VISION 2020

1
VISION 2020

• Kovin Naidoo, Allen Foster, ICEH

2
GLOBAL BLINDNESS

• What do we know?
• What is being done?
• What is VISION 2020?

3
GLOBAL BLINDNESS

• FOUR QUESTIONS
• 1. What is it? DEFINITION
• 2. How many? MAGNITUDE
• 3. Why? CAUSES
• 4. What can be done? CONTROL

4
GLOBAL BLINDNESS

• DEFINITION
• NORMAL 6/6-6/18
• VISUAL IMPAIRMENT lt6/18-6/60
• SEVERE VISUAL IMPAIRMENT lt6/60-3/60
• BLIND lt3/60
• In the better eye with available correction

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GLOBAL BLINDNESS

• FOUR QUESTIONS
• 1. What is it? DEFINITION
• 2. How many? MAGNITUDE
• 3. Why? CAUSES
• 4. What can be done? CONTROL

6
Prevalence of Blindness
EUROPE 0.3
Asia 0.7
Africa 1.0
Lat. Amer. 0.5
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HOW MANY ARE BLIND?

• ECONOMY/ BLIND /
• HEALTH CARE BLIND MILLION
• GOOD 0.25 2500
• O.K. 0.50 5000
• POOR 0.75 7500
• VERY POOR 1.00 10,000

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YEAR 2000
9
Blindness and Impaired Vision

• 45m people are blind
• 135m have impaired vision

Twice as many people will be affected by the
year 2020 unless we do something about it!
WHO Global Initiative Vision 2020, Feb
1999
10
GLOBAL BLINDNESS
BLIND (millions)
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WHY?

• More people are going blind than we are treating
  or are dying.

12
GLOBAL BLINDNESS
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ESTIMATED GLOBAL DISTRIBUTION OF BLINDNESS (1995)
(TOTAL 45 MILLION) REGION NUMBER BLIND
(MILLIONS) India 11.0 Africa 8,5 China
7,0 Rest of Asia 4,5 Eastern
Mediterranean 4,5 Latin America 3,0 Industri
alised countries 2,5 Eastern Europe 1,5 TOTAL
45,0
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MAGNITUDE OF BLINDNESS BLIND PERSON YEARS
Number blind x Average number of years a person
lives blind with this disease This is a measure
of disability over time and indicates that the
younger a person the greater the impact of
blindness and the greater the effects on the
individual and society.
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BLIND PERSON YEARS GLOBAL ESTIMATES (1995)

• Cataract 20m x 5 years 100 million blind years
• Glaucoma 6m x 10 years 60 million blind years
• Diab. retinopathy 3m x 5 years 15
  million blind years
• Child blindness 1,5m x 50 years 75 million
  blind years

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TRENDS IN AGEING POPULATION BLINDNESS

• The number of blind people is increasing in the
  poor areas of the world because of 3 major
  factors-
• Increase in population
• Increase in life expectancy
• Inadequate eye care services (contribution of
  optometrists can reverse this)

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GLOBAL BLINDNESS

• The Future?

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GLOBAL ESTIMATESVISUAL LOSS and BLINDNESS
lt3/60
45m
BLIND
25m
S.V.I.
lt6/60-3/60
110m
V.I.
lt6/18-6/60
6/6-6/18
6,000 MILLION PEOPLE
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GLOBAL BLINDNESS

• FOUR QUESTIONS
• 1. What is it? DEFINITION
• 2. How many? MAGNITUDE
• 3. Why? CAUSES
• 4. What can be done? CONTROL

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GLOBAL BLINDNESS
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GLOBAL BLINDNESS

• SUMMARY
• APPROXIMATELY 45 MILLION
• INCREASING BY 1-2 MILLION/YR
• 90 POORER AREAS OF THE WORLD
• 60 TREATABLE
• 20 PREVENTABLE

