Ординатура / Офтальмология / Английские материалы / Comprehensive Ophthalmology_Khurana_2007

upgradation of eye departments of state medical colleges and by establishment of regional institutes of ophthalmology (RIO).

4. Establishment of an apex National Institute of Ophthalmology. An apex National Institute of Ophthalmology has been established at Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi. This institute has been converted into a centre of excellence to provide overall leadership, supervision and guidance in technical matters to all services and technical institutions under the programme.

C. Intensification of eye health education

Health education is an important long-term measure in order to create community awareness of the problem, to motivate the community to accept total eye health care programmes, and to secure community participation.

Intensification of eye health education is being done through mass communication media (television talks, radio talks, films, seminars and books), school teachers, social workers, community leaders, mobile ophthalmic units, and existing medical and paramedical staff. Main stress is laid on care and hygiene of eyes and prevention of avoidable diseases.

Health education about hygiene of vision in school children is being imparted with regard to good reading posture, proper lighting, avoidance of glare, and a proper distance.

PROGRAMME ORGANIZATION

Various programme activities implemented at central, state and district levels are as follows:13

1. Central level

At the central level, programme organization is the responsibility of the ‘National Programme Management Cell’ located in the office of Director General Health Services (DGHS), Department of Health, Government of India (GOI). To oversee the implementation of the programme three national bodies have been constituted as below:

National Blindness Control Board, chaired by Secretary Health to GOI.

National Programme Co-ordination Committee, chaired by Additional Secretary to GOI.

National Technical Advisor Committee, headed by Director General Health Services, GOI.

Central level activities include:

l. Procurement of goods (major equipments, bulk consumables, vehicles, etc.)

2.Non-recurring grant-in-aid to NGOs.

3.Organizing central level training courses.

4.Information, education and communication (IEC) activities (prototype development and mass media).

5.Development of MIS, monitoring and evaluation.

6.Procurement of services and consultancy.

7.Salaries of additional staff at the central level.

2. State level

The NPCB is implemented through the State Government. A ‘State Programme Cell’ is already in place for which five posts including that of a Joint Director (NPCB) have been created.

State-level activities include:

l. Execution of civil works for new units.

2.Repairs and renovation of existing units/ equipments.

3.State level training and IEC activities.

4.Management of State Project Cell.

5.Salaries for additional staff.

Recently, it has been proposed to establish ‘State

Blindness Control Society’ (SBCS) in major states for monitoring and implementing the programme at the state level. The SBCS will release grant-in-aid to District Blindness Control Societies (DBCS) for various activities.

3. District level

To organize the programme at district level, ‘District Blindness Control Societies’ have been established.

District blindness control society

The concept of ‘District Blindness Control Society (DBCS)’ has been introduced, with the primary purpose to plan, implement and monitor the blindness control activities comprehensively at the district level under overall control and guidance of the ‘National Programme for Control of Blindness'. This concept has been implemented after pioneering work by DANIDA in five pilot districts in India.

Objective of DBCS establishment is to achieve the maximum reduction in avoidable blindness in the district through optimal utilisation of available resources in the district.

Need for establishment of DBCS was considered because of the following factors:

1.To make control of blindness a part of the Government’s policy of designating the district as the unit for implementing various development programmes.

2.To simplify administrative and financial procedures.

3.To enhance participation of the community and the private sector.

Composition of DBCS. Each DBCS will have a maximum of 20 members, consisting of 10 ex-officio and 10 other members with following structure:

Chairman: Deputy Commissioner/District Magistrate.

Vice-Chairman: Civil Surgeon/District Health Officer.

Member Secretary: District Programme Manager (DPM) or District Blindness Control Co-ordinator (DBCC), who is appointed by the Chairman. DPM will co-ordinate the activities of the programme between the government and non-government organizations (NGOs).

Members will include District Eye Surgeon, District Education Officer, President local IMA branch, President Rotary Club, representatives of various NGOs and local voluntary action groups. The exofficio members will be the members of the society as long as they hold the post. The term of other members is notified by the Chairman.

Advisor of the society is the State Programme Manager.

Technical guidance is provided by the Chief Ophthalmic Surgeon/Head of the Ophthalmo-logy Department of Medical College.

