PREVENTIVE

OPHTHALMOLOGY
DR. PRASHANT KUMAR PANDA
ASST. PROF
DEPARTMENT OF
OPHTHALMOLOGY
VSSIMSAR
  PreventiveOphthalmology is otherwise
known as Public health ophthalmology /
Preventive eye care / Community
ophthalmology
 Defined as a system which utilizes the full
scope of ophthalmic knowledge and skill,
INTRODUCTION methodology of public health and services of
other medical and non-medical agencies to
promote ocular health and prevent blindness
at the community level with an active,
recognised and crucial role of community
participation
  Use of appropriate strategies and methods to
reduce the burden of eye diseases in a
community
Basic principles –
 The practice of community ophthalmology
involves –
OBJECTIVE  An assessment of the extent of the
problem of eye diseases and socio
economic impact of blindness on the
community
 Finding and applying the most
appropriate eye care solutions for the
specific community
  WHO definition of blindness:
“Visual acuity of less than 3/60 (Snellen)
or its equivalent”
In order to facilitate the screening of
visual acuity by non-specialised persons, in the

BLINDNES absence of appropriate vision charts, the WHO

in 1979 added the “Inability to count
S fingers in day-light at a distance of 3
metres” to indicate vision less than 3/60 or its
equivalent
Visual filed less than 10º, irrespective
of the level of visual acuity in also labelled as
blindness (WHO, 1977)
  Other definitions of blindness are:
 Economic blindness: Vision in better
eye <6/60 to 3/60
 Social blindness: Vision in better eye
Types of <3/60 to 1/ 60
Blindness  Legal blindness: Vision in better eye
<1/60 to perception light (PL +ve)
 Total blindness: No light perception (PL
-ve)
  Normal vision: 0. 6/6 to 6/18
 Low vision: 1.Less than 6/18 to 6/60
2. Less than 6/60 to
3/60

Categories Of
Visual  Blindness: 3. Less than 3/60 (FC
at 3 m) to 1/60 (FC at 1m) or visual field
Impairment:
between 5 ° - 10 °
5 categories
4. Less than 1/60 (FC
at 1 m) to light perception or visual field less
than 5°
5. No light perception
  Two types:
• Preventable blindness: Can be easily
prevented by attacking the causative
factor at an appropriate time
Eg: corneal blindness due to vitamin A
Avoidable deficiency
blindness
trachoma
• Curable blindness: Vision can be
restored by timely intervention
Eg: cataract blindness
  Causes of global blindness:
 Major causes of blindness and the estimated
number of blinds due to them are as under:
• Cataract 19 million
• Glaucoma 6.4 million
Causes of
Blindness • Trachoma 5.6 million
• Childhood blindness including
xerophthalmia >1.5 million
• Onchocerciasis 0.29 million
• Others 10 million
  THE NATIONAL PROGRAMME FOR
CONTROL OF BLINDNESS

• Launched in 1976

NPCB • Being implemented as 100% centrally

sponsored programme since its inception

• In 1982, it was implemented in the prime

minister’s 20 point socio economic
programme
  Overall objectives are –

Provision of comprehensive eye care facilities

at primary, secondary and tertiary health
Objectives of care level

NPCB
To achieve a substantial reduction in the
prevalence of eye diseases in general and
the overall reduction in the prevalence of
blindness to 0.3% by 2000 AD
  COMPONENT ACTIVITIES UNDER N.P.C.B. :–

Creating an infrastructure for cataract

surgical and support services

School eye screening and refraction services

Components
Strengthening eye health education
activities

Control of corneal blindness including

establishment of eyebanks
  ORGANIZATION OF NPCB –
1. National programme management cell

2. State programme management cell

Organization 3. District blindness control

a. District hospital (Medical Superintendent)
i. Ophthalmic surgeon
ii. District mobile unit
b. District health officer(C.M.O)
i. Community health officer – medical officer –
MPW
ii. Primary health officer – medical officer - MP
  “VISION 2020: THE RIGHT TO SIGHT”

 Global initiative launched by the World

Health Organization and a Task Force of
International Non-governmental
Organizations
VISION
2020  To combat the gigantic problem of blindness
in the world

 It was launched in Geneva on February 18,

1999 by the then Director General of the
World Health Organization, Dr. Gro Harlem
Brundtland
  Globally, five conditions have been identified
for immediate attention for achieving the
goals of Vision 2020

Diseases under Cataract

VISION 2020 Trachoma
Onchocerciasis
Childhood blindness
Refractive Errors and Low Vision
• These conditions have been chosen on the
basis of:

