Vision 2020, the Right to Sight: What can a general medical officer do?

This article focuses on what a general medical officer can contribute to VISION 2020 in a low-income country. VISION 2020: the Right to Sight initiative, was launched in 1999 by the eye care INGOs, and endorsed by WHO. The ultimate goal is that by the year 2020 all “avoidable blindness” will be eliminated, through prevention or treatment. 20/20 stands for full visual acuity of 6/6 or 1.0.

The action plan has four essential pillars:

• Intervention strategies for most common eye conditions that cause avoidable blindness
• Human resource development with emphasis on mid-level eye care personnel
• Adequate supply of infrastructure, equipment and instruments
• Advocacy

Examination by a cataract surgeon at the Nekemte Eye Clinic in Nekempte, Ethopia (2009)

Priorities

The following five eye conditions were selected as priorities:

1. Cataract
2. Trachoma
3. Onchocerciasis
4. Childhood blindness
5. Refractive errors and low vision

These conditions are essentially bilateral and can be successfully and cost-effectively prevented or treated. Glaucoma and diabetic retinopathy are not on the priority list, because these are more difficult to diagnose and to treat, especially in less developed countries. Trauma, although often resulting in blindness in the affected eye, is not on the list either, because most traumas are unilateral and therefore do not cause blindness in a person.

1. CATARACT
   Every survey shows that about 50% of all blindness is due to age-related cataract. Surgery for cataract is one of the most successful medical interventions. It can rehabilitate an elderly blind person or secure jobs for people with early cataract in just 30 minutes surgery time.

What you can do: Visit the nearest facility for cataract surgery, get to know the conditions and costs of surgery and make arrangements.

Organization of cataract surgery

There are two options. Firstly, a team can visit regularly as part of their outreach work and take patients with them for surgery at their base. This removes the important barrier of long travelling for the elderly. Secondly, surgery can be done as an “eye camp” at your hospital. The team will usually carry all necessary equipment, consumables and IOLs (Intra-ocular Lens), so that you only have to offer an examination room, operating theatre (OT), sterilization, beds for 1-2 nights, some laboratory facilities, and some supporting staff. Depending on the population in your area, the capacity of your hospital and the capacity of the surgical team, a visit once or twice a year may be sufficient. Best are fixed timings, taking the farming seasons and local festivities into account. The criteria for patient selection are to be discussed with the surgical team. Good publicity through various channels is of the utmost importance. Follow-up will usually be done through your hospital. It is important to monitor the outcome of cataract surgery. WHO suggests as one of the guidelines after six weeks: an uncorrected poor outcome (VA of < 0.1 (< 6/60) in < 5% of the operated eyes with age related cataract). Poor outcome under field conditions is in reality often 10-15% but should not be higher.

Cost of surgery may be subsidized through Service Clubs, such as Lions, local business people or philanthropists. Sometimes the surgical team has funding, or the health insurance will pay. Some contribution by the patient should be encouraged.

As cataract develops slowly and patients gradually get used to impaired vision, they will not present at the Out Patient Department (OPD) by themselves, so the problem of cataract blindness is underestimated. However, after good publicity, the attendance for a cataract surgical camp can be overwhelming.

In health education programmes, do give attention to “painless and gradual loss of vision in the elderly”, as surveys show that, in remote areas, many elderly blind and their relatives are not aware that cataract blindness can be ‘cured’. Display posters with pictures of happily smiling patients after cataract surgery.

Ideally you should have a small eye clinic with a trained eye nurse.

2. TRACHOMA
   Trachoma is common in the dry and dusty areas of sub-Saharan Africa (SSA). The aim is to achieve elimination of blinding trachoma as a public health problem by 2020. The SAFE strategy of Surgery, Antibiotics, Facial cleanliness and Environmental changes is driving this. In some countries mass azithromycin distribution and water and sanitation programmes are carried out through GET 2020 (Global Elimination of Blinding Trachoma). As a result, the numbers of new infections have considerably decreased. In the absence of a mass distribution programme, individual patients, often young children, should be treated with tetracycline eye ointment, twice daily for 6 weeks.

Meanwhile, more patients with trichiasis – eyelashes scratching on the cornea – are identified. Trichiasis is the late result of repeated Chlamydia infections. Women are affected more than men.

