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Eye health for healthy ageing
Wendy Holmes, Burnet Institute, holmes@burnet.edu.au
Enso, Peradeniya, Sri Lanka
and
Healthy ageing for eye health

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• 285 million with visual impairment, 39 million blind
worldwide
• More than 82% of all blind people, and 65% of visually
impaired, are over 50 years
• 80% of all visual impairment can be avoided or cured.
• Least developed regions have greatest burden of visual
impairment
• Women have a higher risk of visual impairment
Pascolini D, Mariotti SPM. Global estimates of visual
impairment: 2010. British Journal Ophthalmology,
Poor sight is a significant issue

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3333Albion estate Elders’ Club,
Sri Lanka
Holmes W

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www.newdynamics.group.shef.ac.uk/
Spot the difference…
Elders’ group, Sheffield, UK

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Major causes of visual impairment globally:
• uncorrected refractive errors (myopia, hyperopia or
astigmatism) (43 %)
• cataract, (33%)
• glaucoma (2%)
Major causes of blindness:
• cataract (39%)
• uncorrected refractive errors (18%)
• glaucoma (10%)
• age-related macular degeneration (7%)
• corneal opacity (4%)
• diabetic retinopathy (4%)
• trachoma (3%)
• eye conditions in children (3%)
• onchocerciasis (0.7%)

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As people age the normal structure and functions
of the eye deteriorate affecting vision
Blinding disorders increase in frequency
www.hollows.org/

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Nirmalan PK et al. Br J Ophthalmol 2002;86:505–512
Cluster random sample, n = 5411 > 50 years
Bilateral blindness: 11.0%
About 66% due to cataract
About 25% due to refractive
error
Eye survey of older adults in
Tamil Nadu

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Eye health screening
PALM Foundation, with
support from HelpAge Sri
Lanka, conducted 5 eye
screening camps in Nuwara
Eliya district
Anyone over 60 years with any concerns about
their sight invited to attend (43% attended)

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Eye health screening
1,139 people > 60 years screened
525 (46%) of those screened had cataracts
Estimated 20% of estate elders have cataracts,
(if those who were not screened did not have
cataracts)
In addition 13% already operated = ~ 33%
prevalence

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Cataract
• Defined as opacity in the lens
interfering with vision
• Most common age-related eye disease
• Most treatable cause of vision loss in
older adults
• Nearly two thirds of the diabetics in the
Tamil Nadu study had evidence of
cataract (2008)
• Other risk factors:
smoking; obesity; poor diet;
lack of physical activity; poor cardio-
respiratory fitness; genetic
predisposition; UV light exposure
PALM Foundation

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Refractive error
• Failure of the optical surfaces of the eye to focus images
clearly on the retina resulting in a blurred image
• Myopia (short-sightedness) is
especially common in Asia -
tends to begin in youth
• Hypermetropia (long-
sightedness) tends to begin as
people get older
• Presbyopia – ability of the
ageing eye to focus images on
the retina decreases

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Burden of poor sight among older
people increasing dramatically
• The populations of Asian countries are ageing rapidly -
much more rapidly than in developed countries
• At the same time as globalization, migration, modern
influences, urban living, smaller families, changes in
traditional roles, and women working outside the home
• By 2020 it is predicted that 67% of the global population
over 60 years will live in developing countries
Shrestha LB: Population ageing in developing
countries. Health Affairs 2000,

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• Sri Lanka one of the fastest ageing countries
• 9.2% > 60 years old in 2001, predicted to rise to
28.5% in 2050 (WB 2008)
• 2005/6 national survey - one in five adults has either
diabetes or pre-diabetes; one-third of those with
diabetes are undiagnosed (Katulanda P, et al. 2008)
• 1998 study - in Sri Lanka, as in other Asian countries,
diabetic control was generally poor, with 54% of the
sample having HbA1c values over 8%
(Chuang LM, et al. 2002)
Sri Lanka provides a useful example

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Poor vision is often
accompanied by other
disabilities - arthritis,
paralysis, deafness, or frailty,
or by illness, which inhibit
mobility
The impact of poor vision is
often greater in old age
www.ewenbell.com

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Significant international response to
poor vision and blindness in low and
middle income countries
• WHO has led the Vision 2020 Global Initiative since
1999 aiming to ‘eliminate avoidable blindness by the
year 2020’
• Supported by a wide range of eye INGOs
• Addresses specific eye problems in a vertical manner:
Cataract
Childhood blindness
Diabetic retinopathy
Glaucoma
Trachoma

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Sri Lanka Ministry of Health has a:
• National Vision 2020 Secretariat
• National Steering Committee
• National Programme for Prevention and Control of
Avoidable Blindness
• Five year National Plan 2007 – 2012
Urgent need to integrate prevention and care for
vision problems with general PHC and
health promotion
Vision 2020 initiatives at national level

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Sri Lanka
National Action Plan on Ageing
SRI LANKA
2011 - 2015
Ministry of Social Services
National Council for Elders
There is often a split
between responses
to “NCDs” and to
ageing

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WHO approach – illustrated in Sri Lanka MoH plan

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Diabetes prevalence in Australia and Sri Lanka
(2009)
Age group Sri Lanka Australia
30 - 39 ~7% ~1%
40 – 49 ~12% ~3%
50 – 59 ~17% ~8%
60-69 ~20% ~12%

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High prevalence of hypertension
For example:
In a rural Central Indian population of ages 30+
years, the prevalence of arterial hypertension
was 22.1 ± 0.6% with an awareness rate of
20% and a treatment rate of 8%.
Jost B. et al. American Journal of Hypertension
2010; 23 4, 347–350. doi:10.1038/ajh.2009.276