Revised strategies adopted for implementation of programme at district level are:

1.Annual district action plan is to be submitted by DBCS. Funding will be in two instalments through GOI/SBCS.

2.NGO participation made accountable; allotted area of operation.

3.Revised guidelines for DBCS — capping of expenditure; phasing out contract managers.

4.Emphasis on utilization of existing government facilities.

5.Gradual shift from camp surgery to institutional surgery.

6.Development of infrastructure and manpower for IOL surgery.

STRATEGIC PLAN FOR VISION 2020: THE RIGHT TO SIGHT IN INDIA

The Government of India has adopted ‘Vision 2020: Right to Sight’ under ‘National Programme for Control of Blindness’ at a meeting held in Goa on October 1013, 2001 and constituted a working group. The draft plan of action submitted by the ‘Working Group’ to the Ministry of Health and Family Welfare Govt. of India inAugust, 2002 includes following strategies:13

A.Strengthening advocacy

B.Reduction of disease burden

C.Human resource development, and

D.Eye care infrastructure development

A. Strengthening advocacy

To strengthen advocacy and generate public awareness various activities are proposed at national, state, and district level under Vision 2020 initiative in India. The essence of these activities is:

Public awareness and information about eye care and prevention of blindness.

Introduction of topics on eye care in school curricula.

Involvement of professional organizations such as All India Ophthalmological Society (AIOS), Eye Bank Association of India (EBAI) and Indian Medical Association (IMA) in the National Programme for Control of Blindness.

To strengthen the functioning of District Blindness Control Society (DBCS).

To enhance involvement of NGOs, local community societies and community leaders.

To strengthen hospital retrieval programmes for eye donation through effective grief counselling by involving volunteers, Forensic Deptt., Police etc.

B. Reduction of disease burden (disease-specific approach)

Target diseases identified for intervention under ‘Vision 2020’initiative in India include:

Cataract,

Childhood blindness,

Refractive errors and low vision,

Corneal blindness,

Diabetic retinopathy,

Glaucoma, and

Trachoma (focal)

Cataract

Cataract continues to be the single largest cause of blindness. According to latest National Survey in India (1999-2001), 62.6% of blindness in 50 + population of India was found to be cataract related. Objective. To improve the quantity and quality of cataract surgery.

Targets and strategies include:

To increase the cataract surgery rate to 4500 per million per year by 2005, 5000 by 2010, 5500 by 2015 and 6000 by 2020.

To improve the visual outcome of surgery to conform to standards set by WHO (i.e., 80% to have visual outcome 6/18 or >6/18 after surgery).

IOL surgery for >80% by the year 2005 and for all by the year 2010.

YAG capsulotomy services at all district hospitals by 2010.

Grant-in aid for cataract surgery may continue to be released through DBCS.

Childhood blindness

Childhood blindness is an important public health problem in developing countries due to its social and economic implications. Though prevalence of childhood blindness is low as compared to blindness in the aged, it assumes significance due to large number of disability years of every child remaining blind.

Extent and causes of problem. Prevalence of childhood blindness in India has been projected to be 0.8/1000 children by using the correlation between under five mortality rate and prevalence. Currently, there are an estimated 270,000 blind children in India. Common causes of childhood blindness are vitamin A deficiency, measles, conjunctivitis, ophthalmia neonatorum, injuries, congenital cataract, retinopathy of prematurity (ROP), and childhood glaucoma.

Refractive errors are the commonest cause of visual impairment in children.

Aim is to eliminate avoidable causes of childhood blindness by the year 2020.

Strategies and activities under Vision 2020: Right to Sight initiative in India include:

1.Detection of eye disorders. Following schedule of ophthalmic examination of children is recommended to identify early childhood

disorders, refractive errors, squint, amblyopia and corneal diseases:

At the time of primary immunization,

At school entry, and

Periodic check up every 3 years for normal and every year for those with defects.

2.Preventable childhood blindness to be taken care of through cost effective measures:

Prevention of xerophthalmia is of utmost value in preventing childhood blindness (see page 436).

Prevention and early treatment of trachoma by active intervention (see page 67 and 447).

