Jan 2021 CHAPTER 2 Global magnitude: eye conditions and vision impairment lists the common eye conditions that can cause vision impairment. Blindness secondary to cornea problems / scarring is much more common in the developing world. Currently, more visual impairment globally from corneal opacities than diabetic retinopathy. In some countries / regions trachoma, which is an ongoing success story ( S.A.F.E. / azithromycin ) has yet to be eliminated. The prevalence of active trachoma is greatest in equatorial Africa. More common in women. Remember females ( mother / daughters / siblings ) usually have greater contact with small children who often are an ongoing source of active trachoma. That’s what we discovered in our extensive ophthalmic survey in southern Malawi ( Lower Shrine Valley ) many years ago .The rural women got repeated episodes of active trachoma ( conjunctivitis ) caring for the young children in the family. I have done my share of lid procedures for trichiasis but not sure I have ever done a trichiasis lid procedure for trachoma on a man. The tarsal rotation lid procedure for trichiasis appears the best and more long lasting. Incidentally in the States, I occasionally see a recent immigrant who has “ dry eye “ symptoms but everything looks OK except when you flip the lid you see subtle superior. palpebral scarring ( Arlt’s line ? ). I have felt perhaps the patient previously had several episodes of trachomatous conjunctivitis and wiped out their goblet cells ( mucus- producing ) so their pre-corneal tear film is not stable although it looks OK. Obviously I could be dead wrong on that.
As far as eye care services there was mention of availability, accessibility, affordability, and acceptability. Persistent inequalities remain between different subgroups of any population in accessing eye care services. In general, those not able to access eye care services as needed include people living in rural areas, those with low incomes, women, older people, people with disabilities, ethnic minorities, and refugees. Many of these issues are sometimes not a concern in the developed world so the depth of these ocular / logistical problems are not fully grasped. Inadequate access to eye care is a major cause of the unequal distribution of eye care. The closer you can bring your eye care to someone’s village, the more likely you are to help that patient, whatever your intervention ( eye surgery, glasses, medication, etc. ). Years ago in Tanzania, when we looked at where our surgical eye patients were coming from, a huge percentage lived less than 30 km from our eye hospital. In other words, we were not reaching most of our rural blind. As we all know, 90% of the world’s blindness are in the developing world.
Poor vision post-cataract surgery is unfortunately not uncommon. As I have mentioned previously, part of this problem is poor pre-op cataract evaluation which can result in disappointment / poor vision post-op. All white cataracts should not have cataract surgery. If you do that, you will most assuredly have some disappointed patients / poor vision post-op. Not a good way to encourage other patients from that village to come for cataract surgery.
Chapter 3 Addressing eye conditions and vision impairment, discusses strategies to address eye care needs — health-promoting, prevention, treatment, etc. As we know, cataract surgery is highly cost-effective. If at all possible the patient should not require numerous pre-op visits to the eye clinic before their cataract surgery. Cost and logistics of travel are major barriers to accessing eye care / surgery esp. for women. The more the pre-op eye patient has to come back / come back, then the less likely that patient will ever have their cataract operation -! come back for blood work, come back for an EKG, come back to see the nurse anesthetist pre-op, come back for the A-scan, etc. Madness.
Trauma is the most common cause of unilateral cataract. If small kids are left unsupervised, then the 5-year-old can hit the three years in the eye with a stick. When that happens that eye usually ends up with poor vision / phthisis. Unfortunately not an uncommon scenario. I do not think I have ever seen any limbal corneoscleral laceration ( ciliary body involvement ) that has recovered any useful vision. These eyes slowly head toward phthisis with a quite low IOP. Right?
When possible, with any visiting cataract surgical safari the outside visiting team should include the local ophthalmologist in the plans / activity so that the local community can see / appreciate that the local ophthalmologist / ophthalmic surgeon is part of the surgical team. It would be good if the in-country ophthalmologist gets to operate. Who knows, it could / should be a learning experience for everyone esp. the visiting surgeons if they do not routinely perform MSICS. With your visiting eye team, you don’t want to undermine the local ophthalmic infrastructure / personnel. You can certainly do that without even realizing that is what has happened.
You want, if possible, to promote the local ophthalmic surgeon as the local eye leader. I have seen / worked in situations where the local ophthalmologist is “ in charge” and often that can be a good model but obviously, that requires a dedicated local ophthalmologist. I have an ophthalmic friend ( now deceased ) who actually paid the local ophthalmologist to be part of his surgical team. Usually, it is a learning experience for everyone and this relationship may ensure reliable follow-up care as needed. Finding / making a lasting relationship / friendship with the local ophthalmic community could enhance everyone’s efforts / impact.
