Reading Material for the Prevention of Blindness Workshop



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Acknowledgement

The contribution of V. Rajashekar (Admin is trator, ICARE) is gratefully acknowledged in connection with various activities related to setting-up of this rural eye Centre and collection of the data presented.

References


  1. Sommer A. Towards affordable, sustainable eye-care. Int Ophthalmol 1995; 18: 287–92.

  2. Dandona L, Dandona R, Shamanna BR, Naduvilath TJ, Rao GN. Developing a model to reduce blindness in India: the International Centre for Advancement of Rural Eye Care. Indian J Ophthalmol 1998; 46: 263–68.

  3. Shamanna BR (1999). A study of cost-recovery mechanisms during the developmental stage of a new rural eye-centre in South India. MSc Dissertation. Submitted to University College London.

  4. Dandona L, Dandona R, Shamanna BR, Rao GN (2001). A model for high-quality sustain-able eye-care services in rural India. In: Pararajasegaram R, Rao GN, editors. World Blind ness and Its Prevention: Volume 6. Hyderabad: International Agency for the Preven tion of Blindness.

  5. Rao GN. Human Resource Development. J Comm Eye Health 2000; 13: 42–43.

  6. Dandona L. Blindness control in India: beyond anachronism. Lancet 2000; 356: s25. q

New issues in childhood blindness


http://www.jceh.co.uk/journal/40_1.asp
Clare Gilbert
MD MSc FRCOphth
Senior Lecturer
International Centre for Eye Health
11–43 Bath Street

London, EC1V 9EL, UK

The main issues in relation to blindness in children relate to a better understanding of the epidemiology, which has led to improved priority setting. In this article the most recent epidemiological data will be presented, the consequences for the Mision 2020 programme will be discussed, and research priorities considered.

Definitions


A blind child is an individual aged less than 16 years, who has a visual acuity in the better eye of <3/60. However, many studies do not use this definition, which makes it difficult to compare the findings of different studies.

Prevalence and Incidence


The prevalence of blindness in children (i.e., the proportion of the child population who are blind), varies from approximately 0.3/1,000 children in wealthy regions of the world, to 1.2/1,000 in the poorer countries / regions.1ÉBlindness in .children is more common in poor regions for two main reasons: firstly, there are diseases and risk factors which can lead to blindness from causes that do not now occur in industrialised countries (e.g., measles, vitamin A deficiency, ophthalmia neonatorum, malaria), and, secondly, there are fewer well equipped eye departments with ophthalmologists, nurses and ophthalmic paramedics trained in managing treatable causes of blindness (e.g., cataract and glaucoma). The incidence is therefore higher, and fewer blind children have their sight restored.

Incidence data are very difficult to obtain, but it has been estimated that there are 8 new blind children for every 100,000 children each year in industrialised countries. The figures are likely to be higher in developing countries.


Magnitude of Blindness


Globally there are estimated to be 1.4 million children who are blind, and around three quarters live in developing countries. Although the actual number of children who are blind is much smaller than the number of adults blind, e.g., from cataract, the number of years lived with blindness by blind children is almost the same as the total number of ‘blind years’ due to age-related cataract. The high number of blind years resulting from blindness during childhood is one of the reasons why the control of childhood blindness is a priority of the WHO/IAPB Vision 2020: The Right to Sight programme.2
Causes of Blindness in Children

The available data suggest that there is wide regional variation in the major causes of blindness in children. Tables 1 and 2 show the causes of blindness obtained from examining over 10,000 blind children, with the causes classified using the World Health Organization's classification system.3 These data do not take account of children who are ‘blind’ from refractive errors.


In wealthy parts of the world lesions of the central nervous system predominate, while in poorer countries corneal scarring as a result of acquired diseases are the most important causes. Table 3 shows estimates of the number of blind children by anatomical site, and by underlying cause.

Regional Variation in the Magnitude and Major Causes of Blindness in Children

It is possible to combine what we know about the prevalence of blindness in children with data on causes, and apply this to a total population of one million people (Table 4). This information is perhaps more useful for planning. Figure 1 shows these data.


Avoidable Causes


In all regions of the world there are causes which are amenable to primary, secondary and tertiary prevention, but the proportions vary from region to region (Table 5).

Vision 2020 Priorities


Given these findings, the following conditions are priorities for control:(4)

  • Corneal scarring, due to measles, vitamin A deficiency, harmful _raditional eye medicines, and ophthalmia neonatorum: priorities in poor and very poor regions

  • Aataract and glaucoma: important treatable causes in all regions

  • Retinopathy of prematurity, a condition which is preventable and treatable; important in middle income countries, and in urban centres in developing countries

  • Refractive errors: treatable cause in all regions

  • Low vision: services need to be expanded or developed in all regions.



Targets for disease control


The following targets have been agreed for disease control:

  1. Reduce the global prevalence of childhood blindness from 0.75/1,000 children to 0.4/1,000 children.

  2. Elimination of corneal scarring caused by vitamin A deficiency, measles, or ophthalmia neonatorum.

  3. Elimination of new cases of congenital rubella syndrome.

  4. All children with congenital cataract to receive appropriate surgery, with immediate and effective optical correction, in suitably equipped specialist centre
  5. All babies at risk of retinopathy of prematurity to have fundus examination, by a trained observer, 6-7 weeks after birth. Cryotherapy or laser treatment to be provided for all those with treatable disease.


  6. All school children to receive a simple vision screening examination, with glasses provided for all those with significant refractive error. This should be integrated into the school health programme.


Human resource development

The implications and recommendations for human resources development are as follows:



  1. Ensure that prevention of childhood blindness is an explicit aim of all primary health care programmes.

  2. Ensure that all secondary level eye clinics have facilities to provide appropriate spectacles for children with refractive errors.

  3. Train one refractionist per 100,000 population by 2010.

  4. Train at least one low vision worker for every 20 million children, by 2010, and for every 5 million by 2020.

  5. Train one paediatric-orientated ophthalmologist for every 50 million population by 2010, and one per 10 million population by 2020.



Appropriate technology & infrastructure


There is the following need for appropriate technology and infrastructure development:

  1. Development of low cost, high quality low vision devices, which should be widely available, even in low income countries.

  2. Establish a network of specialist ‘childhood blindness’ tertiary centres.

In this edition of the Journal of Community Eye Healthýthere are articles which address some of the priority causes of blindness in children. The article on cataract discusses the relative merits of intraocular lens implantation in children, as a means of correcting their aphakia. The article on retinopathy of prematurity from Brazil highlights how screening programmes need to be expanded in Latin America if blindness from ROP is to be brought under control.



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