Refractive Error: The African Situation

Daveena Brain: ICEE Africa Program Manager

Refractive Error: The African Situation

Daveena Brain: ICEE Africa Program Manager

AFRICAAFRICA

Issues confronting AfricaIssues confronting Africa

• Data • Human Resources• Infrastructure• Access to technology and

spectacles

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)

Negrel, Ellwein, 2001

Negrel et al. (1995)Blindness in BeninNegrel et al. (1995)Blindness in Benin

• Population based study: 7047 examined

• Prevalence of blindness: 0.6%• 9.6% of blindness is due to

refractive errors

International Centre for Eyecare Education

0.7%

Blindness < 3/60: Low vision (best acuity 6/24 - 3/60):

1.4%

(11% due to RE)AFRICA: The Gambia

Faal et al., 1989

Need for Basic Est. no. of peopleOphthalmic Services in need of treatmentCataract surgery 5,500Eyelid surgery 4,600

Need spectacles (distances) 4,600*Medical eye treatment 83,000

Other surgical or medical treatment 6,500

Need for Basic Est. no. of peopleOphthalmic Services in need of treatmentCataract surgery 5,500Eyelid surgery 4,600

Need spectacles (distances) 4,600*Medical eye treatment 83,000

Other surgical or medical treatment 6,500

*Does not include presbyopes who may need spectacles for close work,or those needing glasses after cataract surgery.

EthiopiaZerihun & Mabey(1997) EthiopiaZerihun & Mabey(1997)

• Population based: 7423 examined• Blindness: 0.85%• Low Vision(<6/18-3/60): 1.7% • 28.8% of low vision due to RE

• Refractive Errors study in Urban schools in Moshi (B. Shilio)

•<6/9 11.8%•<6/12 2.2%•<6/18 1.9%•< 6/18-6/60 1.6%•< 6/60 0.12%

DISEASES

CATARACT

REFRACTIVEERRORS

TRACHOMA

VIT A DEF

ONCHOCERCIASIS

DIABETIC

RETINOPATHY

GLAUCOMA

OTHER

DISEASES

50 -60 % < 5 % 15 - 20 % 10 - 15 %

South AfricaSouth Africa

Blindness =1.0%

Low vision= 1.4%

FACTORS AFFECTING BLINDNESSPREVALENCE IN KwaZulu, SOUTH AFRICA

Cook et al, 1993

6,090 screened268 full exam

10% of blindness due to refractive errors

Only 11.8% of people with RE had spectacles

REFRACTIVE ERROR STUDY IN CHILDREN(AFRICA)

Purpose:• assess the prevalence of vision

disorders in children 5-15 years(5599 enumerated)• address the issue of access of care in several settings

4890 Children ExaminedUrban to semi urban area

Myopia: < 0.50DHyperopia: >2D

4890 Children ExaminedUrban to semi urban area

Myopia: < 0.50DHyperopia: >2D

Myopia vs Hyperopia: RESCAMyopia vs Hyperopia: RESCAMyopia Hyperopia

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PROJECTIONS FOR AFRICAPROJECTIONS FOR AFRICA

Country Population Total RE

10% Myopia 4%

Hyperopia 2.6%

Presbyopia 50% of +40 yrs (est 24% of pop +40)

Sub-Saharan Africa

702.6 million 70.2 million 28,104,000

18,267,600 168.62 million

Nigeria 123,338 000 12,334 000 4, 934 000 3,207 000 29,601,000 Ghana 19, 534 000 1, 953 000 781 342 508 000 4,688, 000 Kenya 30, 340 000 3, 034 000 1,214 000 789 000 7,281, 000 Tanzania 35,306 000 3, 531 000 1,412 000 918 000 8,473, 000 South Africa

44,820 000 4,482 000 1,793 000 1,165 000 10,757 000

People needing SpectaclesPeople needing Spectacles

• 10% of population• 70.2 million need correction• 7.2 million have correction• 63 million do not have correction

in Sub Saharan Africa

Projected Situation for TanzaniaProjected Situation for Tanzania

• Population 35,306 000• Estimated refractive error 3.5

million• Children 0-14 45% population,

15.9mill– Est Myopia – 636,000 – Est Hyperopia – 413,400

• Estimated presbyopia 8,4 million

• HUMAN RESOURCES

WHO Provides the Services?WHO Provides the Services?