? OUT OF CONTROL ?
22
VISION 2020
Diseases
AMD and otherdiseases
Cataract RefractiveErrors
Trachoma Vit A Def Onchociasis
DiabeticRetinopathy Glaucoma
FOCAL DISEASES
MORE DIFFICULT
TREAT- ABLE
?
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GLOBAL BLINDNESS

• FOUR QUESTIONS
• 1. What is it? DEFINITION
• 2. How many? MAGNITUDE
• 3. Why? CAUSES
• 4. What can be done? CONTROL

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PREVENTION OF BLINDNESS

• PRIMARY PREVENTION
• stop disease occurring
• SECONDARY PREVENTION
• stop visual loss from established disease
• TERTIARY PREVENTION
• restore vision
• EDUCATION, TRAINING REHABILITATION

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GLOBAL BLINDNESS

• What do we know?
• What is being done?
• What is VISION 2020?

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GLOBAL BLINDNESS

• What is being done - disease control?
• Cataract surgery is increasing 10 million ops /
  yr.
• Endemic areas for Trachoma are decreasing.
• Onchocerciasis is being brought under control.
• Vitamin A deficiency is becoming less common.
• Refractive Errors and Low Vision - there is
  greater awareness of the size of the problem but
  service delivery activities are still limited.

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GLOBAL BLINDNESS

• What is being done - resources?
• Over 100 countries have established programs.
• A group of 40 non-governmental organisationscontr
  ibute approx. 100 million / year.
• Good co-ordination in VISION 2020 programme
• ministries of health
• ophthalmologists and other professional groups
• non - governmental organisations

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World Health Organisation- IAPB
Global Initiative to Eliminate Avoidable
Blindness by the Year 2020
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VISION 2020
Aim
Elimination of all Needless Blindness
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WHO-IAPB
VISION 2020 The Right to Sight
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The broader picture
Ophthalmology/Optometry Societies

• W H O Prevention
• Blindness

NGOs

• I A P B

Professional bodies
Governments
National PBL Committees

• Task force
• Vision 20/20

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GLOBAL BLINDNESS

• The Future?

33
VISION 2020
BLIND (millions)
34
Progress

• Data based on the 2002 global population show a
  reduction in the number of people who are blind
  or visually impaired, and those who are blind
  from the effects of infectious diseases, but an
  increase in the number of people who are blind
  from conditions related to longer life spans.
• This underscores the need to modify the health
  care agenda to include the management of the
  diseases that are now becoming prevalent.

35

• More than 161 million people were visually
  impaired, of whom 124 million people had low
  vision and 37 million were blind.

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GLOBAL BLINDNESS

• What is possible with todays knowledge and
  technology?

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VISION 2020

• COMPONENTS
• 1 Disease control
• 2 Infrastructure development
• 3 Human resource development

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Leading Causes of Blindness
Cataract Trachoma Childhood Blindness Refractive
Errors Low Vision
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CONTROL OF BLINDNESS - TERMINOLOGIES

• Primary prevention prevent the disease from
  occurring.
  
• Eg trachoma.
• Secondary prevention prevent loss of vision
  from established disease.
• Eg glaucoma.
• Tertiary prevention restore vision to a blind
  patient.
• Eg cataract.
  

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VISION 2020
Diseases
AMD and otherdiseases
Cataract RefractiveErrors
Trachoma Vit A Def Onchociasis
DiabeticRetinopathy Glaucoma
15
15
60
10
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MAJOR CAUSES OF BLINDNESS

• AFRICA ASIA - Cataract, trachoma, corneal
  disease, glaucoma, vitamin A deficiency
• LATIN AMERICA - Cataract, glaucoma, diabetic
  retinopathy
• NORTH AMERICA EUROPE - Macular degeneration,
  diabetic retinopathy, glaucoma

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VISION 2020

• COMPONENTS
• 1 Disease control
• 2 Infrastructure development
• 3 Human resource development