1. Their contribution to the burden of blindness

2. The feasibility and affordability of
interventions to control them

 Each country will decide on its priorities based

on the magnitude of specific blinding conditions
in that country
  Under this initiative, five basic strategies
to combat blindness are-

1. Disease prevention and control

2. Training of personnel
STRATEGIES 3. Strengthening the existing eye care
infrastructure
4. Use of appropriate and affordable
technology
5. Mobilization of resources
 Major cause of blindness in the world
An estimated 16-20 million people are
bilaterally blind from cataract and the number
is increasing
Cataract surgical rate - a quantifiable measure
of the delivery of cataract services
Number of cataract operations per million
CATARACT population per year
Meaningful to estimate only when there is
ample information on all cataract surgery
performed in a country, for example including
the private sector
 Aim: Elimination of cataract blindness
(person with vision less than 3/60 in both
eyes)
  An estimated 146 million people have the
active infection with the microorganism
Chlamydia trachomatis - antibiotic treatment
indicated
 Approximately 10.6 million adults with
inturned eyelashes (trichiasis/entropion) -
eyelid surgery is needed
 An estimated 5.9 million adults are blind from
TRACHOMA corneal scarring due to trachoma
 Trachoma is the second cause of blindness in
sub-Saharan Africa, China and the Middle-
Eastern countries
 Implementation of the SAFE strategy
integrated within primary health care in all
communities identified as having blinding
trachoma within a country
 This includes the following:

1. Assessment to identify communities with

blinding trachoma

2. Delivery of community-based trichiasis

surgery by trained paramedical staff (S of
SAFE)

3. Antibiotic treatment (either tetracycline

eye ointment or oral azithromycin) for
children with active disease (A of SAFE)

4. Promotion of Facial cleanliness (F of SAFE)

and Environmental improvement (E of
SAFE), including personal hygiene and
community sanitation as part of primary
health care

 Aim: Elimination of blindness due to

  An estimated 17 million people are infected
with onchocerciasis

 Approximately 0.3-0.6 million are blind from

the disease

ONCHOCERCIA
SIS  Endemic in 30 countries of Africa and occurs
in a few foci in six Latin American countries
and in Yemen

 Aim: Elimination of blindness due to

onchocerciasis
  Estimated 1.5 million blind children in the
world, of whom 1 million live in Asia and
3,00,000 in Africa
 Prevalence = 0.5 - 1 per 1,000 children aged
0-15 years
 An estimated 5,00,000 children going blind
each year (one per minute)
CHILDHOOD  Many of these children die in childhood
BLINDNESS  It is estimated that childhood blindness
causes 75 million blind years (number blind x
length of life), second only to cataract
 The causes of childhood blindness vary from
place to place and change over time
 Aim: To eliminate avoidable causes of
childhood blindness
  Spectacles are an essential part of the
treatment of many eye patients
REFRACTIVE
ERRORS AND
LOW VISION  Their provision is therefore an integral part of
eye care delivery
 The steps in the provision of refraction services and
low vision care for patients are as follows-

i) Screening - Identification of individuals with poor

vision which can be improved by spectacles or other
optical devices
ii) Refraction - Evaluation of the patient to
determine what spectacles or device may be required
iii) Manufacture - Manufacture of the spectacles or
an appropriate device, both of which may be
manufactured locally, purchased externally,or
donated
iv) Dispensing - Issuing of the spectacles or device,
ensuring a good fit of the correct prescription
v) Follow-up - Repair of spectacles/devices or repeat
dispensing

 Aim: Elimination of visual impairment (vision less

than 6/18) and blindness due to refractive errors or
other causes of low vision
 Human
Resource
Developmen
t
 ii) Assessment and diagnosis - PHC workers
can be taught to assess those individuals who
could be helped by the services of a
specialist, for example identifying cataract for
referral to an ophthalmologist

 iii) Referral for management and treatment

- PHC workers can encourage individuals to
go for treatment and can provide the referral
system that will promote this

 iv) Follow-up and evaluation - After

treatment, the PHC worker can follow up the
patient at home to help with visual
rehabilitation (the patient after cataract
surgery, for example), give advice on any
treatment and make sure that spectacles are
available
 Secondary and Tertiary levels:
Ophthalmologists:

Secondary TARGET
2020
2000 2010

and Tertiary Ophthalmologists

Levels Per population

Sub Saharan Africa 1:500000 1:400000

1:250000
Asia 1:200000 1:100000
1:50000
  India was the first country in the world to
launch the National Programme for Control of
Vision 2020: Blindness in 1976 with the goal of reducing
the prevalence of blindness
The Right to
Sight in  Of the total estimated 45 million blind
India persons (best corrected visual acuity < 3/60)
in the world, 7 million are in India
  The target diseases identified for Vision 2020
in India include:

Cataract
Childhood Blindness
Target diseases Refractive Errors and Low Vision
Corneal Blindness
Diabetic Retinopathy
Glaucoma
Trachoma (focal)
  Need to develop 2000 Service Centres, each
with 2 ophthalmic surgeons and 8 ophthalmic
paramedics (hospital)
 20,000 Vision Centres need to be developed,
each with one Ophthalmic Assistant
Human (Community) or equivalent
Resource Needs
 Eye Care Managers will be required at the
Service Centers
 Community Eye Health Specialists will be
required at the Training Centres
Paramedics

 Mid Level Eye Care Personnel

 Two streams of such personnel are

envisaged:

• Hospital based - all categories like

nurses, refractionists, ophthalmic
technicians / assistants, theatre
personnel, etc

• Community / Vision Centre based -

these persons will be responsible for
school eye screening, refraction, primary
eye care, tonometry, etc
  Eye Care Infrastructure
Centres of Excellence (20)

Training Centres (200)

Eye Care Service Centres (2000)

Infrastructure
Primary Level Vision Centres (20000)

 The infrastructure pyramid given above is based

on the structure recommended by the World
Health Organization
  Vision Centres

 Primary Eye Care to a population of

50,000 in the rural areas

 Primary Health Centres

Infrastructure &
Support
 Cooperatives manned by Middle Level
Ophthalmic Personnel (MLOP)

 The target - post one MLOP per 50,000

population throughout the country by
2020
 Identification and Referral of minor external
eye diseases e.g.Conjunctivitis, Eye Injuries,
etc

Vision testing and prescription / dispensing of

glasses

Functions of School Eye Screening programme

Vision Centre
Eye health education

Training of volunteers

Identification / referral of Cataract, Glaucoma,

etc to service centres
  To deliver PEC, following personnel need to
be involved:
1. Area specific involvement of volunteers
from the local community/ NGOs

2. Two teachers from each middle school

Personnel For
Primary Eye 3. Health workers posted at sub-centers
and PHC
Care (PEC)
4. Middle Level Ophthalmic Personnel
(MLOP)

5. Medical officers at P.H.C.s and General

Practitioners
  Facilities for following examinations need to
be made available at each vision center to
carry out functions of PEC:

Torch light examination with the

assistance of magnifying loupe

Examination Retinoscopy, including cycloplegic

Process refraction

Schiotz tonometry

Fundus examination by medical officers

(dilated pupil)
  National Programme for Control of Blindness
should provide following assistance to
develop PEC facilities:

Support Equipment at Vision Centre

Drugs
Materials
Spectacles
  Several inherited eye diseases are due to
defective genes which have been isolated and
characterized or the chromosomal location
determined
TREATMENT
AND  Prevention is the most reliable and effective
PREVENTIO means of dealing with hereditary disorders.
N OF
GENETIC  This approach includes genetic screening,
DISEASES genetic
counselling,
prenatal
diagnosis
  Geneticscreening programmes are for
autosomal recessive disorders and are of two
types:
• homozygote screening or the search
Genetic for individuals who have the disorder and

Screening • heterozygote screening or the search

for individuals who are carriers of a
mutant gene and are thus at risk of
having offspring with a particular disorder
if the partner is also a carrier
  Prospective parents who have a known
genetic disease or hail from a family with a
known inherited disorder must be offered
genetic counselling
 Familiarity with the principles of medical
genetics is therefore a must for every
Genetic physician who should use this knowledge to
Counselling understand and counsel patients
 One aspect of genetic counselling involves
determination of the risk for having an
affected child
 A family pedigree up to a minimum of
three generations must be charted
  Following genetic counselling, the couple at
risk for having a child with a genetic disorder
has certain options, depending on the type of
disorder

 low risk or mild disease - reassured

and may proceed to have a child despite
the risks, without any subsequent
monitoring
Prenatal  high-risk diseases with high morbidity -
Diagnosis perceive the risk as unacceptably high
and decide to have no additional
biological children or may consider
adoption

 Indications for prenatal diagnosis are based

on a comparison of the risk of the diagnostic
procedure with the risk of having an affected