Kovin Naidoo ICEE Africa Director AFCO Vice-President

1. Optometry as part of Vision 2020: global perspective Kovin Naidoo ICEE Africa Director AFCO Vice-President

2. World Health Organisation- IAPB Global Initiative to Eliminate Avoidable Blindness by the Year 2020

3. < 6/18 - 3/60 <0.3 - 0.05 < 3/60 <0.05 Low Vision Blind Present situation • Present estimation: • 45 million people blind + • 135 million visually disabled Best corrected VA International classification ignores the burden of uncorrected refractive error

4. Prevalences: < 0.4% 0.4 - 0.6 0.6 - 1 > 1% World Prevalence of Blindness

5. Prevalence of Blindness 90%+ live in underprivileged communities

6. The ‘blindness’ rate in many developing countries, especially in Africa, is 7 times higher, at 1.4%, than in developed countries

7. Gender is another major issue

8. Global Distribution of Blindness by Cause Other 28 % Macular degeneration Diabetic retinopathy + Refractive errors (uncorrected) Oncho. 1 % Glaucoma 14% Cataract 42 % Trachoma 15 %

9. Present situation 80% of blindness is avoidable preventable or curable

10. Leading Causes of Preventable Blindness: • Cataract • Trachoma • Onchoceriasis • Childhood Blindness • Refractive Error& Low Vision

11. VISION 2020 • Vision 2020 will strive to make refractive services and corrective spectacles affordable and available to the majority of the population through primary health care facilities, vision screening in schools and low-cost production of spectacles. Similar strategies will be adopted to provide low vision services.

12. Global estimates • Magnitude of refractive errors not reliably known • Large global variation in prevalence (by age, gender, and race) • Estimated: 2.3 billion people have refractive error • 1.8 billion have access to refractive services • 500 million do not have access to services

13. Blindness Due To Uncorrected Refractive Errors (<3/60) China 4.4% Due to RE:10% Shaozhen Li, 1999 (n=5342) India 2.5% Due to RE:9.6% Dandona, 1998 (n=2522) 10%+ of WorldBlindness Sth Africa 1.0% RE:10% Cook, 1992 (n=268) Australia 0.15% Due to RE:25% Taylor, 1997 (n=3268) Saudi Arabia0.7% RE: 5.3% Al Faran, 1993 (n=2882)

14. Difficulties with Current Data • Non-uniform definitions across studies • Non-representative study populations (convenience rather than population-based) • Dissimilar demographics of study population (age and sex) • Refraction procedures are different (with/without cycloplegia etc) Negrel, Ellwein, 2001

15. Uncorrected refractive error is the major cause of: blindness following mass cataract surgery using standard power IOL

16. Myopia with Autorefraction: Country Comparison

17. Low Vision • 35m people worldwide have irreversible vision loss and are in need of low vision care. Treatment: Low vision care & vision correction • VISION 2020will enable access to visual devices & low vision care at affordable cost *WHO Global Initiative: Vision 2020, Feb 1999

18. components • Disease control through service delivery • Human resource development • Infrastructure and technology

19. Collaborations • has created valuable and effective collaborations of organisations • WCO until 2002 was not a part of the International Agency for the Prevention of Blindness

20. Optometry a late entrant • It is only recently that uncorrected refractive error and even more recently low vision has achieved prominence • Landmark population-based studies in adults, children and in post-cataract patients.

21. Optometry and Public Health • Mainly private practice • Limited discourse about public sector initiatives • Individual Optometrists and groupings efforts

22. Public Health Challenges • Integration of professions • Expansion of the scope of Optometry • Consolidation of the scope of Optometry • Charity vs Public Health • Health Policy • Health Systems development and Management • Health Promotion

23. Opportunity for Optometry • The realisation of the impact of uncorrected refractive error and Low Vision has provided the opportunity for optometry to play a major part in alleviating vision loss for those most in need.

24. Refractive Error and Vision 2020 • WHO established a Refractive Error Working Group (REWG), as • The REWG is now developing international strategic plans and policies to eliminate uncorrected refractive error.

25. Definitions • Children: • -Myopia: < 0.5D • -Hyperopia: 2D

26. Refractive error in Children • -Binocular vision <6/12 is considered significant • -Should only occur when appropriate resources for follow-up refraction and delivery of spectacles. • -Visual acuity screening of children can be performed at community level by teachers, health care workers etc.

