is 3.2 to 7% as per 2010 census Diabetis is edemic both in developed and indeveloping countries.Nearly 30% to 35% diabetic people are having some degree of diabetic retinopathy DBR is a avoidable visual impairment37 to 56 million people are having vision threatening diabetic retinopathy- 60% visual loss of DBR is reduced by laser treatment.- prevalence of DBR - 35%- diabetic maulopathy - 8%- prevalence of prolofeative DBR - 8% - vision threatening DBR - 10% - In China 100 million diabetic people are present.

Oout of these 43% are having DBR and 6.3% are having vision threatening DBR.- Less than 30 years age is called younger diabetics.- In USA also 29% of diabetic patients are having DBR - In below 30 years age group if diabetis is present more than 10 years - DBR - 75%severe DBR - 60%prolifesative DBR - 17%- If Diabetis is present more than 25 years DBR - 97%D.maulopathy - 30%macularedema - 17%DBR progress to prolifrative DBR - 40% of cases if untreated56 million people are having vision threatening DBR globally.Blindness due to DBR - In Asia - 3.2% to 7%Blindness due to DBR - In USA - 15% to 17% VISUAL LOSS WILL AFFECT DIRECTLY THE INCOME OF PATIENT , INDIRECTLY THE FAMILY , SOCIETY, AND THE COUNTRY .90% OF PUBLIC HOSPITALS ARE NOT HAVING LASER FACILITY FOR DBR.MANY RISK FACTORS ARE PRESENT FOR DBR.EX: 1.HYPER GLYCEMIA2.DYSLIPIDEMIA3. DURATION OF DIABETIS4. HYPERTENSION5. PREGNANCY6. PUBERTY7. LIFESTYLE8. ATTITUDE AND HEALTH BEHAVIOUR9. HEALTH CARE SYSTEM AVAILABILITY10. COLLABORATION BETWEEN PHYSICIANS , DIABETOLOGISTSENDOCRINOLOGISTS, OPHTHALMOLOGISTS.In type 2 Diabetis - severe glycemic control will have more cardiac problems even though visual loss is controlled.For every one lakh population one laser ophthalmic specialist is needed , but in developing countries for every 10 lakh population one opthalmologist is available.Majority laser specialists are present in urban area only.More laser ophthalmic specialists are needed Controlling of DBR is very important.Telemedicine, Tele ophthalmology , information technology is needed to detect and treat DBR, especially in rural areas.low cost, portable fundus camera and portable lasers are needed to detect and treat dbr.

HIGH QUALITY EQUIPMENT AND WELL TRAINED OPHTHALMOLOGISTS ARE NEEDED.IN EYE CARE SERVICE DETECTION AND TREATMENT OF DBR SHOULD BE INCLUDED ALONG WITH CATARACT , GLAUCOMA AND TRACHOMA .SPECIAL HEALTH EDUCATION PROGRAMS ARE NEEDED TO DETECT DBR.FIRST IDENTIFY DBR PATIENT -> EDUCATE THE PERSON -> ANNUAL FUNDUS TEST -> GIVE LASER TREATMENT -> CONSISTENT MAINTAINANCE WITH ADEQUATE FUNDS AND HUMAN RESOURCES -> FOLLOW UP -> EYE CARE WITH QUICK AND WELL ORGANISED MANNER.EVEN IN USA 33% OF DIABETIC PATIENTS ARE NOT GETTING COMPREHENSIVE DILATED PUPIL FUNDUS EXAM.To treat every DBR patient atleast 300 to 500 US dollars are needed.Health beliefs and attitude is also important in treating DBR. Technology , resources , health care system , patient factors are important indetecting and treating DBR.Only 50% DBR people are getting treatment Lack of communication between clinicians and Ophthalmologists, lack of resources , lack of health education , lack of intime referral , lack of laser treatment facilities , lack of sustainable strategies are main causes of visual loss in DBR.PREVENTION OF BLINDNESS UNCORRECTED REFRACTIVE ERRORSThis is globally a public health problemNearly 670 million people are having refractive error and presbyopia defect Out of 670 million people, 520 million people are having presbyopia and 150 million people are having refractive error.World wide 270 billion dollars can be saved by treating VI and refractive errors.90% of uncorrected refractive error people are living in rural areas Out of 520 million people of presbyopia 410 million people are facing lot of difficulty in doing nearwork.Visual impairment leads to poor education , poor job facility , poor income.Poor socioeconomic condition is the main cause for visual impairment.Vision 2020 has included correction of refractive errors in its program.

In children 77% of cases of visual impairment is due to refractive error (globally) .In India it is 83%.When vision is less than 6/12 then it is called visual impairment .When vision is less than 6/60 , it is called severe visual impairment.Spectacles, contact lenses , refractive surgeries are main treatments.1. Primary level (community level) -> nurses eye care by->primary health care worker -> community health care workers II. Secondary level eye care by:- ophthalmic technician - optometrist- ophthalmic nurse - ophthalmic health care worker III. Teritiary level eye care by:- ophthalmologists - preandpostop follow up- Training of ophthalmic, technical persons , optometrists and ophthalmic nurses.- special training fellowship programs to ophthalmologists.

