National Programme for Control of Blindness

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.

6. Three-pronged strategy of Community Ophthalmology

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. Primary eye care workers = Survey – Detection – Referral – Workers SDRW. What is a SDRW ? Is the most important person of this whole programme . Attached to the community ophthalmology center.

12. Duties of SDRW Screen, Sensitize and inform patients and families on their problems. Refer for treatment provide simple medication

13. What is the training a SDRW should have before going to the field ? Basic knowledge on structure and function of the eye Recording of visual acuity. Recognize a normal healthy eye & common eye problems.

14. What is the training a SDRW should have before going to the field ? Ability to identify Cataract / Squint / Refractive errors / Eye injuries / Infections / FB. Identify corneal scars / differentiate from cataract.

15. What is the training a SDRW should have before going to the field ? Explanations about common eye problems - To explain it to the people To recognize and refer serious eye injuries

16. What is the training a SDRW should have before going to the field ? Activities and responsibilities of the eye unit and staff. How to meet with a family (communication skills)

17. What is the training a SDRW should have before going to the field ? During training they should witness at least three cataract surgeries - Taken visual acuity of 10 patient - Perform pinhole test.

18. 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

19. WHO Guidelines for primary eye care 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 -

20. 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

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

22. Burden of Blindness

23. 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.

24. 4 levels of visual function, ICD-10 (Update and Revision 2006): Normal vision Moderate visual impairment Severe visual impairment Blindness. LOW VISION VISUAL IMPAIREMENT

25. World Wide

26. Globally Causes of visual impairment

27. 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

28. Trend of blindness In India

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

30. 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.)

31. 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.

32. 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 ( T richiasis / 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

33. 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

34. 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

35. 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

36. Childhood blindness : Burden

37. Causes of childhood blindness around the world

38. 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

39. low vision definition • (WHO) Low vision is visual acuity less than 6/18 and equal to or better than 3/60 in the better eye with best correction. 

40. 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 .

41. 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)

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

43. Vision 2020: The Right to Sight

44. 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

45. Six key strategic areas to produce an impact Advocacy for Eye Health. Policy & Program Development. Quality in Eye Care. Resource Mobilization & Sustainability. Research. Organizational Development.

46. Global conditions for immediate attention under Vision 2020

47. Five basic strategies to combat blindness

48. 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)

49. Objectives & Strategies under the 12 th Plan

50. 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 .

51. 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;

52. Year Population Projected no . cataract blind at 1995 service level (millions) No. cataract blind (millions) Target Prevalence of cataract blindness Global Surgeries needed (millions) 1990 5400 16 16 0.3 7 1995 5700 20 20 0.35 7 2000 6100 25 15 0.25 12 2010 6800 35 7 0.1 20 2020 7800 50 32

53. 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

54. 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 ;

55. 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

56. 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

57. Strategy 2

58. 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.

59. Strategy Comprehensive Eye care

60. 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.

61. 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.

62. Regional Institutes of Ophthalmology Centers of excellence

63. 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.

64. Regional Insitutes of Opthalmology Regional Institute of Ophthalmology, Hyderabad Regional Institute of Ophthalmology, Kolkata Regional Institute of Ophthalmology, Guwahati Regional Institute of Ophthalmology, Bhopal Regional Institute of Ophthalmology, Sitapur Regional Institute of Ophthalmology, Patna Regional Institute of Ophthalmology, Thiruvananthapuram Regional Institute of Ophthalmology and Government Ophthalmic Hospital, Chennai Regional Institute of Ophthalmology, Ahmedabad Regional Institute of Ophthalmology, Bangalore Regional Institute of Ophthalmology, Allahabad Regional Institute of Ophthalmology, Raipur Regional Institute of Ophthalmology, Jaipur Regional Institute of Ophthalmology, Ranchi Regional Institute of Ophthalmology, Cuttak Regional Institute of Ophthalmology, Rohtak Regional Institute of Ophthalmology, Mumbai Regional Institute of Ophthalmology, Punjab

65. 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;

66. Strategy Establishing Vision Centers in all PHCs with a PMOA in position Multipurpose District Mobile Ophthalmic Units for better coverage. (MDMUs).(12 th Plan)

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

68. 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

69. 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 HealthSpecialists 20 150 200 10 5

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

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

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

73. Strategy

74. 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

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