REFRACTIVE ERROR
CHANGE IN APPROACH
Overview of Refractive Error
Prevalence and Delivery Models
Kocur, 2008
Refractive Error Working Group:
Significant Refractive Error
• < 6/12 in children in the better eye
• < 6/18 in adults in the better eye.
• Myopia >= 0.50 Ds.
• Astigmatism >= 1.50 Dcyl
• Hyperopia >= 2.0 Ds ( >=1.0 Ds in > 40 yrs)
• Anisometropia >= 2.0 Ds (children)
Refractive Errors in Children(RESC)
Hyperopia
>2.0 (%)
Myopia >
0.50 (%)
Astig. >0.75
(%)
S Africa Urban
1.8
2.9
9.2
India - Rural
0.8
4.1
2.8
India - Urban
7.7
7.4
5.4
China - Rural
3.5
16.2
15.0
China - Urban
5.8
35.1
33.6
Chile - Urban
16.3
6.8
19.0
Malaysia Urban
1.3
19.3
15.7
Nepal - Rural
1.4
1.2
2.2
Country
Burden of URE
Resnikoff S, et al. (2008). "Global magnitude of visual
impairment caused by uncorrected refractive errors in
2004. ." Bull World Health Organ 86(1): 8.
Burden of URE - Regions
60
50
54.47
*millions
39.32
40
30
20
10
0
0.96
1.35
3.16
5.83
6.24
6.39
6.86
8.17
8.66
11.8
Resnikoff S, et al., 2008
Global Estimates
Reference: Global estimates of visual impairment: 2010; Pascolini and Mariotti. BJO 2012, 96: 614 -618 December
2011
Global Estimates 2010 …
• Major cause of VI
- Uncorrected refractive
errors
43 %
43%
(123 million)
Pascolini, D. and S. P. Mariotti "Global estimates of
visual impairment: 2010." Br J Ophthalmol.
Presbyopia - Estimates
• 1.04 billion people globally
• 517 million of whom had no spectacles or
inadequate spectacles.
• 410 million prevented from performing
near tasks in the way required.
• 94% from less and least-developed
countries
Holden, B et al., (2008) Global Vision Impairment Due to
Uncorrected Presbyopia. Arch Ophthalmol. 26(12):1731-1739
Prevalence of Uncorrected and Best-Corrected VA
> 20/40, 20/40 - 20/63, < 20/63 in 7 Multi-country
study sites
70
14.6-66.3
Prevalence (%)
60
7.6-49.6
50
40
25.8-39.8
17.4-43.3
15.4-47.8
26.8-39.1
29.0-35.3
30
20
10
0
> 20/40
20/40 - 20/63
< 20/63
Mingguang et al, 2012
Spectacle wearing in participants with uncorrected
near VA 20/40-20/63 in 7 multi-country study sites
120
0.07-98.7
2.38-92.3
Prevalence (%)
100
80
1.34-93.6
0.32-95.4
1.1-87.7
4.62-63.3
60
0.84-39.3
40
20
0
None
Distance only
Distance and Near
Near only
Mingguang et al , 2012
Spectacle wearing in participants with uncorrected
near VA <20/63 in 7 multi-country study sites
120
0.1-98.4
2.3-89.1
Prevalence (%)
100
0.44-86.9
0.67-93.8 0.72-91.4
80
0.84-69.2
4.67-50.8
60
40
20
0
None
Distance only
Distance and Near
Near only
Mingguang et al, 2012
Global Visual Impairment
(<6/18)
123
Mil
Dist
517
Mil
Near
640
million
The vicious cycle of uncorrected
refractive error
Visual
Impairment
Quality of Life
Poverty
Limits
Educational
Oppotunities
Unemployment
International Centre for
Eyecare Education (ICEE)
Smith et al, 2009
How many Optometrists are there?
• Global Estimate (D. Wilson et al., BHVI
2010)
281748
748
281
Varies tremendously from country to country
− from 0.1 per million population
− to 600 per million population
Number of Optometrists per Million
population
250
194
200
150
100
50
0.9
14
Low Income
Middle Income
0
High Income
Number of Optometrists and
Ophthalmologists per Million population
250
200
150
Optometrists
Ophthalmologists
100
50
0
Low Income
Middle
Income
High Income
RE Programs: Core Activities
Sustainable, Accessible, Affordable
SCALABLE
Advocacy
WHO, IAPB, NGOs
Global
Regional IAPB offices
Regional
MOH, NGOs, Professional
bodies
National
Local government bodies,
Community clinic setting,
Community bodies,
Community
Human Resource Development
Who is the refractive services workforce?