OPTOMETRIST CAN DO REFREACTION:- SPECTACLE DISPENSION - SPECTACLE MANUFACTURE - SPECTACLE SUPPLY&DISTRIBUTION - HEALTH PROMOTION - PLANNING EYE CARE PROGRAMMES-OCULARDISEASE SCREENING & REFERRAL.SPECTACLE SHOULD BE AVAILABLE AT VERY REASONABLE COSTMORE TRAINING INSTITUTIONS ARE NEEDED FOR BOTH TECHNICIANS & FOR OPTHALMOLOGISTSEFFECTIVE AND SUSTAINABLE SERVICE DELIVERY IS IMPORTANTANY CORPORATE COMPANY AIM SHOULD BE LOW COST, HIGH QUALITY SUPPLY OF SERVICE AND PRODUCT PRACTITIONERS, COMMUNITIES ALL SHOULD HELP TO TREAT REFRACTIVE ERRORS WITH COMPREHENSIVE EYE CARE SERVICEELIMINATION OF AVOIDABLE BLINDNESS DUE TO CATARACTCATARACT IS THE SINGLE LARGEST CAUSE OF BLINDNESS : THERE ARE 8 MAJOR CAUSE OF VISUAL IMPAIRMENTBLINDNESS DUE TO CATARACT IS 36% TO 89% IN THE WORLD A/C TO WHO BLINDNESS IS DEFINED AS WHEN VISION IS LESS THAN 3/60 OR 20/400A/C TO WHO VISUAL IMPAIRMENT IS DEFINED AS WHEN VISION IS 6/60 TO 6/18VISUAL IMPAIRMENT IS 8 TIMES MORE THAN BLINDNESSAGE, GENDER, ECONOMIC STATUS ARE HAVING UNIVERSAL EFFECT ON CATARACT ABOVE 50 YEARS AGE IS TAKEN TO DETECT CATARACT

0.3% TO 1% CATARACT PREVALANCE 50% CATARACT SURGERIES ARE DONE , STILL 50% CATARACT PATIENTS ARE WAITING FOR SURGERY IN THE WORLDIN CAMP SURGERIES 20% CASES ARE HAVING POOR VISION.CATRACT SURGERIES DONE X 100CATARACT SURGERY WAITING OTSINDIVIDUAL VARIATIONS ARE PRESENT IN THE CHARACTERISTICS OF GROUPIN DEVELOPING COUNTRIES ACTUAL SURGERIES DONE ARE LESS THAN THE SURGERIES SHOWN ON RECORDS.WHEN PREVALANCE IS MORE, CATARACT SURGERIES ARE ALSO MORE (LINEAR RELATIONSHIP).CATARACT SURGERY IMPROVES THE QUALITY OF LIFE IRRESPECTIVE OF CULTURAL BACK GROUND.CATARACT SURGERY SERVICES ARE REACHING MORE AND MORE NEEDY PEOPLE IN INDIA.Vision -20-20 - 8million people need cataract surgery in India.Increased awareness and its technological advancement is giving good results in cataract surgery.Adequate refraction and spectacle use after cataract surgery give more quality of life.Continued emphasis on quality in cataract surgery is the key in increased acceptance of cataract surgery service. There should be local, district, regional level planning in cataract surgery sevice (one shirt does not fit to all).Accurate data is not available where private practice is more in especially highly populated countries.Always strengthen monitary mechanism India is having NSPB(National Society for Prevention of Blindness) program , but monitoring is not good.Vision 2020 should take lead in all the countries in prevention of avoidable blindness.PREVENTION OF BLINDNESSGLAUCOMA IN DEVELOPING COUNTRIESNearly 60 million glaucoma patients are present globally.10% of blindness is due to glaucoma Glaucoma is the 3rd largest cause for blindness on the world.8.5 milion people are blind due to glaucoma.Out of 60 million patients 45 million are OAG patients and 15 million are ACG people. It is a slow progressive disease 3% of prevalance of glaucoma in general population after the age of 40 years In India OAG is more, in China ACG is more Glaucoma blind people 50% are due to OAG and 50% are due to ACG.ACG prevention is only 60% by doing laser peripheral iridotomy.

