Kovin NaidooICEE Africa DirectorAFCO Vice-President

Optometry as part of Vision 2020: global perspective

Global Initiative to Eliminate Avoidable Blindness by the Year

2020

World Health Organisation- IAPB

• Present estimation:– 45 million people blind

+– 135 million visually disabled

• Present estimation:– 45 million people blind

+– 135 million visually disabled

Present situationPresent situation

LowLowVisionVision

BlindBlind< 6/18 - 3/60< 6/18 - 3/60<0.3 - 0.05<0.3 - 0.05

< 3/60< 3/60<0.05<0.05

Best corrected VABest corrected VA

International classification ignores the burden of uncorrected refractive errorInternational classification ignores the burden of uncorrected refractive error

World Prevalence of BlindnessWorld Prevalence of Blindness

0.4 - 0.6 0.6 - 1 > 1%> 1%< 0.4%Prevalences:Prevalences:

Prevalence of BlindnessPrevalence of Blindness

90%+ live in90%+ live inunderprivileged underprivileged

communitiescommunities

• The ‘blindness’ rate in many developing countries, especially in Africa, is 7 times higher, at 1.4%, than in developed countries

• The ‘blindness’ rate in many developing countries, especially in Africa, is 7 times higher, at 1.4%, than in developed countries

Men36%Women

64%

Men

Women

Men36%Women

64%

Men

Women

Gender is another major issue

Global Distribution of Blindness by Cause

CataractCataract42 %42 %

TrachomaTrachoma15 %15 %

GlaucomaGlaucoma14%14%

Oncho.Oncho.1 %1 %

OtherOther28 %28 %

Macular degenerationMacular degeneration

Diabetic retinopathyDiabetic retinopathy

++Refractive errorsRefractive errors

(uncorrected)(uncorrected)

Present situationPresent situation

80% of blindness is avoidable

preventableor

curable

80% of blindness is avoidable

preventableor

curable

Leading Causes of Preventable Blindness:Leading Causes of Preventable Blindness:

• Cataract

• Trachoma

• Onchoceriasis

• Childhood Blindness

• Refractive Error& Low Vision

VISION 2020VISION 2020

• Vision 2020 will strive to make refractive services and corrective spectacles affordable and available to the majority of the population through primary health care facilities, vision screening in schools and low-cost production of spectacles. Similar strategies will be adopted to provide low vision services.

• Vision 2020 will strive to make refractive services and corrective spectacles affordable and available to the majority of the population through primary health care facilities, vision screening in schools and low-cost production of spectacles. Similar strategies will be adopted to provide low vision services.

Global estimatesGlobal estimates

• Magnitude of refractive errors not reliably known

• Large global variation in prevalence (by age, gender, and race)

• Estimated: 2.3 billion people have refractive error – 1.8 billion have access to refractive services– 500 million do not have access to services

• Magnitude of refractive errors not reliably known

• Large global variation in prevalence (by age, gender, and race)

• Estimated: 2.3 billion people have refractive error – 1.8 billion have access to refractive services– 500 million do not have access to services

Sth Africa 1.0% RE:10%

Cook, 1992 (n=268)

China 4.4% Due to RE:10%

Shaozhen Li, 1999 (n=5342)

Australia 0.15% Due to

RE:25%Taylor, 1997

(n=3268)

India 2.5% Due to RE:9.6%

Dandona, 1998 (n=2522)

Saudi Arabia 0.7% RE: 5.3%

Al Faran, 1993 (n=2882)

10%+ of World

Blindness

Blindness Due To Uncorrected Refractive Errors (<3/60)

Difficulties with Current DataDifficulties with Current Data• Non-uniform definitions across

studies• Non-representative study

populations (convenience rather than population-based)

• Dissimilar demographics of study population (age and sex)

• Refraction procedures are different (with/without cycloplegia etc)

• Non-uniform definitions across studies

• Non-representative study populations (convenience rather than population-based)

• Dissimilar demographics of study population (age and sex)

• Refraction procedures are different (with/without cycloplegia etc)

Negrel, Ellwein, 2001

Uncorrected refractive error is the major cause

of:

