COMMUNITY

OPHTHALMOLOGY

Community ophthalmology – use of appropriate strategies and

methods to reduce the burden of eye diseases in a community.

Basic principles –

The practice of community ophthalmology involves –

1. An assessment of the extent of the problem of eye diseases

and socio economic impact of blindness on the community.

2. Finding and applying the most appropiate eye care solutions

fot the specific community.

These solutions comprise of –

a. Preventive activities for control of communicable and non-

communicable eye diseases and environmental health

hazards.

b. Promotive activities concerned with improved nutrition,

intensive eye health education and improved life style.

c. Curative programs addressing the common eye conditions

like refractive errors , trachoma, cataract, xerophthalmia etc.

BLINDNESS

ECONOMIC BLINDNESS – that level of blindness which

prevents an individual from earning his wages.

Presenting vision <6/60 in the better eye.

Since this level of visual impairment hinders a person from

earning – also referred as WORK VISION

LEGAL BLINDNESS – The level of blindness that necessitates

welfare measure and legal protection.

Vision less than 6/60 or 20/200 or less in the better eye , with

correction, and/or a visual field less than 10 degrees.

This definition is used in USA.

SOCIAL BLINDNESS – the degree of disability that hampers an

individual from socially interacting with the family and peer groups

in a satisfactory manner.

The inability to count fingers at a distance of 3m (with the better

eye) with best correction.

Since this level of visual impairment curtails the day to day

movement of an individual – also referred as WALK VISION.

MANIFEST BLINDNESS – V.A < 1/60 .

Seriously constraints the accomplishment of tasks for daily living .

Also impairs mobility. Used as service indicator – as most of the

cataract blind in the developing world are operated at this stage.

ABSOLUTE BLINDNESS – the inabilty to perceive light in any

eye.

CURABLE BLINDNESS – that stage of blindness where damage

is reversible by prompt management. E.g cataract

PREVENTABLE BLINDNESS- the loss of blindness that could

have been completely prevented by institution of effective

preventive or prophylactic measures .e.g xerophthalmia,

trachoma, glaucoma

AVOIDABLE BLINDNESS – the sum total of curable blindness. In

India, 85-90% of all blindness is avoidable.

INCURABLE BLINDNESS – the state of blindness which is

beyond redemption. 5-10%

W.H.O – accepts a cut off of V.A<3/60 in the better eye, with

best possible correction to define blindness.

N.P.C.B – V.A<6/60 in the better eye with best possible

correction to define blindness.

N.P.C.B

THE NATIONAL PROGRAMME FOR CONTROL OF

BLINDNESS

- Was launched in 1976.

- 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 care level.

- 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.

- Strengthening eye health education activities

- Control of corneal blindness including establishment of eye

banks.

As per Survey in 2001-02, prevalence of blindness is estimated to

be 1.1%.

Rapid Survey on Avoidable Blindness conducted under NPCB

during 2006-07 showed reduction in the prevalence of blindness

from 1.1% (2001-02) to 1% (2006-07).

Various activities/initiatives undertaken during the Five Year

Plans under NPCB are targeted towards achieving the goal of

reducing the prevalence of blindness to 0.3% by the year 2020

Main causes of blindness are as follows: -

Cataract (62.6%)

Refractive Error (19.70%)

Corneal Blindness (0.90%)

Glaucoma (5.80%)

Surgical Complication (1.20%)

Posterior Capsular Opacification (0.90%)

Posterior Segment Disorder (4.70%)

Others (4.19%)

Estimated National Prevalence of Childhood Blindness /Low Vision is 0.80 per thousand

Goals & Objectives of NPCB in the XII Plan

· To reduce the backlog of blindness through identification and treatment of blind at primary, secondary and tertiary levels based on assessment of the overall burden of visual impairment in the country.

· Develop and strengthen the strategy of NPCB for “Eye Health” and prevention of visual impairment; through provision of comprehensive eye care services and quality service delivery.