• Ophthalmologists• Optometrists• Ophthalmic Nurses• Ophthalmic Assistants

REFRACTIONISTS: SUB-SAHARAN AFRICA

• 2004 2020*

•Population 703m 1400m•Eye Exams Needed (10%) 70.3m 140m

•Refractionistsneeded (1:100 000)70,000 140,000

• Current 7,000 11,000

• Extra needed 63,000 129,000

AFRICA: The Needs by 2020

Need : Need : 129,000 129,000

“refractionists”“refractionists”

Tanzania Tanzania

• Has the largest percentage of Optometrists in the public sector of any country in the world

• The infrastructure present at KCMC means that significant advances and improvements in eyecare for the people of Tanzania can be achieved

SpectaclesSpectacles

SPECTACLESSPECTACLES

• Inaccessible

• Complicated delivery systems

• Expensive

SPECTACLES: NEEDSSPECTACLES: NEEDS

• LOW COST• READY MADES• DECENTRALISED OPTICAL LABS• COLLOBARATIVE BUYING TO

REDUCE COSTS: – ICEE/SIGHTSAVERS MODEL

The ICEE ResponseThe ICEE Response

• Community Optometrist Model: Unique due to number of public sector optometrists

• Refraction Training• Train the Trainer• Low Cost Spectacles• Research: understand the problem and

develop alternative approaches– Situational Analysis

• THANK YOU

Hyperopia with Autorefraction: MulticountryHyperopia with Autorefraction: Multicountry

Hyperopia with Autorefraction

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Myopia with Autorefraction: Country ComparisonMyopia with Autorefraction: Country Comparison

Myopia with Autorefraction

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Country Population Total RE

10% Myopia 4%

Hyperopia 2.6%

Presbyopia 50% of +40 yrs (est 24% of pop +40)

Nigeria 123,337,822 12,333,782 4,933,512 3,206,783 14,800,538 Ghana 19,533,560 1,953,356 781,342 507,872 2,344,027 Kenya 30,339,770 3,033,977 1,213,590 788,834 3,640,772 Tanzania 35,306,126 3,530,612 1,412,245 917,959 4,236,735 South Africa 44,819,778 4,481,977 1,792,791 1,165,314 5,378,373 Sub-Saharan Africa

702.6 million 28,104,000 18,267,600

Number of Ophthalmologists and OMAsNumber of Ophthalmologists and OMAs

• Optometrists: – SA: 2100– Nigeria: 1100– Tanzania: 350– Ghana: 75– Kenya: 10– Zimbabwe: 20

• 1589 Ophthalmologists(47/million pop/21 countries x 703 million)

• 3620 OMAs(103/20x703 M)• Extra 250 per year

WEST AFRICAWEST AFRICA

• OPHTHALMOLOGISTS• OPHTHALMIC NURSES/ASSISTANTS• NO OPTOMETRISTS

OPTOMETRISTSOPTOMETRISTS

• Untapped Resources

• Need to bring them into the system

Current ProgramsCurrent Programs

• Nigeria: 600 optometrists and 200 ophthalmologists

• South Africa: 2000, only 30 in the Public sector

• Tanzania: 170 optometrists, 30 Ophthalmologists

• Other countries with programs: Ghana, Sudan

What is Needed?What is Needed?

• Flexible Approach: Mobilise all e• Utilise available resources• Integrate into a longterm strategy• Multiple Approaches• Affordability• Comprehensive Eye Care plan• Sustainability