Refractive errors to be corrected at primary eye care centres.

Childhood glaucomas to be treated promptly.

Harmful traditional practics need to be avoided.

Prevention of ROP by proper screening and monitoring use of oxygen in premature new borns.

3.Curable childhood blindness due to cataract, ROP, corneal opacity and other causes to be taken care of by the experts at secondary and tertiary level eye care services.

Targets include:

Establishment of Paediatric Ophthalmology units. In India, 50 Pediatric Ophthalmology units are to be established by 2010 for effective management of childhood diseases.

Establishment of refraction services and low vision centers (see below ).

Refractive errors and low vision

Aim and stratigies are same as described for ‘Vision 2020’ Global initiative (see page 447)

Targets. To combat refractive error and low vision following targets have been set in India:

Refraction services to be available in all primary health centres by 2010. Availability of low-cost, good quality spectacles for children to be insured.

Low vision service centres are to be established at 150 tertiary level eye care institutions. 50 such centres are to be developed by 2010, another 50 by 2015 and the final 50 by 2020.

Glaucoma

As per the ‘National Survey on Blindness’ (1999-2001, Govt. of India Report 2002)9 glaucoma is responsible

for 5.8% cases of blindness in 50+ population. Effective intervention for prevention of glaucoma resultant blindness is quite difficult. Failure of early detection of the disease poses a management problem towards controlling glaucomatous blindness. Population based screening of glaucoma is not recommended as a strategy in developing countries. Following measures are recommended for opportunistic glaucoma screening (case detection) by tonometry and fundus examination:

Opportunisitic screening at eye care institutions should be done in all persons above the age of 35 years, those with diabetes mellitus, and those with family history of glaucoma.

Community based referral by multi-purpose workers of all persons with dimunition of vision, coloured haloes, rapid change of glasses, ocular pain and family history of glaucoma.

Opportunistic screening at eye camps in all patients above the age of 35 years.

Diabetic retinopathy

Diabetic retinopathy (DR) is emerging as an important cause out of 4.7% cases of blindness due to posterior segment disorders in 50+ population (National Survey 1999-2001)9. To prevent visual loss occurring from diabetic retinopathy a periodic follow-up (see page 262) is very important for timely intervention. Following recommendations are made:

Awareness generation by health workers.

All known diabetics to be examined and referred to Eye Surgeon by the Ophthalmic Assistant.

Confirmation by fundus fluorescein angiography (FFA) and laser treatment of diabetic retinopathy at tertiary level.

The strategy must be to bring down the medical management of DR at the secondary level.

Corneal blindness

Background. A significant number of cases of visual impairment and gross degree of loss of vision occur due to diseases of the cornea. There are about 1 million corneal blinds in India. Majority of these persons are affected in the first and second decade of life. The major causes of this blindness are corneal ulcers due to infections, trachoma, ocular injuries and keratomalacia caused by nutritional deficiencies. Thus, corneal blindness is one of the outstanding problems in the field of preventive and community

ophthalmology and is a great challenge to the medical profession in general and ophthalmolgists in particular. This challenge can be faced boldly by the combined efforts of the public and the government; especially the education department, school teachers, general medical practitioners and ophthalmologists. Objectives regarding corneal blindness under ‘Vision 2020’ in India are:

To reduce prevalence of preventable and curable corneal blindness.

To identify the infants at risk in cooperation with RCH programme.

Strategies for control of corneal blindness include:

1.Eye infections. Health education and improvement in personal hygiene will reduce the incidence of conjunctivitis, corneal ulcer and other eye infections. Early treatment of eye infections will prevent corneal blindness.

2.Eye injuries. Education of people regarding avoidance of ocular trauma like cracker blast, industrial accidents, road accidents and other trauma, thereby reducing irreversible corneal blindness. Ocular trauma cases should be immediately referred to specialists for effective management. Facilities for administrating general anaesthesia for ocular trauma patients at secondary eye care level.

3.Trachoma Blindness. In India the corneal blindness due to trachoma (0.39% WHO-NPCB, 1986-88) is on the decline when compared with previous figures (20% ICMR 1975). However, In isolated pockets (focal) blindness related to trachoma continues to be important. For prevention of trachoma blindness see page 67 and 447.