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Infrastructure

• Development of
• -Delivery systems
• -Clinics
• -Access to equipment
• -Access to consumable and appliances eg.
  Spectacle frames at affordable rates

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VISION 2020INTERNATIONAL STRUCTURE
TERTIARY
SECONDARY
PRIMARY (community eye care)
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MODEL FOR 0.5 - 1.0 MILLION POPULATION
Training Motivation
Equipment Supplies
Cataract
Ops /yr
Errors of Refraction
Refraction Spectacles
Glaucoma Diab Ret. Trachoma
Screening Control
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VISION 2020

• COMPONENTS
• 1 Disease control
• 2 Infrastructure development
• 3 Human resource development

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VISION 2020
PERSONNEL IN EYE CARE

• Ophthalmologists
• Cataract Surgeons
• Optometrists and Refractionists
• Ophthalmic Assistants / Nurses
• Community Workers
• Managers Administrative Personnel

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EYE DOCTORS / MILLION POPULATION
0
10
20
40
50
30

• AMERICAS
• EUROPE
• INDIA
• CHINA
• AFRICA

50
40
10
10
1
49
District Health SystemWHO Framework for Delivery
HEALTH DISTRICT
SPECIALIST SUPER-SPECIALIST CARE (30)
2o LEVEL CARE SPECIALISED SERVICES
NON- SPECIALIST
CLINIC
COMMUNITY HEALTH CENTRE
REGIONAL HOSPITAL
DISTRICT HOSPITAL
PROVINCIAL HOSPITAL
CLINIC
COMMUNITY HEALTH CENTRE
DISTRICT HOSPITAL
REGIONAL HOSPITAL
CLINIC
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SUMMMARY OF SERVICE DELIVERY FOR VISION 2020

• For a region of 1 000 000 population-
• Ophthalmologist/ 3 Regional clinic
• ophthalmic medical (1 per 500 000)
• officer
• Optometrist/ 2 District eye clinic
• Ophthalmic nurse (1 per 100 000)
• Clinic nurse 1 District PHC clinic (1
  per 10 000)

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CONTROL OF BLINDNESS - DILEMMAS

• Business approach or service approach
• Practice of optometry/ophthalmology or
  comprehensive eye care
• Individual approach or community approach

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CONTROL OF BLINDNESS STRATEGIES (epidemiology
of eye disease, text)

• General approach
• Disease oriented approach
• Service oriented approach
• Strategy oriented approach
• Community oriented approach

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CONTROL OF BLINDNESS - GENERAL APPROACH

• Assess needs
• Analyze resources and utilization
• Define aim
• Set objectives
• Prepare priorities and a plan
• Set targets and a timetable
• Manage resources
• Monitor performance

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CONTROL OF BLINDNESS - DISEASE ORIENTED APPROACH
Strategies to deal with individual diseases
(vertical approach) - Cataract Trachoma Glaucom
a Vitamin A deficiency Diabetic
retinopathy Onchocerciasis Refractive
errors Trauma Amblyopia Ophthalmia neonatorum
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CONTROL OF BLINDNESS - SERVICE ORIENTED APPROACH

• Primary eye care
• Secondary eye care
• Tertiary eye care
• Training - supervision - support - referral chain

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CONTROL OF BLINDNESS - STRATEGY ORIENTED APPROACH

• Promotive - Health education
• Preventive - Immunisation
• Curative - Cataract, glaucoma, refractive errors,
  diabetic retinopathy
• Rehabilitation - Assessment, education,
  integration, vocational training for incurably
  blind

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CONTROL OF BLINDNESS - COMMUNITY ORIENTED APPROACH
Services target specific groups in the
community. - Neonates - Preschool children -
School children - Working age group - Age group
45 years - Age group 65 years
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MODEL FOR A PBL PROGRAMME

• Target population -
  Varies 50 000 - 1 000 000
• Eye care team - May include ophthalmologist,
  ophthalmic medical officers, optometrists, eye
  nurses, primary health care nurses, community
  health workers, traditional healers

