Impressions of Bangladesh
Further impressions / realities
Malnutrition
Eye care needs
Tackling blindness in Bangladesh
Vision for Blindness
National Blindness and Low
Vision Survey of Bangladesh
Project Aim
To determine the national prevalence and causes
of blindness and low vision amongst persons
aged 30 years and older in Bangladesh, based
on a nationally representative sample.
Demographic Information
• Population (2000) – 130 million
• Adults 30 and older - 44 million (33.6%)
• Six administrative divisions
• 64 districts (zilas) / 490 thanas / 4491 unions
• 59,900 villages (mauzas) and urban wards (603)
Rural villages
Urban slums
Urban slum areas
Coastal areas
Chittagong Hill Tracts
Rural Cluster Sites (104)
Urban Cluster Sites (50)
Research Design
• Cross-sectional, descriptive study of 12,900 subjects
• Multi-stage, random cluster sampling with PPS
• Proportional allocation of clusters to rural (84.4%) and
urban (15.6%) areas
• Enumeration of 100 subjects per rural cluster (104)
• Enumeration of 50 individuals per urban cluster (50)
Logistics - Survey Personnel
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3 Ophthalmologists
3 Ophthalmic Nurses
6 Medical Assistants
6 Logisticians / Supervisors
3 Interviewers
6 Enumerators
2 Data Processors
1 Consultant Ophthalmologist
1 UK Registrar-grade Ophthalmologist
1 Bilingual Secretary
Operational Definitions for
Blindness / Low Vision
• Blindness
Presenting visual acuity < 3/60 in the better eye
• Low vision
Presenting visual acuity < 6/12 but  3/60 in better eye
Interviewing Schedules
• Personal and socio-demographic data (age, sex,
occupation, religion, land tenency, location)
• WHO / PBL III modified questionnaire
• Visual Functioning and Quality of Life instruments
Figure 1. Data Collection Procedures
D emographic Information Interview
Distance V is ual Acuity Tes ting
Visual Acuity of 6/12 or better in b oth eyes
Visual Acuity of les s than 6/12 in either eye
Automated Refraction
A utomated Refraction
External Eye Examination
Previous Eye Health His tory
Optic Disc (CDR) Ass essment
Eye Fundus Ass essment
External Eye Examination
P revious Eye Health History
Optic Dis c (CDR) Assess ment
Eye Fundus Assess ment
Vis ion Function and Quality of Life Questionnaires
(1 in every 20 normal vision subjects)
Bes t Corrected V isual A cuity with Trial Lens
Cataract Grading Assess ment
Intra-ocu lar P res sure ( if Optic Dis c not seen)
DILAT IO N
Age-related Macular Disease Assessment
Diabetic Retinopathy Check (plus Blood Glucose if no known history of DM)
Lis ting of All Causes of Low Vision / Blindness
Selection of Main Cause of Low V ision / Blindnes s for Each Eye
Identification of Main Cause of Low V ision / Blindnes s for the Subject
S ubjects with less than 6/60 V/A
Vis ion Function and Quality of Life Questionnaires
Identification of Barriers to Up-take of Eye Care Services
Aph akics and Pseudo-aphakics
Vision Function and Quality of Life Questionnaires
Interview about Cataract Surgery
Prevalence survey
“It is simple but it will not be easy.”
