National programme for control of blindness

1. Moderator : Prof. Mehendale Presenter : Ranjana National programme for control of blindness

2. Introduction • NPCB was launched in the year 1976 as a 100% Centrally Sponsored scheme with the goal to reduce the prevalence of blindness to 0.3% by 2020. • Rapid Survey on Avoidable Blindness conducted under NPCB during 2006-07 showed reduction in the prevalence rate of blindness from 1.1% (2001-02) to 1% (2006-07).

3. Definition • Low vision – VA of less than 6/18 but equal to or better than 3/60, or a corresponding visual field loss to less than 20°, in the better eye with the best possible correction. (10th revision of the WHO International Statistical Classification of Diseases, Injuries and Causes of Death) • Blindness - VA of less than 3/60, or a corresponding visual field loss to less than 10°, in the better eye with the best possible correction. • ‘Visual impairment’ includes both low vision and blindness. • In 2009, the term ‘low vision’ was deleted from the 10th revision of the ICD (ICD-10), • Moderate visual impairment -presenting visual acuity of < 6/18 to 6/60 and • Severe visual impairment- VA< 6/60 to 3/60 from all causes.

4. Burden of disease Globallyabout 314 million people are visually impaired, 45 million of them are blind. • 1990- ranged from 0.08% of children to 4.4% of persons aged over 60 years, with an overall global prevalence of 0.7%. • 7 million people become blind each year and that the number of blind people worldwide was increasing by 1–2 million per year. In India • 2003-1.1% in the major States and 1.38% in the north-eastern States • 2006-07 -1%.

5. GLOBAL BLINDNESS BLIND (millions)

6. Projected trends in Global Blindness due to demographic changes to 2020 45 to 76 million (73% increase) 2000 2010 2020

7. Major causes of blindness

8. Major causes of blindness in India

9. Key facts • About 314 million people are visually impaired worldwide, 45 million of them are blind. • Most people with visual impairment are older, and females are more at risk at every age, in every part of the world. • About 87% of the world's visually impaired live in developing countries. • The number of people blinded by infectious diseases has been greatly reduced, but age-related impairment is increasing. • Cataract remains the leading cause of blindness globally, except in the most developed countries. • Correction of refractive errors could give normal vision to more than 12 million children (ages five to 15). • About 85% of all visual impairment is avoidable globally.

10. Objectives • To reduce the backlog of blindness through identification and treatment of the blind; • To develop Comprehensive Eye Care facilities in every district; • To develop human resources for providing Eye Care Services; • To improve quality of service delivery; • To secure participation of Voluntary Organizations/Private Practitioners in eye Care. • To enhance community awareness on eye care.

11. Four pronged strategy of the programme • Strengthening service delivery, • Developing human resources for eye care, • Promoting outreach activities and public awareness and • Developing institutional capacity

12. Revised strategies • To make NPCB more comprehensive-corneal blindness, refractive error, post op cataract, glaucoma. • To shift eye camp approach to a fixed facility surgical approach. • To expand world bank project activities like construction of dedicated eye operation theatres • To strengthen participation of voluntary orgnization in programme. • To enhance eye care services in tribal and other under served areas.

13. Organizational structure

14. Composition of state health society (blindness division) • The primary purpose-is to plan, implement and monitor blindness control activities in all the districts of the State as per the pattern of assistance approved for National Programme for Control of Blindness by the cabinet in Centre. • In the state level the State health Society is formed with the following members • Chairman : State Mission Director/Secretary. • Vice Chairman : Director Health Services • Member Secretary : Joint/Dy. Director (from the state cadre)

15. Functions 1. To coordinate and monitor with all the District Health Society 2. To conduct regular review meeting with districts in coordination with Centre. 3. To procure equipment and drugs which required in GOI facilities 4. To receive and monitor use of funds, equipments and material from the Government and other agencies. 5. To involve voluntary organization and Private Practitioners providing free/Subsidized eye care services in district. 6. To promote eye donation through various media and monitor the districts for collection and utilization of eyes collected by eye donation centres and eye banks

16. Composition of DBCS • Maximum of 15 members: • Chairman : District Collector/District Mission Director • Vice-Chairman : Chief Medical & Health Officer/District Health Officer • Member Secretary : Officer of the level of Deputy CMO preferably an Ophthalmologist • Technical Advisor : Chief Ophthalmic Surgeon of District hospital. Members : Medical Superintendent/ Civil Surgeon of Distt. Hospital • District Education Officer • Representatives from NGOs engaged in eye care services • District Mass media/ IEC officer • Prominent practicing eye surgeons

17. Functions • To assess the magnitude and spread of blindness in the district • To organize screening camps for identifying those requiring cataract surgery and other blinding disorders,; • To plan and organize training; • To procure drugs and consumables • To receive and monitor use of funds • To involve voluntary and private hospitals providing free/subsidized eye care services • To organize screening of school children; • To promote eye donation through various media and monitor collection and utilization of eyes collected by eye donation centers and eye banks. • The PMOAs shall be doing the regular screening for and other diseases in the out reach camps.

18. GRANT-IN-AID • Funds will be released by the GOI to State Health Society (or State Health & FW Society) based on Annual Action Plan submitted to GOI. a. Statement on performance and expenditure b. Audited Statement of Accounts c. Utilization Certificate d. State Annual Action Plan for the current financial year. • GOI will release funds in two equal instalments in a financial year; first instalment will be equivalent to 50% of the planned budget. 

