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Blindness Control Programs

Aravind Kumar
• Blindness
• National Programs
• Global Programs
• Conclusion
• Devastating condition
• Deep emotional and economic
implications
• Inability to perceive light
• WHO
– Best-corrected visual acuity in the better
eye less than 3/60 (Snellen)
– Field of vision less than 10°
Economic
Blindness <6/60-3/60

Social
Blindness <3/60-1/60

Legal
Blindness <1/60-PL

Total
Blindness No PL
Preventable Blindness:
Attacking at the
appropriate time
Avoidable Blindness
Curable Blindness:
Restoration by timely
intervention
• 285 million – visually impaired
• 39 million – blind
• 246 million – low vision
• 82% of blinds – 50 and above
• 50% of blinds – low-income areas
• 80% of blindness – preventable or
curable
DEVELOPING DEVELOPED
NATIONS NATIONS
Trachoma Cataract ARMD
Onchocerciasis Refractive Diabetic retinopathy
errors
Childhood blindness
Glaucoma
Xerophthalmia
Infectious diseases
Infants/ School-Age
Adulthood Late Adulthood Elderly
Preschoolers Children
Congenital and Developmental
Diabetes
Anomalies
Congenital Glaucoma Neurological Conditions Cataract
Industrial
Congenital Cataract Trauma Glaucoma
Injuries
Pathological
Optic Atrophy Retinal Vasculopathies
Myopia
Infectious
Retinoblastoma Trachoma
Diseases
Retinopathy of
ARMD
Prematurity
Xerophthalmia
• Blindness due to infections – reduced;
blindness due to age – increased
• Cataract – leading cause of blindness
• Correction of refractive errors – normal
vision for 12 million children
Inadequacy
of
ophthalmic
personnel
Disease Percentage Lack of
Man-made
availability
blindness
Cataract 62.6 of services

Refractive errors 19.7


Corneal blindness 0.9
Factors for
Glaucoma 5.8 Higher Under-
Prevalence
Surgical complications 1.2 of infection Prevalence utilization of
manpower
Posterior capsular 0.9
opacification
Posterior segment 4.7 Lack of
Rural/urban
knowledge
disorders imbalance
and concern
Others 4.2
Control of
Blindness

Strategy Disease Services Community


Strategy
Secondary Tertiary
Primary
prevention – prevention –
prevention –
visual loss from restoration of
causative disease
disease sight
Services for
Cataract Surgery

Vitamin A
Supplementation

Control of
Disease
Trachoma

Screening for
Refractive Errors

Ivermectin for
Onchocerciasis
• Primary Care – at community level
• Secondary care – at eye clinic level
Services • Tertiary care – at training or
referral center level
Community Approach

•Specific blindness measures


•Targeted populations
National Program for
Prevention and Control
of Blindness
India

Other Programs

Global Program for


Control Programs
Control of Blindness

International Association
for the Prevention of
Blindness (IAPB)
Global
Vision 2020: The Right to
Sight

Vision for the Future


“One of the basic human rights
is the right to see. We have to
ensure that no citizen goes blind
needlessly or being blind does
not remain so, if by reasonable
deployment of skill and
resources, his eyesight can be
prevented from deteriorating, or
if already lost, can be restored.”
National Policy Statement, 1975
• Launched in 1976
• 100% centrally sponsored program
• Incorporates Trachoma Program of
1968
• Decentralized in 1994 with formation of
DBCS
• Cataract Blindness Control Project
assisted by World Bank (1994-2001)
• Recent adoption of Vision 2020
• Provision of comprehensive eye care facilities
at primary, secondary, and tertiary levels
• Reduction of blindness from 1.40%-<0.3%
(as of 2004)
• Develop eye care facilities in every district
• Strengthening and upgrading RIOs into
COEs
• Improve quality of service delivery
• Develop human resources and enhance
community awareness
• Basic Program
Components
• Program organization
Plan of Action • Strategic Plan for
and Activities ‘Vision 2020’
Basic Program
Components
Extension of
Eye Health
Services

Establishment
of Permanent
Infrastructure

Intensification
of Eye Health
Education
• Done through state and district mobile ophthalmic
units
• “Eye camp approach” in rural areas
• Facilities provided:
– Medical and surgical treatment of common
ailments
– Detection and correction of refractive errors
– Thorough ocular examination, including in
children
– Rehabilitation
– Surveys
Peripheral
sector –
“primary eye
care”

Intermediate
sector –
“secondary eye
care”

Central sector –
“tertiary eye
care”