· Strengthening and upgradation of RIOs to become centre of excellence in various sub-specialities of ophthalmology

. Strengthening the existing and developing additional human

resources and infrastructure facilities for providing high quality

comprehensive Eye Care in all Districts of the country;

· To enhance community awareness on eye care and lay stress

on preventive measures;

· Increase and expand research for prevention of blindness and

visual impairment

· To secure participation of Voluntary Organizations/Private

Practitioners in eye Care

Three major types of refractive corrective which is to be provided

to the population –

- Myopic correction for school children

- Presbyopic correction to the above 40 years segment

- Aphakic correction to operated cataract patients.

- INTENSIVE HEALTH EDUCATION ACTIVITIES – are central

to the success of the N.P.C.B

- Information, education and communication activities have

recently been augmented.

CORNEAL BLINDNESS AND EYE DONATION – for this purpose

N.P.C.B supports the establishment of eye collection centres and

eye banks both in the government and the NGO sector.

WORLD BANK ASSISTED CATARACT CONTROL PROJECT –

- Was initiated in 1994

- Covers 7 states where the prevalence of blindness and the

backlog of operable cataracts was the highest in the country –

U.P, Rajasthan, M.P, Maharashtra, A.P, Orissa and Tamil Nadu.

- In these states over a period of 7 years (1994-2001)

augmentation of cataract services was attempted.

- 11 million cataract surgeries were planned to be done.

DANIDA SUPPORT TO THE NATIONAL PROGRAMME – the

Danish international development agency has been assisting

NPCB since 1978.

- The DBCS concept was first successfully tried out by DANIDA.

- Vision screening and programmes in schools have also been

pioneered by DANIDA

- In the current phase of assistance, DANIDA has adopted

Karnataka as a pilot state and is funding all eye care activities

in this state.

- Phase III of the DANIDA assistance is being implemented

since 1997.

DFID ASSISTANCE TO NPCB – the department for International

Development of the U.K has been actively collaborating with the

Govt. of India in strenghthening Community Ophthalmology

services in India.

ORGANIZATION OF NPCB –

1.National programme management cell

2. State programme management cell

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 - MPW

VISION 2020: THE

RIGHT TO SIGHT

- Global initiative launched by the World Health Organization and

a Task Force of International Non-governmental Organizations.

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.

- envisages collaboration between governments, World Health

Organization, International Agency for -

Prevention of Blindness, funding agencies, international,

nongovernmental and private organizations that collaborate with

the World Health Organization in the prevention and control of

blindness.

Globally, five conditions have been identified for immediate

attention for achieving the goals of Vision 2020

They are-.

- Cataract

- 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

3. Strengthening the existing eye care infrastructure

4. Use of appropriate and affordable technology

5. Mobilization of resources

Cataract

- 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 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)

Targets

Global cataract prevalence targets 1990-2020

Year Populati

on

Projecte

d no.

cataract

blind at

1995

service

of

cataract

level

No.

cataract

blind

(millions)

Target

Prevalen

ce

blindnes

s

1990 5400 16.0 16.0 0.3

1995 5700 20.0 20.0 0.35

2000 6100 25.0 15.0 0.25

2010 6800 35.0 7.0 0.10

2020 7800 50.0 0 0

Global Cataract Surgical Rate Targets 1995-2020

Year Global cataract

surgical rate

Global no. of

cataract

operations

1995 1100 7.0

2000 2000 12.0

2010 3000 20.0

2020 4000 32.0

Trachoma

An estimated 146 million people have the active infection with the

microorganism Chlamydia trachomatis, for which antibiotic

treatment is indicated.

- There are approximately 10.6 million adults with in turned

eyelashes (trichiasis/entropion), for which eyelid surgery is

needed to prevent blindness.

- An estimated 5.9 million adults are blind from corneal scarring

due to trachoma.

- Trachoma is the second cause of blindness in

sub-Saharan Africa, China and the Middle-Eastern countries.

