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Prevention of Blindness I K Jalili 8.1 Introduction 8.2 Prevention Programmes and VISION 2020 8.3 Prevention of Childhood Blindness 8.4 Conclusions 1 Introduction
onchocerciasis with Ivermectin and vitamin A deficiency with various measures such as vitamin A Prevention Tools
supplements. (2), (6), (7), (18), (31), (32), (33), (34), (35) Prevention should go side by side with sustained Addressing blindness involves multiple approaches efforts to upgrade health facilities such as the transfer encompassing on the one hand prevention and of technology, training of health care personnel, intervention measures, and on the other hand setting up specialised and supporting services such as eye banks, genetic counselling services and genetic governmental levels with individual participation and laboratories, and must not overlook the need to ensure collaboration. Prevention, with mass education being continuous medical education. A more optimistic the core element, should be targeted in line with local target would be the avoidance of wars with all that needs. The issues range from measures such as mass they bring with them; drainage of resources, poverty, vaccination (e.g. rubella, smallpox etc.), to screening malnutrition and disease, not to forget the human programmes. The latter would include locally tailored resources as a result of the exodus of technocrats and projects such as screening children for trachoma and experts that is commonly associated with wars and a further hindrance to already meagre and scarce deficiency, retinopathy of prematurity, diabetic socioeconomic progress. (27), (28), (36), (37), (38) retinopathy and age related conditions including Concomitant economic development is also cataract and glaucoma. (1) When indicated, a referral necessary to reduce, and eventually eradicate, much to specialised centres should follow. (2) (3) (4) (5) of the preventable and avoidable causes of blindness. Education is a major component of prevention in both developed and developing countries for conditions such as glaucoma and diabetic retinopathy, Prevention Programmes
and in developing and least developed countries, for trachoma, onchocerciasis, traditional eye medicines, History of Prevention Programmes
abuse of ‘over-the-counter medications’ such as topical steroids, consanguinity etc. (6), (7), (8), (9), (10), (11), Prevention programmes have been established in most (12), (13), (14), (15), (16), (17), (18), (19), (20), (21), (22), (23), (24), (25), (26), parts of the world to tackle local blinding conditions. The dominant player has been the WHO, which, since The other facet of combating blindness is mass its inception, has endeavoured to support Member intervention to treat endemic conditions such as States in their task of tackling blindness. trachoma with azithromycin/tetracycline; In 1975, the WHO helped in the creation of the International Agency for the Prevention of Blindness (IAPB). This led to several other initiatives. The 64 | Childhood Onset Visual Impairment, IK Jalili
founder members of IAPB included the International (54), (55), (56), (57), (58), (59), (60), (61), (62), (63), (64), (65), (66), (67), (68), Societies), the World Council for the Welfare of the Prevention of Diabetic Blindness
Blind (renamed the World Blind Union), and two In 1989, an initiative to improve diabetic care and international NGOs; the American Foundation for the reduce diabetic complications in Europe was Blind (later renamed Helen Keller International) and pioneered by the WHO together with the International the Royal Commonwealth Society for the Blind (later renamed Sight Savers International). (40) These efforts representatives of Government Health Departments culminated three years later in the establishment of and patients’ organisations from all European the WHO Programme for the Prevention of Blindness countries. together with diabetes experts, was held in St. Vincent, Italy on October 10-12, 1989. It The strategy adopted by the PBL was based on the culminated in the St Vincent Declaration which declaration of the International Conference on recommended combined efforts to improve the life of preventive health care (PHC) held in Almaty, diabetic patients, both quantitatively and qualitatively, Kazakhstan, in the same year. The strategy was the to that of the general population and to promote the delivery of eye care as an integral part of primary prevention and cure of diabetes and of its health care; the concept of ‘primary eye care’’ was complications by intensifying research efforts. (71) developed and has been followed since. The WHO also addressed data collection on blindness and VISION 2020
established standardised guidelines and protocols for this purpose.(41), (42), (43), (44) The initial priorities Emergence of Vision 2020