Adequate facilities should be there in every hospital to detect and treat glaucomaComprehensive eye examination is must to detect and treat every cause of avoidable blindness.This comprehensive eye examination is not done in many institutions India is a low middle income country with 800 to 1500 US dollars income/yearThe risk of glaucoma causing blindness over a period of 12 to 20 years is 14.55% to 27% uni literal and 7% to 9% biliterally in OAG cases.In India 12000 to 15000 ophthalmologists are present (working condition ?) Ocular hypertension is 3% prevalance so this also should be screened Every patient who comes for eye examination should undergo comprehensive eye exam.Govt should include glaucoma screening program in its health program along with water and sanitation , nutrition program .Comprehensive eye examination includes 1. REFRACTION 2. PUPILLARY REFLEX3. SLITLAMP EXAM4. GONIOSCOPY 5. DILATED PUPIL FUNDUS EXAMINATION (OPTIC DISC MACULA)6. INTRAOCULAR PRESSURE CHECKUPBY THIS ALLMOST ALL CASES OF AVOIDABLE BLINDNESS CAN BE DETECTED. IN MANY MEDICAL COLLAGES OPHTHALMIC SURGERY MEANS CATARACT SURGERY ONLY FOR RESIDENCY TRAINING , GLAUCOMA SURGERY SHOULD BE INCLUDED IN THE TRAINING PROGRAM OF PGS.ALL THE MEDICAL TREATMENT AVAILABLE IN THE WEST IS AVAILABLE FOR RICH PEOPLE IN INDIA , BUT THESE TREATMENTS CAN BE PROVIDED TO POORPEOPLE ALSO IF PROPERLY USED BECAUSE INDIA IS A RICH COUNTRY WITH ADED WATE RESOURCESLASER PERIPHERAL IRDECTOMY IS A PRIMARY PROCEDURE FOR ACG PATIENTS GLAUCOMA WITH CATARACT COMBINED SURGERY RESULTS BY MISCS ARE EQUAL TO PHACO TRABECULAR SURGERY.If you include any program in health care please see that adequate facilities should be provided for detection and treatment of that programm.All potentially blinding conditions should be detected and treated.Ex:- cataract , glaucoma , DBR, ARMD, childhood blindness etcAll these eye care programs should be integrated in public health programs.Glaucoma filtering surgery should be done only when IOP is more than 30 mmng and glaucoma is established, and it is going to cause blindness , because surgical mosbidity is more.Improvement in PG residency program is important.Do comprehensive eye exam to all patients Detect and treat all potentially blinding conditions.Prevention of blindness Eye conditions and blindness in childrenPriorities for research programs and policies with focus on childhood cataract:Intra uterine infections and acquired infections are the leading cause for blindness in children along with vit-A deficiency.Blindness in children is 4 to 5 times higher in developing countries than in developed countries.In developed countries the childhood blindness is mainly due to optic nerve , retinal , and higher visual pathway diseases In Latin America R.O.P is the leading cause of blindness in children.In Vietnam vit-A deficiency is the leading cause of blindness in younger children.R.O.P is increasing in India and in China also

Myopia is a leading cause of visual impairment in south east asia and china.Congenital cataract is the most treatable cause of blindness in children.male children are given more preference in treatment than female children in getting treatment in many countries , but both male and female children should get good treatment .Amblyopia is very common even after doing cataract surgery in children.If congenital cataract is present in b/e the other eye should also be operated within one to two weeks of time, otherwise amblyopia will be moreDirect cost and indirect cost of cong. cataract surgery is very high User charges should not be there in public hospitals, otherwise it is very difficult to bear the charges by old people,un employed people, disabled people.Equity in access to health care is very importantIn india eight times equal or more of monthly income is spent on health care in difficult diseases In chronic illness i/3rd of monthly income is spent in medical facilities.For pneumonia 1/2 of monthly income is spentChild health programms are very imp. by govt.Primary health care in children should include eye care.Ophthalmia Neonotarium infection control and red reflex, whiterefex detection in neonates should include in midwites training program.Health education & promotion and disease prevention and theraupeticrole is very imp. in children health programmes.In majority countries child health programs are born by Govt. funds.Quality health care service should available and accessible to all children.R.O.P screening should be included in every premature birth.Refractive errors, squint, allergic conjuctivitis should be included in childhood health programs.Research is important in child Eye care to improve results Ex. Cong. cataract and Cong. glaucoma,and amblyopia treatment etc., PREVENTION OF BLINDNESSCRITICAL ISSUES IN IMPLEMENTING LOW VISION CARE IN THE ASIA PACIFIC REGIONLow vision is a chronic Eye condition in which significant loss of vision occurs and that is not correctable to normal level with spectacles, contact lenses or surgery.To give adequate treatment to low vision people is very important.39 million people are blind, 246 million people are having low vision in the world.2/3 of low vision population resides in Asia Pacific region.Increasing aged population is also causing low vision.

