Blindness ,NPCB

1. Community Ophthalmology
Dr Deodatt M Suryawanshi
Associate Professor Community Medicine

2. Outline
 Community Ophthalmology ?/PEC
 Burden of various blindness causingdisorders
 National Programme for control of Blindness.
 Right to Sight: Vision 2020.

3. Community ophthalmology
Synonyms
= Public health ophthalmology
= Preventive eye care (PEC)
= Preventive Ophthalmology

4. Community ophthalmology
The Aim :
To provide the essential, accessible Quality
Ophthalmologic services to the community at
affordable cost to.

5. Principles of Community Ophthalmology
 Based on principles of Primary health care.
Equitable
Distribution
Community
participation
Inter
sectoral
coordination
Appropriate
Technology

6. Three-pronged strategy of Community
Ophthalmology
prevention,
interventionrehabilitation

7. Fact finding surveys
Research
Screening
Clinical care
 Health education
 Referral
 Follow up
Improvement of basic needs.
Activities in Community Ophthalmology

8. Activity
Primary prevention
Health Education
about Common
Ophthalmic diseases
&
Specific Protection.
Secondary
prevention
Identify and treat in
the community
Primary health care
workers
Volunteers(Trained)
P. H. Workers
General physicians
Community
Ophthalmologist.
Person
Community /SC
Community
/PHC
Place

9. Activity
Identify and refer
for Treatment
Specialized eye care
Rehabilitation
PEC Workers
Optometrists
Ophthalmologist.
Ophthalmologist
VR Surgeon
Person
District Hospitals
Medical colleges,
ROI, Super
specaility
services
Place

10. Delivery of eye care- model
Primary Health center
District hospitals
National teaching
Hospitals,Superspeciality
hospitals
Primary eye care
Secondary eye
care
Tertiary eye care

11.  Village level eye care provider would be responsible for village eye care
activities.
 ASHA , Anganwadi Workers , Health Workers would be key persons
responsible for household survey maintenance of Village Blind Register

12. WHO Guidelines for primary eye care
1. Conditions to be recognized and treated
by a trained primary eye care worker
☞ Conjunctivitis and lid infections
- Acute conjunctivitis
- Ophthalmia neonatorum
- Trachoma
- Allergic & Irritative conjunctivitis
Blinding Malnutrition
-

13. 2. Conditions to be recognized and referred
after treatment has been initiated.
☞ Corneal ulcers
☞ Lacerating or perforating injuries of the eye
ball
☞ Lid lacerations
☞ Entropion / Trichiasis
☞ Burns - Chemical
- Thermal

14. 3. Conditions that should be recognized
and referred for treatment.
☞ Painful red eye with visual loss
☞ Cataract
☞ Visual loss < 6/18 in either eye

15. Burden of Blindness

16. Definition of blindness under NPCB
(ref NPCB website)
Blindness is defined under following headings:
 Simple Definition: Inability of a person to count
fingers from a distance of 6 meters or 20 feet.
 Technical Definition :
Vision 6/60 or less with the best possible spectacle
correction or
Diminution of field vision to 20° or less in better eye.

17. World Wide
285 million Visually
impaired
45 million blind
240 million have low
vision
80% of all visual
impairment can be
prevented or cured.
82% of people living
with blindness are aged
50 or more
90% live in low-
income

18. Globally Causes of visual impairment
Uncorrected
refractive errors
(myopia, hyperopia
or astigmatism) 43
%
Unoperated
cataract, 33%
glaucoma, 2% Others

19. Burden of blindness in India
 Of the total estimated 45 million
blind persons (best corrected visual
acuity < 3/60) in the world,
7 million are in India.
 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.
 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

20. Trend of blindness In India
• ICMR Survey
• (1.38% ) Visual
acuity < 6/60
1974
• Govt & WHO
• 1.49%
1986
1989
• NPCB (rapid
survey)
• 1%
2006
Vision 2020
target
• Reduce
blindness
prevalence 0.3
%

21. Main causes of blindness In India (Ref NPCB
2015)
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%)

22. Cataract
 Major cause of blindness in the world.
 Estimated 16-20 million people are
bilaterally blind from cataract
 The cataract surgical rate is a quantifiable
measure of the delivery of cataract services.
 It is the number of cataract operations per
million population per year.
Aim (Vision 2020)
 Elimination of cataract
blindness (person with vision
less than 3/60 in both eyes.)