- Trachoma is to be controlled through the 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:

i) Assessment to identify communities with blinding trachoma.

ii) Delivery of community-based trichiasis .Surgery by trained paramedical

staff (S of SAFE).

iii) Antibiotic treatment (either tetracycline eye ointment or oral

azithromycin) for children with active disease (A of SAFE).

iv) 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 trachoma

Targets

Global Trachoma Targets for Cases of Trichiasis and Active

Infection

Onchocerciasis

- An estimated 17 million people are infected with onchocerciasis.

- Approximately 0.3-0.6 million are blind from the disease.

- 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.

Childhood Blindness

- 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).

- Many of these children die in childhood.

- 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.

Place Major causes of childhood

blindness

Africa - Corneal ulcer/scar (measles,

vitamin A

deficiency and harmful traditional

practices)

- Congenital cataract

- Hereditary disorders

Asia - Vitamin A deficiency

- Congenital cataract / rubella

- Hereditary retinal diseases

Latin America - Congenital cataract and glaucoma

rubella

- Retinopathy of prematurity

Industrialized countries and urban

centres

- Retinopathy of prematurity

- Congenital cataract

- Hereditary disorders

Vitamin A deficiency

Aim

To achieve and sustain the elimination of blindness due to vitamin

A deficiency.

Surgically avoidable causes

Aim

To control blindness in children from cataract, glaucoma and

retinopathy of prematurity (ROP).

Refractive Errors and Low Vision

- Spectacles are an essential part of the treatment of many eye

patients.

- 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

This aim goes beyond the elimination of blindness and also

includes the provision of services for individuals with low vision.

Human Resource Development

Community Level

Primary Health Care (PHC) is a fundamental concept of the World

Health Organization for improvement in health.

All the elements of primary health care can contribute to the

prevention of blindness.

PHC worker - important role to play in the control of blindness -

i) Identification - PHC workers are ideally placed to identify blind

and

visually disabled children and adults in their own home.

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 –

target 2000 2010 2020

Ophthalmolo

gists per

population

Sub-

Saharan

Africa

500000 1:400000 1:250000

Asia 1:200000 1:100000 1:50000

Vision 2020: The Right to Sight in India

- India was the first country in the world to launch the National

Programme for Control of Blindness in 1976 with the goal of

reducing the prevalence of blindness.

- Of the total estimated 45 million blind persons (best

corrected visual acuity < 3/60) in the world, 7 million are in India

.

- Due to the large population base and increased life

expectancy, the number of blind particularly due to age-related

disorders like cataract, is expected to increase.

-India is committed to reduce the burden of avoidable blindness

by the year 2020 by adopting strategies advocated for Vision

2020- The Right to Sight.

Current Status

Extent of the problem

Three major surveys have been conducted to find out the

prevalence of blindness in the country.

- The first survey- undertaken by the Indian Council of Medical

Research (ICMR) in 1974 indicated a prevalence rate of 1.38% in

the general population (Visual acuity < 6/60).

- Second survey - sponsored by the Government of India/World

Health Organization (1986-89), the prevalence rate increased to

1.49% (presenting visual acuity< 6/60 in the better eye).

As per information available from various studies:

estimated 12 million bilaterally blind persons in India with

visual acuity less than 6/60 in the better eye, of which nearly 7

million have visual acuity less than 3/60 in the better eye

(presenting vision).

Recent survey (1999-2001) in 15 districts of the country-

indicated 8.5% of population aged 50+ years is blind (visual acuity

< 6/60).

Main causes of blindness in 50+ population are as follows:-

Cataract 62.6%

1 Refractive Errors 19.7%

2 Corneal

Blindness

0.9%

3 Glaucoma 5.8%

4 Surgical

Complications

1.2%

5 Posterior

Segment

Disorders

4.7%

6 Others 5.0%

- No nationwide reliable data on refractive errors and low

vision in the country except some isolated studies

- A survey in Delhi, to assess the prevalence and causes of

blindness and low vision in children aged 5-15 years- indicated

that 1 % of children in this age group had vision < 6/18 in the

better eye.