Of interest to me under common conditions amongst adults — Glaucoma treatment: General population screening for glaucoma is not currently considered to be cost-effective in most settings. A couple of times overseas, I have had to remind eye health workers that you really can not screen for glaucoma by just checking IOP. 50 – 50 chance of getting it right — or wrong. I think with eye screening, if you find patients with IOP over 23 mm then these patient should be told they might have glaucoma and when possible referred for further evaluation. Of course a good history might be helpful ( “any one in your family go blind” ? ). Even so, you can miss normal tension glaucoma patients and with a pronounced diurnal variation, as is often common with glaucoma, you may well miss the patient with ocular hypertension / glaucoma. I have repeatedly told eye health workers that checking the IOP a lot and recording the findings are often helpful and quite useful in diagnosing / treating glaucoma. Early glaucoma can be difficult to diagnosis correctly. With a large cup / disc ratio, then if available a OCT / RNFL test can be useful but remember that test may not always be correct. “ Don’t treat the red “. I certainly have seen many patients on one , two or more eye drops who I felt did not have glaucoma but only a large healthy cup / disc ratio. Glaucoma is probably the second leading cause of blindness worldwide. Glaucoma is such a loser that initially ( early on ) IAPB / Vision 2020 did not include glaucoma as a major issue / treatment concern as no one knew how to address glaucoma.. I have seen persons in their 20’s ( Haiti , sub-Saharan Africa ) that have already “ gone blind “ from glaucoma. Dishearting, the number of persons with glaucoma is four times higher in Asia than Africa.
Many of the references at the end of each chapter are of interest to anyone wanting more insight into where we are now and our peer-reviewed literature
Chapter 4 Successes and remaining challenges in eye care. This was written before the coronavirus pandemic so it will be interesting to see what happens in the post-coronavirus ophthalmic world. Many of our projections / long term plans for eye care international will need to be re-assessed in view of this pandemic and the adverse ocular affects in the developing world. Some of the plans / projected challenges might need to be re-thought. The next IAPB meeting should be of interest as we all try to re-group with the way forward.
Mention was made of the adoption of telehealth solutions. No doubt the pandemic has accelerated our use of tele-medicine. The possible of quickly having a second opinion on a complicated eye patient is obviously readily available with our ubiquitous smart phones and many portals including the AAO / ONE program. There is amazing amount of useful information available free through this portal. As most of us know, the International Centre for Eye Health has a twinning program that is ongoing and has helped to enhance the eye care possibilities / treatment strategies / training in many countries / in many eye departments / clinics. Obviously these exchanges are a two way learning opportunity for everyone. More and more informal tele-health consulting are occurring throughout the world. My tele-health problem that I have had with our ongoing diabetic ( retinal ) screening in rural South Carolina is ensuring the 5% with significant diabetic eye findings actually see an ophthalmologist for definite treatment / assessment. If they never get to see an ophthalmologist / eye surgeon , then the program has not accomplished what was hoped. How do you ensure the 5% at high risk , who may have transportation issues, etc. actually receive definitive retinal treatment for their PDR ?
There was mention that increasing life expectancy and population growth will result in additional visual needs / challenges. Some of the issues discussed in this report has been around for decades, many decades. We have made a lot of progress over the last 40 years and there is more to be done. From an ophthalmic standpoint, certainly the ongoing / adverse affects of this pandemic will need to be addressed in the coming years.
Chapter 5 Advancing universal health coverage through eye care. UHC means that all people have access to the health services they need, when and where they need them, without financial hardships. Well I suppose that is a worthy goal. I hope we will one day achieve that in the USA.
Chapter 6 Integrated people-centered eye care. Made reference that ophthalmology is particularly suited to telemedicine. Some of our human resource challenges include general shortages, maldistribution of workers, attrition, imbalances in skill composition and, at times, inadequate regulation. Reference was also made to losing eye care workers to other health sectors ( career opportunities ). That can be a problem if you invest time and efforts to train up the head eye nurse and she gets transfer to a different department as happened to me in Grenada.
Anyway, this concludes the world report. A lot of progress and many issues to be addressed.
The attached slides are of anterior staphyoma ( thinning and bulging ) secondary to old xeropthalmia / keratomalacia. The other slide show a child with a corneal scar secondary to trauma.
Peace,
Baxter McLendon