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1. PRIMARY EYE CARE

2. Today’s session
Primary health care
Primary eye care

3. HEALTH FOR ALL, WHO,
1981
ATTAINMENT OF A LEVEL OF
HEALTH THAT WILL ENABLE
EVERY INDIVIDUAL TO LEAD A
SOCIALLY AND
ECONOMICALLY PRODUCTIVE
LIFE

4. Levels of Care
Primary health care
Secondary health care
Tertiary health care

5. CONTD.
Primary health care
The “first” level of contact between the
individual and the health system.
Essential health care (PHC) is provided.
A majority of prevailing health problems
can be satisfactorily managed.
The closest to the people.
Provided by the primary health centers.

6. CONTD.
Secondary health care
More complex problems are dealt with.
Comprises curative services
Provided by the district hospitals
The 1
st
referral level
Tertiary health care
Offers super-specialist care
Provided by regional/central level institution.
Provide training programs

7. Primary health care (PHC) became a core
policy for the World Health Organization with
the Alma-Ata Declaration in 1978 and the
‘Health-for-All by the Year 2000’ Program.
The commitment to global improvements in
health, especially for the most disadvantaged
populations, was renewed in 1998 by the World
Health Assembly.
This led to the ‘Health-for-All for the twenty-first
Century’ policy and program, within which the
commitment to PHC development is restated.

8. WHAT IS PRIMARY HEALTH CARE
PRIMARY HEATLH CARE IS
ESSENTIAL HEALTH CARE MADE
UNIVERSALLY ACCESSIBLE TO
INDIVIDUALS AND ACCEPTABLE TO
THEM, THROUGH FULL
PARTICIPATION AND AT A COST
THE COMMUNITY AND COUNTRY
CAN AFFORD

9. Contd.
Primary Health Care 
is different in each 
community
 depending  upon: 
Needs of the residents;
Availability of health care providers;
The communities geographic location; &
Proximity to other health care services in
the area.
 

10. ELEMENTS OF PRIMARY
HEATH CARE
Education concerning prevailing health
problems and the methods of preventing and
controlling them
Promotion of food supply and proper nutrition
An adequate supply of safe water and basic
sanitation
Maternal and child health care

11. Contd.
Immunization against major infections
diseases
Prevention and control of local
endemic diseases
Appropriate treatment of common
diseases
Provision of essential drugs

12. PRINCIPLES OF PRIMARY
HEALTH CARE
EQUITABLE DISTRIBUTION
COMMUNITY PARTICIPATION
INTERSECTORAL COORDINATION
APROPRIATE TECHNOLOGY
DECENTRALISATION

13. The Basic Requirements for Sound
PHC
Appropriateness
Availability
Adequacy
Accessibility
(convenience)
Acceptability
Affordability
Accountability
Completeness
Comprehensiveness
Continuity

14. Strategies of PHC
1.Reducing excess mortality of poor marginalized
populations:
PHC must ensure access to health services for the most
disadvantaged populations, and focus on interventions
which will directly impact on the major causes of
mortality, morbidity and disability for those populations.
2. Reducing the leading risk factors to human health:
PHC, through its preventative and health promotion
roles, must address those known risk factors, which are
the major determinants of health outcomes for local
populations.

15. Strategies contd.
3. Developing Sustainable Health Systems:
PHC as a component of health systems must
develop in ways, which are financially sustainable,
supported by political leaders, and supported by the
populations served.
4. Developing and enabling policy and institutional
environment:
PHC policy must be integrated with other policy
domains, and play its part in the pursuit of wider
social, economic, environmental and development
policy.

16. Evaluation of HFA : 1979-2006
Reasons for slow progress:
Insufficient political commitment
Failure to achieve equity in acess to all PHC
components
The continuing low status of women
Slow socio- economic development
Difficulty in achieving inter sectoral action for
Health
Unbalanced distribution of resources

17. Reasons for slow progress
(contd.)
Widespread inequity of health promotion efforts
Weak health information systems and lack of
baseline data
Pollution, poor food safety, and lack of water supply
and sanitation
Rapid demographic and epidemiological changes
Inappropriate use and allocation of resources for
high cost technology
Natural and man made disasters

18. Obstacles to the implementation
of the PHC strategy
Misinterpretation of the PHC concept
Misconception that PHC is a 2
nd
rate health
care for the poor.
Selective PHC strategies
Lack of political will
Centralized planning and management

19. The Challenges of changing World
Unequal growth, unequal outcomes
Adapting to new health challenges
Changing values and rising expectations
PHC reforms: driven by demand

20. EXTENDED ELEMENTS OF PHC

Expanded options of immunization
Provision of essential technologies for
health
Prevention and control of non
communicable diseases
Food safety and provision of selected food
supplements.