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MODEL FOR A PBL PROGRAMME

• Eye care materials - Equipment will be needed for
  different levels (primary, secondary, tertiary)
• Eye care delivery - Delivery of eye care can be
  performed at different levels by different
  categories (screening, selection, service
  delivery)

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SUMMARY OF SERVICE DELIVERY FOR VISION 2020 KEY
TARGETS FOR PROGRAMS
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GLOBAL CATARACT - 2000

• 25 million PEOPLE ARE BLIND
• 100 million EYES NEED SURGERY
• 10 million OPERATIONS / YEAR
• MAYBE 50 WITH IOL

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DEFINITION OF CATARACT BY VISUAL ACUITY

• 6/6 - 6/18
• lt6/18 - 6/60
• lt6/60 - 3/60
• lt3/60

Normal
Visually Impaired
S.V.I
Blind
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INCIDENCE
BACKLOG PREVALENCE
BLIND PEOPLE c CATARACT
OPERABLE EYES
CSR
MORTALITY
RECEIVED SURGERY
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GLOBAL CATARACT

• CATARACT SURGICAL RATE

65
Cataract Surgical Rates 1997 by W.H.O. Region
66
CATARACT

• Barriers
• Lack of Awareness AWARENESS
• Poor care ACCOUNTABILITY
• Cost AFFORDABILITY
• Distance ACCESSIBILITY

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CHILD BLINDNESS

• FOUR QUESTIONS
• 1. What is it? DEFINITION
• 2. How many? MAGNITUDE
• 3. Why? CAUSES
• 4. What can be done? CONTROL

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CHILD BLINDNESS

• DEFINITION
• CHILDREN 0 - 15 YRS
• SEVERE VISUAL IMPAIRMENT lt6/60-3/60
• BLIND lt3/60
• In the better eye with available correction

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CHILD BLINDNESS

• FOUR QUESTIONS
• 1. What is it? DEFINITION
• 2. How many? MAGNITUDE
• 3. Why? CAUSES
• 4. What can be done? CONTROL

70
Child Blindness / mill.pop.
EUROPE 100
Asia 200
Africa 250
Lat. Amer. 150
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HOW MANY ARE BLIND?

• ECONOMY/ /1000 BLIND /
• HEALTH CARE CHILD MILLION
• GOOD 0.25 100
• O.K. 0.50 150
• POOR 0.75 200
• VERY POOR 1.00 250

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HOW MANY ARE BLIND?

• INDIA 250,000
• CHINA 200,000
• AFRICA 200,000
• LAT.AMERICA 100,000
• INDUST. WORLD 150,000
• REST WORLD 500,000
• TOTAL 1,400,000

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CHILD BLINDNESS

• FOUR QUESTIONS
• 1. What is it? DEFINITION
• 2. How many? MAGNITUDE
• 3. Why? CAUSES
• 4. What can be done? CONTROL

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Causes of blindness in children- WHO
classification

• Where? Anatomical classification
• whole globe, cornea, lens, uvea,
• retina, optic nerve, CNS
• When? Aetiological categories
• hereditary, intrauterine, perinatal, childhood,

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CHILD BLINDNESS
Avoidable
Cataract
Corneal Scar Vit A Def Measles
Retinopathy of Prematurity
Low Vision
P.H.C.
NEONATAL UNITS
TREAT- ABLE
TERT- IARY
76
CHILDHOOD BLINDNESS

• FOUR QUESTIONS
• 1. What is it? DEFINITION
• 2. How many? MAGNITUDE
• 3. Why? CAUSES
• 4. What can be done? CONTROL

