MJA: Holden et al., Visual impairment: a correctable global problem

Visual impairment: a correctable global problem

For many in developing countries, treatment may be as simple, and as difficult to obtain, as spectacles

MJA 1997; 167: 351-352

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	Preventable blindness is one of our most tragic and wasteful global problems, restricting the employment and life prospects of otherwise healthy people, and placing unnecessary strain on families and social welfare systems. Blindness and uncorrected low vision affect every aspect of the social and economic welfare of people and countries -- they impede learning in children and may prevent adults finding employment, in turn adding to the burden on welfare resources. Although it may be relatively simple to correct a visual defect, vision restoration is often not a priority in countries where major life-threatening illnesses are common health care problems.
The most wasteful problem in vision restoration is the lack of refraction and spectacles for those who need them	Over the past few years, great advances have been made in this area by the alliance of non-government organisations (such as the Partnership Committee of Nongovernmental Organizations), government agencies, private organisations, the World Health Organization, and the World Bank Development Agency. Programs have now been put in place to tackle blindness and visual rehabilitation in a systematic, cost-effective way. Typical of one such effort is the Nepal Prevention and Control of Blindness Project. The high prevalence of cataract blindness in Nepal sparked development of a program to replace cataracts with intraocular lenses. The combination of overseas experts to provide surgical expertise, training, planning and coordination, together with low-cost intraocular lenses from the Fred Hollows Foundation manufacturing facility in Katmandu, have dramatically reduced cataract blindness in Nepal (Dr Ram Prasad Pokhrel, President, Asia-Pacific Academy of Ophthalmology, personal communication). *The problem:* However, in many areas, such as the Indian subcontinent, it is extremely hard to keep pace with eyecare needs because of rapid population growth, maldistribution of ophthalmic personnel and the difficulty in recompensing ophthalmologists for dealing with the massive backlog of cataract blindness, the major type of preventable blindness today.¹ In Asia, the number of eyecare practitioners (all professions, including ophthalmologists, optometrists and opticians) is only 12 per million population, and in Africa it is only three per million, and even worse in many rural areas.¹ Ratios are slightly better in the Middle East (47), South America (88) and Eastern Europe (108). In contrast, the ratio of eyecare practitioners per million population in developed countries ranges from 151 (Western Europe), to 245 (Pacific region), 262 (North America) and 444 (Japan).¹ The lack of practitioners and services is the main reason for the high prevalence of blindness and other vision problems in many developing countries. The prevalence of blindness in Africa is 1.4% of the population, seven times greater than in developed countries, while in the Middle East it is 1.2%.¹ However, about 90% of the vision problems in the world today are treatable or preventable (see Figure). The intervention of a trained eyecare professional can stop disease progression, correct defects or restore sight by surgery.
	Figure: Major causes of visual impairment worldwide¹ (figures refer to millions of people). The most wasteful, and certainly the most common, problem in vision restoration is the lack of refraction and spectacles for those who need them. Most of those with impaired vision worldwide simply require correction of refractive errors, but for many in developing countries this is either not available or inadequate. Even presbyopia becomes a debilitating condition for the aged. The lack of vision care services was highlighted by the recent estimate that half the children in blind institutions in Africa were there because they had never been refracted (Dr Allen Foster, International Centre for Eye Health, Institute of Ophthalmology, London, personal communication). In fact, they were found to be reading Braille by seeing the dots up close rather than by feeling them! Low vision is less known in the community as a cause of debilitation compared with blindness, and funding for its alleviation is more difficult to obtain. However, international agencies are increasingly emphasising the need for commitment to this area. Institutional low vision clinics, which can provide low vision aids (such as magnifiers and telescopes), as well as refraction and spectacles when appropriate, need to be established throughout the developing world, especially in Africa. These could meet local needs by harnessing the skills and knowledge of experts in this area. *What needs to be done?* Crucial to improving eyecare in developing countries is the provision of well balanced eyecare teams that can effectively deliver quality care. A current model of such a community eyecare team, used by the L V Prasad Eye Institute in Hyderabad, India, provides one ophthalmologist, four optometrists, eight eyecare workers, eight ophthalmic assistants, and 16 ophthalmic nurses per 500 000 people. The number of trained eyecare practitioners in developing countries must be increased. To this end, the World Health Organization has set regional targets for ophthalmologists and optometrists.² While making practitioners available on a part-time or temporary basis in outreach clinics is an important immediate measure for improving eyecare, long term improvement requires that they be permanently available to the community. To achieve this level of practitioner availability, high quality training programs must be established to produce new eyecare practitioners and enhance the knowledge and skills of existing practitioners. These programs should include continuing professional education to ensure that practitioners are kept up-to-date with the latest techniques and equipment. Infrastructure to support these training programs must be established which includes local institutions, associations, industry and service groups. It is also important that practitioners be widely distributed throughout the countryside. In many developing countries, most practitioners work in the capital cities rather than rural areas. Another essential strategy is the education of eyecare educators. Teaching teachers and providing them with educational resources will ensure the continuation and development of eyecare education in developing countries. These educational initiatives will help improve delivery of eyecare to the population, not only in the form of initial diagnosis and treatment, but in ongoing patient support. Ultimately, education is the means to prevent blindness worldwide. Brien A Holden Professor and Director, Cooperative Research Centre for Eye Research and Technology, University of New South Wales, Sydney, NSW Gullapalli N Rao Director, L V Prasad Eye Institute, Hyderabad, India President, Asia-Pacific Division of the International Agency for Prevention of Blindness Kylie M Knox Manager, Cooperative Research Centre for Eye Research and Technology University of New South Wales, Sydney, NSW Sylvie M Sulaiman Director of Education, International Association of Contact Lens Educators Delegate to the WHO Partnership Committee of Nongovernmental Organizations for Prevention of Blindness International Association of Contact Lens Educators. IACLE demographics report, 1995. Sydney: IACLE, 1996. Partnership Committee of International Non-Governmental Organizations dedicated to the Prevention of Blindness and the Education and Rehabilitation of the Blind. World Health Organization global initiatives plan for prevention of blindness. Geneva: WHO, 1997.

©MJA 1997