THINGS NEEDED:Services should be available and these should be delivered to the needy people.Vertical and horizontal integration of services is important.Training facilities should be available to the technical person formal and informal training is needed.Infrastructure development and equipment should be provided.Advocacy and partnership with various organisations is importantTask shifting whenever neededcapacity building to serve more people.Strengthening primary level Eye care.Promoting Govt. and private partnershipA/C TO WHO LOW VISION PEOPLE ARE MAINLY Rural peopleWomenLow Socio Economic personsPeople with disability Ethnic minoritiesRefugees1. In Asia pacific region low vision services are present as morethan 10% in 5 countries only out of 25 countries.2. Low vision care is present in secondary and teritiary Eye care hospitals only.3. In the world out of 195 countries 34 countries are having low visioncare service4. 11% to 50% coverage is present only in 7% of countries.5. Majority people are missing this low vision care service due to - HIGH COST- Transport difficulty- Poor communication between patients and health care persons - Poor referal to higher centre - Long distance to go to service centreComprehensive Eye care Service is very important integrating horizontal and vertical Community based rehabilitation by Govt. and N.G.O is important.In most countries there is lack of prevalence of low vision persons and records.Strengthening Primary eye care service will help patients and their families.Simple refraction, spectacle distribution and non optical care will help a lot within the community level.Health education, social livelihood improvement, empowerment should be linked in the community.Multi disciplinary low vision care services will give significat improvement in eye care and improves quality of life and socioeconomic improvementImplementation of low vision care services to all the needy people is urgent and most important HUMAN RESOURCES AND TRAINING For every one lakh population one ophthalmologist is neededTraining of ophthalmic Tchnicians and optometrists and ophthalmic nurses is important.Short time training in the community level is also important.Funds availability and sustainability of services is importantmainly by Govt and NGOs Charitable trusts Community participationSight savers private and public sector Low vision care should be a part of social welfare programservice should be available in every Govt. and private eye hospital Network program management is important Multisectorial approach is needed at primary and district level withTechnicians , ophthalmic nurses with equipment Alliance between various eye care organisations at local level , district level , regional , country and global level is importantPREVENTION OF BLINDNESS Vision related research priorities and how to finance themThere are number of agencies in the world doing vision related research.National eye institute in USA and European comission are doing research jointly on vision NGOs are also doing research Research for profit Ex: medical companies are doing research Service organisations like Lions club , Rotary club Various eye institutions Individual philanthrophyCollaboration between various organisations is important Federal research organisation give funds directly to the investigatorNow a days federal govt. decreased funds for vision research.- National eye institute in USA is doing research on - retinal diseases - corneal diseases - cataract - Glaucoma - optic neuropathies - strabismus and amblyopia- visual procession- Low vision - Blindness rehabilitation - eye health education