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Major Causes

• Corneal blindness
• Cataract
• Glaucoma
• Refractive error

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PRIMARY
RICH
POOR
SCAR
0
5
10
15
79
TERTIARY
R.O.P
RICH
POOR
0
5
10
15
80
TERTIARY
SECONDARY
PRIMARY
RICH
POOR
CATARACT
0
5
10
15
81
TERTIARY
SECONDARY
PRIMARY
RICH
REFRACTIVE ERROR LOW VISION
POOR
0
5
10
15
82
Every 5 seconds a person goes blind in the world
... Every minute a child goes blind.
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Major Causes

• Feeding into this funnel are major contributors
  like
• complicated measles
• Vitamin A deficiency
• Harmful Traditional Practices
• Ophthalmia Neonatorum
• Other Eye infections/corneal ulcers
• Most of these are avoidable causes of blindness.

84
GLAUCOMA

• FOUR QUESTIONS
• 1. What is it? DEFINITION
• 2. How many? MAGNITUDE
• 3. Why? CAUSES
• 4. What can be done? CONTROL

85
DEFINITION OF GLAUCOMA

• Characteristic field loss
• Cupping of the optic disc
• Association with I.O.P.

86
CHRONIC GLAUCOMAper million pop.

• EARLY MODERATE LATE BLIND
• 5,000 2,000 2,000 1,000

87
CHRONIC GLAUCOMA

• TREATMENT OF CHRONIC GLAUCOMA
• Possible Strategies
• 1 Medical therapy
• 2 Laser trabeculoplasty
• 3 Filtration surgery

88
MEDICAL

• Easy for patient
• Patient compliance often poor
• Cost high
• Efficacy uncertain

89
LASER

• Satisfactory for doctor
• Satisfactory for patient
• Efficacy wears off

90
SURGERY

• One time treatment
• Best efficacy
• Difficult for doctor
• Difficult for patient

91
TRACHOMA

• 150 Million affected around the globe
• 6 million blind or severely visually disabled
• Regions of Africa, Asia, Middle East, and parts
  of South America
• Priority countries targeted by the WHO
• Ghana, Mali, Morocco, Tanzania and Vietnam

92
Loss in Productivity

• US 5 billion per annum

93
SAFE STRATEGY

• S - Surgery
• A Antibiotics
• F Face washing
• E Environmental change

94
Onchocerciasis(River Blindness)

• Parasitic disease Onchocerca volvulus
• 18 million affected
• 500 000 severely visually impaired
• 270 000 blind

95
Location

• 27 countries in tropical Africa
• Major public health problem in West Africa
• In some African Villages blindness may be as high
  as 10 of the population
• Eye complications in more than 50 of the adult
  population

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Management

• Larvicide targets the vector
• Chemotherapy Ivermectin

97
Ivermectin Distribution Programs

• Epidemiological mapping
• Selection of communities to be treated
• Training of health personnel and primary health
  care workers
• Develop health education materials
• Plan distribution
• Monitor and evaluate activities

98
Refractive 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.

99
Impaired Vision

• 153m people worldwide have impaired distance
  vision due to the need for spectacles.

WHO Global Initiative Vision 2020, Feb
1999
100
GOALS

• To make refraction services of good quality
  available, accessible and affordable to all
• To develop human resources of appropriate nature
  which is cost effective

101
Epidemiology

• Wide Variation
• Need agreed definitions and methodologies

102
REFRACTIVE ERROR in Children 5-15 yrsNEI
studies, Ellwein, Zhao, Pokharel,Barroso, 6th,
IAPB, Beijing

• China Nepal Chile
• n selected 6134 5526 6998
• examined 96 92 75
• VA gt 0.80D 83 94 75
• Myopia at 15yrs gt 0.50D
• Females 55 3 15
• Males 37 19
• Hyperopia at 15yrs gt 2.00D 2 lt3 8
• with impairment
• NOT wearing glasses 85 ? 85

103
50 of children in African blind Institutes could
be cured with glasses
They were reading Braille by Seeing the
dots, not feeling them
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The Needs

• Build and fund optometry schools
• Disperse the current optometrists to meet rural
  and indigent needs

105
WHO GUIDELINES
106
Definitions

• Children
• Myopia lt 0.5D
• Hyperopia 2D

107
Refractive Correction Priority

• High Priority lt 6/18
• Moderate Priority lt6/12
• Low Priority lt6/9
• Children lt 6/12
• Adults lt 6/18

108
Priority Groups

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

109
Refractive error in Children

• Binocular vision lt6/12 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.

