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The Official Scientific Journal of Delhi Ophthalmological Society
Status of Eye Care in South East Asia Region
* GVS Murthy, **Sumit Malhotra, **Praveen Vashist
*Director, South Asia Centre for Disability Inclusive
Development & Research,
Indian Institute of Public Health,
(Public Health Foundation of India),
Hyderabad, India.
**Community Ophthalmology,
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences,
New Delhi 110029, India
Corresponding Author:
GVS Murthy
Director, South Asia Centre for Disability Inclusive
Development & Research,
Indian Institute of Public Health
(Public Health Foundation of India),
Hyderabad, India.
Email: gvsmurthy1956@gmail.com

Published Online: 25-SEP-2013
DOI: http://dx.doi.org/10.7869/djo.2013.25
Abstract
South East Asia is one of the most populated regions of the world. The South East Region of the World Health Organization comprises of 11 countries which have differences in governance as well as health indicators. Data available from large population-based surveys in the regions was accessed from published sources to review the existing situation in relation to eye care. The region has provided significant evidence on magnitude of blindness and visual impairment through large population-based surveys conducted periodically. The predominant sector providing eye care services is the government sector in five countries among the 11 countries which constitute this region. Cataract is the leading cause of blindness in the region, as evidenced by surveys. The region has witnessed improved cataract surgical rates and quality of cataract surgery over the past two decades. The gains in the region have a significant impact on the global magnitude of blindness and visual impairment. Eye care infrastructure and availability of appropriate human resources for eye care vary significantly across the region. Adequate focus on health systems strengthening, boosting primary eye care and generating evidence of progress made through monitoring and evaluation mechanisms will be imperative for realizing goal of eliminating avoidable blindness from the region in coming years.
Keywords : Asia • blindness • cataract • cataract surgical rate • visual Impairment
The South East Asia region of the World Health Organization is home to a quarter of the world’s population and is comprised of 11 countries of diverse cultural and social ethos and political dispensations. Not all countries in the region are in geographical contiguity and data flow is not uniform across the region. Some of the countries have not yet developed a national plan for Vision 2020. The population of the countries varies from a low of 329,000 in Maldives to a high of 1.12 billion in India.

There are an estimated 91 million visually impaired persons in the entire South East Asia region, with almost one third of the global share– 12 million with blindness and 79 million with low vision. India alone is responsible for approximately one fifth of the global burden and houses maximum visually impaired adults in the region.[1] Following the global movement and launch of Vision 2020: The Right to Sight in 1999, similar initiative was launched in South East Asia, considering rights based approach to eliminate blindness from the region. It gave priority to avoidable causes of blindness as almost 85% of blindness was attributed to avoidable causes and considered health systems strengthening focus with emphasis on adequate advocacy, human resource development, infrastructure and technology development and partnerships for blindness prevention and control.[2] There has been much progress in the countries in the region since the launch of Vision 2020, yet the region contributes substantially to the global burden. The region has been in the forefront of harnessing population-based evidence for planning eye care programs. This has enabled most countries to prioritize and strategize for providing needs-based services for meeting community eye care needs. The World Health Organization (WHO) has recently finalized the action plan for the last phase of Vision 2020 for the five years (2014-2019) and highlighted key areas to track progress to achieve the blindness reduction goals. This article reviews the current status of eye care in South East Asia region so as to synthesize necessary evidence needed for planning out appropriate strategies for further action in the last phase of Vision 2020.

Methodology

Published literature from South East Asia region was accessed using Pubmed. Studies published from January 2000 to June 2013 were considered for inclusion in the review. The definition of blindness varied across the countries. Most commonly, it was defined as presenting visual acuity of < 3/60 in the better eye while visual impairment was defined as presenting visual acuity < 6/18 to 3/60 in the better eye, as defined by WHO. Studies from India and Nepal have used a different national definition with presenting vision as less than 6/60 in the better eye for blindness. In addition to studies identifying burden, we also searched literature systematically looking onto social determinants of disease. Studies on interventions for improving eye care at the population-level were also scanned to identify successful innovations in eye care. Health sector environment assessment was also done looking into human resources and infrastructure availability for provision of eye care services in the nations.