focused on were onchocerciasis, xerophthalmia, All the previous cooperative activities mentioned was guided by the information compiled in the WHO One of the early initiatives of WHO/PBL was to Global Database on Blindness and the expertise establish methodical programmes for the prevention gained over the years and culminated in the of blindness in a number of Member States. This emergence of the initiative of Vision 2020. This is, promoted and widened the remits of existing and The Global Initiative for the Elimination of Avoidable Blindness referred to as ‘‘VISION 2020 - The Right programmes to encompass xerophthalmia and to Sight’’, launched in 1999, as a collaborative effort between WHO and a number of international NGOs By the mid-1980s, over 50 national programmes, and other interested partners. This aimed at achieving committees, or focal points had been established and the goal of eliminating avoidable blindness worldwide by 1998 this number had increased to over 110. The by the year 2020. The organisations involved are WHO was pivotal in these developments, through called the ‘Task Force’. (27), (36), (37), (38), (72), (73), (74) providing guidelines, sending consultants, and working with international non-governmental organis- Objectives
The objectives of VISION 2020 programme is in the prevention, treatment and rehabilitation of avoidable Onchocerciasis Prevention Programme
blindness. Emphasis is given to the issues of The Onchocerciasis Control Programme (OCP) in 1974 was a major step for the WHO and their efforts mobilization building on the international and to combat this disease in seven countries in West national experience gained through the existing Africa. This programme was jointly sponsored by a national programmes. The approach is based on three large consortium of agencies, organisations and donor strategies namely: (1) developing and improving countries and was scheduled to end by 2002. primary eye care programmes within the primary Additional steps to address onchocerciasis saw the health centres (PHC) set up to eliminate preventable conditions; (2) developing therapeutic and surgical Elimination Programme for the Americas (OEPA), support services to deal effectively with "curable" eye and the African Programme for Onchocerciasis problems; and (3) establishing optical and low vision Control (APOC) in 1995. (46), (47), (48), (49), (50), (51), (52), (53), Prevention of Blindness | 65
This would achieve: disease control, infrastructure Transfer of Technologies
development, and human resource development. Another task for the programme is to promote and support the transfer of technology to developing Implementation
countries by allowing manufacturing, by non-profit The implementation involves three tiers; advocacy making bodies, of high-quality equipment and through WHO/IAPB, planning by national PBL consumables at low cost e.g. intraocular lenses, eye programmes, implementation through Vision 2020 medications, sutures, spectacles and low vision devices, together with the formation of regional Vision 2020 will be implemented through four 5- consortiums for the purchasing in bulk of equipment year periods, the first started in 2000. The three and spare parts, instruments and consumables to subsequent phases of implementation will commence reduce costs, including maintenance and repair in 2005, 2010 and 2015 respectively. Countries are chosen on the basis of the size of the burden of blindness and of available resources. (36), (75) Medical Conditions Selection in VISION 2020
Other Logistic Aspects
The Basis of Selection
In terms of other logistic aspects of achieving the Conditions were chosen on the basis of the burden of blindness they cause and the feasibility and affordability of interventions to prevent and treat Human Resources Development
them. These are cataract, trachoma, onchocerciasis, The programme encourages the development of childhood blindness and refractive errors and low human resources at various levels of the health care vision. Other blinding conditions such as glaucoma system, with emphasis on mid-level personnel and and diabetic retinopathy are to be addressed at a later expanding on the already ongoing programmes in stage. For cataract, the goal is to increase surgical many of the sub-Saharan African countries such as productivity in addition to achieving; high success Bamako (Mali) and Lilongwe (Malawi) in cataract rates, affordable and accessible services, and surgical training. (27), (76) In addition, it is also aimed to measures to overcome barriers and increase the use of deploy Ophthalmologists at higher tiers of the health services. (37) Refractive errors and low vision are care system to provide specialist care. (27) For mid- addressed by making refractive services and level personnel, the target is to achieve a ratio of corrective spectacles affordable and available to the 1:100,000 to 1:50,000 populations, by the year 2020, majority of the population through primary health as compared to 1:400,000 in Africa and 1:200,000 in care facilities, vision screening in schools and low- Asia today. With regard to ophthalmologists, a ratio cost production of spectacles. Similar strategies will of 1:250 000 in Africa is expected from the present be adopted to provide low vision services. (Figure 1:500 000 level by the year 2020. The corresponding target for Asia would be 1:50,000 by 2020 from the present level of 1:200,000. (27) Other categories of Figure 8.1 Vision 2020 initiative and conditions
personnel to be trained include refractionists, targeted
blindness programmes, as well as paediatric ophthalmologists technicians.