Professor Syed Modasser Ali
Dhaka, Bangladesh
Urban settings
Results
11,624 subjects examined
90.9% response rate
Response rate equally high in rural and urban areas
Visual acuity in the ‘better eye’
(Presenting and Corrected)
Visual Acuity
Snellen
Presenting Vision
Corrected Vision
Age-standardised
Equivalent
n/%
n/%
prevalence
(logMAR)
(95% CI)
(95% CI)
(95% CI)
6/12
9,854 / 84.77
10,759 / 92.56
83.57
(<0.30)
(83.80 – 85.75%)
(91.88 – 93.23%)
(82.89 – 84.25)
<6/12 to 6/18
704 / 6.06
329 / 2.83
6.46
‘Near Normal’
(0.30to <0.50)
(5.52 – 6.60%)
(2.47 – 3.20%)
(6.02 – 6.91)
Moderate
<6/18 to 6/60
849 / 7.30
385 / 3.31
7.92
Visual Impairment
(0.50 to <1.00)
(6.72 – 7.89%)
(2.89 – 3.74%)
(7.43 – 8.41)
Severe
<6/60 to 3/60
55 / 0.47
26 / 0.22
0.52
Visual Impairment
(1.00 to <1.30 )
(0.33 – 0.61%)
(0.14 – 0.31%)
(0.39 – 0.65)
Blind
<3/60
162 / 1.39
125 / 1.08
1.53
(1.30 )
(1.17 – 1.62%)
(0.86 – 1.29%)
(1.31 – 1.75)
-
11,624 / 100.0
11,624 / 100.0
11,624 / 100.0
Normal
Total
Presenting VA by 10-year age groups
100%
Prevalence percentage
90%
80%
70%
<3/60
60%
<6/60 to >=3/60
50%
<6/18 to >=6/60
40%
<6/12 to >=6/18
30%
>=6/12
20%
10%
0%
30-39
40-49
50-59
60-69
70+
Causes of blindness in adults
Mature / Hyper-mature Cataract
Blindness prevalence in Bangladeshi adults
30 years and older – 1.53% (age-standardised prevalence)
There are approximately 675,000 blind adults in the country (2000)
95% Confidence interval of 587,000 – 784,000 blind adults
79.6% is due to cataract – about 550,000 cataract blind
In persons 50 years and older – 4.0% blindness prevalence
Estimated number of cataract blind persons 50+ years is 450,000
Age-specific blindness prevalence
Blindness Prevalence by Division
Division
Blindness prevalence (%)
95% CI
Barisal
2.28
1.72 – 2.82
Chittagong
1.43
1.10 – 1.76
Dhaka
1.13
0.78 – 1.46
Khulna
1.97
0.87 – 2.90
Rajshahi
1.21
0.76 – 1.60
Sylhet
1.31
0.49 – 2.10
Low Vision
‘Cut-off’ of <6/12 presenting visual acuity
Vision in the better eye
16.4% prevalence (age-standardised)
Estimated 6.8 – 7.5 million persons <6/12
Main cause of low vision in persons
with <6/12 visual acuity in either eye
Pterygium
Diabetic retinopathy
Chorioretinitis
Phthisical eye
Optic atrophy
Other (including. Incomplete exam)
Glaucoma
Other posterior segment disease
Central Corneal Opacity
Uncorrected aphakia
Macular degeneration
Refractive error
Cataract
0
10
20
30
40
Percentage
50
60
70
80
Refractive Errors in Adults
Second leading cause of visual impairment (18.87%)
Spectacle use is low (3.0%)
Refractive correction shown to be beneficial in survey
Risk factors for blindness / low vision
• Increased age, particularly after 60 years of age
• Female gender (95% CI 1.18 - 2.29)
• Rural resident (95% CI OR 1.34 - 1.79)
• Illiteracy (95% CI OR 5.86 - 9.20)
• Manual labour in men (95% CI OR 1.11 - 9.35)
Need for Low Vision Services in Adults
WHO definition
VA <6/18 - PL after surgical treatment +/or refraction
Prevalence of 0.56% - estimated 250,000 cases in country
Causes:
Retinal diseases (38.4%)
Corneal diseases (21.5%)
Glaucoma (15.4%)
Optic atrophy (10.8%)
Cataract surgical coverage
Population based evaluation:
Proportion of need for cataract surgery being met
Number of aphakic eyes
x100%
Number of aphakic eyes + operable eyes
Ideally should be 100% which means that all those
who need surgery have had surgery
Cataract surgical coverage (eyes)
Division
CSC for blind eyes (%)
Barisal
26.9
Chittagong
34.6
Dhaka
35.5
Khulna
30.5
Rajshahi
30.7
Sylhet
30.6
Total
32.5
Analysis of needs for, and output of cataract
surgical services in Bangladesh
• Between 2,400 and 3,000 cataract operations are
required / million population / year in Bangladesh to
