Preventing Blindness in the Community
Andy Cassels-Brown FRCOphth MScCEH
• Introduction
• Principles of VISION 2020 Community Eye Health
• VISION 2020 Leeds/UK
• VISION 2020 in Asia/Africa
• VISION 2020 Mauritius
Introduction
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Ophthalmologist/Community Eye Health/PH
Leeds Teaching Hospitals Trust NHS (LTHT)
Leeds Primary Care Trust PH Directorate
Senior Lecturer University of Leeds
I.C.E.H. London School of Hygiene/TM
Africa – W.H.O. Nigeria (Tanzania/Kenya/S.A.)
Asia (Pakistan/India) + Americas (U.S. + Latin)
last week linking LTHT with Madagascar…
Bienvenue from Leeds, Yorkshire
North England (near Manchester Utd!)
Leeds Teaching Hospitals Trust
West Yorkshire population 3 million
LEEDS: ¾ million pop.
Wetherby
Otley &
Guiseley
NORTH EAST
NORTH WEST
Moortown
& Roundhay
Cookridge
& Horsforth
LTHT
Chapeltown
Headingley
Seacroft
Pudsey
WEST
EAST
Harehills
Bramley,
Wortley
& Armley
Kippax & Garforth
Beeston
Socioeconomic
deprivation
Middleton
& Hunslet
Boundaries
East PCT
NE PCT
NW PCT
South PCT
West PCT
Morley
SOUTH
Rothwell
Leeds Teaching Hospitals Trust
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Largest teaching hospital in Europe
2 large central + 3 community hospitals
Regional and some National services
Training and Research and Innovation
Links with 2 Universities eg
– Nuffield Centre for International Health
• LTHT supports “Opt in”
– Overseas Partnership Training Initiative
General Infirmary at Leeds
VISION 2020
Projection des tendances globales de la cécité
Nombre de personnes aveugles
(millions)
80
70
60
50
With Vision 2020
40
Without Vision 2020
30
20
10
0
1980 1990 2000 2010 2020
Année
20/20 Vision
Cause of visual impairment?
Causes of blindness?
Cause of visual impairment?
Maladies
- Cataractes
- Vices de
réfraction
- Onchocercose
- Trachome
- Avitaminose A
- Rétinopathie
diabétique
- Glaucome
- Dégénéressence
maculaire
- Autres
Global Diseases
Cataract
Refractive error
Treatable
Onchocerciasis
Vitamin A def.
Trachoma
Preventable
(focal diseases)
Diabetic ret.
Glaucoma
Difficult
Macula
degeneration
and others
??
Range of Prevalence of blindness
• developed economies 0.1-0.3%
• developing economies 0.5-2.0%+
Cataract
Refractive error
60%
Onchocerciasis
Vitamin A def.
Trachoma
15%
Diabetic ret.
Glaucoma
15%
Macula
degeneration
and others
10%
Aim:
To eliminate avoidable blindness and
disability by 2020 (20/20 by 2020)
V2020 CEH prioritises resources into-
Develop Human + Infrastructure resources to
target the major AVOIDABLE blinding
conditions + AVOIDABLE disability with
accepted cost-effective interventions
Human Resources
Eye Care Team Comprising of:
- Ophthalmologist +/- Cataract surgeons
- Ophthalmic Nurses
- Optometrist/Refractionist
- Community workers
- Administrators/Managers
Plus:
- Other traditional healthcare workers
- and non traditional Healthcare workers
Principles of Vision 2020: C.E.H.
Community Eye Health programme
1. Community Needs Assessment
2. Develop control strategies
(eg.Community based services/HPE)
3. Implement/Monitor/Evaluate Programme
4. Engage “Community” Stakeholders/HPE
5. Fund the programme……HOW?
Planning for VISION 2020
stragegy
Here
Needs Assessment
and Situation
Analysis
There
Objectives
-Human Resources Dev.
-Human Resources
-Diseases control
-Diseases
-Infrastructure devel.
-Infrastructure
Does it work in Africa/Asia ?
Latest W.H.O. global data
7
Number in millions
6
5.9
5
4.1
4
1995
3
2002
2
1.9
1.8
0.9
1
0.4
0
Trachoma
Corneal scar
Disease
Oncho
Will it work in Mauritius and UK?