23.  The prevalence of unoperated cataract in people aged ≥60 was 58% in north
India (95% CI, 56–60) and 53% (95% CI, 51–55) in south India (P = 0.01)
Vashist P, Talwar B, Gogoi M, et al. Prevalence of Cataract in an Older Population in
India: The India Study of Age-related Eye Disease.Ophthalmology. 2011;118(2-
19):272-278.e2. doi:10.1016/j.ophtha.2010.05.020.

24. Trachoma : Burden
 Estimated 146 million people have the active infection with the microorganism
Chlamydia trachomatis.
 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

26. Onchocerciasis : Disease Burden
 Onchocerciasis (also called river
blindness or filariasis) is a disease
caused by the nematode (worm)
Onchocerca volvulus.
 An estimated 17 million people are
infected with onchocerciasis.
 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

27. Burden Countries
Ref:www.who.int/blindness/partnerships/onchocerciasis_disease_information/en/, accessed May 5, 2014. - See more at:
http://www.kidsnewtocanada.ca/conditions/onchocerciasis#sthash.WOAYZ1BZ.dpuf

28. Childhood Blindness : Disease burden
 Group of diseases and conditions
 occurring in childhood or early adolescence,
 If left untreated, result in blindness or severe visual impairment that are
likely to be untreatable later in life

29. Childhood blindness : Burden
Estimated 1.5 million blind children in the world
The prevalence is 0.5 - 1 per 1,000 children aged 0-15
years.
1 million live in Asia and 3,00,000 in Africa.

30. Causes of childhood blindness around the
world
Africa
• Corneal ulcer/scar (measles,
vitamin A)
• Vit 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
Retinopathy of Prematurity
Congenital cataract
Hereditary disorders.

31. Refractive Errors
 Very common eye disorder.
 Eye cannot clearly focus the images from the outside world.
 Result of refractive errors is blurred vision,
 Sometimes so severe that it causes visual impairment

32. Refractive errors Burden In World.
 According to the most recent data available to WHO, there are an estimated
124 million people in the world with low vision .
 Severe refractive errors have been estimated to account for about 5 million
blind people.

33. Refractive errors : Burden in India
 No nationwide reliable data on refractive errors.
 A survey indicated that 1 % of children in the age group (5 to 15 ) had vision
< 6/18 in the better eye.(ref CME sereis 2009 NPCB)

34. Initiatives to Prevent blindness
 Global Level :
 Vision 2020 : Right
to sight
 National Level :
 National Programme for
Control of Blindness
(NPCB)

35. Vision 2020: The Right to Sight

36. Vision 2020: The Right to Sight
 Global initiative launched by
the World Health Organization
and a Task Force of
International Non-governmental
Organizations in 1999

37. Six key strategic areas to produce an
impact
1. Advocacy for Eye Health.
2. Policy & Program Development.
3. Quality in Eye Care.
4. Resource Mobilization & Sustainability.
5. Research.
6. Organizational Development.

38. Global conditions for immediate attention
under Vision 2020

39. Five basic strategies to combat
blindness

40. National Programme for Control of Blindness
 Launched in the year 1976
 100% Centrally Sponsored scheme.
 Goal to reduce the prevalence of blindness from 1.4% to 0.3%.(2020)

41. Objectives & Strategies under
the 12th Plan

42. Objective 1. To continue three ongoing
signature activities under NPCB
 Performance of 66 lakh Cataract surgeries per year;
 School Eye Screening and distribution of 9 lakh free spectacles per year
to school children suffering from refractive errors;
 Collection of 50,000 donated eyes per year for keratoplasty.

