Reading Material for the Prevention of Blindness Workshop

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These comparative studies illustrate that the prevalence of myopia and hyperopia varies considerably across geographic regions. They also illustrate that visual impairment, which in this age group is almost entirely because of correctable refractive error, will vary in a corresponding fashion. Unfortunately, it appears that approximately half of the visual impairment associated with easily corrected refractive error remains uncorrected –at least among school-age children in lower and lower middle class populations. To the extent that these data represent children across different geographic and ethnic origins, as well as different cultural settings, reduced vision because of uncorrected refractive error is an important public health problem. Cost-effective strategies are needed to eliminate uncorrected refractive error as a cause of disabling visual impairment, particularly during the formative years of children.


1 World Health Organization. Elimination of avoidable visual disability due to refractive errors. (WHO/PBL/00.79). Geneva: WHO, 2000.
2 Negrel AD, Maul E, Pokharel GP, et al. Refractive error study in children: sampling and measurement methods for a multi-country survey. Am J Ophthalmol 2000; 129: 421-426.
3 Pokharel GP, Negrel AD, Munoz SR, Ellwein LB. Refractive error study in children: results from Mechi Zone, Nepal. Am J Ophthalmol 2000; 129: 436-444.
4 Zhao J, Pan X, Sui R, et al. Refractive error study in children: results from Shunyi District, China. Am J Ophthalmol 2000; 129: 427-435.

5 Maul E, Barroso S, Munoz SR, et al. Refractive error study in children: results from La Florida, Chile. Am J Ophthalmol 2000; 129: 445-454.

6 Dandona R, Dandona L, Srinivas M, et alE Refractive error study in children in a rural population in India. Invest Ophthalmol Vis Sci 2002; 43: 615-622.
7 Murthy GVS, Gupta SK, Ellwein L, et al. Refractive error in children in an urban population in New Delhi. Invest Ophthalmol Vis Sci 2002; 43: 623-631.

3. Action ‘urgently needed’ to advert crisis in Canadian ophthalmic health care , warns study

by Pippa Wysong in Toronto.
CANADIAN ophthamology is facing a shortage of ophthalmologistmas the problem will only worsen as the population ages and the health care budget shrinks.
A recent study commissioned by the Canadian Ophthalmological Society ( COS ) suggests that a way to battle the defict is to share the workload. The report suggests that specialist should zero in on complex and accute cases, while fanily physicians and optometrists should take over more primary eye care.
Indeed , because of a medical manpower shortage , many areas of the country will be without medical or surgical eye care. This is according to a document created by the COS as a submission to the Commission on the Future of Health Care in Canada.
The Commission was launched in 2000 by the federal government to investigate Canada’s ailing health care system,. It was to create recommendations for sustaining and improving public health care , while maintaining the key principle of Canada ‘s Health Act – having a national system that is universally accessible and publicity funded. The final report was released in November 2002.

In ophthalmology, as with other specialities in Canada , there is an increasing demand for services while waiting lists get longer and longer . The report stressed that “ action is urgently needed in order to advert a crisis in the provission of vision care”

A key part of the crisis stern from action taken by the provincial governments when positions in medical school were reduced back in the early 1990’s. This parellels the current situation in France , which is also facing an acute shortage of new ophthalmologists .

‘ Historically, we have trained about 40 ophthalmologist a year in Canada. We ‘re down to about 20 now,’ said President of the COS, Duncan Anderson MD.

The governments are now starting to increase the positions in medical schools so new ophthalmologists can be trained, but it will take 12 to 15 years for them to finish their training and get into practice, he said.

In the meantime, the average age of ophthalmologist already in practise is 50, meaning significant numbers will either swicth to part time practice or retire over the next few years, thereby adding to the crunch.

According to the COS reports, the ophthalmologists to population is 128,000. To meet this , Canada needs to produce 35 to 40 ophthalmologists annually. With current trends, the ratio is expected to increase to 1,38,845 in 2016.
Close to 67% of ophthalmic services go to patients aged 65 and older. Patients who are aged 80 years and over have a per capita fee for- service payment of Cdn $108.00 comparted to only Cdn $4.20 for people in the 10 to 49 age group
Unfortunately, there is a bulge in the population with baby boomers rapidly headings into those older age groups. Already, there are waiting lists for the eye care, especially for cataract surgery, Dr Anderson said.

There is no good data showing exactaly how long waiting lists are across the country but it’s safe to say people have to wait “a number of months” to see an ophthalmologist after referal from a family physician.

They then have to waitt “a number of months”after seeing the specialist before going for surgery, he said.
In all, people are waiting a good six to eight months or more to get from the family physician to the operating room ( OR ). There is reginol variation too, with waits longer for people who live in smaller remote communities where the ophthalmologist shortages are already acute.
We’re just getting by now. There is triage in the system and patients who need urgent care who bumped up and can get to the OR more quickly. But without change or new approaches, the problems will worsen as times goes by. Manpower isn’t the only problem. Resources are tight and there is a shortage of nurses, technician and OR availability”. Dr Anderson said.
One of the ways to alleviate the crisis is to share the burden of eye care with other health care professional. Family physician already treat about 50% of eye problems without ever referring patients to a specialist. Optometrists could be doing more too and ophthalmologists could focus more on the complex and severe cases.
The COS recommended establishing provicial vision care advisory panels whose role would be to inform policy makers of the cost effectiveness of new eye care technologies, enhance multidiciplinary interaction and networking advise on resource allocation and so on.

Some provinces are already experimenting with multidiciplinary models for providing eye care, and Nova Scotia is in the lead. This east cost province established the Comprehensive Vision Care Programme.

Health care will probably move away from individual to team work, to something that is more streamlined, efficient and cost- effective”.

It was developed by ophthalmologist, optometrists and family physicians who came up with optometrists and family physicians who came up with algorithms for treating specific types of eye problems, shifting certain aspects of the care to different providers. Screening and treatment of specific eye conditions was devided up with optometrists taking on a bigger role.
“It’s a shared care model”, said Raymond Le Blanc MD, President of the National Coalition for Vision Health. The model reflects what was already happening in practise, many ophthalmologists no longer follow patients unless they have chronic disease.
Its development was driven by a mix of acesss problems and acknowledgement that optometrists have more extensive trainning than in the past. Traditionally , when optometrists saw patients who needed additional care, they had to refer them to the family physician who in turn made the refereal to an ophthalmologist.
Under the new model, optometrists make the referral directly. They can also now prescribe first line antibiotic and non-steroidal anti-inflammatory preparations.
One condition optometrists are doing more for now is diabetic retinopathy, something for which fewer than a third of diabetics in the province were being screened or got an annual eye examination.
With 45 ophthalmologists in the province, they couldn’t do it alone. Add in the optometrists and more of these patients can be screened.” Dr Le Blanc said . Diabetics can now be referred to an optometrists for the annual eye examinations and dilated fudus assassments. Photography-based screening complements the examinations . While there are still turf battles between ophthalmologists and optometrists, a multidiciplinary approach in the way of the future, he said.

It’s a matter of having people working together and it’s not going to be easy. The bottom line is finding ways to make sure patients get the care they need.. Over time, this shared care approach will be more-effective in terms of per patient interventions. But with the ageing population, which needs more care, costs will increase overall. Other province overall. Other province are taking note of Nova Scotia’s comprehensive vision care programmes and are working to implement similar co-operative programmes. Quebec and Ontario and also a national groups are looking into such shared care models, Dr Le Blanc said.
“Health care will probably move away from individual to team work, to something that is more streamlined, efficient and cost-effective,” Dr Anderson agreed.

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