Building National Capacities
Apart from human resource development, Vision
2020
capacities that could work towards universal coverage and easy access to eye care services. (77) Global targets include the achievement of not less than 95% availability, 90% accessibility, 90% utilisation and 90% coverage of services by 2020, as compared to 50%, 40%, 25% and 25% respectively in 2000. 66 | Childhood Onset Visual Impairment, IK Jalili
Age-Related Blindness
such as Helen Keller Worldwide. The various bodies Attention has been paid recently to addressing the involved in the prevention of trachoma are grouped prevalence of age-related cataract in the developing under the ‘WHO Alliance for the Global elimination countries, top of the list of conditions focused upon by Vision 2020. Surgical throughput in poor countries The initiative (ITI) aimed at: 1) identifying is very low as a result of a combination of factors, trachoma endemic countries; 2) mapping the disease; including financial constraints and cultural barriers in 3) initiating community-based hygiene programmes; accessing services together with low productivity. The and 4) ensuring surgery was widely available. programme aims to increase the number of cataract Approaches were self-tailored to suit the various surgeries performed which is currently estimated to socio-cultural settings. (4) The initiative (ITI) was average 200 Cataract Surgical Rate per million (CSR) modelled on the implementation of ‘SAFE’ strategy in the whole of Africa, compared to that of the relying on mass treatment using azithromycin. The Australia with 6,300; USA 5,500; and the UK 3,800. projections were to treat at least 60 million people The CSR in developing countries varies from 100 in with active disease and perform some 5 million Nigeria, 450 in Kenya to 3,100 in India. Table 8.1 trichiasis surgeries between 2000-2010. (4), (32), (36), (37), gives estimated CSR for different WHO regions. The strategies applied will include concerted Considerable success has been achieved. In four years, more than 7 million individuals have received monitoring and evaluation of services. In global treatment, resulting in a cumulative reduction of 50% terms, the WHO believes in the need to increase the in active disease rates in children. More than 60,000 number of cataract operations which was estimated to have also benefited from lid surgery. Morocco and be seven millions at the planning of the global Tanzania are two of the countries that benefited from initiative programme to 12 million by the year 2000, the programme. The former is expected to attain the 20 million by 2010, reaching a final target of 32 elimination of blinding trachoma by 2005. The million by the year 2020. (27), (36), (37), (75), (78), (79) programme continues to focus on residual foci of severe disease and to evaluate techniques used in trichiasis surgery. Some recently evaluated techniques Table 8.1 Estimated CSR for different WHO
offer particularly good results. (2), (84) The rate at which regions worldwide in 1999
ocular chlamydial infection returns to a community after mass treatment suggests that the elimination of WHO Region
M / year CSR*
infection in a hyperendemic area is feasible with Currently, trachoma control will be executed through WHO Global Elimination of Trachoma 2020 programme (GET 2020), which is a component of Vision 2020. (36), (37) Bailey and Lietman raised the likelihood of some hurdles that might be faced by the programme. These include: aspects of trichiasis surgery and the frequent recurrence of entropion, the existence of other ocular abnormalities that could trigger blindness such as the tear film and lid closure, the possible emergence of a serious resistance to antibiotics and the risk of their side effects, the populations (Pop). Adopted from Foster’s update of limited duration of the efficacy of antibiotics, cultural barriers and the bureaucratic obstacles in some countries that might arise from poor communication Prevention of Trachoma
between the administrative authorities. (85) In 1985, the International Trachoma Initiative (ITI) was founded with the co-operation of Pfizer and Edna Onchocerciasis
McConnell Clark Foundation, the WHO, the Onchocerciasis is the third condition addressed by ministries of health in certain countries, and NGOs Vision 2020. Over the last 25 years considerable Prevention of Blindness | 67
progress has been made by the Onchocerciasis Control supplementation by the periodic supply of high-dose Programme in West Africa (OCP) through vector vitamin A. This policy has succeeded in reducing control and Ivermectin distribution, the distribution mortality by 23% overall, and by up to 50% for acute strategy being designed to control the skin and eye measles sufferers. However, as breastfeeding is time- disorders that result from heavy infections. (29), (86), (87) limited and the effects of vitamin A capsules last only This success, when expressed in health, economic and 4-6 months, additional long-term solutions have been development terms, was the motivating rationale for implemented including food fortification (e.g. sugar the launching in December 1995 of a new programme, in Guatemala) and promoting home gardens for African Programme for Onchocerciasis Control vulnerable rural families as a complimentary measure. (APOC). (37), (88) This latter programme is a vector These have been tried in Africa and South-East Asia control to completely