43. Strategy
 Continued emphasis on free cataract surgery through the health care
delivery system as well as by the involvement of NGO sector and
private practitioners.
 Reduction in the backlog of blind persons by active screening of population
above 50 years, organizing screening eye camps and transporting operable
cases to fixed eye care facilities;

44. Cataract Operations
Year Target
No. of Cataract
operations
performed % Surgery with IOL
2010-11 60,00,000 60,32,724 95
2011-12 70,00,000 63,49,205 95
2012-13 66,00,000 63,02,894 95
2013-14 66,00,000 62,63,150 95
2014-15* 66,00,000 23,43,573 95

45. Strategy
 Refractive Errors comprises a major part of avoidable blindness.
 Screening of children at school ,aanganwadi for for identification and
treatment of refractive errors
 provision of free glasses to those affected and belonging to poor socio-
economic strata;

46. School Eye Screening Programme (NPCB
2015)
Year
No. of free spectacles provided to school children
suffering from refractive errors
Target Achievement
2010-11 6,00,000 6,26,839
2011-12 6,00,000 6,58,061
2012-13 10,00,000 7,08,861
2013-14 9,00,000 6,24,942
2014-15* 9,00,000 1,21,262

47. 2. Reduce the backlog of avoidable blindness
 Identification and treatment of curable blind at primary, secondary and
tertiary levels, based on assessment of the overall burden of visual
impairment in the country

48. Strategy 2
Early
Detection
Diabetic
Retinopathy
Avoidable
blindness
Glaucoma

49. Objective 3.Develop and strengthen
 The strategy for “Eye Health for All”
 Prevention of visual impairment.
 Provision of comprehensive universal eye-care
services.
 Quality service delivery.

50. Strategy
Retinopathy of
Prematurity
(ROP)
Corneal
Transplantation
Vitreo Retinal
Surgery
Treatment of
childhood
blindness
Comprehensive Eye care

51. Objective 4. Strengthening and up-gradation
 Regional Institutes of Ophthalmology (RIOs) to become Centre of
Excellence
 Medical College, District Hospitals, Sub-district Hospitals, Vision Centers,
NGO Eye Hospitals.

52. Strategy
 Regional Institutes of Ophthalmology and Medical Colleges of the
states to be strengthened in a phased manner with latest equipments
& training of manpower so that they can be upgraded as Centers of
Excellence in the regions.

53. Regional Institutes of Ophthalmology
• Latest technology
• High quality eye care
Strengthening
eye care service
deliveries
• Training of Opthalmologist,Opthalmic
assiatnts
• Paramedical personnel
Development of
human resources
• Patient care
• Training & Research
State of art
services
Centers of excellence

54. Under 12 th Five year plan
 A provision of Rs. 130.00 crore has been made for Upgradtaion of
Medical colleges to RIOS and further strengthening of RIOs.

55. Regional Insitutes of Opthalmology
1. Regional Institute of Ophthalmology, Hyderabad
2. Regional Institute of Ophthalmology, Kolkata
3. Regional Institute of Ophthalmology, Guwahati
4. Regional Institute of Ophthalmology, Bhopal
5. Regional Institute of Ophthalmology, Sitapur
6. Regional Institute of Ophthalmology, Patna
7. Regional Institute of Ophthalmology, Thiruvananthapuram
8. Regional Institute of Ophthalmology and Government Ophthalmic Hospital, Chennai
9. Regional Institute of Ophthalmology, Ahmedabad
10. Regional Institute of Ophthalmology, Bangalore
11. Regional Institute of Ophthalmology, Allahabad
12. Regional Institute of Ophthalmology, Raipur
13. Regional Institute of Ophthalmology, Jaipur
14. Regional Institute of Ophthalmology, Ranchi
15. Regional Institute of Ophthalmology, Cuttak
16. Regional Institute of Ophthalmology, Rohtak
17. Regional Institute of Ophthalmology, Mumbai
18. Regional Institute of Ophthalmology, Punjab

56. Strategy
 The District Hospitals to be strengthened by upgrading infrastructure,
equipment and providing adequate manpower like Ophthalmologists and
PMOAs on contractual basis and provide earmarked funds for basic
medicines and drugs;

57. Strategy
 Establishing Vision Centers in
all PHCs with a PMOA in
position
 Multipurpose District Mobile
Ophthalmic Units for better
coverage. (MDMUs).(12th Plan)
Eye Care
Infrastructure
Centre’s of
Excellence (20)
Training Centers
(200)
Service Centers
(2000)
Primary Level Vision
Centers (20000)