19. Grant-in-aid • Honorarium to Member Secretary and other staff • Procurement of goods • Provision of spectacles • Information Education and Communication • Grant-in-aid to voluntary organizations • Training activities within the District • Operational Expenditure

20. Record maintenance • blind register, • cataract surgery record, • diabetic register, • glaucoma register, • squint register, • keratoplasty, • monthly and quarterly reporting format, cash book, balance sheet, utilization certificate

21. MONITORING FOR QUALITY CONTROL • Random checks need to be carried out to assess the validity of reported data, status of follow-up, provision of glasses and patient satisfaction. • Standard Cataract Surgery Records (Format II) should be filled up for each operation performed. • Periodic review should be undertaken by the District Health Society to assess the progress in each block and by each provider unit. • The District Health Society should be concerned about the outcomes i.e. number of persons whose eyesight is restored rather than be satisfied with the product i.e. no. of cataract operations performed.

22. Training activities under NPCB • 1. (a). General Training in ECCE / IOL, SICS and Phaco Emulsification(2months) - Keratometry, Biometry and Yag Laser Capsulotomy along with surgery techniques. • 1. (b).SICS and simultaneously SICS trained surgeons only will be sent for Phaco • 2. Pediatric Ophthalmology(3 mths) - management of Amblyopia and squint, Cataract, Glaucoma and Retinopathy of pre-maturity (ROP). • 3. Medical Retina & Vitreo Retinal Surgery(3 mths) –indirect Ophthalmoscope, fluorescence angiography • 4. Low Vision Services – 1 week Training. • The trainees will be posted to Low Vision units of training institutions. They should be taught handling of various instruments / L.V Aids and Management of patients.

23. New initiatives • Construction of dedicated Eye Wards and Eye Operation theaters in Districts • Appointment of Ophthalmic Surgeons and Ophthalmic Assistants in new districts • Appointment of Ophthalmic Assistants in PHCs/ Vision Centers where there are none (at present ophthalmic assistants are available in block level PHCs only) • Appointment of Eye Donation Counselors • Grant-in-aid for NGOs for management of other Eye diseases other than Cataract like Diabetic Retinopathy, Glaucoma Management, Laser Techniques, Corneal Transplantation, Vitreoretinal Surgery, • Treatment of childhood blindness etc of Rs. 750 per case for Cataract/IOL Implantation Surgery and Rs.1000 per case of other major Eye Diseases as described above. For North-Eastern States, Hilly and Desert Areas Rs. 850 for Cataract and Rs.1100 for other major Eye Care Management is proposed. • Special attention to clear Cataract Backlog and take care of other Eye Health Care Centers from NE States. • Telemedicine in Ophthalmology {Eye Care Management Information and Communication Network} • Involvement of Private Practitioners. • A provision of Rs.1550 crorehas been proposed for implementation of NPCB during 11th Five Year Plan.

24. Role of international agencies • WHO- 40 intra country fellowship in institute of Excellence under specialities, corneal transplantation,vitreo-retinal surgery,laser in opthal, paedopth • Launch workshop on Vision 2020, “the right to sight”initiative • World Sight day • Danish International Development Agency • World Bank- assisted cataract blindness control project, in which Rs. 554 crore had spent.

25. Achivements • 307 Dedicated eye operation theatres and eye wards built in District level hospitals; • Supply of Ophthalmic equipment for diagnosis and treatment of common eye disorders • More than 2000 Eye Surgeons trained in IOL surgery and other super specialties. • During the year 2006-07, a total 50,40,336 Cataract Surgeries were performed against the target of 45,00,000, out of which 94% Surgeries were with IOL Implantation. • The volume of cataract surgery has steadily increased since 1993. Currently, Cataract Surgery Rate is 4500 per million populations. There has been a significant increase in proportion of cataract surgeries with IOL implantation from <9 % in 1994 to 93% in 2006-07.

26. Special drive in NE States • To make the drive a success, Eye Surgeons from reputed institutions like Dr. R.P. Centre, New Delhi, Venue Eye Hospital, New Delhi and Aravind Eye Hospital, Madurai (TN) have been deputed in NE States for Cataract Surgeries. • Against the target of 59,000 cataract surgeries for 2005-06, around 57141 cataract surgeries were performed in these states during 2005-06. During the year 2006-07, around 62,145 cataract surgeries have been reported by NE states against the target of 59,000 cataract surgeries. • This is the first time in recent years that NE states have achieved more than their annual target for Cataract surgeries

27. References: • Govt. of India. National Programme for Control of blindness:Guidelines for State Health Society and District Health Society, Opthalmic/Health division, NirmanBhavan New Delhi, 2009 • World health organization. Vision 2020 the right to sight, Global Initiatiative for the elimination of avoidable blindness , Action plan 2006-2011 • R. Serge et al. Global data on visual impairement in the year 2002. Bulletin of the World Health Organization ,2004 november;82(11):844-849 • B. Thylefors,' A.-D. Negrel,2 R. Pararajasegaram,2 & K.Y. Dadzie2.Global data on blindness . Bulletin of the World Health Organization, 1995, 73 (1): 115-121 • World health organization. Trachoma Control ,a guide for trachoma managers, 2006 • World health organization. Magnitude and causes of visual impairment,2007 • Dua A. National commission on macroeconomics and health, Govrnment of India Background Papers·Burden of Disease in India • R . Jose. Present status of the national programme for control of blindness in India .Community Eye Health J 2008;21(65): s103-s104