110
Screening
111
Screening

• Frequency of screening will depend on available
  resources and magnitude of the problem
• In countries where evidence indicates that the
  prevalence of significant refractive error is
  high in younger age groups, screening of these
  children should be considered.

112
Refractive 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.

113
Minimum Standards for Children

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

114
People over the age of 45

• Ready mades for near vision at the clinic level
• 6/18 or better in each eye prescribe
• lt 6/18 in each eye then refer to secondary level
• Aphakic patients ready mades at clinic level or
  refer to secondary level

115
Spectacles
116
Provision of Spectacles

• Must be Affordable and or subsidised
• Ready mades
• Should be used only if Anisometropia is less
  than 0.5D in both eyes and less than 0.75D
  astigmatism in both eyes. Prism limit is 0.5D

117
Provision of Spectacles

• Ready mades can meet the needs of up to 70 of
  the communities
• Recycling not a cost effective program

118
Human Resources

• Need trained and equipped personnel to implement
  refractive services at the community, mid level
  and specialist level of health care

119
STRATEGIES
Vision 2020
Ophth., Opt., Managers
Specialists
OphN., Oph.Tech, Dispensing Opt.
Mid Level Personnel
Com Worker, Teacher, PHCW
Comm. Level
120
Coordination and Research

• Need for collaboration between government,
  non-government and private sectors
• Research into assessment, cost-effectiveness of
  interventions, and outcome measurement

121
Establishing Numbers

• No individual is employed only for refraction
  therefore this should be factored into our
  calculations
• We need to promote integrated health care teams
  and ensure that different health care
  professionals at different levels of the health
  care system collaborate eg. Nurse screening and
  referring for refraction to an optometrist
• If no formal district health system we can still
  use primary secondary and tertiary centers as a
  guideline for allocation of human resources

122
NGDOs and PROFESSIONAL ASSOCIATIONS IN REFRACTION

• Useful in alleviating backlogs
• Co-ordination of NGDOs is useful in ensuring the
  maximum use of existing resources.
• They should serve those parts of the country
  where there is a shortage of skills
• Training of personnel should be encouraged so
  that long terms sustainability is ensured.

123
Low Vision

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

Treatment Low vision care vision correction

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

WHO Global Initiative Vision 2020, Feb
1999
124
Definition of Low Vision

• LV corresponds to visual acuity of less than
  6/18(0.3) but equal to or better than 3/60(0.05)
  in the better eye with the best possible
  correction (WHO 1997)

125
Objective of Low Vision Programme

• Elimination of visual impairment less than
  6/18(20/60) but better than 3/60 with the best
  conventional correction in the better eye and/or
  a visual field of 10 degrees from the point of
  fixation, by providing services for individuals
  with low vision

126
Aim of Low Vision Services

• To reduce the time individuals spend with visual
  disability by providing optical and low vision
  services

127
Components of a Low Vision Service

• Provision of devices
• Orientation and Mobility Services
• Understand the environment and then acquire the
  skills to be mobile within this environment

128
Human Resources

• Ophthalmologists
• Optometrists
• Orientation and Mobility Officers

129
Priority Groups for service

• Children
• Older personsgt60 years of age

130
Low Vision Aids

• Cost a limiting factor
• The basic low vision aids
• Hand held magnifiers
• Stand magnifiers
• Telescopes

131
Conclusion

• Given the priorities of Vision 2020 Optometry can
  play a particularly significant role in
  Refractive Error and Low Vision as well as in the
  co-management of patients with cataracts and low
  vision.