58. Activities by Multi-purpose District Mobile
Ophthalmic Unit
1. Screening Eye
2. School Eye Screening
3. Transporting patients from Screening Centers to
the nearest District Hospital/Referral Centre for
further management
4. On the spot refraction and provision of glasses
5. Diagnosis of diseases like Diabetic Retinopathy,
Glaucoma, etc.
6. Display of IEC messages on its outer panels

59. Objective 4. Developing Human resource and
Infrastructure
 Strengthening the
existing infrastructure
facilities
 Developing
additional human
resources for
providing high quality
comprehensive Eye
care in all Districts of
the country

60. Human resource needed (refer CME series NPCB)
Category Current
Year Year Output No. of
2015 2020 p.a. Training
Institutions
Ophthalmic
Surgeons 12000 21000 25000 1200 150
Ophthalmic
Assistants
(Community) 6000 20000 25000 1200 50
Ophthalmic
Paramedic 18000 42000 48000 1500 50
Eye Care
Managers
Community 200 1500 2000 100 5
Eye
HealthSpecialis
ts 20 150 200 10 5

61. Objective 5.To enhance community
awareness
 On eye care
 On preventive
blindness

62. Objective 6.Stimulate research
 Increase and expand research for prevention of
blindness and visual impairment

63. Objective 7.Developing partnerships.
 To secure participation of Voluntary
Organizations/Private Practitioners in delivering eye
Care

64. Strategy
Coverage of underserved area for eye care
services through public-private partnership.
Capacity building of health personnel for
improving their knowledge and skill in delivery
of high quality eye services.

65. Budgetary allocation for 12th Five Year
Plan
 Out of a total projected budget of Rs. 2800 crore, a provision of Rs. 2506.90
crore has been approved by the Empowered Programme Committee (EPC)
for Eye-care activities upto district level.
 A provision of Rs. 130.00 crore has been approved by the Expenditure
Finance Committee (EFC) for continuing tertiary level activities (RIOs,
Medical Colleges etc.) during the years 2013-14 and 2014-15

66. Decentralized Approach : Districts
Blindness Control societies (DBCS)
 District Blindness Control Societies (DBCS) have
been set up as the nodal agencies.

67. DBCS
Composition of
DBCS
• District
Administration
• Health
• Department of
Social welfare
• NGOs/Private
sector
Functions of DBCS
• Screen blind people in
every village.
• Organize diagnostic
camps.
• Arrange for transport
and treatment
• Follow up pts for
review
Receives
funds
directly from
Government

68. Monitoring and Evaluation : How ?
 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.

69. Monitoring & evaluation : Where ?
Sentinel surveillance units (SSUs)
• SPM & Ophthalmology (25).
• Asses visual outcomes of
cataract patients.
• Ocular morbidity data
National Surveillance units
• AIIMS
• Compilation of data
• Technical support
DGHS
• Administrative &
Financial matters

70. Cornea Blindness
 0.12 million Cornea blind people due to various causes.
 Affected mostly are young adults.
 45000 to 50000 corneas are collected yearly in eye banks.
 Huge shortfall .
 Eye Donation forthnight 25 th August to 8 th August scale up IEC activities.

71. Criticism of NPCB
Village /Sc/PHC level.
 Poor motivation of health
workers.
 No additional allowance .
 Overburden with other national
health programs.
 Shortage of staff ,OA coming
irregularly.
 Transport of patients ?
 IEC activities lagging behind.
District
 Shortage of trained Ophthalmic
surgeons and paramedical staff
thus delaying operations and
causing backlog.

72. Take home message
 Prevalence of cataract Blindness down but absolute numbers increasing as
Population rises.
 Human Resource deficiency/understaffed /Over worked staff may act as as
threat.
 Institutional mechanisms ,Infrastructure development and budgetary
provisions in place.
 Threat of Diabetic Retinopathy and other chronic diseases remains.

73. IEC & Special Events
 National Eye Donation Fortnight was observed from
25th August to 8th September.
 World sight day : 8th October
 Theme 2015 Eye Care for All

74. reference
 http://www.who.int/blindness/causes/priority/en/index3.html.
 CME series 2009 ,Vison 2020.
 MOHFW ,National health Programmes 2014/2015 document.
 Guidelines for Operationalization of Multi-Purpose District Mobile Ophthalmic Units
under the National Programme for Control of Blindness

75. Thanks