Showing papers in "Community eye health / International Centre for Eye Health in 2001"

Assessment of learning.

Abstract: So far in this series we have looked at how people teach and learn. We have discussed how we should go about planning a curriculum, and we have considered the methods that are available for us to use when we teach. In this article we look at a critically important aspect: the assessment of learning. Why is it so important?

Vision 2020: Update on Onchocerciasis

Abstract: Onchocerciasis, also known as ‘river blindness’, is an insect-borne disease, caused by a nematode worm, Onchorcerca volvulus. It is the world's second leading infectious cause of blindness. In most of these countries it constitutes a public health problem and a serious obstacle to socio-economic development.

Causes and Visual Outcomes of Perforating Ocular Injuries among Ethiopian Patients.

Abstract: Ocular trauma, in particular open globe injury, is an important cause of monocular visual impairment and blindness in the younger and economically active age group.1 Besides loss of vision, earnings (job opportunities) and productivity, it increases the cost to society because of increased healthcare spending. Although it affects all age groups, previous reports have indicated that ocular trauma victims are predominantly males and young, with the majority under 30 years of age. In those between 20 and 44 years of age, injuries account for 10% of incident bilateral blindness.1 The magnitude of ocular injuries in our country has not been studied previously. This review was conducted to assess the magnitude, causes and visual outcomes of ocular trauma cases at Menelik II Hospital in Addis Ababa.

The case of ivermectin: lessons and implications for improving access to care and treatment in developing countries.

Abstract: On October 21, 1987, Merck & Co., Inc., announced plans to donate Mectizan (ivermectin), a new medicine designed to combat onchocerciasis (‘river blindness’), for as long as it might be needed. Merck took this action, working in collaboration with international experts in parasitology, the World Health Organization, and other agencies to reach those affected by the illness. This unusual decision came twelve years after the discovery of ivermectin by Merck scientists and nearly seven years after human clinical trials in Dakar, Senegal. Merck chairman, Raymond V Gilmartin, has since reaffirmed the company's commitment to donate ‘as much Mectizan as necessary, for as long as necessary, to treat river blindness and to help bring the disease under control as a public health problem’. Through the continuing collaboration of an international, multi-sectoral coalition including the WHO, the World Bank, UNICEF, the Mectizan Expert Committee, dozens of Ministries of Health, the international donor community, more than thirty non-governmental development organizations, and local community health workers, there is hope that onchocerciasis can be eliminated as a major public health problem and socioeconomic development constraint within the next decade. The Merck Mectizan Donation Program (MDP) is now the largest ongoing donation program of its kind. There are active treatment programs in 33 of 35 countries in sub-Saharan Africa, Latin America, and Yemen in the Middle East, where onchocerciasis is endemic. To date, more than half a billion Mectizan tablets have been donated and shipped since the inception of the Program. An estimated 25 million individuals are treated annually, with the 200 millionth treatment scheduled to take place this year.

Secondary glaucomas: the tasks ahead.