Achievements

- All surveys indicated cataract as the single largest cause of

blindness in India.

- Controlling cataract blindness- given priority in India.

- Funds were mobilized from the World Bank during 1994-2002. -

- Assistance was provided to seven major states, estimated to

contribute 70% of the country’s cataract blind.

Under this project, following have been the achievements -

1.307 dedicated eye operation theatres and eye wards

constructed in district level hospitals

2.Supply of ophthalmic equipment for diagnosis and treatment of

common eye disorders, particularly for intra-ocular lens (IOL)

implantation at all district hospitals

3.More than 800 eye surgeons trained in IOL surgery

4. 30 non-governmental organizations (NGOS) assisted for setting

up/ expanding eye care facilities

5. Volume of cataract surgery has steadily increased since 1993.

Cataract Surgery Rate is 3800 per million population (2003-04).

There has been a significant increase in proportion of cataract

surgeries with IOL implantation from <5% in 1994 to 85% in 2003-

04.

- There has also been an increase in coverage of eye care

services

- A Rapid Assessment survey carried out in 14 districts in 1998

indicated coverage of 70% persons having access to eye care

services.

Decentralized Approach

India is a vast country having 28 States and 7 Union Territories

with 593 districts, with an average population of nearly two million

per district.

The programme implementation has been decentralized upto the

district level where District Blindness Control Societies (DBCS)

have been set up as the nodal agencies.

Members of the DBCS include officials from District

Administration, Health, Education and Social Welfare

Departments, media, community leaders and NGOs/Private

Sectors involved in eye care.

These societies directly receive funds from the Government.

The concept is to establish a bottom up approach in dealing with

blindness through multi sectoral and coordinated efforts.

These societies are responsible for identifying blind in every

village, organize diagnostic screening camps at suitable locations,

arrange transportation of patients to the designated facilities, and

ensure follow up.

1.Monitoring and Evaluation

Following tools have been developed for effective monitoring of

the programme:

- Standard prototypes for reporting of performance and

expenditure by District Blindness Control Societies;

- Standard Cataract Surgery Records & Patient’s Discharge

Cards

- Standard Referral Card for children having refractive errors;

- Specific software to facilitate computerized MIS at various levels.

2. Sentinel Surveillance Units (25) - set up in the Departments

of Ophthalmology and Preventive and Social Medicine in Medical

Colleges for:

a. assessment of beneficiary profile

b. visual outcomes based on cataract surgical records and follow-

up of a sub-sample of operated cases to assess visual outcomes.

c. Ocular morbidity data also collected to assess patterns and

trends of eye disease.

3.National Surveillance Unit - established in the Department of

Community Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi.

Functions of this unit –

a. Establishing a database for all blindness

control activities in India

b. Providing technical support for the network of Sentinel Surveillance Units established in the country

c. Disseminating information on trends in blindness control activities in the country,

d. Developing information resources and relevant software

packages for monitoring and evaluation of programme implementation

including mapping of services for end-users, etc.

4.Independent studies have been undertaken to evaluate the

programme activities. These include:

1. Communication Needs Assessment;

2. Beneficiaries Assessment;

3. Evaluation of trained eye surgeons;

4.Rapid Assessment for estimation of prevalence, coverage and

outcome;

5. Epidemiological survey on blindness in population aged 50+

years in 15 districts.

Quality of Services

-substantial efforts have been made by discouraging outdoor

surgical camps

-emphasis on IOL implantation at institutional level

-emphasizing follow up of operated cases and greater coverage

for women and underprivileged sections of the society.

The programme is being implemented in collaboration with

centres of excellence in the Government and Non-Government

sectors which have emerged as leading training and research

institutions capable of taking a leadership role for shaping eye

care programme not only in India, but in other countries as well.

- These institutions have excellent infrastructure, human

resources and patient volume required for imparting training and

conducting research.

- There is close coordination, formal or informal, between

these institutions in the country.