In case of trichiasis / entropion there are two options:

Eyelid surgery, to evert the inward-turned lashes and lid margin. This can be learned through the excellent surgery training DVD (English & French) through Teaching-aids At Low Cost (TALC) (1). Trained eye nurses often do trichiasis surgery.

Epilation of the eyelashes as soon as they are felt, either by patients themselves or by a close family member (2). This has to be done lifelong! In areas where trichiasis is common, the tweezers are often locally made. Provided epilation is done well, it protects the cornea from scarring.

3. ONCHOCERCIASIS
   APOC (African Programme of Onchocerciasis Control) runs a successful programme ‘Community Directed Treatment with Ivermectin’ (CDTI), in oncho-affected regions. The number of people developing vision loss due to onchocerciasis has already markedly decreased. Community distributors, who hand out the ivermectin -once or twice a year- can sometimes be involved in other interventions as well.
4. CHILDHOOD BLINDNESS
   In the past, corneal blindness was the main cause of blindness in children in poor countries. This was due to Vitamin A deficiency, often triggered by measles, and made worse by traditional eye medicines. Wider coverage of measles vaccination, and better nutritional status, with/without high dose Vitamin A mass distribution to under-fives, have greatly reduced corneal blindness. Main causes of blindness in children today are retinal diseases, often hereditary and untreatable, and congenital or developmental cataract.

Children with cataract should be referred as soon as they are diagnosed, preferably to a tertiary paediatric eye department, as treatment in children is much more complicated than in adults (see Courtright in this issue).

5. REFRACTIVE ERRORS AND LOW VISION
   Uncorrected refractive error (URE) is the most common cause of visual impairment worldwide. Do try to provide simple refraction and prescription of glasses. Studies show that children in rural areas, in SSA in particular, will have only few refractive errors [3]. In Asia myopia is more common, especially in cities and among students from middle class families. School screening programmes are most effective if carried out among urban lower high school students (10-15 yrs).

However, there is often a high demand for reading glasses in people aged over 40 and sale of standard reading glasses may be a great service and can also create some income for the hospital. Prescription goes by age, with a simple reading test (e.g. newspaper) or threading a needle.

Guidelines for reading glasses:

• 40-45 yrs S+ 1.25
• 45-50 yrs S+ 1.5
• 50-55 yrs S+ 2.0
• > 55 yrs S+ 2.5 – S+3

If there is a blind school nearby, be aware that often half of the children or more are not ‘blind’ but rather ‘low vision’. Many students can greatly improve with proper refraction and strong reading glasses or loupes, in order to read print rather than Braille (see the article by Karin van Dijk).

In 2013 the World Health Assembly (WHA) passed a resolution that in 2019 visual impairment should have decreased by 25% from the baseline in 2010. Particular focus should be on cataract surgery and correction of refractive errors, as these constitute 75% of all visual impairment!

Action at local level

Actions at local level are 1) arranging cataract surgery, 2) providing antibiotic treatment and lid surgery for trachoma, 3) creating awareness to refer any blind or severely visually impaired child, whatever the cause, to a paediatric eye unit and 4) providing a refractive service or at least standard reading glasses; all this will contribute greatly to the success of VISION 2020.

With a torch, an ophthalmoscope, a vision chart and a trial lens set, you can diagnose and act on most of the VISION 2020 priority conditions.

References

1. http://www.talcuk.org/videos-and-dvds/trachomatous-trichiasis-surgery-training-dvd.htm, in French: http://www.talcuk.org/videos-and-dvds/dvd-de-formation-pour-chirurgie-du-trichiasis-trachomateux.htm
2. Rajak SN, Habtamu, E, Weiss, HA, et al. Epilation for trachomatous trichiasis and the risk of corneal opacification, Ophthalmology 2012;119:84-9.
3. Wedner S, Masanja H, Bowman R, et al. Two strategies for correcting refractive errors in school students in Tanzania: randomised comparison, with implications for screening programmes. Br J Ophthalmol. 2008;92(1):19-24.

Further reading

http://www.iapb.org/vision-2020
www.cehjournal.org/changing-patterns-in-global-blindness-1988-2008/
www.who.int/blindness/GLOBALDATAFINALforweb.pdf