Innovative research is going on on these conditions i.e., to conduct and support research.- Blinding eye diseases - visual disorders - mechanism of visual funtion- preservation of sight- special eye health problems- Requirements of blind people -Giving training and health information dissemination and other programs NATIONAL EYE INSTITUTE OF USARecently they have conducted research on ocular pain and sensitivityophthalmic geneticsadvances in optical imaging and bio medical scienceocular epidemelogyNEI solicited opinions from the following sections of people likecliniciansscientific personsmedical persons patient community To shape its research model The needs , the gaps, the oppurtunities that can be addressed by NEI EUROPEON COMMISSION IS DOING RESEARCH ON CLINICAL NEEDS VISION SCIENCE AND OPHTHALMOLOGY SCIENTISTS CLINICIANS PATIENT ORGANISATIONS ACADEMIC AND PRIVATE INSTITUTIONS COMPANIES ETC...THESE PEOPLE ARE ASKED ABOUT FUNDS FOR INNOVATIVE RESEARCHIAPB (INTERNATIONAL AGENCY FOR PREVENTION OF BLINDNESS) IS MAINLY CONCENTRATED ON VISION -2020 TO ELIMINATE PREVENTABLE AND AVOIDABLE BLINDNESS.INTERNATIONAL COUNCIL OF OPHTHALMOLOGY RESEARCH COMMITTEE IS CONCENTRATING RESEARCH ONEpidemeology risk profileOperations research Basic biological needs of peopleInternational council of ophthalmic research is doing research on Trachoma OnchocerciasisXerophthalmiaGlaucomaDiabetic retinopathyARMD (Aged Related macular Degeneration )Refractive errors.Estimate the disease Monitoring the out comes of interventions Collecting and distributing funds Showing the lessons learned during implementing the programs Getting consortium of scientists from developed and developing countriesTesting new drugs and new discoveries for applicability.All vision related communities should collaborate each other toget good result on eye research .India and USA are collaborating in many fields in prevention of blindness programs FINANCING VISION RESEARCH NEI OF USA (NATIONAL EYE INSTITUTE)NIH OF USA (NATIONAL INSTITUTE OF HEALTH )NHMRC AUSTRALIA (NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL )EUROPEAN COMMISSION MRC (UK) MEDICAL RESEARCH COUNCILARVO (ASSOCIATION OF RESEARCH ON VISION AND OPHTHALMOLOGY )ONE IN 5 I.E., 20% SUBMISSIONS ARE GETTING FUNDS AS A GRANT.ALLOCATION OF FUNDS ARE DECREASED BY GOVT. EVEN THOUGH THE INFLATION IS INCREASED.RESEARCH GRANTS DECREASED NEARLY 17% IN USA BUT THE APPLICATIONS FOR RESEARCH AWARDS ARE INCREASED THE RESEARCH PROJECT SHOULD FIT THE FUNDING PRINCIPLES THESE ARESCIENTIFIC MERIT ACHIEVABILITY REAL WORLD APPLICABILITYINSTITUTIONAL INDIRECT COSTS AND ADMINISTRATION COSTS ARE ALSO INCLUDED IN THE GRANTS, GOVT. WILL ALLOW BUT SOME INSTITUTIONS WILL NOT ALLOW THESE COSTS ON RESEARCH GRANT.FEDERAL GOVT IS THE PRIMARY FUNDING SOURCE FOR MANY RESEARCH PROJECTSNGOS (NON GOVT. ORGANISATIONSFOR PROFIT ORGANISATION EX:- MANUFACTURERS AND PHARMACEUTICAL COMPANIES THEY COLLABORATE TO DO RESEARCH ON THEIR PRODUCTS.EX:- ALCON , ALLERGAN, ABBOT ETC..INDIVIDUAL PHILANTHROPHY GIVING FUNDSNON PROFIT RESEARCH INSTITUTES FROM DONORS ON SPECIFIC RESEARCH PROJECTS OR ON SPECIFIC DISEASES OR SPECIFIC PROGRAMS.SERVICE ORGANISATIONS GIVING FUNDS LIONS CLUB INTERNATIONAL (LIONS EYE HEALTH PROGRAM )ROTARY CLUB INTERNATIONAL THEY SELECT SPECIFIC PROJECT ON LOCAL NEEDS COLLABORATION IS NEEDED BETWEEN SENIOR AND JUNIOR INVESTIGATORS AND NATIONAL AND INTERNATIONAL COLLABORATION IS NEEDED.Various fundingAdvantages TimeDisadvantages AgenciesLarge amount of funds9 monthsAllowed Other costsNET, NIH, MRC, "NHMRC, NGOs:AllowedPrevent blindnessVariable Amount of 6 monthsAllowedAmerican Assn.American Health Assn.Less funds--AllowedGlaucoma ResearchLess funds----FoundationMacular Degeneration------ FoundationPharmaceutical Huge Amount of CompaniesFundsVariableNegotiable 6.Individual Philanthrophy Variable fundsVaries No7.Service Organisations Restricted funds Restricted timeNo8.Vision children foundation Not outside U.S.A9.American Diabetic Assn.Funds both in usa & Outside10.CRVO foundation & Eye researchCrvo, RD11.ARMD FoundationARMD12.Glaucoma FoundationResearch on Glaucoma13. Helen Keller FoundationResearch on Glaucoma14.Juvenile DiabeticResearch on DBR Foundation15.Prevent Blindness America Research on Eye diseases causing vision loss16.Foundation fight blindness Research on Usher syndrome and retinal degeneration PREVENTION OF BLINDNESS CHALLENGES IN IMPROVING OUTCOMES OF CATARACT SURGERIES IN LOW AND MIDDLE INCOME COUNTRIES Cataract is the leading cause of blindness in the world Cataract surgery is the commenest surgery performed in the world 90% of cataract blindness is in low and middle income countries common causes for cataract areradiation geneticall causesDiabetis Main treatment for cataract is surgery In cataract surgery outcome we have to see visual acuity contrast sensitivity service after surgery patient own feeling