Apex National
Institute of
Ophthalmology
• Components
– Community worker
– Ophthalmic Assistant at PHC or BPHC
• Strengthened by:
– Providing necessary equipment and ophthalmic
Peripheral
assistants
sector
– Organizing refresher courses
• Services
– Treatment of common eye ailments
– Vitamin A prophylaxis
– Correction of refractive errors
• Components
– Subdivisional hospital
– District hospital
• Strengthened by:
Intermediate – Development of diagnostic and treatment facilities
sector at district and subdivisional levels
• Services
– Treatment of common causes of blindness
– Organization of MOU
– Eye camps through MOU
• Components
– Medical Colleges and RIOs
– State and National Hospitals
• Strengthened by:
Central – Upgradation of eye departments
sector – Establishment of RIOs.
• Services
– Sophisticated eye care
– Organization of eye banks
– CMEs and specialized training programs
– Research
• Dr. Rajendra Prasad Institute of
Ophthalmic Sciences, AIIMS, New Delhi
Apex National – Converted into a COE
Institute of
Ophthalmology – Overall leadership, supervision, and
guidance in matters to all services under
NPCB
• Done through mass media (IEC)
• Emphasis:
– Care and hygiene of eyes
– Prevention of avoidable diseases
• Hygiene of vision in school
– Good reading posture
– Proper lighting
– Avoidance of glare
– Maintenance of proper distance
• Cataract Surgery (2 months)
– ECCE, IOL, SICS, Phaco, Keratometry, Yag-laser
Capsulotomy
– SICS-trained surgeons proceed to Phaco
• Pediatric Ophthalmology (3 months)
– Amblyopia, Squint, Cataract, Glaucoma, and ROP
• Medical Retina and Vitreo-retinal Surgery (3 months)
– Indirect Ophthalmoscopy, Fundus Fluorescein
Angiography
• Low Vision Services (1 week)
– Handling of instruments, management of patients
• Construction of dedicated eye wards and operation
theaters
• Appointment of ophthalmic surgeons and assistants
• Ophthalmic assistants at primary health care centers
• Appointment of eye donation counselors
• Grant-in-Aid to NGOs for management of eye
ailments
• Treatment of childhood blindness
• Clearing cataract backlog from the northeastern
states
• Involvement of private practitioners
• Responsibility of National Program Management Cell,
DGHS, Govt. of India
• Bodies
– National Blindness Control Board
– National Program Coordination Committee
– National Technical Advisor Committee
• Activities
– Procurement of goods, services, and consultancy
– Aid to NGOs
– Organization of programs and IEC activities
• Implemented through State Governments
• State Program cell
– Five posts, including a Joint Director (NPCB)
• Activities
– Execution of civil works for new units
– Repair and renovation of existing units
– State Project Cell
– State-level training and IEC activities
• Functions
– Coordinate and monitor with district health societies
– Conduct regular review meetings with districts
– Procure equipment and drugs for use in GOI
– Receive and monitor use of funds, equipment, and
material
– Involve voluntary organizations
– Promote eye donation through various channels
• Formed in 1994
• “Achieve maximum reduction in avoidable blindness
through optimal utilization of available resources”
• Components
– Comprehensive Eye Care
– School Eye Service
– Community-based Rehabilitation
• Need for Establishment
– Control of blindness as part of Govt. policy
– Simplify administration and financial procedures
– Enhanced participation in both community and private
sectors
• Revised Activities
– Annual district action plan – submitted to
DBCS
– Accountability of NGO participation
– Utilization of existing govt. facilities
– Shift from camp surgery to institutional
surgery
– Infrastructure and manpower for IOL
implantation
• Functions
– Assess the magnitude and spread of blindness
in the district
– Organize screening camps
– Plan and organize training programs
– Receive and monitor use of funds
– Involve voluntary and private organizations
– Screening for schoolchildren
– Promotion of eye donation
• 307 dedicated wards and operation theaters built in
district-level hospitals
• Supply of equipment for diagnosis and treatment of
common ophthalmic ailments
• >2000 eye surgeons trained in IOL and other super-
specialties
• 50,40,336 cataract operations performed in 2006-07;
94% were with IOL implantation
– Passes the target of 45,00,000
• Increase of Cataract Surgery Rate – currently
4500/million
• Vitamin A Prophylaxis
– 2 lacs IU orally between 1-6 years
• Occupational Health Service
– Prevent and treat eye hazards in the
industrial force
• Launched by WHO in 1978
• Control Strategies
– Assessment of common blinding
disorders
– Establishment of national-level
programs
– Training of eye care providers
– Operational Research
• Established on January 1, 1975
• Coordinating, umbrella organization
• International effort for blindness
prevention activities
• Links professional bodies, NGOs,
educational institutions, and interested
individuals
• Universal Eye Health: A Global Action Plan
2014-2019
• Provision of effective and accessible eye care
• Three indicators to measure progress at the
national level:
– Prevalence and causes of Eye Impairment
– Number of eye care personnel
– Cataract surgical service delivery
• Global initiative by WHO
• February 18th, 1999
• Broad coalition with Task Force of
International NGOs
• Reduce avoidable (preventable and
curable) blindness by 2020
Objectives