Abstract: While the prevalences of morbidity and visual impairment due to primary open angle and angle-closure glaucomas have been fairly well established by population surveys in the west and, recently, in the developing world, the issue of blindness from secondary glaucomas has received little attention from most investigators. Individuals with secondary glaucoma tend to report promptly to the ophthalmologist since there is often marked reduction in visual acuity, apart from pain and ocular discomfort. As a consequence, these are largely self-reported. Information on secondary glaucomas in published eye surveys is limited and the cause of glaucoma seldom identified, although in several prevalence studies secondary glaucomas are numerically important (Table ​(Table1).1). Based on the WHO Blindness Data Bank, Thylefors and Negrel, in their world estimate of glaucoma blindness, found it was not possible to determine the number of blind from secondary glaucoma, although they estimated the world prevalence to be 2.7 million.1 Quigley emphasised that few studies describe secondary glaucomas as a separate entity and most investigators do not provide the criteria used in defining this potentially blinding disorder. The mean prevalence of this condition is 0.44 [SD 0.36%] or 18% of the mean prevalence of primary open angle glaucoma in the world.2 Quigley estimated that 6 million people in the world have secondary glaucoma compared with 67 million with the primary glaucomas. Table 1 Prevalence of Secondary Glaucomas as Reported by Population Based Surveys The Glaucoma Services at the Aravind Eye Hospital, a large tertiary eye care centre in South India, registered 367 individuals with various secondary glaucomas (Table ​(Table2)2) in the year 2000. This represents about 6.0 % of total new cases of glaucoma seen annually. Table 2 Common Causes of Secondary Glaucomas seen in a Tertiary Eye Care Hospital in South India.∗ Lens Induced Secondary Glaucomas Lens induced glaucomas due to hypermature cataracts are an important cause of secondary glaucoma in the developing world. Cataract accounts for 50–80% of the world's blind and in the developing world financial, cultural and psychosocial barriers to accessing excellent surgical services still exist. There is an ever increasing backlog of cataract due to the population explosion, increased life expectancy and low productivity in terms of utilisation of the available surgical services. The uptake of eye care services by the rural community has also been suboptimal in countries like India3 where lens induced glaucomas are a common cause of ocular morbidity. It should be recognised that reduced vision is not the only indication for cataract surgery. An enlarged, cataractous lens can cause phacomorphic glaucoma (see below), the treatment of which is removal of the lens. Under Vision 2020, the global initiative of the WHO and voluntary service organisations, to reduce significantly ‘avoidable’ blindness by the year 2020, it is intended that cataract surgeries performed will increase, particularly in the developing nations. Currently, it is estimated that about 12 million cataract operations are performed each year the world over. Vision 2020 aims to achieve a target of about 20 million cataract operations by the year 2010 and ultimately reach a target of 32 million people receiving cataract surgery annually by 2020. Although recent advances in sutureless small incision cataract surgery and phacoemulsification and improved IOL designs have resulted in vastly superior outcomes with reduced complications related to wound repair and secondary glaucomas, several problems still remain. These require training of ophthalmologists in the emerging, new techniques and tackling complications peculiar to the new surgical methods, which may include glaucoma and inflammation secondary to retained lens fragments. These measures will also reduce complications such as pseudophakic glaucoma, for example, yet another significant cause of secondary glaucoma. Phacomorphic glaucoma The cataractous lens may become swollen (intumescent) which causes relative pupil block, the iris root is moved forward and this may result in blockage of outflow of aqueous fluid at the angle of the anterior chamber. This is a secondary form of angle-closure glaucoma.

The clinical picture of vernal kerato-conjunctivitis in Uganda.

Abstract: Vernal keratoconjunctivitis (VKC) is a recurrent, bilateral, interstitial inflammation of the conjunctiva, resolving spontaneously after a course of several years and characterised by giant papillae (with a cobblestone appearance) on the tarsal conjunctiva, a discrete or confluent gelatinous hypertrophy of the limbal conjunctiva, and a distinct type of keratitis. It is associated with intense itching, redness or brownness, lacrimation, photophobia and a mucinous, ropy discharge containing eosonophils. VKC is a type 1 hypersensitivity reaction but with additional immune mechanisms involved in its pathogenesis. VKC has a global distribution with a widely varying incidence. It is less common in northern Europe and North America, and more common in the African continent, the Mediterranean countries, in Central and South America, and the Indian subcontinent.1,2 All patients in this study were indigenous Africans, and all had been exposed to similar environmental conditions. Vernal keratoconjunctivitis affecting the limbus (left), the conjunctiva and cornea (right). The conjunctiva has pronounced papillae (‘cobblestones’) and fluorescein dye shows a corneal ulcer Photos: John Sandford-Smith

A Clinic-based Survey of Blindness in Kenya.

Abstract: During the course of a seven-month period in 1998 and 1999, 617 new patients with unilateral or bilateral blindness were evaluated as to the underlying cause. This was done at the Lighthouse for Christ Eye Centre in Mombasa, Kenya. These patients came not only from the Mombasa area, but from the entire coastal region – from the frontier with Somalia in the north to the border with Tanzania in the south. Others were from towns in the interior along the highway to Nairobi. Many of these had been made aware of the medical and surgical care available at the Lighthouse through our mobile clinics. Upon arrival at the Lighthouse each patient was registered and then a history of vision problems was obtained. Visual acuity was measured using the Snellen E chart at six metres. Patients were then examined with a slit-lamp, an applanation tonometer and either a direct or indirect ophthalmoscope. Where question existed regarding the degree of vision loss, the patient was referred to the clinic refractionist. With the exception of twelve patients seen by the clinical officer, all others were evaluated by one of the ophthalmologists at the Lighthouse. Patients with visual acuity of less than 3/60 in one eye, but 3/60 or better in the other eye were considered unilaterally blind. Those with less than 3/60 in both eyes were considered bilaterally blind. When compound causes for blindness were present in one eye, the most preventable or avoidable one was selected as the main cause of the blindness. This same principle was applied when different causes led to blindness in both eyes.