Latest W.H.O. global data
Number in millions
20
18
16
18.9
17.3
14
12
1995
10
2002
8
6
6.3
4.4
4
2
2
1.8
0
Cataract
Glaucoma
Disease
Diabetic
retinopathy
VISION 2020 LEEDS
Community Eye Health
Modernisation Programme
Leeds South
Leeds West
Primary Care Group
Primary Care Group
THE LEEDS TEACHING HOSPITALS
Yorkshire 2020:World Blindness Project
Vision 2020: Leeds
AIM: To eliminate avoidable blindness and
disability in Leeds by the year 2020
Phase 1 April 2001-2003
• determine need (recognised/unknown)
• commence community service development (CEC)
Phase 2 April 2003-2006
• meeting recognised need (known to us)
• developing human resource/infrastructure
• develop a formal PBL programme
Phase 3 April 2006-2009
• targeting unmet need/prioritisation
• prevention/health promotion + OPH Fellowship
NEEDS ASSESSMENT PROJECTS
CITY-WIDE PROJECTS
COMMISSIONING
CLINICAL GOVERNANCE
CATARACT
DIABETIC RETINOPATHY
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AGE RELATED MACULAR
DEGENERATION
GLAUCOMA
LOW VISION
GENERAL OPHTHALMOLOGY
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Rapid Ophthalmic Assessment
LTHT Referral Triage Exercise
LTHT Patient Flow Demand Exerc.
LTHT Capacity Exercise
NHS Modernisation Agency Project
Patient/Practitioner CG Framework
Acceptability
CG Framework Annual Review
Action on Cataracts Pathway
Evaluation
Additional Surgical Capacity Exerc.
Primary Care N.S.F. Demand Ex.
Barriers to Asian Diabetic Uptake of
H.E.S. MPH Dissertation
Barriers to Non Asian Uptake of
HES SpR Ophthalmology Research
BD8 Registration Project
MSc CEH Dissertation
 Evidence Based Glaucoma
Protocols MSc CEH Dissertation
 BD8 Registration Project
 Low Vision Services Committee
Benchmarking Exercise
 Sensory Impairment Questionnaire
 Optimising City Outreach Services
COMMUNITY CENTRE
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Capacity/Demand Exercise
Centre Costing Exercise
Community Referral Triage Ex.
Activity Read Coding Exercise
NHS Modernisation Agency Project
Commission for Health
Improvement Evaluation
Care Pathway Clinical Governance
Action on Cataracts Pathway
Evaluation
Additional Capacity Exercise
Patient Acceptability of
Register/Screening
BSc. P.H. Dissertation
Community or Hospital Based
Digital Camera Screening Exercise
ARMD Care Pathway
Development/Evaluation
 Eyetrack Electronic Patient Record
 Evidence Based Protocols
 Pilot Low Vision Care Pathway
 Pilot Rehabilitation Officer + Multidisciplinary Review Project
 GP Ophthalmic Specialist Exercise
Leeds Quantitative Needs Assessment
Eligible for cataract surgery = 55,503!
V2020 Leeds integrated
community based services
LEEDS: ¾ million pop.
Wetherby
Otley &
Guiseley
NORTH EAST
NORTH WEST
Moortown
& Roundhay
Cookridge
& Horsforth
HES
CEC
GPSI
RSS
Chapeltown
Headingley
Seacroft
Pudsey
WEST
EAST
Harehills
Bramley,
Wortley
& Armley
Kippax & Garforth
Beeston
Socioeconomic
deprivation
Middleton
& Hunslet
Boundaries
East PCT
NE PCT
NW PCT
South PCT
West PCT
Morley
SOUTH
Rothwell
+ 150 Optometrists + orthoptists
Leeds/Bradford has large population from India/Pakistan
Barriers to accessing services include language/culture
V2020 Leeds Qualititative Assessment:
Barriers to the utilisation of glaucoma service
in Afro-Caribean in Chapeltown - J.Awobem
Chapeltown North Leeds Suburb
Barriers = A+B+C+D
• Awareness of Glaucoma.
“No, I don’t know anything about it . I know very little about it. All I can say is that my father have it
and when you have it you can get blind”…….
• Bad Service.
“Long waits for appointments, long waits in clinics, short consultation times, staff can be rude”…..
• Cost of eye test and glasses.
“So the last test I had I had to pay nearly £105…… So I leave her and went somewhere else…..
a lot of people get to find out, to my opinion, that they are cheating the pensioners because they
are not supposed to pay”……...
• Distance.