Results

Burden of Blindness, causes and determinants

A number of population-based surveys[3-12] on blindness and visual impairment were available from the region. These included studies at the national level as well as studies conducted in smaller population segments within the countries. Studies on the prevalence of blindness and visual impairment were conducted either using a comprehensive detailed examination protocol or rapid assessment techniques. Rapid assessment methods like Rapid Assessment of Avoidable Blindness (RAAB) predominated at the local level while national level estimates were generally derived from more detailed comprehensive eye examination protocols. These assessments have been done predominantly in rural areas amongst people aged 50 years and above. Majority of the studies were reported from India, Nepal and Bangladesh and these have done mostly examining a sample size above 4000. Some surveys have included age group 30 or 40 yrs and above. Major studies from the countries of the region are presented in (Table 1).

The burden of blindness varies from country to country and within country from one zone to another. The last nationwide assessment in India reported prevalence of blindness as 8% amongst 50 years and older persons (presenting visual acuity <6/60 in better eye). In Nepal, the prevalence of blindness ranged from 0.7% in Bhaktapur district[13] to 17.4% in Rautahat district. A single study each reported from Myanmar and Timor Leste reported high prevalence (above 7%). Cataract is the most common cause of blindness in the region and is responsible for 50-80% of all blindness. The cataract surgical coverage at visual acuity 6/60 in India and Nepal varies from as low as 37% to as high as 80%, highlighting the varying nature of the problem and pockets existing with low access to services resulting in low coverage. Ensuring a high coverage of post operative follow up is a challenge in the region. Few studies have also reported post-operative cataract surgical outcomes. A recent study that reported cataract surgical outcomes from Bangladesh cited a figure of 20% of surgeries having adverse outcome (vision worse than 6/18).[14] A recent multi-centric study that included India and Indonesia, apart from four other nations, reported adverse outcomes for postoperative uncorrected visual acuity in 29% surgeries in India and in 50% of surgeries in Indonesia.[15] WHO recommends that 80% of patients should have uncorrected visual acuity of 6/18 or better in the operated eyes.[16]

Refractive errors are an important cause of visual impairment in the region. However the spectacle coverage rates are poor and unmet needs are still high in most countries.[17-19] Diabetic retinopathy, glaucoma and age related macular degeneration, though not picked up adequately in rapid assessment studies; with increase in life expectancy and rise in burden of non-communicable diseases, these conditions pose additional burden to eye health care service delivery in the countries of the region.

Amongst the factors associated with blindness; income, level of education, working status are important determinants. Low income, unemployment, illiteracy have been associated with blindness.[20] Gender inequities also contribute to burden of blindness in the region. Systematic reviews that have included studies from South East Asia region have reported consistently that women have significantly fewer cataract operations than men, though the magnitude of cataract blindness is seen more in females than males.[21] A recent study from South India, revealed that a higher proportion of women attended walk- in subsidized (56%) or free camp sections (55%) compared to walk- in paying system (42%) [OR 1.40 95% CI 1.25-1.57 and OR 1.33 95% CI 1.19 -1.49 respectively], that remained significant after adjustment with other socio-economic variables.[22] The study highlighted the need for public sector services for reaching out to women.

Childhood blindness

Though epidemiologic studies for blindness focus largely on adult population in the region, few studies have also examined childhood population for blindness. The community- based studies on paediatric population are challenging to conduct as they require huge sample sizes, owing to overall low prevalence of childhood blindness. In India, the population- level surveys that have examined prevalence of childhood blindness, have estimated the prevalence ranging between 1.06/1000 (using VA <3/60) to 1.7/1000 (using VA <6/60).[23,24] Socio-economic development (as measured by under-five mortality rates) has been correlated with the prevalence of childhood blindness. Studies done on children in schools for the blind are available from the region.[25-28] India based studies reveal congenital anomalies and retinal problems have become more prominent while childhood onset disorders especially Vitamin A deficiency has declined.[29] A study on blind children in Myanmar, reported corneal abnormalities and measles keratitis as the most common cause for childhood blindness.[30] These studies are less reliable; throw light on past prevalent causes and under-represent true picture from the community.