• Individuals with clearly defined:
− Roles and responsibilities
− Job descriptions
− Career structure
• All cadres, should possess:
− Competencies and skills
− Complementary functions with other cadres
− TEAM APPROACH
Who is the refractive services workforce
Ophthalmologists
Optometrists
Mid-level personnel
Primary level personnel
Optical dispensers
Spectacle technicians
Optical Dispensary Staff
The strategy for eye care delivery determines
where the work force operates
WHO, IAPB, NGOs
Vision
2020
Refraction
Diagnosis &
Management
Training
Centre
Specialists
Screening
Refraction
Dispensing
Case
finding
Service Centre
Mid-level personnel
Community Level
Vision Centre
Specialists –
Ophthalmologists,
Optometrists, Disp &
Manuf technicians
Optometrists,
Ophthalmics Nurses
Ophthalmic technicians
Vision technicians
Community Worker,
Teachers, Primary
health care worker
Challenges to HRD
• Personnel retention
• Multi-tasking
• Sustainability
• Career path
• Remote communities
• Maintaining standards
• Changing scope of practice
Providing refractive correction
• Providing the refractive
correction depends on local
conditions and resources
• Accessibility
− Providing a supply chain
• Quality
− Equipment sourced and
incorporated into service
delivery programmes
− Ready made spectacles
• Lower cost
•
Rapid treatment
− Adaptive Spectacles
An optical supply chain with social and
economic benefit
SUPPLIER
Minimum
Price
Mark Up
GLOBAL
RESOURCE
CENTRE
NGOs & PUBLIC
HEALTH SECTOR
Purchase in bulk
(no middle man)
= reduced product
cost
VISION
CENTRES
PATIENTS
Cost Recovery /
Minimum Markup
= Affordable to
Pts
Service Delivery
Refractive Service/Vision
Centres/Refraction Clinics
• Partnerships with governments
• NGO led
• Entrepreneurship
District Health System
NON- SPECIALIST
3o LEVEL CARE
SPECIALISED SERVICES
SPECIALIST & SUPERSPECIALIST CARE (40)
CLINIC
COMMUNITY
HEALTH
CENTRE
DISTRICT
HOSPITAL
REGIONAL
HOSPITAL
CLINIC
PROVINCIAL
HOSPITAL
COMMUNITY
HEALTH
CENTRE
CLINIC
HEALTH DISTRICT
Fig 1.
DISTRICT
HOSPITAL
REGIONAL
HOSPITAL
Primary Eye Care
• Integration of primary eye
care into primary health care
• Strong primary health care
development = strong eye
care programmes
• Different personnel in different
contexts
• Roles and tasks need to be
clarified
Service Delivery in KZN
4
3
2
3
3
2
3
2
8
1
2
33 optometrists
11 Districts
123 clinics
1000 000
patients
Social Entrepreneurship and Public
Private Partnership
• Addressing Poverty and Eye Health
through entrepreneurship and within a
health systems perspective
• Have to balance public protection with
profitability and a purely financial model
cannot be adopted
Infrastructure & Service Development
Vision Centres
• LVPEI model
• An eye care facility that provides a
range of eye care services,
including:
• Eye examinations
• Refraction (i.e. determining the
spectacle prescription required)
• Supply and dispensing of
affordable spectacles
• Detection of potentially blinding
diseases
• Treatment of minor eye diseases
Tanzania
Vision Centers
Enterprise for Sight Program in South
Africa
D
Partnerships with private practitioners
• Get private optometrists
involved for our mission
• Package of 20 to 30 affordable
frames and ready-made
spectacles
• Supported by Optometry
Associations
• CPD for participating
optometrists
• Target customers: Low income
consumers (working poor)
Vision screening in China
SCHOOL HEALTH AND SCHOOL EYE
HEALTH
Screening in Lechang, China, 2010
Strategic partnerships to support
sustainability
• Governments
• Major Development
Agencies
• Rural agencies
• Women's Groups
• Professional Associations
• Business Development Units
• Micro-finance Groups
THANK YOU
k.naidoo@brienholdenvision.org