Eliminate Reduce the


avoidable global burden of
blindness by 2020 blindness
• Disease Prevention and Control
• Training of Eye Health Personnel
• Strengthening of Existing Eye Care
Infrastructure
• Use of Appropriate and Affordable
Technology
• Mobilization of Resources
• Five Major Conditions
– Cataract
– Childhood blindness
– Trachoma
– Refractive Errors and Low Vision
– Onchocerciasis
• Cataract
– Aim: Decrease no. of blinds from 19M to zero
– Strategy – increase Cataract Surgery Rate (CSR)
to:
• 12 million by 2000
• 20 million by 2010
• 32 million by 2020
– Emphasis
• High success rate in restored vision
• Affordable and accessible services
• Overcome barriers and use of services
• Childhood Blindness
– Prevalence – 0.5-1 per 1000 children
– Causes – vary from place to place
– Aim – eliminate avoidable causes by 2020
– Elimination of Preventable Blindness
• Immunization against measles
• Vitamin A supplementation
• Monitoring use of oxygen in neonates
• Avoidance of harmful traditional practices
• Screening programs and eye health education
– Surgically avoidable cases – cataract, ROP, etc.
• Trachoma
– Elimination of blindness – feasible;
eradication – not feasible
– Prevention based on SAFE strategy
• S – surgery to correct lid deformity and prevent
blindness
• A – antibiotics for acute infections and
community control
• F – facial hygiene
• E – environmental changes
• Refractive Errors and Low Vision
– Screening individuals with low vision
– Refractive services
– Ensure optical services
– Low vision aids and services
• Onchocerciasis
– Endemic in 37 countries
– ‘National Onchocerciasis Control Program’
– Ivermectin in all endemic countries
• Adopted by Government of India in
2001
• Draft plan involves:
– Strengthening advocacy
– Reduction of disease burden
– Human resource development
– Eye infrastructure development
• Strengthening Advocacy
– Public awareness and information about eye
health and blindness
– Introduction of eye health in schools
– Involvement of professional organizations
– Strengthening the functioning of DCBS
– Enhance involvement of NGOs, etc.
– Strengthening hospital retrieval system for
eye donation
• Reduction of Disease Burden
– Cataract
– Childhood blindness
– Refractive errors and low vision
– Corneal blindness
– Diabetic retinopathy
– Glaucoma
– Trachoma
• Cataract
– Increase the cataract surgery rate to:
4500/million/year by 2005, 5000 by 2010,
5500 by 2015, and 6000 by 2020
– Improve visual outcomes to conform with
WHO standards
– IOL surgery for >80% by 2005 and for all by
2010
– YAG capsulotomy in all district hospitals
• Childhood blindness
– Detection of eye disorders at the time of
• Primary immunization
• School entry
• Periodic checkups every three years
– Preventable childhood blindness (trachoma,
xerophthalmia, refractive errors, glaucoma,
ROP) through cost-effective measures
– Curable childhood blindness – taken care by
experts at secondary and tertiary levels
• Refractive errors
– Refraction services made available in all
primary health centers by 2010
– Availability of low-cost, good quality glasses
for children
– Low Vision Service Centers established at
150 tertiary level centers
• Glaucoma – opportunistic screening by
tonometry and fundus exam
– Done in all persons above age 35, who
have diabetes and family history
– Community-based referral
– At eye camps in all patients above 35
• Diabetic retinopathy
– Periodic follow-up is essential
– Awareness generation
– Examination and referral to eye
surgeon by ophthalmic assistants
– Confirmation by FFA and laser
treatment
• Corneal Diseases
– Eye infections – awareness by health
education and improvement in personal
hygiene
– Avoidance of ocular trauma
– Trachoma blindness – on decline
– Prevention of xerophthalmia
– Ban on practice by quacks
– Keratoplasty and eye protection
Item 2001 2005 2010 2015 2020
Ophthalmic
12000 15000 18000 21000 25000
Surgeons
Ophthalmic
6000 10000 15000 20000 25000
Assistants
Paramedics 18000 30000 36000 42000 48000
Eye care
200 500 1000 1500 2000
managers
Community
Eye Health 20 50 100 150 200
Specialists
• Mid-level Ophthalmic Personnel – full-
time paramedics who work in eye care
– Hospital-based MLOP – nurses,
technicians, optometrists, etc.
– Community-based MLOP – primary eye
care workers and ophthalmic assistants
• Primary-level Vision Centers
– 2000, with one community-based MLOP
– Population of 50000
• Service Centers
– 2000 at secondary level
– With two ophthalmologists and 8 paramedics
• Training Centers – 200 for training
ophthalmologists
• COE – 20 with all sub-specialties in
ophthalmology
• Launched in February 2001
• Implementation by International Council of
Ophthalmology
• Top Priorities of Action:
– Enhancement of residency training
– Development of guidelines and
recommendations
– Dissemination of sample curricula
– Support for Vision 2020
– Help regional ophthalmic societies
• Blindness – heavy burden on individuals
and society
• Must be tackled from grassroots to
centralized sectors
• Programs – prevent blindness, help
people, and provide better services
• Tamomayam jayata Ekarupam
“The eye is the lamp of the body. If your eyes are good, your
whole body will be full of light.”
– The Holy Bible

BLINDNESS CONTROL PROGRAMS

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