interrupt the transmission cycle by promoting the growing of fruits and vegetables. of the parasite by applying larvicide to riverine Considerable success has been achieved, and in 1998 breeding sites. In the Americas, another strategy alone vitamin A supplements were delivered through being implemented is to use ivermectin more than national immunisation days to children in 40 once a year, not only to stop progression of disease, but also to interrupt transmission. The long-term sight- It is also important to address malnutrition in saving effect of ivermectin in cases of established general. The challenge is to deliver interventions ocular lesions has not been ascertained. (2) Elimination dealing with malnutrition in the areas of need of onchocerciasis from most endemic foci in Africa effectively. (92), (93) It has been suggested that the appears to be possible. However, the requirements in formation of an African food and nutrition group, terms of duration, coverage, and frequency of working with all African food and nutrition workers, treatment may be prohibitive in highly endemic can lead the way in addressing this problem and make areas.(89), (90) It has been suggested that for most use of under-utilised African resources in solving the affected parts of Africa, in the absence of vector control, ivermectin treatment should primarily be considered as a measure for controlling morbidity by Emerging Diseases Trends
reducing transmission and microfilarial loads, for The needs of countries in terms of specific emerging which purpose annual treatments would probably diseases such as diabetic retinopathy, glaucoma and age-related macular degeneration will be included in In Latin America, the Onchocerciasis Elimination VISION 2020 activities, as some of the more easily Programme in the Americas (OEPA) is successfully preventable and curable priority conditions come using ivermectin distribution. A coordination group of under control. However, in countries where many of NGOs is working closely with all three onchocerciasis the other diseases currently included as global control programmes and with national counterparts in priorities for VISION 2020 do not exist, attention should be given to specific emerging ocular diseases, Onchocerciasis is expected to be brought under some of which are already assuming public health control by the year 2010 if present efforts in endemic countries are successfully completed. (37) Eradicating Vitamin A Deficiency
Prevention Objectives in The Middle East
Eradicating blindness from vitamin A deficiency by the year 2000 was the goal set by the World Summit Objectives to address blindness in the MEC have for Children in 1990, and this has been successfully achieved in some countries. However, there are still 1. Cataract; both age related and paediatric. 78 countries where vitamin A deficiency remains a 2. Trachoma and corneal ulcerations; identification public health problem. (37) This task has been adopted and treatment including surgical treatment of by the WHO in partnership with several NGOs. The approach involves both short-term interventions side- by-side with long-term sustainable solutions. The 4. Addressing the common practice of consanguinity short-term measures are through encouraging proper with a systematic approach to include participation feeding at infancy via the encouragement of of religious bodies in any educational campaign. 68 | Childhood Onset Visual Impairment, IK Jalili
5. Improving surgical training to combat high by Jay and Johnson and Green. (98), (99) This would involve a primary and a secondary prevention. The 6. Legislation restricting ‘over-the-counter’ medicine former involves genetic counselling and the latter is with or without carrier detection, prenatal diagnosis and treatment or selective abortion of the affected 7. Educational campaigns on blinding conditions foetuses. It was estimated that maximal application at such as glaucoma and diabetic retinopathy, folk that time might reduce the rate of genetic blindness in the west by one third from 0.3% to 0.1% of the population. 8.3 PREVENTION OF CHILDHOOD
Prevention of Childhood Blindness in the Middle
BLINDNESS
Childhood Blindness in Vision 2020
Required Measures
The programme focuses on the preventable and In the Arab world and the rest of Middle East and treatable causes of childhood blindness.(35), (96) The
North Africa group of countries, with their wide gulf former includes: corneal scarring from vitamin A in the availability of resources and health services, the deficiency/measles, and in the treatable conditions main objectives of any prevention programme would cataract, retinopathy of prematurity, low vision and need to address the following issues: (13), (28), (100), (101), (102), (103), (104), (105), (106), (107), (108), (109), (110) Gilbert summed up the tasks required to be addressed in tackling congenital blindness as: female Screening of neonates for ocular abnormalities education, empowerment of women, addressing and cataract at birth and ensuring early case cultural practices, good primary health care and detection and prompt referral to the specialised primary eye care, good optical services, good surgery Introducing screening programmes for preschool Vision 2020 Targets in Childhood Blindness