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Quality of life
Focusing on death as the outcome of concern may result in neglect
of common conditions that affect quality of life
For example:
• visual impairment
• pain and restricted movement associated with arthritis
• depression, anxiety and dementia
• urinary incontinence
• sexual health problems
• falls
• violence or neglect - often hidden

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Population burden of disease
• National cross-sectional multistage random sampling survey in
Thailand in 1997
• 4,048 > 60 years interviewed
• 769 (19%) reported having a long-term disability
• Nearly half with disability suffered 2 or more health problems
• Population burden of disease:
hemiparesis; arthritis; accidents; blindness and other eye diseases;
kyphosis; weakness of limbs; deafness; hypertension.
“This ranking of public health priority differs from conventional
approaches using mortality statistics and disability adjusted life
years (DALYs).”
Jitapunkul S, et al. Determining public health priorities for an ageing population:
the value of a disability survey. Southeast Asian
J Trop Med Public Health.
2003 Dec;34(4):929-36.

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The health problems of ageing in low income
settings are characterised by:
• Chronicity
• Co-morbidity
• Preventable disability
• Earlier health hazards
• Barriers to health care
• Potential for catastrophe
• Increasing vulnerability
• But also - resilience

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Barriers to health care for elders
• Transport costs
• User fees
• Cost of drugs
• Lack of mobility
• Health care provider attitudes
• Long waiting times
• Fear of forms

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Implications for health services
We need:
• Continuous rather than episodic care – older person primary
manager of own health care
• Home based elders’ health records
• Strong referral links to specialists and social welfare services
• Respite and palliative care
• Integration between health facilities and community – home
visits, links with CBOs and NGOs
• Integration across the life span – preparation for healthy ageing

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Implications for health services
Older people’s contact with health services often through
grandchildren
Front line health care workers need training:
• in communication and counselling skills
• to assess older people: BP; pulse; teeth; visual acuity; peak
flow; “how are things at home?”
• to give simple health promotion advice – and how to help older
people to manage their medicines

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WHO have a useful
toolkit on PHC for
elders – and many
other useful
resources at their
web-site

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Efforts to improve vision can
contribute to the prevention and
management of NCDs and other
age-related health problems
• When older people are able to see clearly they have a better quality
of life and can continue to take an active part in their families and
communities
• Social participation protects against many ageing-related conditions,
through both physiological and psychological mechanisms
Holt-Lunstad J, et al. Social relationships and
mortality risk: A meta-analytic review. PLoS Med
2010, 7:e1000316.

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• Poor vision makes it difficult for elders to prevent and
manage other health problems:
- limits physical exercise, increases risk of injuries,
increases social isolation, difficult to travel to health care
services, and to take medicines correctly
• Prospect of improved sight - motivating factor for older
people to attend health services, where they can then
be screened and treated for other conditions
• Preventing blindness from diabetic retinopathy may be a
strong motivator for diabetics to manage their own
diabetes well and to attend for regular health checks

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• Older people make
significant economic, social
and emotional
contributions to their
families and communities
• But poor sight can limit
their ability to contribute
• Adds to the burden of care for other family members,
usually women, and limits carers’ participation in the
paid workforce or their community
Poor sight inhibits older people playing productive
roles in their families and communities:

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• Elders’ Clubs provide
opportunities to reach older
people with screening and
referral for cataract surgery,
spectacles, or other eye care
• facilitate discussion of eye health
promotion messages
Healthy ageing programs and activities can
contribute to improved vision:

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Re-orienting health systems for older patients and
chronic conditions - important to advocate
inclusion of eye health
• procurement of commodities - include intra-ocular lenses,
spectacles and essential eye medicines
• health information systems and personal health records
-include space for recording visual acuity and results of
eye screening
• include eye health in health worker training, and in
management and referral protocols
• make health facilities accessible to older people with poor
vision, including provision of suitable transport

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• Strengthening systems for cataract surgery can provide lessons
about strengthening health care systems for other types of surgery
• Need for surgery increasing with population ageing
• Two billion lack access to surgery worldwide
Funk L, et al. Lancet 2010

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“A lot of people think that when this happens (cataract)
to eyes it is the end of life, When you take them for
surgery they feel like they are given another life”
[Young man, Agarapatana]
“When I was blind I felt like my hands and legs are not
functional, now I can walk well and go anywhere, that is
why I could come for this discussion too”
[Older woman, Agarapatana]
“In Mahauva, in a family one person was paid to look
after the elder who had cataract. Now after surgery
there is no need for a person to look after him.”

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“Only after the eye surgery I can see all the faces that I
cannot see earlier, before 6 months for about 6 years I
could not see, only now I am mobile, I can cook, prepare
milk for my grandchild, get water from the tap, light the
hearth. I have become functional in these 6 months.”
[Older woman, Brookside estate]
“In Kahagalla, after the elder was operated for cataract, she
came for the Elders’ Club meeting for the first time, and
her daughter-in-law was able to go back to work.”
[Community mobiliser]
“We have come from darkness to light”
[Older man, Agarapatana]

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Achieving improved vision for elders
Better
general
health of
elders
Lessons learned on
how to improve
health promotion and
health systems for
healthy ageing in
general
Elders contributing to
health and well-being
of children, youth and
adults
Reduced burden of
care on family and
on government
services
Improved quality of
life and social
participation
Improved development outcomes

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Thank you
Holbrook estate elders’ club