4.Prevention of Xerophthalmia will make a strong dent in the number of corneal blinds. The three major known intervention strategies for the prevention and control of vitamin A deficiency are described on page 436.

5.A total ban should be placed on the ophthalmic practice by quacks and sale of harmful eye medicines especially various ‘surmas’.

6.The eyes of industrial workers and agriculturists should be given protection by goggles and eye shades.

7.Corneal blindness and keratoplasty. There is a need of around 1 lakh corneas per year for transplantation to clear the backlog of corneal

blindness. Currently we are collecting around 25000 eyes per year. As keratoplasty operation can restore vision in a significant number of corneal blinds, an intensive publicity and cooperation of government and non-government agencies is needed to enhance the voluntary eye donations. More eye banks should be established and more ophthalmic surgeons should be trained for corneal grafting. Under Vision 2020: Indian initiative emphasis is on hospital retrieval system to get better donor material.

C. Human resource development

For ‘Vision 2020’initiative in India, the human resource needs identified to combat blindness by 2020 are depicted in Table 20.4.

Mid-Level Ophthalmic Personnel (MLOP). The term MLOP has been introduced to include all categories of paramedics who work full time in eye care. Broadly two streams of such personnels are envisaged:

1.Hospital-based MLOP. These include ophthalmic nurses, ophthalmic technicians, optometrists, and orthoptists etc.

2.Community-based MLOP include those with outreach/field functions such as primary eye care workers and ophthalmic assistants.

D. Eye care infrastructure development

Based on the recommendations of WHO, there is need to develop the infrastructure pyramid which includes (Fig. 20.1):

1.Primary level Vision Centres. There is a need to develop 20000 vision centres, each with one Ophthalmic Assistant or equivalent (Community based MLOP) covering a population of 50000.

2.Service Centres. There is need to develop 2000

Fig. 20.1. The infrastructure pyramid, based on the recommendations of WHO.

service centres at secondary level — each with two ophthalmologists and 8 paramedics (Hospital based MLOP), covering a population of 500000. One eye care manager will be required at each service centre.

3.Training Centres. There is a need to develop 200 ‘Training Centres’ for the training of Ophthalmologists. Each tertiary level training centre will cater to a population of 5 million.

4.Centre of Excellence (COE). There is need to develop 20 COE with well developed all sub specialities of Ophthalmology. Each advanced tertiary level center of excellence will cater to a population of 50 millions.

ROLE OF EYE CAMPS IN PREVENTION OF BLINDNESS

Objectives

Eye camp approach for prevention of blindness still plays a vital role in the developing countries where infrastructure is not fully established. It is particularly more relevant keeping in view the fact that still 62.6% of blindness in India is due to cataract which can be very well cured in eye camps.

Organization of an eye camp

Presently two types of eye camps are held:

Comprehensive eye care camps with ‘Reach-out Approach’, and

Screening eye camps (Reach-in-Approach with comprehensive eye care).

As mentioned earlier the recent emphasis is on the ‘Reach-in-Approach’.

I. Comprehensive eye - care camps with ‘Reach- Out-Approach’

A. Preparatory phase is most important for the successful organization of an eye camp. Activities during this phase are:

1.Finalization of organizers and medical team.

Presently, most of the eye camps are planned and co-ordinated by the DBCS. Usually, the organizers are voluntary organizations of repute. The medical team is either from district mobile ophthalmic units or charitable hospitals or state mobile ophthalmic units.

2.Permission to hold eye camp. Permission is sought by the organizers from the Chief Medical Officer/ Civil Surgeon of the district.

3.Selection of the camp site. The eye camps should preferably be held at CHC/PHC/charitable hospitals/ civil hospital, so that available operation theatre facilities can be used.

4.Publicity and mobilisation of community resources. These are most important aspects for the success of an eye camp. Publicity should start at least a fortnight prior to the actual camp dates. Method of publicity should include public announcements, radio broadcast and display of banners and posters at prominent places like bus-stands, railway stations, schools etc.

5.Other activities. These include arrangement for medicines and food for the patients, stay arrangements for the medical team and mobilization of volunteers and social workers, for rendering assistance to the camp team.