Uncorrected refractive error is the major cause

of:blindness following mass cataract surgery using

standard power IOL

blindness following mass cataract surgery using

standard power IOL

Myopia with Autorefraction: Country ComparisonMyopia with Autorefraction: Country Comparison

Myopia with Autorefraction

4

7.3

21.6

5.67.4

1.2

0

5

10

15

20

25

SA Chile China Hyd Delhi Nepal

Countries

Perc

en

tag

e

Series1

Myopia with Autorefraction

4

7.3

21.6

5.67.4

1.2

0

5

10

15

20

25

SA Chile China Hyd Delhi Nepal

Countries

Perc

en

tag

e

Series1

Low Vision Low Vision

• 35m people worldwide have irreversible vision loss and are in need of low vision care.

• 35m people worldwide have irreversible vision loss and are in need of low vision care.

*WHO Global Initiative: Vision 2020, Feb 1999

•VISION 2020 will enable access to visual devices & low vision care at affordable cost

Treatment: Low vision care & vision correction

componentscomponents

• Disease control through service delivery

• Human resource development• Infrastructure and technology

• Disease control through service delivery

• Human resource development• Infrastructure and technology

CollaborationsCollaborations

• has created valuable and effective collaborations of organisations

• WCO until 2002 was not a part of the International Agency for the Prevention of Blindness

• has created valuable and effective collaborations of organisations

• WCO until 2002 was not a part of the International Agency for the Prevention of Blindness

Optometry a late entrantOptometry a late entrant

• It is only recently that uncorrected refractive error and even more recently low vision has achieved prominence

• Landmark population-based studies in adults, children and in post-cataract patients.

• It is only recently that uncorrected refractive error and even more recently low vision has achieved prominence

• Landmark population-based studies in adults, children and in post-cataract patients.

Optometry and Public HealthOptometry and Public Health

• Mainly private practice

• Limited discourse about public sector initiatives

• Individual Optometrists and groupings efforts

• Mainly private practice

• Limited discourse about public sector initiatives

• Individual Optometrists and groupings efforts

Public Health ChallengesPublic Health Challenges

• Integration of professions• Expansion of the scope of Optometry• Consolidation of the scope of Optometry• Charity vs Public Health• Health Policy• Health Systems development and

Management• Health Promotion

• Integration of professions• Expansion of the scope of Optometry• Consolidation of the scope of Optometry• Charity vs Public Health• Health Policy• Health Systems development and

Management• Health Promotion

Opportunity for OptometryOpportunity for Optometry

• The realisation of the impact of uncorrected refractive error and Low Vision has provided the opportunity for optometry to play a major part in alleviating vision loss for those most in need.

• The realisation of the impact of uncorrected refractive error and Low Vision has provided the opportunity for optometry to play a major part in alleviating vision loss for those most in need.

Refractive Error and Vision 2020Refractive Error and Vision 2020

• WHO established a Refractive Error Working Group (REWG), as

• The REWG is now developing international strategic plans and policies to eliminate uncorrected refractive error.

• WHO established a Refractive Error Working Group (REWG), as

• The REWG is now developing international strategic plans and policies to eliminate uncorrected refractive error.

DefinitionsDefinitions

• Children:• -Myopia: < 0.5D• -Hyperopia: 2D

• Children:• -Myopia: < 0.5D• -Hyperopia: 2D

Refractive error in Children Refractive error in Children

• -Binocular vision <6/12 is considered significant

• -Should only occur when appropriate resources for follow-up refraction and delivery of spectacles.

• -Visual acuity screening of children can be performed at community level by teachers, health care workers etc.

• -Binocular vision <6/12 is considered significant

• -Should only occur when appropriate resources for follow-up refraction and delivery of spectacles.

• -Visual acuity screening of children can be performed at community level by teachers, health care workers etc.

Refractive examsRefractive exams• Children:

• Exams should be carried out only by eyecare personnel(ECP) with the appropriate skills in objective and subjective refraction, ocular motility, basic eye examination, ability to detect potenially

blinding diseases and communication skills.

• Children:

• Exams should be carried out only by eyecare personnel(ECP) with the appropriate skills in objective and subjective refraction, ocular motility, basic eye examination, ability to detect potenially

blinding diseases and communication skills.