The outcome of cataract surgery is suboptimal in low and middle income countries . Inless than 5% of surgical cases only vision should be less than 6/60 or 20/200 many countries failed to reach this goal on cataract surgeries .changing surgical techniques and good training will improve results The result vary from hospital to hospital and govt. and private hospital depending on surgical technique and equipment and training .Surgical outcomes are poor in many countries.Causes for poor outcomes in cataract surgeries - Patient related causes - PCO (Posterior Capsule Opacity ) pre existing diseases - reasons are specific to each patient - post op-un corrected refractive error - service related factors - surgical complications - mainly due to human errors - equipment related Poor outcome results means poor quality of life once one patient has poor visual outcome , people in that community will not come for surgery , so good visual outcome will increase demand for more surgeries.Outcome is a part of quality eye care Follow total care pathway to improve out comes Communication between doctor, technician , patient is very important for good outcome.Human, physical, financial resources should be good LIST OF ITEMS CONSIDERED IN MEASURING OUTCOME OF CATARACT SURGERY Reading small print Ex:- news paper , telephone directory, medicine names on tablets etc- Reading large numbers - Recognising people when they are close to you- seeing steps , stairs , cleaning - reading traffic signals , symbols , street boards - Doing hard work Ex:- knitting , sewing , carpentor work etc...- Filling forms or signing cheques - Taking part in sports Ex:- bowling , handball, tennis etc...- cooking - watching television - Daytime driving - Night time driving - PATIENT FEELING ABOUT THERAPHY AND HEALTH CONDITION, VISUAL , PSYCOLOGICAL , FUNCTIONAL COMPONENTS ARE ALSO IMPORTANT - PATIENT - SATISFACTION - SYMPTOMS- VISION - HEALTH CONDITION BY THESE WE CAN ASSESS THE OUTCOME - INFORMATION MANY PEOPLE DOES NOT PROVIDE INFORMATION ABOUT THEIR SERVICE. MORE INFORMATION MEANS MORE EFFECTIVE SERVICE GOOD CLINICAL OUTCOME MEANS HIGHER QUALITY SERVICE SEVERAL FACTORS AFFECTS THE OUTCOMEHIGH COMPLICATION RATE DURING SURGERY MEANS POOR OUTCOME POOR VISUAL OUTCOME DOES NOT MEAN POOR SURGERY BECAUSE MANY CONDITIONS AFFECT THE VISION POOR SURGERY POOR TECHNIQUE COMPLICATIONS IN SURGERY THESE ARE THE CAUSES FOR POOR OUTCOMEMANAGEMENT OF COMPLICATIONS - SPECIAL SOFTWARE IS USED TO ASSESS THE OUTCOMEChallenges in improving the outcome of cataract surgery These vary depending on location of surgery Ex:- equipment - consumbales used - infrastructure - surgeon skills and other staff skills Basic low level hospitals will have poor outcome, Ex. some hospital willnot have even A scan.Procuring equipment , consumables , adequate staff , adequate funds is important to maintain quality service . Follow up and monitoring is important post op. refractive correction is important monitor patient and his visual outcome In middle income and high income hospitals, the outcomes are slightly better.- Collecting and understanding information about - patient experience - patient satisfaction is important - patient reported outcome Identity where service is required and provide that service Middle income hospitals may provide surgery service , but follow up is difficult , monitoring quality is difficultMonitoring clinical outcome is simple than monitoring records Every aspect of cataract surgery should be linked and monitored to improve outcome both clinically and record monitoring .PREVENTION OF BLINDNESS APPLYING PRINCIPLES OF HEALTH SYSTEM IN STRENG THENING EYE CAREA/C to WHO health system means all organisations , people , actions whose primary intention is to promote , to restore or to maintain health.To define health system is really difficult Increasing collaboration between global health system and local health system is important Every country has its own health system.Centralised , decentralised , mixed type , district level , local level health system is needed.After many years of research and study they have found that disease specific health system doesnot give good results.Ex:- malaria control programTrachoma control programHIV/AIDS program T.B control programComprehensive health care combining all the programs will give very good results.Vision -2020 is promoted extensively by integrating all vision services.By early detection of DBR, glaucoma they can be controlled.You should shift from vertical to horizontal system Health system should be sustainable and effective GOVERNANCE:- - policy making - allocation of budget.- selection of priorities - incentives introductionSERVICE DELIVERY :-PUBLIC SECTOR PRIVATE SECTOR NGOS EYE CARE VOLUNTEERDECENTRALISED HEALTH SYSTEM REDUCE THE DISTANCE TO PATIENTS OPHTHALMIC TECHNICIANS AND OPTOMETRISTS AVAILABILITYFINANCING :-- PRIMARY LEVEL - SECONDARY LEVEL- TERITIARY LEVEL MAINLY - RUNNING COST- CONSUMABLE COST - STAFF COST - ACTIVITIES COST - INSURANCE SYSTEM- DIFFERENT HEALTH SECTOR SPENDINGHUMAN RESOURCES MANAGEMENT:-- RECREUITMENT OF STAFF - GIVING TRAINING - DEPLOYMENT OF WORK FORCE LACK OF DRUGS AND EQUIPMENT IS ONE MAJOR FACTOR IN UNDER UTILISING THE STAFF STRENGTHENING OF HEALTH SYSTEM:-IT IS A COMPLEX SYSTEM IT SHOULD BE CONNECTED TO GENERAL HEALTH SYSTEM POLICY MAKERS AND PROGRAM MANAGERS SHOULD WORK TOGETHER - INTERNATIONALLY TESTED METHODS SHOULD BE USED INCLUDE EYE CARE SERVICE AND CATARACT SURGERY AS A FREE OF COST SOCIAL HEALTH PROGRAM RECRUIT AND TRAIN THE EYE CARE PROFESSIONALS, GOVT. SHOULD WORK AT NATIONAL , DISTRICT AND LOCAL LEVELGLOBAL COST OF ELIMINATING AVOIDABLE BLINDNESS90% OF AVOIDABLE BLINDNESS PRESENT IN DEVELOPING COUNTRIES YEARLY 30 BILLION DOLLARS IS NEEDED TO ELIMINATE AVOIDABLE BLINDNESS.592 BILLION DOLLARS WILL BE SPENT ON VISION 2020 IN THE COMING YEARSGLOBALLY IN THE NEXT FEW YEARS OUT OF THIS, 397 BILLION WILL BE USED IN DEVELOPED COUNTRIES AND REMAINING IN DEVELOPING COUNTRIES DEVELOPED COUNTRIES POPULATION IS ONLY 16% BUT 68% MONEY IS SPENT FOR DEVELOPED COUNTRIES IN DEVELOPED COUNTRIES PRIMARY EYE CARE IS MORE IMPORTANT.IN DEVELOPING COUNTRIES SECONDARY AND TERITIARY EYE CARE IS MORE IMPORTANT.BETTER DATA , BETTER INFORMATION WILL HAVE POSITIVE EFFECT ON RESULTS EACH PERSON WILL REQUIRE 6 TO 10 DOLLARS FOR AVOIDABLE BLINDNESS LIMITED DATA IS AVAILABLE ACROSS GLOBALLY- TOP 3 BLINDING CONDITIONS ARE - CATARACT - GLAUCOMA - MACULAR DEGENERATION TOP 3 VISUAL IMPAIRING CONDITIONS ARE - CATARACT - GLAUCOME - REFRACTIVE ERRORS BUILD MANY PRIMARY AND SECONDARY EYE CARE CENTRES TO REMOVE BACK LOG OF AVOIDABLE BLINDNESS INVESTMENT IS REQUIRED TO RECRUIT AND TRAINING EYE CARE PROFESSIONALS TO FILL GAP BETWEEN EXISTING INFRASTRUCTURE AND NEED FOR VISION 2020.EVERY WHERE COST OF SERVICE IN PROVIDING SERVICE DEPENDS ON 3 FACTORS COST OF LIVING (PURCHASING POWER ) WAGE LEVELS FOR HEALTH WORKERS (VARIES IN DIFFERENT COUNTRIES )10% MORE COST FOR REGIONAL AND REMOTE AREAS OF COUNTRY.VARIES IN HIGH INCOME , MIDDLE INCOME AND LOW INCOME COUNTRIES.(AUSTRALIAN DATA IS TAKEN AS AN EXAMPLE FOR HIGH INCOME GROUP COUNTRY )LIMITED DATA AVAILABLE ABOUT TRAINING COST OF HUMAN RESOURCES

- ABOUT WORK FORCE- About infrastructure - changes in data over the time - cost on developing each center- Treatment cost - for continuous improvment in developing eye care - evaluation of investment on eye care.PREVENTION OF BLINDNESS CAUSES AND LONG TERM OUTCOME ON TRAUMATIC CATARACT IN CHILDREN IN RURAL INDIAOCULAR TRAUMA IS MORE COMMON IN BOYS THAN IN GIRLS I.E., 60% BOYS AND 40% GIRLS 80% ARE CLOSED GLOBE INJURIES AND 20% ARE OPEN GLOBE INJURIES MAJORITY CHILDREN TRAUMA IS UNILATERAL IN 25% OF CASES CHILDREN AGE IS 5 TO 10 YEARS IN ANOTHER 25% CASES AGE IS 10 TO 15 YEARS 66% OF CHILDREN ARE FROM LOW SOCIOECONOMIC CONDITION AVERAGE AGE OF INJURY IS 10 YEARS POOR RESULT IS MAINLY DUE TO SHARP INJURIES AND OPEN GLOBE INJURIES.AFTER TREATMENT LESSTHAN 50% CASES WILL GET VISION 6/18 OR MORE.AVERAGE 2ND SURGERY IS 5 WEEKS AFTER FIRST INJURY HOSPITAL VISIT AFTER TRAUMA IS FROM SAME DAY TO YEARS AFTER INJURY AGRICULTURAL AND RURAL BACKGROUND IS MAJOR CAUSE FOR INJURY.