B. Intensive phase. Eye camps should last 7 days out of which 2-3 days should be set apart for intensive phase, during which following activities need to be performed:

1.The medical team comprising at least one resident doctor, 2 nurses, 2 operation theatre assistants and 2 paramedical personnel should reach the camp site an evening before the scheduled commencement of the camp. They should set up the OPD, ward and operation theatre. The OT room should be fumigated with formalin vapours and kept closed overnight.

2.Patients are provided comprehensive eye care services including refraction. Those requiring surgical intervention for cataract or other diseases are admitted in the ward. For performing ophthalmic surgery, following guidelines laid down by Govt. of India should be adhered to:

At least one anaesthetist with arrangements to meet common emergencies should be available.

At least one, preferably two, operating surgeons should be there and each surgeon should not perform more than thirty operations in a day.

Presently extracapsular cataract extraction (by any technique) with posterior chamber intraocular lens implantation is the recommended method.

Ideally the number of operations performed per day should not exceed 50 and in a camp should not exceed 200 to maintain quality and safety of sterilization, surgery and postoperative care.

Both the eyes should never be operated at one go.

Cases with poor surgical risk such as severe diabetics, severe hypertensives and those having cardiac problems should not be operated in camps. The cases associated with problems like these should be referred to the base hospitals.

3.Along with curative and preventive services, eye health education is also carried out simultaneously.

C. Consolidation phase of 4-5 days follows the intensive phase with following activities:

Care of operated and other admitted patients.

Out-patient’s care including refraction.

Community eye health and morbidity surveys with greater emphasis on school children.

D.Culmination and retrieval phase. On the morning of last day, each patient is very carefully examined and discharged after proper guidance. After this, the men and material resources are packed up and transported back to the base hospital.

E.Follow-up phase. One ophthalmic surgeon with the help of one ophthalmic assistant, one staff nurse and paramedical personnel conducts the follow-up examination after 4-6 weeks of closing of the camp. During this, phase, glasses are prescribed after removing the sutures and the patients are given further necessary advice.

II. Screening eye camps (Reach-in-Approach)

According to revised strategies, emphasis is to shift from ‘Reach-out to the ‘Reach-in-Approach’. In ‘Reach-in-Approach’, the ‘screening camps’ are held in rural and remote areas where eye-care facilities are not available. Patients are provided comprehensive eye care services including refraction. Patients in need of cataract surgery are then transported to the nearest well-equipped hospitals (Base hospital approach).

Emphasis is on extracapsular cataract extraction with posterior chamber IOL implantation for better quality of vision. Many eye surgeons are now performing sutureless small incision cataract surgery (SICS) with posterior chamber intraocular lens implantation. The trained surgeons are even performing the cataract surgery by latest technique i.e., phacoemulsification in eye camps.

Documentation, monitoring and evaluation

A complete and meticulous record of the patients treated in the eye camp along with the post-operative complications noted and managed should be kept. Each eye camp should be monitored by the competent authorities and evaluated in terms of various activities assigned to such camps and the results obtained.

EYE BANKING

Eye bank is an organization which deals with the collection, storage and distribution of cornea for the purpose of corneal grafting, research and supply of the eye tissue for other ophthalmic purposes.

Functions of an eye bank include:

1.Promotion of eye donation by increasing awareness about eye donation to the general public.

2.Registration of the pledger for eye donation.

3.Collection of the donated eyes from the deceased.

4.Receiving and processing the donor eyes.

5.Preservation of the tissue for short, intermediate, long or very long term.

6.Distribution of the donor tissues to the corneal surgeons.

7.Research activities for improvement of the preservation methodology, corneal substitute and

utilisation of the other components of eye.

Eye bank personnel include:

1.Eye bank incharge. He should be a qualified ophthalmologist to evaluate, process and distribute the donor tissue.

2.Eye bank technician. The duties of a trained eye bank technician are:

To keep the eye collection kits ready.

To assist in enucleation of donor eyes.

To record data pertaining to donor material and waiting list of patients.

To process and treat the donor eyes with antibiotics.

To assist in corneal preservation and storage.