“it’s a bit far. You have to take bus go to town and take the next one to go there,.the
buses that are running are disgusting. You stand there all the day before you get one”
“Community Directed Case Detection”
Train non-traditional eye care workers to
case detect/promote eye health
• Home wardens/Residential care
• Health/Community Centres
• Falls prevention Teams
• Intermediate/Social Care teams
• Voluntary sector (eg NNSchemes)
• Libraries, outreach services
Health Education and Promotes free
sight tests (>60yrs)
Empowered to refer (94%sens/78% spec)
Tells how to refer + domiciliary visit
WORLD SIGHT DAY OCT.10th 2002
Media Launch of the Leeds:
Low Vision Services Committee
“Action Plan”
• Evidence based “Having your say”
• Piloted C.E.C. Low Vision Service
• Modernised Low Vision Pathway
Primary care in the
community
August 2005
UK Vision Strategy
January 2007
PAKISTAN
(Per million population)
Disease
Cataract
Refractive error
5000
+
1000
NO ONCHO
Vitamin A def.
Trachoma
1500
Diabetic ret.
Glaucoma
500
+
1000
Macula
degeneration
and others
1000
Munawwar Memorial Hospital
Chakwal District (1.1 million)
MMH’s Chakwal Community Programme
The Leeds “Save Your Sight” Leaflet:
Community Directed Case Detection?
CAMEROON/TANZANIA
(Per million population)
Disease
Cataract
Refractive error
5000
+
1000
Onchocerciasis
Vitamin A def.
Trachoma
1500
Diabetic ret.
Glaucoma
500
+
1000
Macula
degeneration
and others
1000
Childhood Blindness –
Refractive Error School Screening
Madagascar 2005-7 = ¼ million children
Childhood Blindness - CATARACT
Visual rehabilitation
• Eye continues to grow,
hence need for frequent
refractions and change of
spectacles
• Amblyopia management
(prevention and
treatment)
• Development of aftercataract
Childhood Blindness – Vitamin A
Childhood blindness Retinoblastoma
DD: Retinoblastoma
Vision 2020 Mauritius
Cataract
Refractive error
60%
Onchocerciasis
Vitamin A def.
Trachoma
15%
Diabetic ret.
Glaucoma
?30%
Macula
degeneration
and others
10%
VISION 2020 MAURITIUS
• W.H.O. workshop April 08 will advise:
• V2020 National Prevention of Blindness
Committee with NGO’s/INGO’s
• National Coordinator within Ministry
• Lead Ophthalmologist/other professionals
• Needs assessment/situation analysis
• National Eyecare Plan Adults/Children
• Community Eye Health training
• Integrate health/social care/rehabilitation
and education
VISION 2020 MAURITIUS
Probable Disease Priorities:
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Cataract
Refractive Error
Diabetic Retinopathy
Glaucoma
Childhood blindness
? Retinopathy of Prematurity
Community case detection
Health Promotion
Low Vision/Rehabilitation/Education
VISION 2020 MAURITIUS
Possible needs assessment priorities:
• Rapid assessment survey to determine
prevalence + causes avoidable blindness
• Barriers to accessing services survey
• Blind school/rehab services survey
• Hospital diabetic retinopathy patterns
• Ongoing Cataract surgical outcome audit
• Review of role of multidisciplinary input
• Review of training needs
VISION 2020 MAURITIUS
Probable Control Strategy Priorities:
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N.S.F. for Diabetes 10 year plan
Increase volume of cataract surgery
Community case detection
Community health promotion strategy (Diabetes)
Training of ophthalmologists eg retinal
screening/laser/Vitreo-retinal service
• Training of other cadres
• Low vision services/rehabilitation
• Integrate with community services
– community physicians, optometrists
– health centres, dispensaries
Diabetic Maculopathy
Early new vessels on disc
Proliferative Diabetic Retinopathy
Current diabetic V-R service
• Local lasers available including indirect
• Local vitrectomy for simple vitreous hge
• Local Endolaser/vitrectomy equipment
• 400 complex V-R cases go to Chenai with
potential for redirecting money to local service
development
Where is Mauritius?
Ophthalmologists per million
VISION 2020 Target
Cameroon
Africa
India
Latin America
Western Europe
Russia
0
20
40
60
80
100
120
Moka Eye Hospital
• Very busy outpatients and emergency
service
• Operating theatres currently on overdrive
• National training programme justifiable for
1.3 million people
• Trainees will enhance service delivery and
build capacity for the future