Minimum Standards for ChildrenMinimum Standards for Children

• -Retinoscopy plus subjective refraction, with cycloplegia for young children as needed.

• -Autorefractometry plus subjective refraction with cycloplegia

• -Retinoscopy plus subjective refraction, with cycloplegia for young children as needed.

• -Autorefractometry plus subjective refraction with cycloplegia

Refractive Correction: PriorityRefractive Correction: Priority

• -High Priority: < 6/18• -Moderate Priority: <6/12• -Low Priority: <6/9• -Children: < 6/12• -Adults: < 6/18

• -High Priority: < 6/18• -Moderate Priority: <6/12• -Low Priority: <6/9• -Children: < 6/12• -Adults: < 6/18

Priority GroupsPriority Groups

• Children aged 11-15 with myopia and people over the age of 45 years who require spectacles for near vision

• Children aged 11-15 with myopia and people over the age of 45 years who require spectacles for near vision

Not Restricted to RefractionNot Restricted to Refraction

• Integrated into the eye team and blindness prevention

• Teaching eye care personnel, especially in refraction and low vision care

• Providing screening and vision care services at secondary and tertiary levels

• Detection and management of potentially;blinding diseases such as cataract, diabetes and glaucoma

• Research into the understanding of global eyecare needs and solutions,especially in vision correction and vision care service delivery

• Building models of self-sustainable eyecare.

• Integrated into the eye team and blindness prevention

• Teaching eye care personnel, especially in refraction and low vision care

• Providing screening and vision care services at secondary and tertiary levels

• Detection and management of potentially;blinding diseases such as cataract, diabetes and glaucoma

• Research into the understanding of global eyecare needs and solutions,especially in vision correction and vision care service delivery

• Building models of self-sustainable eyecare.

Optometry's Role in Correcting Refractive Error

Optometry's Role in Correcting Refractive Error

• Public health optometry has not reached the• communities that are in most need in any

organised way. • Develop a concerted effort to create local

capacity in these communities, in collaboration with its partners in Vision 2020, through service delivery, by creating human resources and by helping to develop the infrastructure needed, the three cornerstones of the Vision 2020 programme.

• Public health optometry has not reached the• communities that are in most need in any

organised way. • Develop a concerted effort to create local

capacity in these communities, in collaboration with its partners in Vision 2020, through service delivery, by creating human resources and by helping to develop the infrastructure needed, the three cornerstones of the Vision 2020 programme.

What is Needed?What is Needed?

• Developed countries: optometrist to population ratio is 1:10,000.

• Developing countries the ratio is 1:600,000, and much worse in many rural areas, up to millions of people per optometrist.

• Developed countries: optometrist to population ratio is 1:10,000.

• Developing countries the ratio is 1:600,000, and much worse in many rural areas, up to millions of people per optometrist.

What is needed?What is needed?

• Increase in the number of eyecare personnel trained in refraction and vision correction.

• Training mid-level personnel in refractive care.

• Interim measures using nurse-refractionists or ophthalmic or optometric technicians that refract are essential.

• Increase in the number of eyecare personnel trained in refraction and vision correction.

• Training mid-level personnel in refractive care.

• Interim measures using nurse-refractionists or ophthalmic or optometric technicians that refract are essential.

STRATEGIESSTRATEGIES

Ophth., Opt., Managers

OphN., Oph.Tech, Dispensing

Opt.Com Worker, Teacher, PHCW

Vision 2020

Specialists

Mid Level

PersonnelComm.

Level

• One effective current model, developed by the LV Prasad Eye Institute in Hyderabad,

• India, for the efficient and cost-effective delivery of eyecare is a community eyecare

• ‘team’. For every 1,000,000 people the team has:

• · 1 ophthalmologist• · 4 optometrists• · 8 eyecare workers• · 8 ophthalmic assistants• · 16 ophthalmic nurses.

• One effective current model, developed by the LV Prasad Eye Institute in Hyderabad,

• India, for the efficient and cost-effective delivery of eyecare is a community eyecare

• ‘team’. For every 1,000,000 people the team has:

• · 1 ophthalmologist• · 4 optometrists• · 8 eyecare workers• · 8 ophthalmic assistants• · 16 ophthalmic nurses.