Cost containment in eye care.

Abstract: Voluntary eye hospitals committed to serving the community must understand the reality of increasing costs due to inflation, advancements in medical technology and changing expectations of staff and patients. However, these costs are often not matched by the patients' paying capacity. While increasing income, through increased user fees or donations are financial options which will be considered, this article will focus on cost containment.

Advances in the understanding of primary angle-closure as a cause of glaucomatous optic neuropathy.

Abstract: In the last few years the classification of angle-closure glaucoma has undergone revision. This is a result of population research in regions where angle-closure glaucoma is a major cause of blindness. Several studies have shown that most cases of angle-closure that cause glaucomatous optic neuropathy occur without the symptoms that Western ophthalmologists associate with episodes of acute angle-closure.1–3 We have, therefore, started using the classification scheme detailed in Table ​Table11 in our research. Table 1 Classification of Primary Angle-Closure Other ocular tissues may be damaged by angle-closure. These are illustrated in Fig. ​Fig.1.1. Damage to different structures should be specifically described when recording case details. Fig. 1 Damage to ocular tissues in angle-closure glaucoma

Chronic glaucoma case finding and treatment in rural Africa: some questions and answers.

Abstract: Primary health care workers (clinic nurses, community health workers, traditional healers, and others) who work in the community and at primary care clinics should be involved in case finding of patients who have glaucoma.

Intraocular Lens (IOL) Implants in Children

Abstract: Healthy eyes (left) Bilateral congenital cataract (right) Photos: Murray McGavin & Allen Foster

Guidelines for setting up a low vision programme for children.

Abstract: Blindness and low vision are major causes of morbidity and have profound effects on the quality of life for many people. They inhibit mobility and economic well-being of the individuals affected as well as their families. Childhood blindness (CBL) is one of the challenges faced by the world generally and developing countries in particular. In industrialised countries, certain mechanisms for normal schooling and socio-economic rehabilitation of visually impaired children exist. However, in developing countries due to scarce resources and traditional taboos, these children are rarely able to attend the normal educational institutions. Vision 2020: The Right to Sight, has recognised CBL and low vision and refraction as important strategic themes for control of avoidable blindness. This paper attempts to provide some guidelines on how a low vision programme for children could be set up in a developing country.

The elim care groups: a community project for the control of trachoma.

Abstract: The Far North of South Africa, where Elim Hospital is situated, has been known as the trachoma belt. The disease was the main cause of preventable blindness in the area. In the 1970s the local epidemiological pattern of trachoma was studied in the region served by Elim Hospital.1 Several randomised population surveys were carried out, and the results indicated that pre-school children aged 2–4 years represented the main reservoir of infection in the community; that spontaneous cure tended to occur at school-going age; and that repeated re-infections later in life eventually led to blinding complications, especially in women tending young children (Fig.​(Fig.1).1). Men who were absent from their homes most of the time as migrant labourers, were much less affected. These findings explained why many years of school treatment schemes had not reduced the overall prevalence of intense trachoma and its complications in the population, as pre-school children continued to spread the disease. Hence, measures to control trachoma should have two main goals. First, to reduce the infective load in the community by treating young children with tetracycline eye ointment. Second, to prevent re-infection by motivating mothers to improve hygienic conditions in their homes. This rationale led us to involve the communities themselves in the control of trachoma. Fig. 1 Population-based Surveys of Trachoma in a Rural South African Community Approaching the Community The project was set up in 1976 to establish groups in villages in the area around the hospital. Because the majority of the men were working in distant cities, the groups, later called Care Groups, were mostly joined by women. The Project Co-ordinator, based in the hospital, was assisted by a number of Motivators. The idea spread very rapidly, and by the end of the first year 24 of the approximately 80 settlements served by the hospital already had a Care Group. Trachoma was well known in the area, and the people were concerned about it. Several popular beliefs about the disease, handed down over many generations, testify to this concern. Some examples illustrate the remarkably accurate observations, which have become disguised in so-called superstition. For example, people insist that every child should have ‘mavoni’, i.e., discharging eyes in childhood, in order to see well later in life. In fact, the majority of children acquire trachoma within the first three years of life, and by the time they go to school the disease has usually resolved without affecting vision. Also, it was said that a multiparous woman who fails to inform her mother-in-law about her new pregnancy will get eye trouble after the birth of the child and her mother-in-law will get ‘xinyeku’, that is entropion, or will go blind (‘mahlo ya xidzhwele’). Obviously people have observed that blinding complications occur most frequently in large families with many children – a fact we also found in our surveys.2 Finally, the word ‘xinyeku’ is also used to describe a careless, poor and untidy woman, i.e., entropion has long been associated with poor hygienic conditions favouring re-infection with Clamydia trachomatis. Health education could thus be built upon traditional wisdom, and the feeling that their ideas were respected won the people's trust and interest. Mothers were keen to learn more about the nature and spread of trachoma in order to protect their own and their neighbour's children from infection. Thus, starting in three villages, interested women joined together to form Groups of unpaid volunteers. Their aim was to improve health and the quality of life in their homes and in their community. In most cases they started with trachoma and later moved on to general health and development. Good standards of personal hygiene Photo: Erika Sutter