control cataract blindness
• This translates to a total of 307,000 - 384,000
cataract operations annually
• Currently 50-55,000 cataract operations are being
done, which represents <20% of the estimated need
Persons having had cataract surgery
Functional visual acuity in (pseudo)aphakic eyes
(Presenting and Corrected)
Visual result
Snellen
equivalent
Presenting vision
n / (%)
Corrected vision
n / (%)
GOOD
> or = 6/18
99 (43.8)
114 (63.3)
BORDERLINE
<6/18 to 6/60
63 (27.9)
52 (23.0)
POOR
<6/60
64 (28.3)
31 (13.7)
Quantity and quality
Possible relationships between quantity and quality
Quantity sacrificed for quality
improving
Quality sacrificed for quantity
Quality and quantity both
Estimates of Visual Impairment in Bangladesh
Cause
Estimated number of
cases in Bangladesh
Estimated number of cases
per million population
550,000 blind
4,200 blind due to cataract
840 new blind per year
Refractive errors in adults
3.3 million cases <6/12
27,300 cases
Refractive errors in children
1.3 million cases <6/18
9,925 cases
Childhood blindness
40,000 from all causes
12,000 due to cataract
300 children blind
100 children (200 eyes) due
to cataract
250,000 with low vision
1,950 cases
Cataract in adults
Low vision services for adults
Summary of Results
• Major cause of blindness / low vision is cataract
• Need for high quantity / quality cataract service delivery
• Approximately 550,000 blind due to cataract
• Refractive error is an important cause of low vision
• Higher prevalences in Districts in rural areas
• Disproportionate visual impairment amongst women
Bangladesh population projection - 2020
Estimated total of 190 million population
85 million persons aged 30 years and older
32 million persons 50 years and older
In 2000, 4% of 50+ were bilaterally blind
1,280,000 million blind persons 50 years and older
Barriers to up-take of cataract surgery
Barriers
Costs – both direct and indirect
Fear of damage to the eye due to undergoing surgery
Attitude of being able to cope with daily activities
Attitude of ageism by the person and the family
Belief that it has been due to God’s will / curse
Barriers to up-take of cataract services in Bangladeshi adults (n = 1,274)
God's will
Vision is decreased due to being old, 'natural'
Waiting for maturation of cataract
Ill with other disease
Other reasons
Old age
No time
Fear
No accompanying person
Lack of interest
Adequate vision according to subject
Does not know about having cataract
Poverty
0
5
10
15
20
25
Percentage
30
35
40
45
50
Complex socio-cultural (mis)understandings
Beliefs and attitudes regarding blindness, ageing
Perceptions as to:
actual cost of surgery or purchase of spectacles
value of undergoing cataract surgery
relative ‘utility cost’ of treatment
Lack of awareness about cataract as an eye condition
Why? What? Whether?
(Mis)understanding concerning ‘treatment seeking behaviour’
Who? Where? When? How often? How much?
Questions as to overcoming the barriers
How can surgery be made affordable for all in need?
What are the possible payment options to consider?
How can one raise awareness about cataract?
How can equity of delivery be assured? (targeting?)
How to / Whether to prioritise sight restoring surgery?
Ottawa Charter on Health Promotion
Healthy public policy
Personal skills development
Community participation
Healthy environments
Re-organisation of health service delivery
Equity
Advocacy
Social support
Role of health education in eye care
What is the content of eye health education?
Who is responsible for delivering the information?
Have these persons been trained specifically for this task?
To whom is the eye health education targeted?
Is this part of PHC or as a separate activity, i.e. PEC only?