Situational Analysis of Eye Care Infrastructure and Human

Resources

- Situational Analysis of Eye Care Infrastructure and Human

Resources in India - conducted by the Ophthalmology Section of

Directorate General of Health Services, Ministry of Health and

Family Welfare, Government of India and Dr. R. P. Centre for

Ophthalmic Sciences in 2002-03.

An attempt was made to collect information on infrastructure

and human resources for training as well as service delivery in

the whole country.

Data was collected from two different sources:

1. Teaching institutions for assessing the status of ophthalmology

training;

2.District Blindness Control Societies for assessing infrastructure

foreye care service delivery in districts.

These data were supplemented by other sources like MIS data

base and private hospitals.

Performance of Cataract and Other eye Surgeries

ECCE/IOL was the commonest procedure for Cataract Surgery.

Phacoemulsification and Small Incision Cataract Surgery are

gradually being performed on more patients.

- Other surgeries performed in medical colleges

are 1.trabeculectomy

2. Squint

3.Keratoplasty

4. vitreo-retinal surgery and

5.DCR/DCT.

Mean number of ECCE/IOL per medical college per year -1215

operations.

On an average, 866 other eye operations were performed

per medical college per year.

Ophthalmic Equipment

Most of the colleges had all equipment related to cataract surgery,

but they were not fully equipped for managing other eye diseases

particularly posterior segment disorders.

Eye Care Facilities and Human Resources

- 47% of all eye care facilities are in the Private Sector

- 49% of all eye beds are in voluntary sector.

- Government sector contributed 33% of facilities and 28% of

eye beds.

- 37% of eye surgeonswere employed in the Government Sector

and the rest were evenly distributed in Private and Voluntary

Sector.

- Wide inter-state variation in eye care facilities and human

resources was observed in the study.

Vision 2020: The Right to Sight was launched in India on October

10-13, 2001 at Goa.

- A Working Group was constituted by the Government

of India for preparing the Plan of Action and Strategies on “Vision

2020-The Right to Sight” initiative in India.

-The Working Group met at Manesarand Lucknow to develop the

Plan of Action.

-The Draft Plan of Action was submitted by the Working Group to

the Ministry of Health and Family Welfare in August 2002.

-This was approved in principle as a document for future planning

of National Programme for Control of Blindness in India.

The target diseases identified for Vision 2020 in India

include:

1. Cataract

2. Childhood Blindness

3. Refractive Errors and Low Vision

4. Corneal Blindness

5. Diabetic Retinopathy

6. Glaucoma

7.Trachoma (focal)

Human Resource Needs

-There is a 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 (Community) or equivalent.

-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:

1. Hospital based - all categories like nurses, refractionists,

ophthalmic technicians / assistants, theatre personnel, etc.

2.Community / Vision Centre based - these persons will be

responsible for school eye screening, refraction, primary eye care,

tonometry, etc.

Objectives for the year 2002-2007

1. To improve the quantity &quality of cataract surgery.

2. Development of pediatric ophthalmology departments in training centres and centres of excellence.

3. To screen known diabetics for D.R in clinics and to screen >35 years attending the clinic.

4. Low vision services to be initiated at tertiary level with adequate linkages with secondary level and with primary care in a phased manner.

5. Development of safe eye banks and networking of eye donation and training centres.

6. Integration of primary eye care with primary health care throughout the country by training MO and OA and other paraprofessional staff.

Eye Care Infrastructure

Centre’s of Excellence (20)

Training Centres (200)

Service Centres (2000)

Primary Level Vision Centres (20000)

The infrastructure pyramid given above is based on the structure recommended

by the World Health Organization.

Under the National Programme for Control of Blindness, a

Conference on Primary Eye Care to support Vision 2020 was

held on April 11 -14, 2002 at Coimbatore.

The participants included the members of the Working Group and

experts in the field of primary eye care in India.

The recommendations of this meeting focused on:

1. Infrastructure and support for Primary Eye Care

2. Human Resource Development and Training Needs

3. Models for Service Delivery and Community Participation.

A. Infrastructure & Support for Primary Eye Care

1. Vision Centre

Vision centres - Primary Eye Care to a population of 50,000 in the

rural areas.