21. Primary Eye care

22. According to vision 2020, right
to sight
Primary eye care (PEC) is an integral part of
comprehensive eye care.
It is targeted not only towards preventing blindness and
visual impairment, but also towards providing services to
redress ocular morbidity.
PEC is a frontline activity, providing care and identifying
disease before it becomes a serious medical condition.
Primary eye care is delivered in many different ways.
However, it all aims at making eye care services
available within reach of the community.
In the long run this allows better penetration of services
and reduced cost for the patient.

23. Components of primary eye care
Eye health education
Symptom identification
Visual acuity measurement
Basic eye examination
Diagnosis
Timely referral

24. Primary eye care services
include the following:
Educating patients about maintaining and promoting
healthy vision.
Performing a comprehensive examination of the visual
system.
Screening for eye diseases and conditions affecting
vision that may be asymptomatic.
Recognizing ocular manifestations of systemic diseases
and systemic effects of ocular medications.
Making a differential diagnosis and definitive diagnosis
for any abnormalities that are detected.
Performing refractions.

25. Cont..
Fitting and prescribing optical aids such as glasses and contact
lenses.
Deciding on a treatment plan and treating patients’ eye care needs
with appropriate therapies.
Counseling and educating patients about their eye disease
conditions.
Recognizing and managing local and systemic effects of drug
therapy.
Determining when to triage patients for more specialized care and
referring to specialists as needed and appropriate.
Coordinating care with other physicians involved in the patient’s
overall medical management.
Following up with patients to monitor their compliance to advice –
referral, surgery, medication or review visits.

26. THE IMPORTANCE OF PRIMAR
Y EYE CARE
The principles of PHC (i.e., fair distribution;
community involvement; focus on prevention;
appropriate technology; multi-sectorial
approach) should all apply in primary eye
care.

27. WHO GUIDELINES FOR
PRIMARY EYE CARE

28. Conditions to be recognized and
treated by a trained primary health
care worker
• Conjunctivitis and lid infections
Acute conjunctivitis
Ophthalmia neonatorum
Trachoma
Allergic and irritative conjunctivitis
 Lid lesions, e.g., stye and chalazion
• Trauma
Subconjunctival haemorrhages
Superficial foreign body
Blunt trauma
Blinding
malnutrition

29. Conditions to be recognized and referred
after treatment has been initiated
• Corneal ulcers
• Lacerating or perforating injuries of the
eyeball
• Lid lacerations
• Entropion/trichiasis
• Burns: chemical, therma

30. Conditions that should be recognised
and referred for treatment
Painful red eye with visual loss
• Cataract
• Pterygium
• Visual loss;

31. WHO integrated the following
conditions into primary eye care
• Cataract (age-related/‘senile’ type)
• Trachoma and its late complications
Eye injuries
• Corneal ulcer
• Glaucoma, acute attack and cases with one blind eye
Ophthalmia neonatorum
Eye infections
Pterygium*
• Refractive errors and reading difficulties
• Conditions with visual acuity less than 3/60

33. Primary eye care in India

34. Primary eye care in India

35. NPCB
The Government of India's strategy to control blindness took shape in 1978 with the
launch of the National Program for Control of Blindness.
 
 At the time, the estimated prevalence of blindness in India was 1.49%, with an
estimated 9 million blind people and 45 million people with VI.
This effort was followed by a major national survey in the years 1986-1989, which
showed that the prevalence of blindness was 1.5%, with an estimated 12 million blind
people.
 
 This survey indicated clearly that cataract was responsible for 80% of all blindness.
A World Bank grant to tackle the problem of cataract blindness helped initiate a
project in the seven most populous states of India (Maharashtra, Uttar Pradesh,
Madhya Pradesh, Orissa, Rajasthan, Andhra Pradesh, and Tamil Nadu).
 