With improvements in neonatal care in the countries and survival of low birth weight babies, retinopathy of prematurity as a condition will require focus in context of screening and management. Uncorrected refractive errors are another vital contributor to childhood visual impairment. Epidemiological studies have been conducted in the region to guide programmes about this common problem.[31,32] School Vision programmes are implemented in the countries to tackle the burden through schools.

Health Sector assessment

It was observed that the public sector was the predominant health care provider in Bhutan, DPR Korea, Indonesia, Maldives and Myanmar, while the private sector was the predominant provider in Sri Lanka and Thailand. In Bangladesh, India and Nepal there is a mixed system whereby both the public and private sector are important providers. Non - governmental organizations have made a big difference to eye care services in India and Nepal over the past three decades.

In both India and Nepal, more than 60% of cataract surgery is performed by the NGO sector which only accounts for a third of all ophthalmologists, thereby reiterating the fact that efficiency increases outputs.[33] The CSR-cataract surgical rate (defined as number of cataract surgeries per million population) is a quantitative measure of delivery of cataract services in the country. India has a high CSR above 6000 per million population. Almost half of the countries in the region have achieved their target CSR levels. DPR Korea, Indonesia, Maldives and Timor Leste have CSR below 1000 and need marked improvement in provision of cataract surgical services.[34] WHO recommends an ophthalmologist-population ratio as 1:100,000 for effective eye specialist care. There is huge variation in this indicator amongst the nations of the region. Maldives with a low overall population has a ratio of 1:16 263. Only four nations- Maldives, India, DPR Korea and Thailand achieved the norm of one ophthalmologist for less than 0.1 million population, indicating the need for more eye care specialists in most of the region’s countries.[34] Every vision centre for 50,000 population should have one Mid-Level Ophthalmic Personnel (that includes optometrists, ophthalmic assistants and technicians, refractionists, ophthalmic nurses and orthoptists). Four nations- Myanmar, Nepal, Thailand and Timor Leste have not been able to achieve this norm. The lack of mid-level ophthalmic personnel adversely affects refractive services in many countries. Even where such personnel are available, their skills and competencies are variable as there is no standardization of either the curriculum or duration of training.[35]

Improvements in infrastructure are largely focused on secondary and tertiary care level, primary eye care by and large is a neglected area requiring concerted focus for future strategies. Though primary health care system in the countries has been improving for providing universal access to care, eye health has not been integrated well into this system. Largely programmes are cataract centric and areas like low vision and rehabilitation, eye banking and posterior segment disease management require attention.[34]



Innovations in health service delivery

Eye camps in make-shift setups have been consigned to history in most places, though still not universally. These have been replaced by different modalities of screening camps wherein clients are screened as part of outreach activities and then either transported or motivated to attend base hospitals for surgery. The initiation of the vision centre concept has helped in improving refraction and optical services in the rural areas in countries like Bangladesh and India.[36] Such centres also help in screening for operable cataracts and follow up of operated individuals. The facilities offered by vision centres also varies significantly with some lacking even functional trial sets while others having access to appropriate diagnostic services and tele-ophthalmology linkages. The numbers required are phenomenal while the numbers available are paltry. Telemedicine approaches have been employed for diabetic retinopathy and retinopathy of prematurity. Many innovative models are tried using mobile vans with ophthalmic technicians taking fundus images and transferring them to distant ophthalmologist. The model has been an important means to reach remote rural populations where access to specialist eye care is challenging. Government of Karnataka under National Rural Health Mission, has adopted a novel strategy for reaching at risk premature babies through the aid of technicians trained in using portable RetCam taking images and transferring them to tertiary care facilities with immediate signal if any further management is required.[37] Bangladesh has successfully tried reaching out to paediatric visually impaired population through community based approaches and linking them adequately to paediatric eye care centres for further management. The novel key informant approach was used. Key informants (KIs) were volunteers, school teachers, village leaders that were provided with training and were asked to identify and refer blind children to eye camps held in local vicinity. The operational research findings revealed that these KIs were able to identify younger children of both genders from rural areas with blindness and having multiple concomitant impairments. Children identified also belonged to severe Visual Impairment (VI) category more than the blindness, thus offering an opportunity to act for sight restoration if possible. Significantly more children with avoidable causes were identified using KI method than other methods – special education schools or the community based rehabilitation methods (OR 1.6, p=0.001, OR 1.51, p=0.031 respectively).[38]