To maintain asepsis in the eye bank.

3.Clerk-cum-storekeeper. The duties are:

To maintain meticulous records.

To coordinate with other eye banks.

To deal with other eye banks and exert with efficiency regarding donor’s correspondence.

To distribute cornea to eye surgeons/eye banks.

4.Medical social worker or public relation officer is required:

To supply publicity material to common public

To promote voluntary eye donation. He may be a voluntary or paid worker.

5.Driver-cum-projectionist is required:

To maintain vehicle of the eye bank.

To screen films of eye donation promotion in the community.

Eye collection centres. These are the peripheral satellites of an eye bank for better functioning. One collection centre is viably located at an urban area with a population of more than 200,000. About 4-5

collection centres are attached with each eye bank.

Functions of eye collection centre are:

Local publicity for eye donation.

Registration of voluntary donors.

Arrangement for collection of eyes after death.

Initial processing, packing and transportation of collected eyes to the attached eye bank.

Personnel needed for eye collection centre are:

Ophthalmic technician trained in eye bank.

Local honorary workers/voluntary agencies like Lions club, Rotary club etc. to boost the eye donation campaign.

Services of honorary ophthalmic surgeon or medical officer trained in enucleation available on

call.

Legal aspect. The collection and use of donated eyes come under the perview of ‘The Transplantation of Human OrgansAct, 1994’.

Facts about eye donation

Almost anyone at any age can pledge to donate eyes after death; all that is needed is a clear healthy cornea.

The eyes have to be removed within six hours of death.

Eye donation gives sight to two blind persons as one eye is transplanted to one blind person.

The eyes can be pleged to an eye bank and can be actually donated to any nearest eye bank at the time of death.

The donated eyes are never bought or sold.

Eye donation is never refused.

The eyes cannot be removed from a living human being inspite of his/her consent and wish.

REHABILITATION OF THE BLIND

Rehabilitation of the blind is as important as the prevention and control of blindness; spiritually speaking even more. A blind person needs the following types of rehabilitation:

1.Medical rehabilitation. By low vision aids (LVA) many visually handicapped can have a useful vision.

2.Training and psychosocial rehabilitation. It is the most important aspect. First of all the blinds should be assured and made to feel that they are equally useful and not inferior to the sighted persons. Their training should include:

Mobility training with the help of a stick.

Training in daily living skills such as bathing washing, putting on clothes, shaving, cooking and other household work.

3.Educational rehabilitation. It includes education avenues in ‘Blind Schools’ with the facility of Braille system of education.

4.Vocational rehabilitation. It will help them to earn their livelihood and live as useful citizens. Blinds can be trained in making handicrafts, canning, book binding, candle and chalk making, cottage industries and as telephone operators.

To conclude, it should never be forgotten that, one of the basic human rights is the right to see. The strategicians MUST ensure that:

No citizen goes blind needlessly due to preventable causes.

All avenues are exhausted to restore the best possible vision to curable blinds.

Blinds not amenable to curable measures receive comprehensive rehabilitation.

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2. The Prevention of Blindness. Report of a WHO Study Group. Geneva, World Health Organization, 1973 (WHO Technical Report Series, No. 518).

3. WHO (1979). WHO Chronicle 33: 275.

4. WHO (1977). International Classification of Diseases. Vol. 1, p. 242.

5. WHO (1997), The World Health Report 1997, Conquering suffering, Enriching humanity, Report of the Director-General WHO.

6. Thylefors B et al. Global Data on Blindness. Bull. WHO 1995; 73: (1) 115-121.

7. Indian Council of Medical Research : Collaborative study on Blindness (1971-74).

8. Report of National Workshop (1989). National Programme for Control of Blindness. Director

General Health Services, Ministry of Health and Family Welfare, New Delhi.

9. Govt of India, National Survey on Blindness: 19992001, Report 2002.

10 . Strategic plan for Vision 2020: The Right to Sight WHO Report. SEA-Ophthal 177, 2000

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13 . Strategic plan for Vision 2020: The Right to sight initiative in India, National Programme for control of blindness, Director General of Health Services, Ministry of Health and Family Welfare Govt. of India.