- Primary Health Centres

- Cooperatives manned by Middle Level Ophthalmic Personnel

(MLOP).

The target - post one Middle Level Ophthalmic Personnel(MLOP)

per 50,000 population throughout the country by 2020.

2. Functions of Vision Centre

a. Identification and Referral of minor external eye diseases e.g.

Conjunctivitis, Eye Injuries etc.;

b. Vision testing and prescription / dispensing of glasses;

c. School Eye Screening programme;

d. Eye health education;

e.Training of volunteers;

f. Identification / referral of Cataract, Glaucoma etc. to service

centres.

3. Personnel For Primary Eye Care (PEC).

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;

3. Health workers posted at sub-centers and PHC;

4. Middle Level Ophthalmic Personnel (MLOP);

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

4. Examination Process

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;

- Retinoscopy, including cycloplegic refraction;

- Schiotz tonometry;

- Fundus examination by medical officers (dilated pupil).

5. Support

National Programme for Control of Blindness should provide following assistance to develop PEC facilities:

a. Equipment at Vision Centre:

1. Trial Set

2. Trial Frame (Adult and Child)

3. Vision Testing Drum

4. Plane Mirror Retinoscope

5. Streak Retinoscope

6. Snellen’s Charts

7.Binomag / Magnifying Loupe

8. Schiotz Tonometer

9. Torch (with batteries)

10. Lid Speculum

11. Epilation Forceps

12. Foreign body spud and needle

13. Direct Ophthalmoscope (for use by Medical Officers)

14. Rechargeable Batteries

b. Drugs

1. Cyclopentolate Eye Drops

2. Tropicamide Eye Drops

3. 4% Xylocaine Eye Drops

4.Ciprofloxacin Eye Drops

5. Chloramphenicol Eye Drops

6. 1% Tetracycline Eye Ointment

7. Ciprofloxacin Eye Ointment

8. Neosporin Eye Ointment

9. Artificial Tears

10. Oral Vitamin ‘A’ Solution and Capsules

Materials

1. Blindness Registers (For Village Surveys)

2. Referral Cards for patients needing further evaluation of PHC

3. Vision card with prescription for spectacles

4. Flip Book for Eye Health Education

5. Charts and Posters

6. Do-it-yourself Vision Testing Posters

7. Cataract Card for Health Workers

Spectacles

Free / Subsidy for Spectacles for

1. Children (5-15 years)

2. Aphakic Patients

B. Human Resource Development and Training Needs

Personnel to be trained in Primary Eye Care:

a. Medical Officers at PHCs

b. Staff at PHC/Sub centers

c. School teachers

d. Village level volunteers

Training needs assessment should be carried out after defining job

responsibilities of above personnel.

- Village level activities could be contracted to local NGOs / self help

groups and this would allow decentralization to become a reality and

it would be a sustainable model. This could include optical cooperative units.

It is proposed to develop mobile primary eye care kit for the health workers / volunteers. The kit may contain-.

a. Simple questionnaire on PEC

b. Common eye ailments

c. Simple tips on how to deal with these ailments

Eye Care Education

Eye care education should target the following

a. Mothers regarding hygiene, nutrition, prevention of injuries;

b. Children regarding good reading habits, safety at play;

c. Teachers regarding identification of symptoms using simple

checklist.

Training

Training on PEC should include:

a. DRIP Training:-

One hour thematic training at PHC for transfer of skills related to

Primary Eye Care for Health Workers/ Village level volunteers.

b. Cascading training

-Training to function as a team. Training of teachers should

include refractive errors and common eye symptoms, do’s and

don’t’s.

-Training of VHW should include skills for vision testing, diagnosis

of operable cataracts, monitoring use of spectacles.