Update on ocular leprosy.

Abstract: The widespread use of Multiple Drug Therapy (MDT) in leprosy control programmes has resulted in a great reduction in worldwide prevalence. There is a mixed picture from country to country, so that there is still a high incidence of newly diagnosed cases in some regions, for example in northern Brazil and parts of India. At the beginning of 2000 there were approximately 640,000 cases registered for treatment with MDT, and around 680, 000 had been newly detected in 1999. More than 10 million previous leprosy patients have been released from treatment (RFT), and removed from registers. Many of them have disabilities or the potential to develop disabilities. In countries such as China and South Korea, there are many elderly people with disabilities, some still living in leprosy settlements or colonies. In West Bengal alone there are 64 such settlements.

Developing a course curriculum.

Abstract: In the last article in this series we looked at the different teaching methods that we can use. Now that we have some ideas on how to teach, the question arises: what do we need to teach? How do we decide what students need to learn? How do we decide what to include in a course, and what to leave out? Fortunately, there is a clear path that we can follow (Abbatt and McMahon, 1993) which is shown in Figure ​Figure11. Fig. 1 The Process of Curriculum Development

Update on ocular leprosy.

Abstract: Dear Editor The report by Professor Gordon Johnson and the recommendations by Dr Paul Courtright summarise beautifully the Workshop on Practical Eye Care Guidelines for Leprosy Patients. (J Comm Eye Health 2001; 14: 25–26). In addition, I would like to clarify one point on treatment of lagophthalmos: Recent lagophthalmos, independent of size of lid gap, should be treated first with a course of systemic steroids as per general guidelines for type 1 reaction and recent nerve damage in leprosy. Usually a duration of nerve damage of ≤ 6 months, is taken as indication for steroid treatment in leprosy. Even recent lagophthalmos with a lid gap of 8–10 mm in mild closure may recover, provided steroid treatment is given in time. Meanwhile the cornea should be protected by conservative means in combination with blinking exercises.1

Food acceptance and selection: activities for promoting pro-vitamin a foods among young children in urban slums.

Abstract: Nutrition education initiatives aimed at promoting desirable change in vitamin A behaviour have led to varying degrees of success in several Asian countries1 However, failures have also occurred because the nutrition education methods used have not led to the desired behaviour change Nutrition education, in the past, has too often been conducted in an unimaginative way2 In order to change eating habits, communicators must learn what motivates food behaviour by mothers and young children and other key household or community members Understanding the factors that constrain children from following desirable dietary practices will help to find practical and acceptable solutions for improvement of food and dietary behaviour Dietary and eating habits are largely formed during early childhood, and healthy eating habits acquired at this age will provide sustainable nutrition and dietary benefits Vegetables and fruits are generally disliked by young children and one of the ways of promoting pro-vitamin A food intake is using a food based approach through effective nutrition communication The present study made a preliminary attempt to understand the natural choice and spontaneous selection of fruits and vegetables by pre-school children in an urban slum site in the city of Mumbai, Western India

What's New in Primary Open Angle Glaucoma?

Abstract: Primary open angle glaucoma (POAG) involves a spectrum of disorders typified by a characteristic optic neuropathy and field loss in eyes with open drainage angles It is currently a leading cause of blindness worldwide, and in the future should become even more important as populations age throughout the world Recently, we have witnessed a number of exciting advances in glaucoma Developments have occurred regarding diagnosis, treatment, genetics and the relationship of intraocular pressure (IOP) to disease progression