Is this a ‘once-off’ information session or is it continuous?
Personnel required to reduce barriers
Community participation
Locally-based, health workers trained in eye care
Local leaders, key informants, liaison persons, volunteers
Community ophthalmologists / Public health personnel
Ophthalmologists – organisation of hospital / out-reach care
Eye care programme administrators and policy makers
‘Provider’ barriers
Lack of prioritisation of eye care in health care
Reproductive health
Cyclone preparedness / disaster relief
Arsenic poisoning of water supply
Food security
Lack of perceived importance (e.g. economically)
Lack of resources (personnel, costs, equipment)
Eye Care Service Delivery
Eye care service provision
Acceptable
Accessible
Affordable
Appropriate
Resource availability
‘Manpower’ (all levels of human resources / personnel)
Materials (theatres ‘eye beds’, surgical equipment, transport)
Management (structures and information systems)
Money (capital and running costs)
Money
Sources of funding
* Government funding
* International non-government development organisations
* Patient fees
* Cost-recovery schemes
* Charitable activities
Cost recovery schemes – Do these exist? Do they work?
Examples of Good Practice
S Choudhary Eye Hospital in Lahan, Nepal
Aravind Eye Hospital in Madurai, India
BNSB Hospital in Sirajganj District, Bangladesh
Community Eye Research
Extracapsular cataract surgery compared with
manual small incision cataract surgery in
community eye care setting in western India: a
randomised controlled trial
P M Gogate, M Deshpande, R P Wormald,
R Deshpande, S R Kulkarni
BJO 2003
Increasing the quantity of cataract operations
Two different situations:
High output:
increase efficiency
overcome barriers
Low output:
overcome barriers
High output situations
Improve resource utilisation:
• day case surgery
• reduce in-patient stay to increase bed occupancy
• increase number of operating days
• increase number of tables in operating theatre to increase
number of cases / operating list
• use of mid-level workers in OPD and theatre
• ‘one stop’ assessment clinics with programmed date for surgery
‘Aravind model’
Local organisations arrange venue, advertise and mobilise
patients, pay for venue, and transport to-and-from base
Team from the hospital examines and treats patients
Patients needing surgery are identified and transported to the
base hospital for surgery
After a short in-patient stay the persons are transported back
Advantages:
Disadvantages:
High volume, high quality surgery
Follow-up services not guaranteed
Aravind model
Model of eye care delivery
Satellite unit model
Base hospital visits hospitals without surgical services on a
regular basis
Staff in satellite unit have been trained to identify cataract
patients who are asked to return on a pre-arranged date
Base hospital team examines patients, identifies those needing
surgery, and operates
Satellite unit staff assist in all activities, including follow up
Advantages:
Disadvantages:
Regular service of high quality possible
Builds and uses local capacity
Lower volume
Mobile surgical units
Base hospital has a mobile facility equipped for surgery
Local organisations arrange screening camps
Mobile team examines patients, selects those needing
surgery, operates in the mobile unit, and examines patients
1-2 days following surgery
Advantages:
Disadvantages:
Reaches remote areas
Low volume, high cost, difficult for
staff, follow-up difficult
Eye camps
Local organisations arrange venue, advertise and mobilise patients
Visiting team examines patients, selects those needing surgery,
operates, and examines patients before discharge
Advantages:
Disadvantages:
Potential for high volume
Acceptable if all costs covered
Can reach even remote areas
High quality harder to achieve
No capacity building
Inadequate follow up
Which is/are the best models for Bangladesh
for increasing number of cataract operations?
Need to consider:
Population density and size of catchment population of
hospital
Number of trained staff at the base hospital
Mobility of staff
Availability of infrastructure for ‘satellite’ surgery, staffing
levels, and equipment
Financial support
Would outreach be needed if every District had a well
equipped eye unit?
Clouds come floating into my life, no longer to carry rain or
usher storm, but to add color to my sunset sky.
Rabindranath Tagore