ICEE Africa“Graduation Day”Nurse Training ProgramICEE Africa“Graduation Day”Nurse Training Program

What is needed?What is needed?

• Establishment of infrastructure• Development of effective models

and• Programmes• Funding needed for the provision

of training and low cost spectacles.• Low Cost laboratories

• Establishment of infrastructure• Development of effective models

and• Programmes• Funding needed for the provision

of training and low cost spectacles.• Low Cost laboratories

• Refraction services as an integral part of general health care systems and

• comprehensive eyecare.

• Refraction services as an integral part of general health care systems and

• comprehensive eyecare.

The Role of ResearchThe Role of Research

• Adequate prevalence data determines those most in need of intervention

• Provide the basis from which interventions in the future can be evaluated

• Adequate prevalence data determines those most in need of intervention

• Provide the basis from which interventions in the future can be evaluated

AFRICAN VISION RESEARCH INSTITUTE (AVRI)

AFRICAN VISION RESEARCH INSTITUTE (AVRI)

African Vision Research Institute (AVRI) addresses

the need for Africa based eye research.

Based in South Africa it will link:• Intellectuals• Institutions• Organizations • Other personnel in the pursuit of solutions to

the various community eye health issues in Africa.

African Vision Research Institute (AVRI) addresses

the need for Africa based eye research.

Based in South Africa it will link:• Intellectuals• Institutions• Organizations • Other personnel in the pursuit of solutions to

the various community eye health issues in Africa.

• Optometry can significantly contribute to the understanding of:Worldwide blindness and impaired

vision-the burden and its effectsHealth care planningService deliveryOutcomes of intervention.

• Optometry can significantly contribute to the understanding of:Worldwide blindness and impaired

vision-the burden and its effectsHealth care planningService deliveryOutcomes of intervention.

Self-Sustainability, Refractive Error and Optometry

Self-Sustainability, Refractive Error and Optometry

• Developing the logistics and economics of self-sustaining eyecare at the

• community and institutional levels• · Mobilising worldwide resources to

develop models and create the educational and delivery infrastructure for refractive and general vision care.

• Developing the logistics and economics of self-sustaining eyecare at the

• community and institutional levels• · Mobilising worldwide resources to

develop models and create the educational and delivery infrastructure for refractive and general vision care.

Cross SubsidizationCross Subsidization

• Spectacle supply can effectively fund more expensive or

• Intensive needs such as low vision and cataract surgery.

• Refract and supply spectacles and vision care, including the

• Detection and treatment of minor problems, and referral of those with more serious problems, at the community level.

• Optometry can make a major contribution in supporting eye care at this more convenient and cost-effective level.

• Spectacle supply can effectively fund more expensive or

• Intensive needs such as low vision and cataract surgery.

• Refract and supply spectacles and vision care, including the

• Detection and treatment of minor problems, and referral of those with more serious problems, at the community level.

• Optometry can make a major contribution in supporting eye care at this more convenient and cost-effective level.

OPTOMETRY’S RESPONSEOPTOMETRY’S RESPONSE

• Public Health and Development Committee of WCO

• Vision 2020 membership• OGS• Public Health Agenda• Membership in Country of Vision

2020 committees • Involvement in the National Plan

• Public Health and Development Committee of WCO

• Vision 2020 membership• OGS• Public Health Agenda• Membership in Country of Vision

2020 committees • Involvement in the National Plan

Tanzanian OpportuntiesTanzanian Opportunties

• Community Optometry a model for the world

• Community Optometry a model for the world

• Preventable blindness is one of our most tragic and wasteful global problems.

• Optometry is an essential part of the team that will eliminate this tragedy, by understanding global eyecare needs and delivering effective and sustainable visioncare to people in need, thereby ensuring their fundamental right to sight.

• Preventable blindness is one of our most tragic and wasteful global problems.

• Optometry is an essential part of the team that will eliminate this tragedy, by understanding global eyecare needs and delivering effective and sustainable visioncare to people in need, thereby ensuring their fundamental right to sight.

• THANK YOU• THANK YOU