Discussion

The South East Asia region witnesses high burden of blindness. Despite substantial gains in the past years tackling high disease load, much remains to be done for elimination of avoidable blindness. Cataract and refractive errors remain the most common contributors for blindness and visual impairment. Newer disease challenges confront the region owing to increase in ageing population and risk factors for non-communicable diseases. The eye care infrastructure and human resource availability vary significantly across the countries of the region. In fact the health care systems also vary dramatically across the whole region. Primary eye care will require a substantial investment in coming years. The focus on public health ophthalmological approach is imperative to reach the unreached and enhance access to challenging geographical areas. How to increase the numbers of skilled personnel to manage vision centres is the big challenge confronting many large-populated countries like Bangladesh and India. The development of strategies like vision entrepreneurs who market near glasses in Bangladesh and India at the village level using basically trained women from the local communities is a novel idea to increase the reach of spectacle services. The adoption of this strategy by an established development non-governmental organization (NGO) like BRAC in Bangladesh is an example that can be emulated by other countries. Innovation in technology and bridging the gap between the providers and the clients have led to improved access and cataract surgical rates and improved quality of surgery and therefore surgical outcomes. Efficiency of the operating rooms has improved by increasing number of tables and supportive staff and this has led to increased surgical coverage. In countries like India and Nepal, cross-subsidization schemes have made cataract surgery affordable to all sections of the society including the itinerant poor. Quality of surgeries and establishing monitoring mechanisms for post operative visual outcomes should receive due attention for further action.

Diabetes and consequently diabetic retinopathy are emerging challenges in the region due to extremely high prevalence of diabetes in the region, especially in Bangladesh, India, Nepal and Sri Lanka. Innovative approaches including teleophthalmology and use of non-ophthalmologists for screening for diabetic retinopathy have been piloted in some of the countries.[39-42] The pattern of childhood blindness in the region can be attributed to improved immunization coverage rates, vitamin A supplementation programs, early identification of childhood blindness including pediatric cataracts using innovative methods like Key Informants, increased awareness, development of pediatric eye care units (with support from Lions Sightfirst, ORBIS and Sightsavers International) and improvement in the developmental indicators in the region.[43,44]

The WHO global action plan for eye health 2014-19 focuses on universal access to eye care and gives prime importance to health systems strengthening and integrating eye care into routine health system delivery. Countries in the region will have to work towards universalizing eye care to all people through adequate focus on health systems issues that include human resources, finances, infrastructure, medicines and supplies, management information systems, leadership and governance. Investments in quality driven service delivery, centric to local eye care needs will need to be coupled with monitoring and evaluation mechanisms to track the progress made in overall eye health of populations. Strengthening primary eye care through concerted action involving multiple stakeholders and fostering long term partnerships with multiple players will be critical in realizing the goal of eliminating avoidable blindness in the South East Asia region in coming years.

Financial & competing interest disclosure

The authors do not have any competing interests in any product/procedure mentioned in this study. The authors do not have any financial interests in any product / procedure mentioned in this study.

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