36. OBJECTIVES, NPCB
To reduce the backlog of avoidable blindness
– through identification and treatment of the curable blind at all the
three (primary, secondary and tertiary) levels
• To develop Comprehensive Eye Care facilities in every district as
the strategy for controlling blindness and not just curative, i.e. “Eye
Health for All”
 Upgradation of Regional Institutes of Ophthalmology (RIO’s) to
become centers of excellence in the sub-specialties of
ophthalmology
• To improve quality of service delivery by strengthening the existing
infrastructure facilities and additional human resources for these
• To enhance community awareness on eye care especially
PREVENTIVE measures
• Encourage research for prevention of blindness and visual
impairment
•

37. Services are delivered at Primary,
secondary and tertiary level, NPCB:
Primary level
• Sub-district hospitals
• CHC
• Upgraded PHC
• Mobile units
Secondary level
• District hospital
• NGO hospital
Tertiary level
• Regional Institutes of Ophthalmology
• Centre of excellence in medical colleges

38. Target diseases
 Cataract
 Refractive errors
 Glaucoma
Diabetic retinopathy

40. NGOs and non-Govtment
bodies

41. The main goal of the NPCB project was to bring down the
prevalence of blindness from 1.5% to 0.3% by the year 2000.
This decrease in prevalence of blindness was tied to a
corresponding increase in the number of cataract surgeries
performed to 3-4 million annually.
Subsequently, in the years 1996-2000, the Andhra Pradesh Eye
Disease Study (APEDS) was conducted in the state of Andhra
Pradesh (AP) by L V Prasad Eye Institute (LVPEI) to obtain baseline
information that would inform long-term strategies to control
blindness in the state. This study found the prevalence of blindness
to be 1.84%, with 10% of this attributable to visual field constriction.
 
[
Similarly, the prevalence of moderate visual impairment (MVI) was
found to be 8.1%, with nearly 1% due to visual field constriction.
 
 Both blindness and MVI was higher in rural area

42. Cataract and uncorrected refractive errors were found to be the
major causes of blindness and were responsible for 60.3% of the
total blindness and 85.7% of MVI.
 
In addition, approximately 20-40% of the eyes remained blind
postcataract surgery.
 
Uptake of services was also an issue, predominantly among lower
socio-economic populations, women, and rural populations. Certain
cultural factors also contributed to the poor uptake of services.
On the basis of this analysis, LVPEI developed a pyramidal model of
eye care delivery.
This model is based on the goal of delivering excellent, efficient and
equitable eye care services and making them available, affordable,
and accessible to all sections of community, irrespective of their
ability to pay.

43. A 'bottom-up' pyramid represents
LVPEI's model of holistic Eye Care
 
At the base of the pyramid are VISION GUARDIANS that represent community
involvement. Vision guardians comprise trained young people who keep a close vigil
on the eye health of about 5,000 persons within communities, through door-to-door
surveys and other informal means.
VISION CENTRES form the next level and serve the primary eye health needs of the
community. Drawing upon local talent and staffed by persons from the local
community, each Vision Centre caters to a cluster of villages, individually servicing a
target of around 50,000 people.
SECONDARY EYE CARE CENTRES are networked to the Vision Centers and each
serves a population of 500,000 persons. These centres provide care that can
diagnose the complete range of ophthalmological diseases and offer high quality
surgical care for cataract - the most common cause of blindness. These centres draw
upon local talent too, with team members recruited from the local community and
trained at LVPEI’s advanced tertiary centres.

44. Cont..
TERTIARY CARE HOSPITALS / TRAINING CENTRES
are linked to Secondary Centers and each serves a
population of 5 million persons. These centres provide a
comprehensive range of services and also serve as
training centres to the secondary centres.
CENTRES OF EXCELLENCE are linked to tertiary
centers and each serves a population of 50 million
persons. These centres treat complex diseases, train the
trainers in subspecialties & rehabilitation and engage in
advocacy.

46. Vision centres as primary eye
care providing centre

47.  benefit of incorporating VCs into
eye care services
Service on the spot.
Linking to sight. 
Reducing barriers and cost: 
Improving health seeking behaviour. 
Gender equity

51.  
 
Service Delivery
Carry out three basic functions—Recognize 
eye
conditions,
 
Refract 
for refractive error and provision of spectacles,
and
 
Refer 
a patient to the referral hospital and do network in the
community.
Beyond this, some of these organizations have tele-ophthalmology
consultations; have capacity to also prescribe medication (via tele-
ophthalmology),
provide low vision and rehabilitation services and to provide
screening in schools.

52. Cont..
The average output varies a lot across these VCs, ranging from five-
100 per day, with average being ten-15 per day.
On an average 25%–30% are spectacle advised and 25%–30% are
referred to higher level.
However, there were issues related to uptake of referral services—
ranging from 20% to 80%.
All the hospitals use different tracking mechanisms for improving
uptake of referral services, mainly being telephonic calls and
tracking of Medical records. In terms of spectacle delivery, majority
were able to deliver the spectacle within week duration.