- Need to develop modules for training different functionaries;

- Orientation of indigenous practitioners in modern management should be undertaken for corneal ulcers, conjunctivitis and dangers of harmful traditional medicines. The training should include recognition of sight-threatening symptoms and referral system;

- Need to augment training capacity for Mid Level Ophthalmic

Personnel;

- Mechanisms for monitoring should be developed to assess the

effectiveness of training at various levels;

- Referral and support system should be developed to link PEC

to secondary & tertiary levels

c. Models for Service Delivery and Community Participation.

Childhood Blindness:

- “Pediatric Ophthalmology Facility” should be developed at Tertiary

Level.

- Existing eye surgeons need to be trained in Pediatric

ophthalmology.

There may not be a need to create separate post of pediatric

ophthalmologists at this point of time.

- Training of Ophthalmic Surgeons in Pediatric Ophthalmology for a

minimum of 6 months at identified tertiary eye care centres.

- Support development of Pediatric ophthalmology Team ( including

Pediatrician, Anesthetist, MLOPs)

- In case a hospital is already doing Pediatric Ophthalmic surgeries,

some support systems may be required to develop Pediatric Ophthalmology

Facility.

- Equipment required for Pediatric Ophthalmology need to be provided.

- Depending on the volume of Pediatric Ophthalmic Surgery, decision

regarding setting up of a dedicated pediatric OT or providing adequate

O.T time may be taken.

- As more than half (57%) of childhood Blindness is avoidable, emphasis

should be given to prevent Childhood Blindness through cost effective

strategies.

Low Vision & Refractive Errors:

- Refractive Errors screening within a specified period of admission

toschools should be done by schools in collaboration with District

Blindness Control Society / District Education Department.

- Address the organised sectors initially for screening and managing

Presbyopia.

- Screening and services for refractive errors / low vision should be

integrated with cataract screening programme.

- Constitute a Task force to develop strategies for Low Vision

services.

Corneal Blindness:

- Emphasis on Hospital Retrieval System to get better donor

material.

- There is an urgent need for assessment of number of people

who would benefit by corneal grafting.

- For vitamin A supplementation, we should focus on areas that

are economically backward. Priority should be given to slum

populations,tribal regions, drought and flood prone areas and

migrant populations.

Posterior Segment Disorders:

- Medical Retina Services need to be developed in tertiary eye

care institutions.

These units shall attend to various posterior segment disorders,

primarily, diabetic retinopathy.

- Awareness about diabetic retinopathy should be created in

clinics

managing diabetic patients.

- A small pamphlet on Diabetic Retinopathy needs to be

developed for the physicians.

-Some inexpensive screening mechanisms for diabetic retinopathy

should be established at the diabetic clinics. On a pilot basis, fundus

cameras can be introduced in some clinics that are located centrally

where diabetics can be invited to have free fundus photographs

taken.

- Patients of age-related macular degeneration need low vision

services.

Linkage needs to be established between the medical retina services

and the low vision services.

Advocacy & Public Awareness:

- Various guidelines and training manuals need to be made

available on the MOHFW website.

- Advocacy workshops should be organized involving the

ophthalmologists and communication experts.

Annual Plan should list specific time bound activities for advocac

Trachoma:

Information on Surgery for entropion and trichiasis should be

collected from endemic areas to assess current situation.

Human Resource Development:

- Ophthalmology as a separate subject in MBBS course;

- Interaction with Universities through Medical Council of India for

uniform system for Ophthalmology as separate subject, common

curriculum, evaluation;

- Increase in number of eye surgeons- MS/ Primary DNB slots;

- Continued professional improvement through CME for eye

surgeons and MLOPs and fellowship courses in super specialties

for ophthalmologists;

- Desired ratio of Ophthalmologist- MLOPs in hospitals should be

1:3 to 1:4; (MLOPs include dedicated Ophthalmic paramedics and

Nurses in Ophthalmology Departments);

- Explore feasibility of 3 month resident exchange programme at

selected institutes during final year of PG course.

Data base on Eye Care Infrastructure & Human resources:

- Dissemination of Report to all Stakeholders / States for use in

identifying under-served areas

- Periodic update of data + Strengthening of Surveillance

Network

THANK YOU