COMMUNITY OPHTHALMOLOGY Ahmad Ashraf

Social ophthalmology = Community ophthalmology is one of ophthalmology subdivision that oriented to comprehensive health community (promotive, preventive, curative dan rehabilitative)with focus on promotive and preventive aspects

Clinical Ophthalmology is a branch of medical science that focus to individually and oriented to secondary services and located in institution

ophthalmology include :Promotive Target is communityPreventive Promotive = Promotion is a process of study from, by and for community that is fixed with local social culture .

Promotif = Promotion is a process study from, by and for community that fixed with local social culture Community = participated

People can recognize, maintain, protect and improve eye health

Preventive in community ophthalmology focus on:- Glaucoma- Refraction- Degenerative- Corneal disorder

Preventive3 type :Primary prevent diseases Sekunderprevent loss of visual acuity3. Tertiaryrehabilitation of visual acuity to blind person ex : cataract

primary prevention prevention of diseases occurrence Examples : Vitamin A deficiency : good nutritionTrachoma: good sanitation varicella / mumps: imunizationrefractive errors : watching TV with minimal distance 5X TV diagonal. Reading distance 30 cm with good enough lightGlaucoma: above 40 yo, control IOP regularly

Sondary prevention : prevent loss of vision from existing disease, example : Vitamin A deficiency : if there are symptoms of night blindness, vitamin A 2x per year and improve nutrient cataract : surgery if decrease vision Glaucoma : saving sight with surgery or regular check up Diabetic Retinopathy : saving sight with retinal laser

Tertiary prevention : improve vision in blind person , example : cataract: surgery Corneal scar : keratoplasty Low vision person : low vision aid, example : loup, magnifier

Blindness : condition of vision that 3/60 with best correction or visual field 10o from fixation point.

How many people are blind : Almost 50 million persons are blind worldwide, where 1,5 million below 16 yo.

Prevalence of blindness varied in many places

In Indonesia prevalence of blindness about 1,5%

Some termsUKM/PK: upaya kesehatan mata dan pencegahan kebutaanPKKP: penanggulangan kebutaan katarak paripurna

Both are implemented integrated to all sector and active role from community are needed to realize eye health for all

Magnitude of blindness in Indonesia:Based on sight survey 1993-1996 : prevalence of blindness 1,5%1,5% X 200 m = 3 million

Causes of blindness :- 52% cataract : 52% X 3 jt = 1.560.000- 9,5% refractive error : 9,5% X 3.000.000 = 285. 000- 13,4% glaucoma: 13,4%X3 jt = 402.000- 8,5% retinal disorder : 8,5% X 3.000.000 = 255.000- 6,4% corneal disorder : 6,4%X3 jt= 192.000- 10,2% other diseases : 10,2%X3.000.000 = 306.000

Cataract blindness in productive ages about + 14-16% from all cataract = 249.000If average income Rp. 80.000,-/month, so economic loss because of cataract blindness in productive age about 250.000 X 12 X Rp. 80.000,- = Rp. 240.000.000These not yet include economic loss due to cataract blindness because of family burden .Cataract incidence 0,1% 0,1% X 200.000.000 = 200.000

Cataract blindness : burden to family and local income due to decrease of productivity

Eye Survey results :19821,2% blind rate1993-1996 1,5% (52% by cataract)8 provinceWhy increase: 1,2% 1,5% cause by:1. UHH: usia harapan hidup / life expectancy increase from 60 to 66 yo 2. Degenerative diseases more than infectious disease3. Lack of eye health facility.

Problem in community :

Increasing Prevalence : 1,5%Man Power : lack of ophthalmologist , eye paramedic, Low Budget , community ability to pay also decrease Political will does not strong enough to take community participation

THE MAIN EYE MORBIDITY PREVALENCI

Refractive Error22,1Pterygium13,9Cataract7,3Conjuntivitis2,0Corneal Scar1,4Glaucoma0,4Blepharitis0,3Retinopathy0,2Hordeolum0,3Strabismus0,3

BLINDNESS PREVALENCE AND CAUSES OF BLINDNESS OF BOTH EYE

Lens0,78Glaucoma / N II0,20Refractive Error0,14Retina0,13Cornea0,10Others0,15Total blindness1,5

Blind Rate: 1,5% Population 200.000.000

Blind : 1,5% X 200.000.000 = 3.000.000by cataract: 0,78% x 200.000.000 = 1.560.000

Number of surgery in Indonesia / year :+ 60.000 remain : 1.560.000-60.000= 1.500.000This number : BACK LOG

Defenition Back Log: Number of cataract patients that not operated in 1 yearIncidence: Number of new cases in 1 year: 1 o/ooSo, every year new cases of cataract : 1o/oo X 200.000.000 = 200.000/tahun

Causes of Back Log:- Social economy- Lack of knowledge in community- Geography- Lack of eye specialist- Majority in rural area - Mainly facility located in urban area Strategic steps cataract management : - Social marketing- Operational preparation- Surgery - Follow up by ophthalmologist or GP

Social marketing: Local populationMap of area Determine target surgeryCooperation with health infrastructure Local government announcementLocal NGO participation

WHO , if prevalence of blindness :0,5%: clinical problem >0,5% - < 1%: community problem >1%: social probleminfluencing national health development , specially eye health National program are :Decreasing blindness rate < 1% in 2003Decreasing eye morbidity Socialization eye services in community

Blind criteria WHO:

Visual acuity < 3/60 with maximal correction

Ratio: 1 ophthalmologist for 350.000 populationWHO: 1 ophthalmologist for 250.000 population

Government strategies to solve high blindness rate with cooperation LSM (Lembaga Swadaya Masyarakat) / NGO local, national or international : Training UKM/PK for eye cadres for case finding of operable cataract Training for paramedic for cataract case finding and post operative management Training for General practitioners in PHC Training for teacher for early detection of refractive error Mass cataract surgery called SAFARI KATARAK with low cost or free of charge

Glaucoma as second causes of blindness following cataract : 0,2%

To decrease this number : intraocular pressure (IOP) regular check for patient 40 yo or above to detect : chronic simple glaucoma:Symptoms : Intraocular pressure > 20,6 mmHg visual field defect cupping of the disc

Visual field :

Medial: 50 oSuperior: 60 oInferior: 70 oLateral: 90 o

Visual category in opthalmology: > 6/18: normal6/60 - 6/16: visual impairment3/60 6/60: low vision< 3/60: blind

Some NGO that in cooperation in cataract eradication program : yayasan Dharmais Perdami Lions Club Rotary Club Hellen Keller InternationalDark and Light International Christoffell Blinden Mission: CBM dll

Infrastructure eye services : primary eye care : Puskesmas Secondary eye care: RS type C/B dan BKMM Tertiary eye care: RS type A subspesialistic services

BKMM : Balai Kesehatan Mata Masyarakat secondary services provide by ophthalmology

Important activities to decrease blindness : In all places there must be :Providing eye services Early Detection / screening and refractive error management3. In specific place : - Vitamin A supplement- Trachoma program with SAFE strategy (Surgery, antibiotic, Face washing, Environmental)

Specialistic services:

1. Diagnostic and management of glaucoma2. Diagnostic and management of retinopathy3. Specialist center for childhood blindness

Thank you