27. Refractive exams • Children: • Exams should be carried out only by eyecare personnel(ECP) with the appropriate skills in objective and subjective refraction, ocular motility, basic eye examination, ability to detect potenially blinding diseases and communication skills.

28. Minimum Standards for Children • -Retinoscopy plus subjective refraction, with cycloplegia for young children as needed. • -Autorefractometry plus subjective refraction with cycloplegia

29. Refractive Correction: Priority • -High Priority: < 6/18 • -Moderate Priority: <6/12 • -Low Priority: <6/9 • -Children: < 6/12 • -Adults: < 6/18

30. Priority Groups • Children aged 11-15 with myopia and people over the age of 45 years who require spectacles for near vision

31. Not Restricted to Refraction • Integrated into the eye team and blindness prevention • Teaching eye care personnel, especially in refraction and low vision care • Providing screening and vision care services at secondary and tertiary levels • Detection and management of potentially;blinding diseases such as cataract, diabetes and glaucoma • Research into the understanding of global eyecare needs and solutions,especially in vision correction and vision care service delivery • Building models of self-sustainable eyecare.

32. Optometry's Role in Correcting Refractive Error • Public health optometry has not reached the • communities that are in most need in any organised way. • Develop a concerted effort to create local capacity in these communities, in collaboration with its partners in Vision 2020, through service delivery, by creating human resources and by helping to develop the infrastructure needed, the three cornerstones of the Vision 2020 programme.

33. What is Needed? • Developed countries: optometrist to population ratio is 1:10,000. • Developing countries the ratio is 1:600,000, and much worse in many rural areas, up to millions of people per optometrist.

34. What is needed? • Increase in the number of eyecare personnel trained in refraction and vision correction. • Training mid-level personnel in refractive care. • Interim measures using nurse-refractionists or ophthalmic or optometric technicians that refract are essential.

35. STRATEGIES Vision 2020 Ophth., Opt., Managers Specialists OphN., Oph.Tech, Dispensing Opt. Mid Level Personnel Com Worker, Teacher, PHCW Comm. Level

36. One effective current model, developed by the LV Prasad Eye Institute in Hyderabad, • India, for the efficient and cost-effective delivery of eyecare is a community eyecare • ‘team’. For every 1,000,000 people the team has: • · 1 ophthalmologist • · 4 optometrists • · 8 eyecare workers • · 8 ophthalmic assistants • · 16 ophthalmic nurses.

37. ICEE Africa“Graduation Day”Nurse Training Program

38. What is needed? • Establishment of infrastructure • Development of effective models and • Programmes • Funding needed for the provision of training and low cost spectacles. • Low Cost laboratories

39. Refraction services as an integral part of general health care systems and • comprehensive eyecare.

40. The Role of Research • Adequate prevalence data determines those most in need of intervention • Provide the basis from which interventions in the future can be evaluated

41. AFRICAN VISION RESEARCH INSTITUTE (AVRI) African Vision Research Institute (AVRI) addresses the need for Africa based eye research. Based in South Africa it will link: • Intellectuals • Institutions • Organizations • Other personnel in the pursuit of solutions to the various community eye health issues in Africa.

42. Optometry can significantly contribute to the understanding of: Worldwide blindness and impaired vision-the burden and its effects Health care planning Service delivery Outcomes of intervention.

43. Self-Sustainability, Refractive Error and Optometry • Developing the logistics and economics of self-sustaining eyecare at the • community and institutional levels • · Mobilising worldwide resources to develop models and create the educational and delivery infrastructure for refractive and general vision care.

44. Cross Subsidization • Spectacle supply can effectively fund more expensive or • Intensive needs such as low vision and cataract surgery. • Refract and supply spectacles and vision care, including the • Detection and treatment of minor problems, and referral of those with more serious problems, at the community level. • Optometry can make a major contribution in supporting eye care at this more convenient and cost-effective level.

45. OPTOMETRY’S RESPONSE • Public Health and Development Committee of WCO • Vision 2020 membership • OGS • Public Health Agenda • Membership in Country of Vision 2020 committees • Involvement in the National Plan

46. Tanzanian Opportunties • Community Optometry a model for the world

47. Preventable blindness is one of our most tragic and wasteful global problems. • Optometry is an essential part of the team that will eliminate this tragedy, by understanding global eyecare needs and delivering effective and sustainable visioncare to people in need, thereby ensuring their fundamental right to sight.

48. THANK YOU