The approved targets for disease control are: (97) Early diagnosis and treatment of congenital 1. Reduction of the global prevalence of childhood blindness from 0.75/1000 children to 0.4/1000 Early and prompt management of bacterial 2. Eradication of corneal scarring from vitamin A deficiency, measles, and ophthalmia neonatorum. Genetic counselling, including pre-marital risk 3. Elimination of new cases of congenital rubella Concerted multidisciplinary programme to 4. Surgical management of paediatric cataract in address consanguinity with the involvement of specialised centres together with immediate and the media, non-governmental organisations and religious bodies and ensuring that there is an 5. Screening of all babies at risk of retinopathy of enlightened preaching on this issue in mosques, prematurity and treatment to be provided when 10. Emphasis on the need to establish specialised 6. Vision screening to all school children, as part of paediatric ophthalmic services in dedicated school health programmes, with provision of centres with expertise in the assessment, surgical glasses for those with significant refractive error. treatment, and long-term management of the Genetic Counselling
11. Orthoptic services at hospital and community Methods of prevention of hereditary disease by levels to ensure continuity of care for these screening and early treatment of people were outlined Prevention of Blindness | 69
WHO Countries Priorities
irregular control of diabetes and insufficient resources For the WHO, prevention of congenital blindness is a priority. Five countries in the Region, namely Egypt, In Yemen, a collaborative national programme Islamic Republic of Iran, Morocco, Sudan and Pakistan, will receive support from the Lions Clubs IMPACT/EMR, was launched for the prevention of International Foundation over the next five years to blindness from cataract in 1995 and carried out in address CB in their countries with an emphasis on several locations in 3 cities. In addition to the elimination of the backlog of cataract, the programme Steps Taken by Arab Countries
A number of Arab states are taking serious steps ophthalmologists by training local Yemeni doctors. towards the elimination of preventable blindness For this purpose, a 12-month diploma course in including Saudi Arabia, Oman, Morocco and have ophthalmology has been initiated in collaboration achieved considerable results in the control of with the WHO. Fifteen doctors were enrolled in the blinding trachoma. As stated earlier, trachoma is also 1996-1997 courses and priority in selection was given a priority of the WHO campaign for the Global to those from rural areas. It was ensured that the Elimination of Trachoma (GET2020) in these ophthalmologists trained through the programme countries. (13), (14), (28), (85), (100), (101) Vision 2020 has serve a minimum of two years in remote villages been launched in 10 Member States in the Region, namely; Bahrain, Egypt, Lebanon, Saudi Arabia, Tunisia, Sudan, UAE, Qatar and Yemen. (14) The educational programme set up in Oman to Conclusions
target the rural population and shed light on the causal relations between chlamydial conjunctivitis and the In conclusion, there have been ongoing campaigns to later complications, trichiasis, corneal ulcer and combat blindness in poorer countries with special eventually blindness, was not successful and did not emphasis on Africa. (Figure 8.1) These initiatives match the socio-cultural aspects of the population. (112) were pioneered by the WHO, in close partnership The booklet prepared for this purpose was very with other organisations such as the World Bank, poorly understood as a result of the high rate of national governments and a large consortium of illiteracy of the population, and unsuitability of the international NGOs. Examples of these programmes illustrations used. Currently, the Oman Government has set up the mid-decade and end-decade goals and implemented in 36 endemic countries. In 2001 alone, the 6th Five-Year Plan of the Ministry of Health has some 200 million treatments with Ivermectin were laid down the objectives and activities of the Prevention of Blindness Control Programme in The newer initiative, Vision 2020 on the other hand, shall also address, in addition to disease control, According to the WHO, the prevalence of trachoma infrastructure and human resource development in in Oman is low (< 1%) and the SAFE programme is these countries. There will be specialist training well underway. Early detection and management of programmes in East, West and French speaking diabetic retinopathy have been strengthened at the Africa and paramedic national training programmes regional hospitals. In addition, measures to control in the larger countries. All these efforts shall be diabetes have been undertaken such as the integration targeted to the 65% treatable and preventable causes of diabetes control programme to PHC, a national which are cataract, refractive errors, trachoma and its diabetes registry and annual training workshops, and sequelae, vitamin A deficiency and onchocerciasis. a policy for ocular examination for all new diabetics In the prevention of blindness, a lack of information on the public health importance of glaucoma, low awareness of glaucoma and difficulties in the early diagnosis and prompt treatment of glaucoma have been major constraints, followed by the high cost of importation of donor cornea, the presence of trachomatous dry eyes, prevalence of maculopathies, 70 | Childhood Onset Visual Impairment, IK Jalili
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