STATISTICS ARE BASED ON BINARY VISION I.E., 6/60 OR 6/18 USUALLY UNILITERAL CATARACT OCCURS BY TRAUMAMANUAL SMALL INCISION CATARACT SURGERY IS THE MAIN TREATMENT FOR TRAUMATIC CATARACT I.E., 40% CASES, AND PHACO IS USED IN 30% OF CASES.WOODEN STICK AND SHARP THORN ARE THE MAIN CAUSES FOR INJURY I.E., 40% CASES.SNELLEN CHART IS USED FOR VISUAL ASSESSMENT FOR MORETHAN 5 YR AGE CHILDREN.CARDIFF CARDS ARE USED FOR CHILDREN LESS THAN 5YR AGE.NEARLY 65% OF CASES PCO OCCURS AFTER CATARACT SURGERY DIRECT AND INDIRECT COSTS ARE MORE IN CATARACT SURGERY FOR CHILDREN IN 10% CASES POST OP IOP IS MORE AND ANOTHER 10% OF CASES UVEITIS IS MORE.THOSE WHO DONOT HAVE PCO, 50% PATIENTS HAVE MORE THAN 6/18 VISION OUTCOME DEPENDING AGE , INJURY, SURGEON , HOSPITALS ETC...VARIOUS DEMOGRAPHIC AND OCULAR FACTORS PLAY IN THE OUTCOME OF RESULTS.VERY YOUNGER CHILDREN WILL GET POOR OUTCOME BECAUSE OF SEVERE REACTION65% OF CASES OF YOUNGER CHILDREN VISION IS 6/60 OR LESS POST .OP.GIRLS HAVE POORER OUTCOME THAN BOYS EVEN THOUGH THE INJURY IS SIMILAR IOL USAGE WILL GIVE BETTER RESULTS PCO IS VERY COMMON EVEN AFTER PUTTING SQUARE EDGE IOL.PPVT WITH POST COPSULECTOMY HAVE POORER RESULTS THAN CLASSICAL TYPE OF SURGERY.GOOD EYE CARE SETUP HOSPITAL IN RURAL AREA WILL GIVE BETTER RESULTS.PREVENTION OF BLINDNESSKEY FACTORS IN DETERMINING SUCCESS OF PRIMARY EYE CARE THROUGH VISION CENTER IN RURAL INDIA PERSPECTIVE- Every service should be - accessible - affordable - available- approachable- acceptableAim of vision center is to treat avoidable blindness and vision technician is the main person in vision center His duties are :- - refraction- spectacle giving - detection of ocular diseases- refer the cases to higher center Patient satisfaction depends on many factors Patient expectations are differentOne year training is given to vision technician on primary eye carePATIENT SATISFACTION DEPENDS ON FOUR FACTORS - AMOUNT OF TIME SPENT ON VISION CHECKUP- PERSONAL CARE TAKEN BY VISION TECHNICIAN- INFORMATION AND GUIDANCE RECEIVED BY PATIENT FROM VISION TECHNICIAN.- OVERALL BEHAVIOUR AND IMPRESSION OF VISION TECHNICIAN.ONLY 29% OF PATIENTS ARE SATISFIED BY VISION CENTERS OTHER FACTORS PLAY IN - LOCATION OF VISION CENTRE PT SATISFACTION - COST AND QUALITY OF SPECTACLES - TRANSPORT TO REACH VISION CENTER - CULTURAL BACKGROUND OF PATIENT - PATIENT EXPECTATIONS - QUICKNESS IN EYE CARE DELIVERY - AWARENESS LEVEL OF HEALTH STATUS - GOOD COMMUNICATION BETWEEN DOCTOR AND PATIENTPERSONAL CARE MEANS - good listening of patient problems - good behaviour of doctor or technician - Empathy - good communication - good advice to patient and his family members - good educationHigher patient satisfaction, more patients will come for treatment Evaluate qulity eye care by patient satisfactionPREVENTION OF BLINDNESS CHANGING TRENDS IN THE PREVALANCE OF BLINDNESS AND VISUAL IMPAIRMENT IN RURAL DISTRICT IN INDIA SYSTEMATIC OBSERVATIONS OVER A DECADE Adilabad district in A.P is selected Total population in the district is 2.5 million i.e., 3% of total A.P population Agriculture is the main profession Literacy is 53% Above 50yrs age is 13% population In 1997 - 9 million blind people in India In 2010 - 6.7 million blind people in IndiaBLINDNESS IS DECREASED DUE TO - MORE CATARACT SURGERIES - MORE CONTROL OF TRACHOMA - MORE HEALTH EDUCATION - MORE SOCIOECONOMIC IMPROVMENT- MORE AVAILABILITY OF SERVICES - MORE GOVT FUNDS - MORE FACILITIES- MORE HEALTH SEEKING BEHAVIOUR- NGOS VISION 6/60 OR LESS IS DEFINED AS BLINDNESSVISION 6/60 TO 6/18 IS DEFINED AS VISUAL IMPAIRMENTPINHOLE WAS USED TO ASSESS VISION CATARACT IS MAIN CAUSE OF BLINDNESS - 1990 - 61% CASES 2007 - 72% CASES POOR VISUAL OUT COME - 1990 - 34% CASES 2007 - 17% CASES VISUAL IMPAIRMENT ---- 1990 - 40% 2007 - 14% PREVALANCE OF BLINDNESS OVER 50YRS AGE - 9.5% - 1971 - 8.5% - 2001 - 7% - 2010Aphakia - 1990 - 70% cases 2001- 16.5% cases 2010 - 5% casesCataract surgery rate - 8% in 1990 - 12% in 2007In 21% of cases of poor vision posterior segment diseases are the main cause previously camp based surgeries are more butNow a days hospital based cataract surgeres are done so visual outcome is improved. THANK YOU